Role of Alexithymia and Self-Concealment in Predicting Readiness to Change Among Patients with Substance Use Disorders

Background: Substance use disorders can cause serious harm and manifest as psychological, physical, or legal issues. Drug abuse may be used as an alternative strategy since people struggle to manage their emotion regulation problem. Hence, it is hindering their ability to change as a consequence. Aim: to assess the role of alexithymia and self-concealment in predicting readiness to change among patients with substance use disorders. Subjects and method: Design: A descriptive correlational design was utilized in this study. Setting: The study was conducted at neurology, psychiatry and neurosurgery center, Tanta university. Subjects: A purposive sample of 107 patients with substance use disorder was chosen to be subjects for this study. Tools: Sociodemographic and clinical data questionnaire, Toronto Alexithymia Scale (TAS-20), Self-Concealment Scale and Readiness to Change Questionnaire [Treatment Version]: RCQ[TV]. Results: 74.8 % of study subjects had high and moderate degree of alexithymia. Also, 78.5% of them had a high and moderate degree of self-concealment. Regarding readiness to change, 52.3% of the study subjects have merely mild degree of readiness to change. Alexithymia acts as a predictor of readiness to change among patients with substance use disorders. Conclusion: Patients with substance use disorders are often less aware of their emotions and hide their negative experiences from others. Subsequently, this is affecting their willingness to modify the current state of abuse. Recommendation: Improving realization of emotions and emotional management is an important part of the treatment of patients with substance use disorders.


