Title: Effectiveness of mental imagery for relapse prevention for recovering addicts
CITATION THUMBNAILS PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00102718/00001
 Material Information
Title: Effectiveness of mental imagery for relapse prevention for recovering addicts
Physical Description: Book
Language: English
Creator: Butkins, Peter A., 1945-
Copyright Date: 1994
 Record Information
Bibliographic ID: UF00102718
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: ltuf - AKL1495
oclc - 32886005

Full Text











EFFECTIVENESS OF MENTAL IMAGERY FOR
RELAPSE PREVENTION FOR RECOVERING ADDICTS












By

PETER A. BUTKINS


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1994

































Copyright 1994
by

Peter A. Butkins














DEDICATION

I dedicate this study to my mother, Rosemary, the

smartest woman I know; my sister, Tina; and my brother-in-

law, Hank, for their unconditional love, support, and

wisdom.














ACKNOWLEDGMENTS

Many patient, tolerent, and loyal persons are

responsible for the completion of this research. I thank

Dr. Larry Loesch for his expertise, guidance, and support.

His dedication to his profession, clear-thinking, and

willingness to lead have been an inspiration to me both

personally and professionally.

I wish to thank the other members of my supervisory

committee. Dr. Crocker has provided a great deal of

expertise and direction. Dr. Gonzalez has been instrumental

by adding an element of expertise and guidance in the area

of chemical dependence. Dr. Bollet has been a mentor and

inspiration even before this project was undertaken. I am

deeply grateful to all of the above.

Without the assistance of Eileen Atkinson, this study

would have been much more difficult. Pat Hill and Marie

Winslow added an element of support as well as clerical

work.

The facilitators, Mark Griffin, Larry Shyers, Virgil

Bryant, and Michael Ladwig, were generous in giving their

time, skills and professionalism.

I have special friends, Tom L., Bob D., Scott G., and

Scott D., and many others, who were there for me time after








time and helped me to learn and even prosper. I am grateful

to them for teaching me gratitude, my greatest gift.

Gratitude goes to AA for its help.

My family has always been there for me. I thank my

mother and father for their gifts of patience, intelligence,

a success identity, and love. Without them I would be

nothing. I thank my brothers and sisters who have helped to

shape me since I was a child. My nieces and nephews are

very special to me, and I am fortunate to have them. I am

grateful for all of the above and their support both before

and during this project.















TABLE OF CONTENTS

page

ACKNOWLEDGMENTS.................................... .... iv

ABSTRACT.... ........................................... viii

CHAPTERS

1 INTRODUCTION..................................... 1

Overview......................................... 2
Theoretical Framework of Relapse Prevention...... 8
Statement of the Problem......................... 13
Hypotheses....................................... 15
Definition of Terms................................ 19
Overview......................................... 21

2 REVIEW OF RELATED LITERATURE..................... 22

Support for the Need for the Study............... 25
Support for the Theoretical Framework............ 30
Support for the Approach to the Study............. 36

3 METHODOLOGY...................................... 57

Delineation of the Variables..................... 57
Population.. ...................................... 58
Sampling Procedures......... ... ................ 60
Measurement Instruments.......................... 63
Research Design.................................. 69
Treatment........................................ 70
Research Procedures.............................. 72
Research Participants............................ 76
Data Analyses..................................... 76

4 RESULTS.......................................... 78

Treatment History Information.................... 95
Followup......................................... 96

5 DISCUSSION....................................... 99

Limitations of the Study......................... 99
Conclusions...................................... 101









Discussion .......................................
Implications.....................................
Recommendations..................................

APPENDICES


A

B

C

D


G

H

I

J


RATIONALE FOR INTERVENTIONS ...................

BRIEF WORKSHOPS AND THEIR EFFECTIVENESS.......

ABSTINENCE LIKELIHOOD INVENTORY (ALI).........

ELEMENT (OR ITEM) REFERENCE SUPPORT FOR
THE ALI........................................

HELP-SEEKING LIKELIHOOD INVENTORY (HSLI)......

ELEMENT (OR ITEM) REFERENCE SUPPORT FOR
THE HSLI.......................................

DESCRIPTION OF TREATMENT......................

AGENDA..........................................

FOLLOWUP FORM .............. ..................

TREATMENT HISTORY FORM........................


REFERENCES ............................................

BIOGRAPHICAL SKETCH....................................


106
107
108



111

115

120


121

128


129

135

161

162

164

166

184


vii














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

EFFECTIVENESS OF MENTAL IMAGERY FOR
RELAPSE PREVENTION FOR RECOVERING ADDICTS

By

Peter A. Butkins

August, 1994


Chairperson: Larry C. Loesch
Major Department: Counselor Education

Relapse among recovering addicts is a common phenomenon

which counselors frequently encounter. Relapse-prevention

activities have not been tested that focused upon mental

imagery within a strong theoretical framework. Therefore,

the purposes of this study were to investigate (a) the

effectiveness of such an approach and (b) how selected

attributes related to treatment outcome variables.

A randomized, posttest only control group design was

used. Forty-nine persons in the experimental group provided

data and were tested immediately after participating in a

mental imagery relapse prevention workshop. Experimental

group members were contacted six weeks after the workshop to

assess their opinions of its effectiveness. The 36 control

group members provided personal data and were assessed prior

to participation in the workshop. Personal data collected

viii







included age, gender, race, drug of choice, number of 12-

step meetings attended, and length of time in recovery.

Outcome variables included level of self disclosure,

perception of unmanageability, help-seeking behavior, and

lifestyle behavior change.

Analyses of variance and multiple regression analyses

using weighted, linear combinations yielded few

statistically significant relationships or interactions

among the demographic, treatment, and outcome variables.

