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.

Personal data sheet. Developed by the researchers; it includes (patient code, age, residence, level of education, marital status, and occupation).

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.

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.

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.

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.

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.

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.

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.