INTRODUCTION
Substance use may entail behavioural, social, and lawful problems. (Smith, 2018). Since they are linked to an increased risk of HIV and other communicable and noncommunicable diseases, interpersonal violence, and injury. Untreated drug use disorders have a harmful effect on public health globally. (Di Cesare et al., 2013;Wechsberg et al., 2012). It is believed that a crucial component of substance-related behavioural changes is the willingness to change. Studies have revealed that readiness to change (RTC) is a predictor of great results (Collins, Malone & Larimer, 2012;Bertholet, Cheng, Palfai, Samet & Saitz, 2009). Many patients who enter treatment are unprepared to make the adjustments necessary for recovery and are frequently unwilling to modify their behaviour. So, the main role of health care workers in the addiction field is to stress the importance of patient readiness or motivation to treatment of substance use disorders (SUDs). (Gregoire & Burke, 2004). The Trans -theoretical model is the one that is most frequently employed model to operationalize patient's readiness to switch to drug treatment regimens. Much of the research on preparation for change in drug use is psychologically and theoretically based on Prochaska and DiClemente's work on "stages of change." This concept may be seen as a continuum in which people search for longlasting or ongoing change. Three phases are envisioned by the paradigm, each representing a growing level of commitment to change (Prochaska, DiClemente & Norcross, 1992).
Precontemplation is characterized by a lack of intention to change. The issue could not yet be seen as worrying, or it might be believed that it benefits the individuals more than hurt them. The stage of contemplation is when a patient examines the current behavioural patterns and potential shifts in risk-reward analyses. When someone is thinking of a change, they are often looking for and assessing information but are not yet entirely ready for the change. Action stage serves as a model for the phases in which a patient implements a plan, modifies current patterns of behaviour, and actively works to build new forms of conduct such as entering treatment. When the action stage initiated, the patient starts to change problem behaviors (such as increasing activity in treatment sessions, avoiding drug use for longer periods of time, and desire to attend self-help meetings, asking for help, and using help, etc….) to learn new skills to prevent relapses to problem habits. Additionally, during this stage the patient honestly speaking about craving issues and\or engaging in alcoholics anonymous sponsors) (Prochaska, DiClemente & Norcross, 1992).
Alexithymia has been proven to occur in people with drug use and addiction problems. (American Psychiatric Association, 2013). Since alexithymia has a multifaceted structure. The emotional awareness and discrimination are crucial for emotion regulation. (Parolin et al., 2017), (Berking et al., 2011). There are four essential elements to alexithymia: Having trouble recognizing and/or explaining emotions, having trouble saying them apart from physical experiences, having little to no symbolic thinking, and having an externally oriented cognitive style (Goerlich, 2018;Orsolini, 2020). Studies have looked at how alexithymia impacts drug addicts' motivation and willingness to seek treatment, but the results of these studies are conflicting. Alexithymia, which includes low self-awareness and an interest in introspective activities, little empathy and the ability to regulate emotions, high negative affectivity and impulsivity, and maladaptive coping mechanisms, may make it difficult on the patient to be ready for treatment and make it easier to use drugs when there is increased distress (Shishido, Gaher & Simons, 2013;Oyefeso, Brown, Chiang & Clancy, 2008).
One hypothesis stated that, alexithymia may be a stable personality trait that is strongly influenced and caused by a number of variables, such as preceding relationships, lifetime experiences, early distressing experiences (such as mistreatment and/or abuse of children) and the attachment style (such as insecure attachment), which may increase a person's vulnerability to substance use disorders (Thorberg et al., 2011;El-Rasheed, ElAttar, Elrassas, Mahmoud & Mohamed, 2017). According to the literature, high rates of substance use may be justified if alexithymia occurs before the beginning of drug use in order to treat the emotional dysregulation brought on by alexithymia. In this condition, people have trouble identifying and describing their emotional states. They may also find it challenging to successfully manage these circumstances or realize how they relate to starting or continuing of drug use. (Stasiewicz et al., 2012) In a similar vein, Alexithymia may contribute to the emergence of addiction and may be connected to emotional dysregulation, as reported by Morie et al., (2016).
Another supposition generated that alexithymia is a fluctuating condition and may serve as a defense mechanism in response to psychological anguish, which may cause or intensify an existing behavioural addiction or a drug use problem (Morie et al., 2016). People who have alexithymia seem to have trouble handling stressful events, and they are more inclined to employ "addictive" modalities as coping mechanisms to handle potentially upsetting circumstances. (Gao et al., 2018). In actuality, higher teenage cannabis usage and increased caffeine intake are strongly linked to alexithymia. ( Kajanoja, Scheinin, Karukivi, Karlsson & Karlsson, 2019), (Dorard et al., 2017. Furthermore, research found that risky substance use, severe addiction and increased desire for taking drugs are associated with presence of alexithymia. (Thorberg et al., 2011), (Thorberg, Young, Sullivan & Lyvers, 2009;Morie et al., (2016). It is crucial to remember that alexithymia might obstruct therapeutic objectives, particularly in emotional and insight-based therapies (Cruise & Becerra, 2018;Lumley, Neely & Burger, 2007). Patients with drug use disorders who have high alexithymia scores could find it difficult to access psychotherapy and might develop poorer therapeutic relationships (Cleland, Magura, Foote, Rosenblum & Kosanke, 2005). Additionally, higher alexithymia scores have been linked to higher levels of anxiety, impulsivity, sadness, and worse health related quality of life (Palma-lvarez et al., 2021).
Self-concealment is a significant element that might affect a patient with a drug use disorder's willingness to change. Self-concealment is the behavioural tendency to purposefully keep embarrassing or upsetting information about oneself hidden from others (Fridlander, Nazem, Fiske, Nadorff & Smith, 2012). The following steps are parts of the self-concealment process: "(a) possesses secrets that are negatively regarded, (b) hides them from others, and (c) avoids or fears self-disclosure" (Masuda & Latzman, 2012). Self-concealment does, in fact, predominantly present itself in interpersonal interaction and is linked to lower well-being due to secrecy, dysfunctional emotion regulation, and the adoption of repressive or avoidance-based coping mechanisms (Larson, Chastain, Hoyt & Ayzenberg, 2015). Various negative consequences for one's mental and physical health are linked to higher degrees of self-concealment (Hartman et al., 2015;Masuda & Latzman, 2012). Low self-esteem, lack of desire, anxiety and depression (Hartman et al., 2015), misbehaviors (Jäggi, Drazdowski & Kliewer, 2016), lack of self-control, increased drinking (McCann, Perra, McLaughlin, McCartan & Higgins, 2016), and suicidal thoughts are a few of these (Fridlander, Nazem, Fiske, Nadorff & Smith, 2012)). As well, it was shown that self-concealment was statistically significant and strongly correlated with the signals of risky and damaging alcohol consumption (D'Agata, Holden & Nazarov, 2021). In this context, Hartman et al., (2015) discovered that decreased drinking control brought on by self-concealment is linked to alcohol-related issues.
However, prior studies have shown that those who have self-concealment are more frequently avoid going to counselling or seeking emotional assistance. (Wheaton, Sternberg, McFarlane & Sarda, 2016). These findings are troubling since a high level of self-concealment reduces a person's likelihood of seeking professional aid three times more than others. This will eventually influence the capacity for direct problem-solving and willingness to modify. (Masuda, Anderson & Edmonds, 2012) Adding to, the difficulties that the persons experience in knowing themselves and their feelings, may also lead to the tendency towards self-concealment, which brings about the necessity to provide those individuals with the skills such as expressing themselves and being aware of their feelings. (Çalık & Çelik, 2019)