The major finding was that persons in the experimental group

significantly increased their abstinence likelihood (i.e.,

perception of unmanageability) following participation in

the workshop. At followup, a large majority of experimental

group participants reported that the workshop was a positive

and helpful experience.

It was concluded that the workshop generally was not

successful in effecting immediate changes. Therefore, it

was recommended that mental health counselors explore other

methods to attempt to quickly facilitate and enhance relapse

prevention. However, because feedback on the workshop was

positive, it also was recommended that variations in the

approach used in this study be explored.













CHAPTER 1

INTRODUCTION

F. Scott Fitzgerald complained that he could never get

sober long enough to tolerate sobriety (Goodwin, 1988),

suggesting that sobriety is not as easily attained as might

be thought. In American society, it is evident that the

problem of addiction includes not only alcohol but other

drugs as well. The various drugs available today are just

as cunning and lethal as Fitzgerald's drug of choice, yet

they affect the body and mind much more quickly. However,

for the purpose of this study, alcoholism and drug

dependency are encompassed under the general rubric

"chemical dependence" (CD). Talbott (1985) reported that

the phenomena involved in alcohol and drug dependence are

similar in that both have a set of symptoms including

withdrawal and tendency to relapse. He noted that the

standard definitions of alcoholism and drug addiction

include compulsive use while experiencing adverse

consequences. He continued, "In 1985 I hope we're not going

to worry about whether we are talking about cocaineism,

alcoholism, darvonism, quaaludism, fentanylism, valiumism or

libriumism. We're talking about the disease of chemical

dependence" (Talbott, 1985).








2
Researchers have found in numerous case studies that the

psychological cravings characterizing chemical dependence

can be satisfied by any mood-altering drug (Selby, 1985).

Millham and Mason (1987) concurred in writing, "We keep

coming back to the fact: Addiction is addiction is

addiction, no matter what chemical is being abused" (p. 6).

Counseling for substance addiction is usually viewed as

a difficult, often hopeless, clinical undertaking (Nace,

1987). Marlatt and Gordon (1985) added that it is a virtual

truism that addictive disorders are characterized by high

rates of relapse following initial treatment success. Thus,

many attest to the severity and depth of addiction, alluding

to the difficult problems in maintaining successful

abstinence. Because of the frequency of relapse, there

remains a need for effective approaches to preventive

treatment for recovering addicts.

Overview

Relapse (used here as synonymous with recidivism) is

defined as return to the compulsive use of drugs in the face

of adverse consequences (Talbott, 1985). Recidivism occurs

frequently among recovering persons; those who previously

"stopped" use of the addictive substance. Many vow to stop,

but make attempts to do so and fail--sometimes with tragic

results. For example, Ohlms (1981) reported that 96% of

alcoholics will die of their disease. The substance-abuse

(chemical-dependence) problem in general is at epidemic










levels in the United States. Talbott (1985) noted that the

great tragedy of the entire twentieth century in this

country is that it is moving deeper and deeper into an

addictive chemical culture. Chemical-dependence problems

dramatically affect industry, youth, addicts, families, and

counseling professionals among other groups. For example,

alcohol abuse ranks third behind only cancer and heart

disease in numbers afflicted. The casualty figures arising

from abuse of alcohol on the highways, in crime, in

hospitals, at the workplace, and in the family are

staggering. Alcohol problems alone are costing the American

society over $135 billion per year in medical expenses, time

lost from work, and treatment costs. Moreover, there is a

cost in human suffering that cannot be measured in dollars

(Jacobson, 1990).

American industry has had to make major philosophical

and operational changes because of employees' chemical-

dependence problems. For example, the problem is so serious

that the federal government has implemented several antidrug

rules that apply to private-sector employers. These rules

include the U.S. Department of Defense (DOD) policies, which

require that defense contractors implement antidrug programs

for employees in sensitive positions; the Drug-Free

Workplace Act of 1988, which requires federal government

contractors and employers receiving federal grants to

maintain a drug-free workplace; and the U.S. Department of









Transportation regulations, which apply to the various

transportation industries and call for, among other things,

mandatory drug testing (Harrison & Simpler, 1989). To

illustrate further, every employee with an alcohol or drug

problem costs each citizen at least 25% of his/her salary

each year in hidden expenses: absenteeism, mistakes, extra

medical premiums, and more (Jacobson, 1990). Watkins (1989)

reported that between 1% and 23% of all American workers use

dangerous drugs--including alcohol--on the job. Other

employees may be under the influence when they arrive at

work, or they may use alcohol and other drugs so extensively

outside the workplace that their health and judgment are

chronically impaired.

As many as 65% of young people entering the workforce

have used illegal drugs. Jones (1988) reported that over 3

million of 50 million Americans who drink are under age 17.

One in every five teenagers is experiencing, or has

experienced, problems with alcohol. Up to 24% of teens

nationwide reported alcohol abuse as being a "tremendous"

problem in their schools. Nine of 10 teenagers and young

adults have consumed alcohol at least once. Richmond and

Peeples (1984) noted that substance abuse has been

established as a part of the lives of many middle school-

aged children and is often quite extensive by adolescence.

Most people do not perceive addicts as being victims of

addiction, including addicts themselves--a problem that










affects addicts in insidious ways. For example, chemical

addiction is the third leading cause of suicide in the

United States (Heilman, 1980). However, many of these

deaths are disguised as "accidents." Kinney and Leaton

(1987) cited half of all successful suicides and 67% of

homicides as having involved the use of alcohol.