Significance of the Study:
A closer examination of the forementioned analysis showed that, in comparison to their normal counterparts, individuals with drug use disorders reported higher issues with alexithymia and self-concealment. (Thorberg, Young, Sullivan & Lyvers, 2009). The fact that alexithymia is a crucial component of emotional dysregulation and may play a role in the etiology of drug use disorder may help to explain this. Because individuals with substance use disorders may take drugs as a trial to avert undesirable states that are directly caused by alexithymia, this ultimately makes things worse for them. (Hamidi, Rostami, Farhoodi & Abdolmanafi, 2010) On the other side, self-concealment is closely linked to ambivalence about emotional expression, self-silencing, worry of revelation, motivation for concealment, behavioural restraint, and hiding and refusing oneself (Reyome, Ward & Witkiewitz, 2010;Cruddas, Gilbert & McEwan, 2012). All these aspects emphasize the need to improve patients' capacity to communicate themselves, differentiate between ideas, feelings, and concentrate on specific issues to promote readiness for change, lessen stress, and expand positive coping. (Chaudhry & Sadiq, 2021).
In conclusion, substance use disorder will obviously cause clients' lives to become more difficult. Even though we are aware that a variety of factors interact to cause the disorder, we must continue to offer support and assistance to these clients for them to grow into well-adjusted and self-driven individuals. (Hamidi, Rostami, Farhoodi & Abdolmanafi, 2010). As well as learning how to be aware of their feelings and describing it rather than resort to self-concealment. Therefore, the aim of this study is to assess the role of alexithymia and self-concealment in predicting readiness to change among patients with substance use disorders.

AIM OF THE STUDY:
-To assess the role of alexithymia and self-concealment in predicting readiness to change among patients with substance use disorders.

Research objectives:
1. Evaluate the degree of alexithymia among patients with substance use disorders.
2. Measures the degree of self-concealment among patients with substance use disorders.
3. Identify the degree of readiness to change among patients with substance use disorders.
4. Explore the role of alexithymia and self-concealment in predicting readiness to change among patients with substance use disorders.

SUBJECT AND METHOD:
A. Technical design: Study Design: A descriptive correlational design was utilized in this study.

Study Setting:
The Neurology, Psychiatry, and Neurosurgery centers that are affiliated to Tanta University were the sites of this study. There are two words for addiction there: one with 20-bed for men and one with 20-bed for women. Patients with psychiatric and drug use disorders can receive assistance from the facility around-the-clock. seven days every week.

Study Subjects:
The study subjects consisted of a purposive sample of 107 patients who were attended the previous mentioned setting and fulfill the following criteria:
-At least 3 weeks of admission (to reduce the impact of acute stage on the intensity of symptoms and patient's ability to listen and understand).

2-Comorbid psychiatric disorders
Sample Procedure: Sample sizes were calculated using the statistical package of Epi-Info software.
The sample size calculation criteria expected prevalence of willingness to change of 80% with 95% confidence limits and 5% error margin.

Sample Size:
Based on the above criteria, the sample size should be N > 100.

Tools for data collection:
Four tools were used for collection of data and tested for reliability and validity:

Tool (I): Demographic and clinical data questionnaire
The tool was developed by the researchers in an Arabic language to illicit data about age, sex, religion, and marital status. In addition to data about onset of substance use, types of substance, previous exposure to psychological trauma, date of beginning of treatment, relapse frequency, and presence of any legal issues related to substance use.
Difficulty describing feelings (DDF) items numbers 2,4,11,12,17 and Externally oriented thinking (EOT) items numbers 5,8,10,15,16,18,19,20. The total score is the sum of the ratings for each of these items, the higher the score, the higher alexithymia. The scale has shown its validity and reliability across several cultures and languages (Goerlich, 2018;Taylor & Bagby, 2004). The TAS-20 uses cutoff scoring: A score of 51 or less denotes a mild degree of alexithymia, a score of 52-60 indicates a moderate degree, and a score of 61 or more signifies a high degree.
Tool (III): Self-Concealment Scale-A 10-item self-report scale developed by Larson and Chastain, (1990) in an English language to measures the tendency to actively conceal personal information from others. Responses on this scale can range from "strongly agree" to "strongly disagree," using a 5-point (1-5) Likert scale. The scale implies using three dimensions to quantify self-concealment. The inclination not to disclose personal data, propensity to keep secrets or negative thoughts about self-hidden from others, and fear of self-disclosure. However, factor analysis and high internal consistency supports one-dimensionality of this scale. A higher score indicates a higher level of selfconcealment. The scale has been shown to be satisfactory reliable (Larson & Chastain, 1990). The internal consistency of the scale was acceptable, measuring a Cronbach alpha of 0.83 and a test-retest reliability of r = 0.81 at 4-week intervals. The scores used in this study were: patients with a score < 50% implies mild degree of self-concealment, 50%-75% indicate moderate degree and > 75 represent high degree of self-concealment.

Tool (IV): Readiness to Change Questionnaire [Treatment Version]: RCQ[TV]
The scale developed by Heather, Luce, Peck, Dunbar and James, (1999) to identify how the client personally feels about his drinking right now. All items are scored on a 5-point scale ranging from: Strongly disagree to strongly agree. The scale comprised from three subscales namely, Precontemplation (PC); items numbered 1,3,6,10. Contemplation (C); items numbered 2,4,7,11 and Action (A); items numbered 5,8,9,12. A negative scale score indicates an overall disagreement with items measuring the stage of change, whereas a positive score represents overall agreement. The highest scale score denotes the stage of change designation. The internal consistencies of the three scales at 3-months and 12-months follow-up were all above.70 (Heather & Hönekopp, 2009). The score used in this study was as follow: patients with a score < 50% denote mild degree of readiness to change, 50%-75% indicate moderate degree and > 75 represent high degree of readiness to change.

B. Operational design:
The operational design included the preparatory phase, pilot study, validity & reliability of the tools.

Preparatory phase:
The researchers carry out a lot of internet search on specialized sites to formulate the study titles and aims, find suitable tools, and build theoretical background for the study. This was done based on relevant literature and previous research findings.

Content validity:
Researchers first translated the tools into an Arabic language before doing the opposite. The backtranslation was similar to the original translation, according to the results.
A jury made up of five psychiatric experts was assembled to assess the validity of the study tools. Based on their views the tools were valid.

Pilot study:
On 10% of the total subjects (10 patients), a pilot study was carried out to confirm the applicability and clarity of the instruments and to identify any obstacles to data collection. These clients are not included in the actual study. Depending on the results of the pilot study, the appropriate modifications were made.

Field work:
During the actual study, the researchers met each client who matched the inclusion and exclusion criteria on an individual basis and conducted a private interview.
This was done to establish rapport and initiate relationships with clients, explain the study's goals, get their informed permission, and complete the research tools. Each interview lasted between 30 to 45 minutes. The four-months period from mid-August 2022 to mid-November 2022 was the completion period of data collecting.

C. Administrative design:
Formal approval to conduct this study has been obtained from the director of the neurology, psychiatry, and neurosurgery center.