Many automobile-accident fatalities are the result of

substance abuse. Michael (1990) reported that (almost) one

out of every four drivers between the ages of 16 and 45 who

were killed in New York traffic accidents in recent years

tested positive for cocaine use. Experts on cocaine use

noted in the article that they were surprised by the large

proportion of drivers using cocaine. However, in traffic

fatalities in New York, as elsewhere, alcohol remains the

number one substance abused by drivers. It was found that

11% of men 15 through 34 years old who were drivers in fatal

accidents had tested positive for cocaine use. These data

were gathered before the cocaine epidemic "hit" the media.

As noted, a newer study found that 23% of victims between 16

and 45 tested positive for cocaine use. About one-half of

New York drivers who were killed had used alcohol, and about

half of those using cocaine also had used alcohol.

Jones (1988) stated that although there are 23 million

alcoholics in the U.S., over 90 million other people become

affected by their disease. For example, over 30 million of

those affected live in alcoholic homes or are closely










associated with alcoholic's children and/or adult children

of alcoholics. Wegscheider-Cruse (1987) also explained that

it is not just the abusers who suffer. Their problems

affect family members, friends, and business associates.

For example, cocaine is having devastating impacts on the

lives of a booming generation of babies born to addicted

women. The effects include stroke while babies are still in

the womb, physical malformation, and increased risk of death

during infancy. The number of repeated cases of cocaine-

exposed babies is growing explosively, doubling each year in

major cities. Recent estimates placed the figure in the

U.S. as high as 200,000 (Revkin, 1989). Also, fetal alcohol

syndrome is widespread and producing alarming damage to

infants.

Talbott (1985) has reported that, tragically, only 4%

of alcoholics have an opportunity to recover. To make

matters worse, many are "relapse prone." Gorski and Miller

(1982) noted that recidivists are among the most desperate

clients because they are caught in a trap of

misunderstandings. They fail to recover in spite of their

best efforts, and when the relapse takes its toll, they

blame themselves. When they seek renewed treatment, they

often feel the anger and misunderstanding of therapists;

professionals often blame them for relapsing. This

compounds the guilt and sense of helplessness, and

reinforces the tendency to relapse.










On a somewhat more positive note, Gorski (1986)

observed that approximately one-half of alcoholics who "come

to the door of sobriety" enter and stay. Of the remainder,

many stay for a time, have one or more relapses, then grasp

the sober life, and stay sober until death. Many others,

however, go through "the revolving door" over and over

again: drinking-sobriety, drinking-sobriety and so forth.

Kinney and Leaton (1987) wrote that reentry into

treatment after a relapse may be especially difficult for

the alcoholic who has attained substantial recovery. In

many cases, the family's involvement in the relapse syndrome

is strongly influenced by co-dependence. Co-dependence is a

primary condition that results from the debilitating

physiological stress produced by living with an alcoholic or

drug-dependent person. Co-dependent persons often develop

physical, psychological, behavioral, and asocial symptoms

resulting from attempts to adapt to and compensate for the

debilitating effects of physiological stress (Gorski &

Miller, 1983).

It is obvious that many problems confront the

counseling profession in attempts to help chemically-

dependent persons, not the least of which is that relapsed

addicts have great difficulty reentering treatment.

Embarrassment and guilt sometimes delay treatment, and may

even be used as reasons to avoid it if the addiction has

been reactivated strongly. Gorski and Miller (1982) noted










that many persons who have achieved degrees of abstinence

relapse in spite of their best efforts while skilled

treatment professionals stand by helplessly because

traditional approaches to counseling and treatment do not

work. Trubo (1989) noted that, "Despite the proliferation

of treatment centers and the millions spent on chemical-

dependency research, professionals in the field still can't

agree on the best therapy for alcoholism" (p. 56).

Therefore, there is clearly need for specialized relapse-

prevention treatments.

Theoretical Framework of Relapse Prevention

Any theory of relapse prevention must develop from a

theory of addiction. That is, in order to understand the

process of relapse, it is necessary to know the condition to

which the addict is relapsing. This section includes an

overview of these two phenomena as well as an overview of

the theories underlying the interventions to be used in this

study: relaxation, mental imagery, and cognitive behavioral

restructuring.

The biopsychosocial model, which is emerging from the

area of behavioral medicine, provides a heuristic framework

within which to understand and assess addictive behaviors

(Donovan, 1988). Gorski and Miller (1986) defined addiction

as a condition in which a person develops biopsychosocial

dependence on any mood-altering substance. This means that

it is a physical disease (bio) that also affects a person










psychologically and intellectually (psycho) and in

relationships (social). In brief, all life areas are

affected.

Both biological and nonbiological factors are

ingredients of addiction (Mueller & Ketcham, 1987). Such a

model provides a metatheoretical framework in which the

factors interact to determine a health status, which

includes obsession, compulsion, and loss of control and is

primary, chronic, progressive, and fatal (Ohlms, 1981).

There are also predictable stages of addiction with

accompanying symptoms: early, middle, and chronic. The

first stage is marked by a growing tolerance for dependence

on the substance; larger and larger quantities are used

without intoxication and/or harmful consequences. Symptoms

are subtle, and diagnosis is difficult in this stage. The

middle stage is marked by progressive loss of control. The

addict is no longer able to use the same quantities without

intoxication or adverse consequences. Pain develops as

problems proliferate. The chronic stage of addiction is

marked by physical, psychological, behavioral, social, and

spiritual deterioration. All body systems can be, and

usually are, affected. Loss of control becomes obvious to

the addict and to others.

The recovery process develops through task-oriented

stages (Marlatt, 1985). The first involves the using stage

and is marked by recognition of the addiction. The second








10
is the treatment decision stage and is marked by a conscious

choice to seek help. The third stage is maintenance, marked

by a quest for balanced living to achieve healthy

biopsychosocial goals.

Gorski and Miller (1982) listed six recovery periods

(developmental in nature) along with the goals for each.