Ethical Considerations:
The ethical committee that is affiliated to the Faculty of Nursing, Tanta University, gave its approval to this study (code number 169-1-2023). After explaining the study purposes, the clients gave their consent. Confidentiality and privacy are ensured. The client's choice to decline participation in research was honored, and the client was given the assurance that any information acquired would be kept private and used exclusively for research objectives.

D. Statistical design
Data were analyzed using Statistical Program for Social Science (SPSS) version 24.0 Quantitative data were expressed as mean± standard deviation (SD). Qualitative data were expressed as frequency and percentage. The Chi-square (X 2 ) test of significance was used to compare proportions between qualitative parameters. Pearson's correlation coefficient (r) test was used for correlating data. Regression analysis to influence of one or more independent variables on a dependent variable.

RESULTS:
Table (1): presents the socio-demographic and clinical characteristics of the studied participants. In relation to age, the total subjects mean age was 35.1 ± 5.27 years with the highest percent being in the age group ranging from 20 to less than 40 years. As for sex, 57.9 % was male patients and 42.1 % was females. Concerning religion, most of them were Moslems (80.4 %) compared to only 19.6 % who were Christians. Regarding marital status, the highest percent (42.1 %) were divorced while the lowest one was widow (4.7%). As regards the starting of abuse, more than three quarters of the studied subjects (76.6%) started from two years and nearly one half of them (48.6%) started treatment from one year. 52.3 % of the studied subjects had previous exposure to psychological trauma which led to the start of abuse and 45.8% of them had two times of relapse frequency. 85% of subjects did not have any legal issues related to substance use. Finally, in relation to addicted substance, all patients use hashish (100 %) followed by tramadol 93.5% and the least addicted substance was cocaine (4.7%) Table (2): illustrates the distribution of the studied participants according to their percent and mean scores of alexithymia, self-concealment, and readiness to change. From this table it can be observed that the highest percent of the studied subjects had high degree of alexithymia and self-concealment (40.2 % & 42.1 % respectively) with the mean scores of 63.66 ± 14.83 & 32.93 ± 9.61 respectively. In relation to readiness to change, more than one half of subjects (52.3 %) had mild degree of readiness to change compared to only 15.9 % who had high degree of readiness to change with a mean score of 31.93 ± 11.51. Table (3): illuminate the distribution of alexithymia and readiness to change subscales and their mean scores. Firstly, regarding alexithymia subscales, the table shows that the highest mean score 25.60 ±8.08 was observed for difficulty identifying feelings subscale followed by 22.73 ± 6.96 for difficulty describing feelings and finally 16.10 ± 4.34 for externally oriented thinking subscale. In relation to readiness to change subscale, it was found that precontemplation subscale take the greatest mean score among all of them13.91 ± 3.93, then contemplation subscale 10.25 ± 4.49 and finally 10.11 ± 4.01 for action subscale.

Table (4):
shows the relationship between readiness to change, alexithymia and self-concealment. It was noted that there is a statistically significant relationship between readiness to change with alexithymia and self-concealment. (P=0.001*). In more details, 76.5% of subjects with a high degree of readiness to change had mild degree of alexithymia and 82.4 % of those who had high degree of readiness to change had mild degree of self-concealment.

Table (5):
displays the relationship between alexithymia and self-concealment. It can be seen that, a statistically significant relationship between alexithymia and selfconcealment was detected. (P=0.001*). More specifically, 82.6% of those who had mild degree of alexithymia had mild degree of self-concealment and 53.3% who had high degree of self-concealment also had high degree of alexithymia.

Table (6):
illuminate the correlation between readiness to change, alexithymia and self-concealment. A statistically significant positive correlation between alexithymia and self-concealment was discovered. On the contrary, a statistically significant negative correlation between readiness to change and both alexithymia and self-concealment was found. (P=0.001*) Table (7): reveals the role of alexithymia and self-concealment in prediction of readiness to change. It was found that both alexithymia and self-concealment had a significant effect and act as a predictor to readiness to change among patients with substance use disorders, but alexithymia had a more significant effect on readiness to change.

DISCUSSION:
Frequent seeking and use of drugs that result in psychological dependency (habituation) is characterize substance use disorders. A continuous need (craving) for the substance and the emotional nature of the urge are indicators of psychological dependency. These manifest as compulsive actions to get drugs and to get out of a restlessness, anxiety, or depressed mood. (American Psychiatric Association, 2013); Smith, 2018). There is a lot of evidence to support the idea that people with substance use disorders have a high prevalence of alexithymia. Nehra, Kumar, Sharma, and Nehra (2014) ;Torrado, Ouakinin, and Bacelar-Nicolau (2013). Significant positive correlations between alexithymia traits, the intensity of drug use, and related challenges provide evidence that alexithymia and addiction are related. (Thorberg et al., 2010(Thorberg et al., , 2011. In a similar manner, earlier study discovered that self-concealment has a detrimental impact on life satisfaction. To avoid self-disclosure and to get away from embarrassing and unpleasant feelings, people start abusing drugs. The study also noted that they don't get support from psychologists when they have to ( Çelik, 2015 ( The first crucial finding in the existing study is that around three-quarters of participants showed high to moderate levels of alexithymia and self-concealment. The alexithymia subscales also yielded the highest scores for difficulties in recognizing and describing emotions. This indicates that individuals occasionally struggle to identify and express their emotions and occasionally choose to conceal uncomfortable or embarrassing feelings, ideas, or private information. The findings also indicate a strong positive association between self-concealment and alexithymia. The possible justification for these results might be the intrinsic disability in patients with substance use disorders in expressing themselves, communicating their problems and in regulating their negative emotions and dealing with it constructively. Moreover, self-concealers may feel abandoned, ignored, and unacknowledged, and may experience more relationship deficits than others. (Kaya, Sahranç, & Çelik, 2019) Consequently, this may lead to an increase in the possibility of drug use to overcome this difficulty and maintain their life. Besides, the negative effect of alexithymia and self-concealment may be inhibited by addictive behavior which may be a kind of protective act against these destructive experiences. The psychoanalytic view of this issue supports that addicted clients may have struggle in realizing their own personality and knowing themselves accurately. This in turn may lead to constant feeling of worthlessness and incompetence and diminish their ability to realize the truth. Theoretically, this occurs due to faulty personality development, parent deprivation, earlier painful incidents and self-damaging nature which are present in addictive personality. (Brook, Pahl, & Rubenstone, 2008) Diminished emotional awareness might decrease the confidence to communicate distress to others and damage the quality of social relationship, according to Cox et al., (2020). When expressing worries and concerns, surrounding others are more likely to understand, validate, and support which enhances the quality of social connection. Alexithymia and stress concealment have been linked by research, therefore people with low emotional awareness may be less self-expressing, threaten relationships, and have less options for social assistance. (O'Loughlin, Cox, Kahn, & Wu, 2018). In fact, other studies have demonstrated a connection between loneliness and distress concealment. (Cox et al., 2020) The finding of the current study is constant with other study which reveal that, greatest of the individuals who were high in alexithymia stated that they feel difficulty in disclosing their thoughts and feelings to others as they face difficulties in understanding the emotions of others and social signals because they are incapable to regulate their emotions. Even if they would like to reveal their emotions they cannot as they feel isolated and detached from others, which makes them miserable and anxious. The study also showed that most of the individuals notified that they want to release their feelings despite their negative experiences because they sometimes feel intense emotions, but they are unable to relate their emotions with their action as they cannot behave in a reasonable manner. Therefore, they turn to conceal and hide these emotions from others. (Chaudhry & Sadiq, 2021).