The first is pretreatment in which the goal is recognition

of addiction. The second is stabilization, to achieve

withdrawal and crisis management. The third period is early

recovery and the goal therein is acceptance and nonchemical

coping. The fourth is middle recovery in which the goal is

balanced living. The fifth is late recovery, including the

goal of personality change. The sixth period is

maintenance, in which the goal is (further healthy) growth

and development.

The process of relapse involves becoming dysfunctional

in non-dependency. This can occur in any of Gorski and

Miller's stages and in physical, psychological, or social

health. Similar to the recovery process, it is

developmental in nature, not an isolated event. Using the

mood-altering chemical medicatess" the dysfunction. Relapse

prevention therefore is implementation of interventions to

interrupt the potential, always impending, relapse process.

A recovering addict is likely to face a multitude of

problems (Kinney & Leaton, 1987). One is a high level of

stress, either temporary or chronic, for which the person








11
has low tolerance. Many alcoholics, for example, have used

alcohol for the temporary but "quick" relief of anxiety.

What is remembered (and longed for!) in sobriety is the

almost instant relief of an intoxicant. When alcohol or

drugs are no longer an option, the alcoholic has quite a

problem: how to cope with stress. Some things can be done

to alleviate this stress. One is relaxation therapy, based

primarily on the assumption that when the body and breathing

are relaxed, it is difficult to feel anxious. The mind

rejects the paradox of a relaxed body and a "tense" mind.

Another technique often used is imagery. Witmer and

Young (1985), for example, proffered use of visual imagery

as an intervention which helps to reduce stress and also to

overcome negative emotions. Pleasant mental images are used

to evoke a relaxation response. Mental imagery, therefore,

is the mental representation of a sensory--or perceptual-

like--experience that occurs in the absence of the stimulus

that would produce the genuine experience (Richardson,

1969). These images may be made to occur in any sense

modality.

Sheikh and Jordon (1983) summarized a rationale for

clinical use of imagery as a tool for therapeutic

intervention. They reported that invoking mental images

tends to bypass unconscious defenses and inhibitions. They

further suggested that imagery has the power to produce a

variety of physiological changes. Lazarus (1977) noted that










imagery may be the only practical way to develop control

over the autonomic nervous system, indicating that goals and

solutions rehearsed through imagery during therapy seem to

apply outside the therapy session and are a motivation for

future behavior. Finally, rational-emotive imagery changes

"inappropriate" emotions to "appropriate" ones (Ellis &

Dryden, 1987). Clinical research data support the

contention that rehearsals of fantasy material through

imagery produce cognitive restructuring (Beck, 1970).

Behavioral therapies, as part of treatment programs for

substance abuse, have gained clinical favor in recent years

(Spitz & Spitz, 1987).

The basic assumption underlying cognitive-behavioral

treatment is that maladaptive behaviors and feelings are

mediated by distorted or maladaptive thinking and that

clinical intervention should be used to alter cognitive

processes (Garner & Bemis, 1985). Behavior therapy

proponents advocate its use primarily as a method of symptom

control with substance abusers. According to Spitz and

Spitz (1987), the initial goal of behavioral therapies is to

achieve abstinence rapidly. Treatment then focuses upon

assessment of the stimuli that contribute to perpetuation of

the substance abuse habit and upon alteration, interruption,

or creation of (new) behaviors to replace dysfunctional

ones. Notably, cognitive components are a major part of the

method. Behavior rehearsal, cognitive restructuring, and









the creation of alternative behaviors other than drug

ingestion are cardinal components of behavioral approaches.

Correcting cognitive distortions, or "mind traps," that

generate maladaptive feelings and behaviors is an essential

part of relapse prevention (Washton, 1989). Marlatt (1985)

reported that cognitive restructuring has as its principal

aim the countering of cognitive and affective components of

the Abstinence Violation Effect (AVE). Annis and Davis

(1988) also noted that cognitive appraisals can be effected

at any point in the relapse process. Specific distortions

in thinking and defensive tactics may inhibit more general

coping patterns. Finally, Yalom (1985) reported that

cognitive restructuring is necessary for the client to be

able to generalize counseling experiences to other life

arenas.

Statement of the Problem

A major problem to be addressed in this study is that

the effectiveness of mental-imagery training intended to

prevent relapse is unknown. Another significant concern is

that it is unknown whether the effectiveness of mental-

imagery training varies as a function of demographic

factors, as well as factors particular to addiction. The

demographic variables to be investigated include gender,

race, age, and level of education. The addiction-related

variables include length of recovery, drug of choice, and








14
number of weekly 12-step meetings because these factors may

influence treatment effectiveness.

The specific dependent variables used in this study

include (a) self disclosure, (b) help-seeking behavior, (c)

perception of unmanageability, and (d) lifestyle behavior

change.

Giddan and Rollin (1975), Gorski (1989) and Spitz and

Spitz (1987) suggested that cognitive-behavioral

interventions are legitimate strategies to pursue in

chemical-dependence relapse-prevention treatment.

Similarly, Marlatt and Gordon (1985), Sheikh (1989), and

Siegel (1986) all suggested that mental-imagery

interventions are legitimate strategies to pursue in

chemical-dependence relapse-prevention treatment.

Relatedly, Gorski and Miller (1982), Kinney and Leaton

(1987), and Knudson (1987) suggested that relaxation

interventions are legitimate strategies to pursue in

chemical-dependence relapse-prevention treatment.

Therefore, there is good basis for the suggestion that this

direction has potential for success.

Particularly needed are brief interventions. Long-term

interventions are not practical and have not been found to

be more effective. Also, Shorkey and Whiteman (1977),

LaVecchia (1981), Crowley (1982), Brantlinger (1983), and

Gillis (1986), among others, conducted studies which

produced effective results using brief interventions










(Appendix B). Therefore, it is reasonable and appropriate

to use a brief intervention in this study.