The present results are consistent with past research which discovered that people with drug use disorders are more likely to have alexithymia than those without a substance use disorder. (Ghalehban & Besharat, 2011). Furthermore, participants who undertaking drug and alcohol rehabilitation programs frequently exhibit alexithymia, and research indicates that the condition itself might be challenging to treat. (Lyvers, Lysychka, & Thorberg, 2014;D'Agata, Holden, & Nazarov, 2021) discovered that selfconcealment to be statistically significant and positively linked with risky and hazardous alcohol consumption. Another significant finding in the existing study is more than half of the study subjects have merely mild degree of readiness to change, and the greatest mean score was reported for precontemplation subscale, while the lowest mean score was for action subscale. This means that a large percentage of those patients did not recognize their abuse state as a problem consequently, they do not have any intention to change the current situation. In other words, this indicates a tiny level of willingness and enthusiasm to alter their existing status and produce any new turn. This is also suggested their inability to view the risks around substance abuse and look at the perceived benefits only from it. Which may be an important marker on the effect of alexithymia and selfconcealment on patients with substance use disorders. Along the same line, the present results also found that both alexithymia and self-concealment had a significant negative correlation with readiness to change. This finding supports the previous rationale and signifies the effect of them on the patients' desire to make any improvement in their condition. On the same respect, the literature indicated that alexithymia is related to dangerous substance use. (Lyvers, Jamieson, & Thorberg, 2013;, more severe addictions, (Thorberg et al., 2011), complex craving levels, (Saladin et al., 2012), and more treatment dropouts/relapses. (Morie et al., 2016). It is essential to notice that alexithymia may hinder treatment objectives, especially in emotional and insightoriented treatments. (Cruise & Becerra, 2018). Substance use disorder patients with elevated levels of alexithymia may have more difficulties in entering psychotherapeutic treatments and would form weaker therapeutic relationships. (Cleland, Magura, Foote, Rosenblum, & Kosanke, 2005). Regarding the effect of self-concealment, Hartman et al., (2015) found that self-concealment was connected to alcohol-related problems through diminished control over drinking. Another possible justification for increased level of alexithymia and selfconcealment and lowered level of readiness to change amongst patients with substance use disorders is the possibility that those patients may turn to using substance in a way to deal with different life stressors that facing them regularly with limited other constructive methods to deal effectively with diverse challenges. Those patients may use substances as a coping mechanism in their daily life to decrease their level of stress and anxiety, which in turn increase drinking state and produce a more sever degree in the level of alexithymia and self-concealment. This rationale goes in the same line with other studies which revealed that alexithymia and anxiety could lead to substance use as a selfmedication approach for controlling distress. (Morie et al., 2016);Arunogiri & Lubman 2015). In this vein, Dorard et al., (2017) imply that patients with alexithymia and anxiety may use cannabis as a stress-coping strategy. De Rick and Vanhuele, (2007); Thorberg and Lyvers, (2006) in their studies found that, the motive for drinking among alcohol addict with alexithymia may be because alcohol use signifies a coping strategy of emotional self-regulation that is influenced by alexithymia and positively modified by alcohol use.
On the other side, high self-concealer suffers from difficulty in controlling emotional stress and incorporating challenging life experiences. Thus, while selfconcealment raises distress, it also prevents any constructive resolution of buried traumas, shameful circumstances, and other distressing experiences. Which leads to ego diminution and a failure of healthy self-regulation. The healthiness consequences of this conflict can also expand to distal outcomes associated with negative health behaviors such as substance use, and to a failure to get specialized support. (Larson, Chastain, Hoyt, & Ayzenberg, 2015).
When investigating the role of alexithymia and self-concealment as predictors of readiness to change, the current research discovered that both have significant effect and act as a predictor, but alexithymia has more impact on readiness to change among patients with substance use disorders. In other words, when patients with substance use disorder have difficulty in being aware of and describing their emotions, this impedes their ability to make efforts to change and to manage their condition. Factually, lack of awareness about one's own emotions and inability to put it in specific words have a detrimental influence on ability to deal effectively with it. Also, this reflects problems in emotion regulation and its consequences on magnifying drinking state. When the patients are faced with multiple situations that involve negative emotions, they are lacking ability to discover and recognize their emotions and deal directly with it, subsequently, make the patient resort to substance use as a way to escape from this negative state to more apparently positive one.