The measurements (i.e., surveys) to be used in this

study have been shown to be valid and reliable. They

include the Abstinence Likelihood Inventory (ALI), Help-

Seeking Likelihood Inventory (HSLI), Jourard Self-Disclosure

Questionnaire (JSDQ), and the Health Attribution Test (HAT).

Their use is more exact than other forms of measurement,

e.g., observation or interviews (Kerlinger, 1973). In

addition, their use is cost effective and less time

consuming than the alternatives. Therefore, this method is

efficient.

The major disadvantage of this type of measurement lies

in its lack of flexibility. Areas of investigation are

limited to questions on the instruments. However, although

behavioral observations and/or interviews might allow for

more extensive investigation of respondents' opinions, the

advantages of surveys outweigh the disadvantages when cost,

time, and efficiency are considered.

Hypotheses

It is apparent in the research literature that

chemical-dependence relapse varies as functions of many

variables, both demographic and substance-abuse related.

The variables included in this study have not been

empirically investigated previously in this context and

therefore little is known about their interactions with








16

relapse. Accordingly, hypotheses addressed were as follows:

1. There is no significant relationship between ALI and

a weighted, linear combination of demographic

variables (gender, race, age, and education).

2. There is no significant relationship between ALI and

a weighted, linear combination of demographic

variables, treatment, and the interactions of

treatment with these demographic variables.

3. There is no significant relationship between ALI and

a weighted, linear combination of substance-abuse

variables (drug of choice, number of weekly 12-step

meetings, and months of recovery).

4. There is no significant relationship between ALI and

a weighted, linear combination of substance-abuse

variables, treatment, and the interactions of

treatment with these substance-abuse variables.

5. There is no significant relationship between ALI and

a weighted, linear combination of treatment,

selected demographic variables, selected substance-

abuse variables, and interactions of treatment with

the selected variables.

6. There is no significant relationship between HSLI

and a weighted, linear combination of demographic

variables (gender, race, age, and education).

7. There is no significant relationship between HSLI

and a weighted, linear combination of demographic










variables, treatment, and the interactions of

treatment with these demographic variables.

8. There is no significant relationship between HSLI

and a weighted, linear combination of substance-

abuse variables (drug of choice, number of weekly

12-step meetings, and months of recovery).

9. There is no significant relationship between HSLI

and a weighted, linear combination of substance-

abuse variables, treatment, and the interactions of

treatment with these substance-abuse variables.

10. There is no significant relationship between HSLI

and a weighted, linear combination of treatment,

selected demographic variables, selected substance-

abuse variables, and interactions of treatment with

the selected variables.

11. There is no significant relationship between JSDQ

and a weighted, linear combination of demographic

variables (gender, race, age, and education).

12. There is no significant relationship between JSDQ

and a weighted, linear combination of demographic

variables, treatment, and the interactions of

treatment with these demographic variables.

13. There is no significant relationship between JSDQ

and a weighted, linear combination of substance-

abuse variables (drug of choice, number of weekly

12-step meetings, and months of recovery).










14. There is no significant relationship between JSDQ

and a weighted, linear combination of substance-

abuse variables, treatment, and the interactions of

treatment with these substance-abuse variables.

15. There is no significant relationship between JSDQ

and a weighted, linear combination of treatment,

selected demographic variables, selected substance-

abuse variables, and interactions of treatment with

the selected variables.

16. There is no significant relationship between HAT

and a weighted, linear combination of demographic

variables (gender, race, age, and education).

17. There is no significant relationship between HAT and

a weighted, linear combination of demographic

variables, treatment, and the interactions of

treatment with these demographic variables.

18. There is no significant relationship between HAT and

a weighted, linear combination of substance-abuse

variables (drug of choice, number of weekly 12-step

meetings, and months of recovery).

19. There is no significant relationship between HAT and

a weighted, linear combination of substance-abuse

variables, treatment, and the interactions of

treatment with these substance-abuse variables.

20. There is no significant relationship between HAT and

a weighted, linear combination of treatment,








19
selected demographic variables, selected substance-

abuse variables, and interactions of treatment with

the selected variables.

Definitions of Terms

The following definitions are used in this study:

Abstinence is a condition in which there is no chemical

dependence (i.e., use) at all (Milam & Ketcham, 1981).

Addiction is a phenomenon characterized by tolerance

changes for, physical dependence on, and loss of control

over use of a drug (Mueller & Ketchman, 1987).

Alcoholism is a primary, progressive, chronic, often

fatal disease which is characterized by a physical

compulsion, obsessive thinking, and loss of control

(Ohlms, 1981).

Chemical dependence is a generic term which encompasses

alcoholism and drug-dependence characteristics and is

synonymous with either for purposes of this study.

Cognitive behaviorism is a theory which is recommended

in the treatment of chemical dependence and mediates

distorted thinking (Garner & Bemis, 1985).

Gender is self-designation as male or female by the

respondent.

Help-seeking behavior is the score on the Help-Seeking

Likelihood Inventory.

Length of education is self-reported as the last grade

completed in number of years of schooling.








20
Length of recovery is defined by the respondent as the

number of months abstinent from chemical (drug) use.

Lifestyle behavior change is defined as the score on

the Health Attribution Test.

Mental imagery is the mental representation of a

sensory or perceptual-like experience that occurs in the

absence of the stimulus that would produce the genuine

experience (Richardson, 1969).

Powerlessness is defined as a score on the Help-Seeking

Likelihood Inventory.

Progressive relaxation therapy is the reduction of

physiological tension so as to be incompatible with anxiety

(Jacobson, 1929).

Race/ethnicity is defined through self-designation as

Caucasian, Black, or Hispanic American by the respondent.

Relapse is a movement away from recovery which ends in

a return to abuse of a mood-altering chemical after a

period of abstinence (Gorski & Miller, 1986).

Self Disclosure is the score on the Jourard Self-

Disclosure Questionnaire.

12-step meetings are closed meetings of Alcoholics

Anonymous or Narcotics Anonymous.

Unmanageability is the score on the Abstinence

Likelihood Inventory.








21

Overview

Presented in Chapter 1 was the introduction to the

study. The review of the literature is presented in Chapter

2. The methodology of the study, including procedures and

statistical methods, are covered in Chapter 3. Presented in

Chapters 4 and 5, respectively, are the results and

discussion of the study.














CHAPTER 2

REVIEW OF RELATED LITERATURE

People of the United States suffer from tragic

ramifications of chemical-dependence problems (Talbott,

1985). According to Lewis, Dana, and Blevins (1988), drug

use and abuse is a mass phenomenon in the United States: 32

million Americans smoke marijuana at least once a year; 20

million smoke it at least once a month; annual cocaine

abusers number over 12 million; and several million others

take hallucinogens, stimulants, sedatives, and tranquilizers

without medical supervision. And of course these figures

are dwarfed by the number of people who use "legal drugs,"

including alcoholic beverages (125 million) and tobacco

products (70 million) (Polich, Ellickson, Reuter, & Kahan,

1984).

Dr. Padraic Sweeny, Vice Chief of Emergency Services for

Detroit Receiving Hospital, is but one reporting rapidly

increasing drug-related shootings, stabbings, and assaults

(Shannon, 1990). Relatedly, police make drug arrests in Los

Angeles at a rate of 60,000 per year. It is readily evident

beyond these examples that there would be far less drug-

related crime if jails, courts, and parole systems were not

already strained to the breaking point. Thus, despite the








23

passage of stringent antidrug laws and police efforts, drug-

related crime continues to surge. For example, the nation's

violent-crime rate rose 10% in the first six months of 1990.

Murders were up 8% in the same six months and armed robbery

rose 9%. Drug-related crime is perhaps the most obvious

ramification of chemical-dependence problems in the United

States.

Cocaine has become one of the most debilitating

chemicals in history. Its epidemic use started among the

upper middle class in the mid-1970s. Recently, "dealers"

have touted a Caribbean import called crack (or rock) that

sells for $10.00 or $20.00 a vial, compared to $50.00 to

$100.00 for a gram of cocaine powder (Shannon, 1990). The

result has been widespread use of cocaine even among the

poor.

To date, the antidrug offensive's main accomplishment

has been to dissuade some experimenters and "weekend users"

from increasing their dependencies. Unfortunately, however,

the effort has not reached the millions of people so bereft

of hope that they are willing to risk everything they have,

or will have, for a few moments of psychological oblivion.

Alcoholism is perhaps still the most insidious offender.

Lewis et al. (1988) noted that the use, misuse, and abuse of

alcohol is one of the major health problems in the United

States and is the third most prevalent public health

problem. But the problems associated with alcohol abuse are










not limited to health problems because alcoholic behavior

also leads to familial, social, vocational, and legal

problems. Patterns of alcohol abuse also contribute to

health impairment, vehicular and pedestrian accidents,

criminal behavior, destructive social behavior, and other

adverse consequences. Therefore, alcohol-related problems

are not limited to the alcoholics themselves. Literally

everyone encounters the ramifications of use, misuse, and

abuse of alcohol in daily life (Pattison & Kaufman, 1982).

The financial costs of the chemical-dependence epidemic

also are staggering. Jacobson (1990) reported that alcohol

dependence alone costs the federal government about $25

billion a year. Overall, chemical dependence costs the

nation an estimated $135 billion a year in medical expenses,

time lost from work, treatment costs, and the like, yet

state and federal governments combined collect only $12

billion in excise taxes to support remediation programs.

Unfortunately, the massive public health effects of

alcohol consumption in the United States are just beginning

to be understood. Many Americans are shocked to learn that

the economic costs associated with alcohol-related problems

are even greater than those associated with problems due to

cigarette smoking, cancer, or heart disease. One reason is

that smoking-related diseases, e.g., cancer and heart

disease, generally affect middle-aged or older people, but

alcohol-related problems affect people of all ages. These









(and other forms of chemical dependence) are particularly

prominent among children and youth. The earlier the age of

onset, the longer the need for treatments and the greater

the dispersion of negative effects; phenomena which greatly

increase costs.

Support for the Need for the Study

An inherent problem in the chemical-dependence field

centers around differences among professionals regarding

legitimate treatment theory, models of treatment, and

strategies and tasks/goals of therapy, all of which

complicate treatment. Milam and Ketcham (1981) reported

that thousands of alcoholics are seen every year by

professionals--psychiatrists, psychologists, social workers,

clergy, counselors, nurses, and doctors -- yet, tragically,

they are almost always misdiagnosed and often harmfully

treated. For example, Rogers and McMillin (1989) speculated

that they have seen practically every form of group yet

devised being used to treat alcoholism at some facility in

America. It may not be "coincidental" that about two-thirds

of all relapses occur within the first 90 days following

treatment (Marlatt & Gordon, 1985).

Three different schools of thought seem to dominate

current directions in chemical-dependence treatment. One

espouses that relapse need not be an either/or situation

(Donovan, 1988; Marlatt & Gordon, 1985). Thus, the goal of

treatment is not necessarily abstinence, but rather








26

improvement in drinking behavior. Another theory focuses on

the absence of psychotherapy in early recovery due to

neurological deficits, addictive instability, and the

primacy of the need to focus on relapse prevention (Bean,

1984; Crewe, 1986; Flores, 1988). A third model would treat

the character disorder along the road to recovery from

addiction (Ellis & Dryden, 1987; Khantzian, Halliday, &

McAuliffe, 1990). This approach is psychodynamically

oriented.