A previous study on alexithymia amongst long-term drug users found elevated rates of the condition in their subjects, suggesting a high incidence of emotional awareness deficits that impede the growth of institutional and familial support networks with significant ramifications for developing social integration plans (at the work and family levels) that safeguard quality of life. (Souto, Alves, Conde, Pinto, & Ribeiro, 2019). These drawbacks affect patients' readiness to change their addictive state and complicate the situations. Additionally, according to another study, alexithymia influences how well individuals respond to mental health therapy, and it commonly results in poor treatment outcomes. (Hungr, Ogrodniczuk, & Sochting, 2016). Thus, alexithymia becomes a problem for mental health providers as a result. The likelihood that many of the patients may be alexithymic must therefore be considered by clinicians when developing treatment strategies in the context of mental health, and particularly in the field of addictions. As a result, they must incorporate particular psychotherapeutic techniques that encourage both the recognition and the variation in emotionally dysfunctional patients. (Souto, Alves, Conde, Pinto, & Ribeiro, 2019). This effort may have a great effect on increasing patients' readiness to change and heighten their motivation for treatment.
Another factor may be important and should be taken into consideration when interpreting the role of alexithymia in predicting readiness to change among patients with substance use disorders could be that; state of alexithymia in the patients might be precede the onset of addiction which means that the patients have deficits in emotional awareness before the beginning of substance use which make the situation more complex and necessitate great effort to be improved. This justification supports the idea that alexithymia could be a susceptibility factor that precedes SUD. (De Rick & Vanheule, 2006;De Timary, Luts, Hers, & Luminet, 2008). According to Taylor, Bagby, and Parker (1997), the role of alexithymia as a risk factor for SUD may be explained by basic structural characteristics such underdeveloped self-awareness and insufficient cognitive regulation of one's emotions. Alternately, it could emerge from interactions with additional risk variables such drug expectancies, unfavorable emotions, insecure connection, and personality problems. (Lyvers, Onuoha, Thorberg, & Samios, 2012 ;De Carli, Tagini, Sarracino, Santona, & Parolin, 2016). Similar reports indicated that alexithymia is a risk factor for psychosomatic and addictive illnesses. (Cruise and Becerra, 2018); Gao et al., (2018). Teixeira, (2017), on the other hand, said that the association between alexithymia and drug addiction is still ambiguous and that alexithymia may result from or be linked to drug use. Other empirical research shows no connection between alexithymia and abstinence, length of treatment, and adherence to treatment. (De Haan et al., 2011 ;Morie, Nich, Hunkele, Potenza, & Carroll, 2015). The absence of correlation can be attributed to the fact that dropout and recurrence of substance use depend on numerous factors rather than a single element. It is crucial to note that the most accurate and trustworthy dropout prediction models take a variety of indicators and their interactions into consideration (Brorson, Arnevik, Rand-Hendriksen, & Duckert, 2013;Brecht & Herbeck, 2014).

CONCLUSION:
Patients with substance use disorders are often less aware of their emotions and hide their negative experiences from others. Subsequently, this is affecting their willingness to modify the current state of abuse. Moreover, lack of emotional recognition among these patients acts as a strong predictor and trigger for addictive behavior and persistence of it with no desire to change.

RECOMMENDATION:
Based on the findings of the present study, the following recommendations are suggested: -Evaluating levels of emotional awareness and self-concealment among patients with substance use disorders is crucial point to be done regularly to prepare effective strategies to deal with them.
-Improving realization of emotions and emotional management is an important part of the treatment of patients with substance use disorders. This can be achieved through different treatment programs directed at increasing emotional awareness.
-Strengthening motivation among patients with substance use disorders becomes a persistent need to enhance their readiness to change the addictive status and overcome their problem.
-Psychological counselling program with semi-structured groups based on expressive activities should be implemented with patients to help in learning expressive skills and decrease self-concealment.
-Promote patients' self-confidence and elevate their level of trust in themselves using numerous therapeutic interventions to increase their ability to deal effectively with substance abuse crises.
-Future study needs to be carried out to investigate other factors that might affect patients' readiness to change and mitigate these factors.

Conflicts of Interest:
-The authors proclaim that there are no conflicts of interest.