A review of the family therapy for alcoholics literature

indicates that clinicians are experimenting with at least

three additional approaches to involvement of family members

in the treatment process. These are conjoint family therapy

(Esser, 1968, 1971; Meeks & Kelly, 1970), multiple couple

therapy (Cadogan, 1973; Gallant, Rich, Bey, & Terranova,

1970; Steinglass, Davis, & Berensen, 1977) and conjoint

hospitalization (McCrady, Paolino, Longabaugh, & Rossi,

1979; Steinglass et al., 1977). However, careful reading of

this literature still supports the view that family systems

approaches to alcoholism treatment have yet to mature fully

(Steinglass et al., 1977).

There is also consensus in the literature that

chemical-dependence problems among American workers have

risen significantly in the past decade (Dickman & Emener,

1982; Gerstein & Bayer, 1988; Michael, 1990). Investigators

have suggested that 10% to 18% of those employed experience








27

such difficulties (Masi, 1984; Watkins, 1989). As a result,

employees have begun to exhibit dysfunctional work behaviors

which have become more and more prevalent and noticeable.

Bell (1988) also noted the severity of chemical

dependence in the workplace and emphasized the high

incidence of absenteeism and sick days taken, two variables

not often recognized as symptoms of chemical dependence.

Employees affected by chemical-dependence problems exhibit

myriad dysfunctional work behaviors such as absenteeism, "on

the job" absenteeism and high accident rates. They

therefore have more insurance claims, spasmodic work

patterns, difficulty in concentration, confusion, lack of

task tenacity, coming to/returning to work in an obviously

abnormal condition, generally lowered job efficiency, poor

employee relations, misconduct, and poor supervisory

relationships. Each of these behaviors usually results in

significant personal and organizational costs (Management

Writes, 1989). Chemical dependence has escalated to a major

economic problem in the United States (Gold, 1988). Today,

employee alcohol and drug use cost business and industry

over $100 billion per year (Desmond, 1987).

In the handbook, What Works: Schools Without Drugs,

former Secretary of Education, William J. Bennett (1986)

stated that, "In America today, the most serious threat to

the health and well-being of children is drug use" (p. v).

California Attorney General, John Van De Kemp (1986)








28
explained that "It is a sad and sobering reality that trying

drugs is the norm, not the exception among high school

students" (p. iv). Other researchers and treatment

providers concur that the problem of chemical dependence

among youth has reached pandemic proportions (e.g., Gold,

1988; Guydish, 1982; Jones, 1988; Richmond & Peeples, 1984).

Guydish (1982) suggested that one in every six adolescents

had a problem with addiction. Nowinski (1990) reported that

for the past decade, therapists have seen a marked increase

in the number of youths to be treated for chemical

dependence and/or increased severity of symptoms.

Gonzalez (1990) stated that alcohol abuse has long been

recognized as a leading threat to the academic, social, and

physical well-being of college students. Colleges have been

confronting problem drinking by providing education and

rehabilitation programs, alternatives to the campus "bar

scene," and stricter regulation of on-campus parties. For

example, Rutgers University set aside dorm rooms for

recovering student alcoholics. However, Robert Hochstein,

spokesman for the Carnegie Foundation for the Advancement of

Teaching, issued a report saying that colleges are

(generally) sidestepping the problem of chemical dependence

(Rabinowitz, 1991).

A common phenomenon characteristic of chemical

dependence is recidivism. The danger of relapse is ever

present in a chronic, addictive disorder (Johnson, 1980),








29
and the results of relapse are often tragic. Unfortunately,

accurate relapse figures are difficult to obtain. In

addition, there are few relapse studies covering any

appreciable period of time (Weisman & Robe, 1983).

Relapsers disappear not only from records, but also from

sight. They are often lost in "geographic cures" (i.e.,

changing locales and hoping the problem will disappear),

with no way for researchers to know whether disappearance

was followed by relapse, recovery, or premature death.

Thus, relapse-treatment approaches are difficult to develop.

However, a classic survey of nearly 25,000 members in

Alcoholics Anonymous revealed that relapse occurred in

almost 60% of those who had been sober for only one year.

Reentry into recovery is difficult after relapse (Kinney

& Leaton, 1987). Schrenck (1990) reported that it is much

worse "the second time around" because the progression of

adverse consequences occurs faster. Long-term followup data

suggested that more than 90% of those who leave treatment

will drink or use again at some time in the future (Heltzer,

Robins, Taylor, Carey, Miller, Combs-Orme, & Farmer, 1985;

Polich, Armor, & Braiker, 1981). Gorski (1989) reported

that many chemically-dependent persons relapse many times

before finding sobriety or freedom from addiction. Even

they are fortunate, however. Others give up in despair and

eventually die from their disease.








30
Within the context of the disease process, addiction is

often referred to as a "chronically-relapsing" condition

(Marlatt & Gordon, 1985). Relapse is always a possibility

within chronic diseases, even after years of good health.

Mueller and Ketcham (1987) stated that chemically-dependent

persons are not safe from relapse even after 10, 15, or 20

years of sobriety, unless they continue to use the tools

acquired in treatment. Previous treatment is an important

component in this study. The participants all have been

involved in a form of treatment, whether AA, NA, or

inpatient or outpatient care.

The problem of recidivism in chemical-dependence

treatment leads to the need to provide effective relapse-

prevention approaches. Desmond (1987) suggested that

addicts know how to get sober, but the problem lies in

keeping them in that state. Relapse prevention is the

latest attempt to help reduce the number of recovering

persons who return to using.

Support for the Theoretical Framework

No one argues any longer with the fact that alcoholism

is a disease (Chopra, 1987). The American Psychiatric

Association (1975) defined alcoholism as a "chronic disease

manifested by repeated drinking that produces injury to the

drinker's health or to his social or economic functioning"

(p.13). The term "suffer" and the concept of disease imply

that the alcoholic is a victim of his/her demise.








31

Johnson (1980) agreed that these defenses are not self-

imposed but occur as the disease progresses. Ohlms (1981)

added that the disease has a specific set of defenses along

with progressively escalating symptoms. One of the chief

defenses which prohibits recognition of the problem is

denial. Thus, alcoholics can't "see" what is happening to

them. The reason for this is understandable. Johnson

(1980) elaborated that, as their condition develops, the

self-image continues to deteriorate and ego strength ebbs.

For many reasons, alcoholics are progressively unable to

keep track of their own behavior and begin to lose contact

with emotions. Their defense systems continue to grow so

that they can survive in the face of their problems. The

greater the pain, the higher and more rigid the defenses

become. This process is entirely unconscious.

Relapse is often a family concern. The family becomes

afraid to upset the person and thus becomes victimized by

the chemical-dependency system (Empry, 1990). These fears,

coupled with a tendency to support the chemical-dependent

behavior, lead many chemically-dependent persons back to

"using." This irony is supported by families at their own

expense. Relatedly, Fish (1991) indicated that much of the

responsibility for chemical-dependence problems often rests

with parents who are drug users.

Chemical-dependence treatment is greatly affected by the

lack of a sound theoretical base. There are many different










models of addiction, but little consistent thinking as to

the most effective approach (Lewis et al., 1988). Within

some models it is difficult to address the issues of relapse

and relapse prevention. For example, the moral model of

addiction holds the addict solely responsible for the

relapse. This approach prohibits identification of relapse

triggers.

Relatedly, chemical-dependence treatment is difficult at

best because of the complicated nature of the problem.

Denial and repression hinder acceptance of the reality of

the situation; the chemically-dependent person usually goes

back to the same environment. This exposes him/her to the

very "cues" which preceded use (Donovan & Marlatt, 1988).

The environment can be the job, school, neighborhood,

friends, spouse, or family. Complicating all this is the

fact that many community role models are drug dealers and

their role suggests (particularly financial) success,

especially to teens (Fish, 1991). Further, the enticement

of "easy money" makes it difficult for many users to avoid

the drug culture. These complications have led experts to

believe that success often depends on the individualized

characteristics of the client rather than the treatment

(Desmond, 1987).

The results of many studies (e.g., Hosie, West & Mackey,

1988; Richardson & Bradley, 1985) indicated that counselors

are now established in the substance-abuse field. For








33

example, Hershenson and Power (1987) reported a substantial

increase in community counseling centers specializing in the

treatment of substance abuse. With this service comes a

variety of problems for counselors. For example, although

counselor education departments have acknowledged this

specialization and counselor educators have been developing

courses since 1980 to train counselors in chemical

dependence (Hollis & Wantz, 1986), there are still confusing

treatment guidelines and high counselor burnout to name only

two apparent problems.

The problem of treatment effectiveness also exists in

the area of counselor education. Gonzalez (1990) noted that

the efficacy of alcohol and other drug education to reduce

the problems related to chemical dependence is questionable.

Other studies (e.g., Mauss, Hopkins, Weisheit, & Kearney,

1988) assessed the relative contribution that traditional

variables such as self-esteem, attitude, and decision-making

skills have made to drinking behavior. Suggested is that

such variables make only a small contribution compared to

other social and psychosocial variables not amenable to

intervention. Therefore, researchers have expressed doubt

that even a highly successful classroom intervention

directed at traditional variables would do much to prevent

alcohol use or abuse by youths.

Krestan (1989) found it necessary to provide a direction

for counselors. She has admonished family (and other)








34
therapists to relinquish attempts to be totally in charge of

treatment and/or all phases of treatment. She delineated

different roles at different stages. Before sobriety, the

family therapist should unbalance the system sufficiently

for the family to enter chemical-dependence treatment. In

early recovery, the family therapist should work to

stabilize the family system around family members'

participation in chemical-dependence treatment and self-help

programs. The role in long-term recovery is more central,

to establish resonance in the family in ways that are

functional and satisfying for all family members.

Misinformation and/or misdiagnosis is a major problem

which leads to proliferation of chemical dependence.

According to Aitchison (1990), in Alcoholism Briefs

Newsletter (in "New York Intervention Program Helps Identify

850 Problem Drinkers") a minimum of 25% of all hospitalized

patients reportedly have a significant alcohol problem,

regardless of the admitting diagnosis. Misinformation comes

in many different forms. Alcohol often mimics other

diseases, including gastrointestinitis, colitis, depression,

and stress-related illnesses. It often is the cause of

stroke and heart attacks. It also is easy to confuse with

certain psychological diagnoses such as conduct disorders,

depression, and personality disorders.

The issue of prescribing medication to recovering

addicts is controversial. One school of thought contends










that mood-altering chemicals block the process of

development needed to grow; another suggests that there are

certain problems in recovery that warrant medication. For

example, a frequent problem centers around the treatment of

depression. Many medical doctors, including psychiatrists

especially in hospital inpatient settings, medicate addicts

for this problem. Talbott (1985) claimed that because

alcohol is a depressant, depression in early recovery is

normal and may dissipate with abstinence. This phenomenon

leads to much stress for counselors who view indiscriminate

medication as anathema, yet have to witness it frequently.

There is a problem in the misreporting of CD treatment

success. In many followup studies that include longitudinal

assessments researchers report findings as cross-sectional

or "dipstick" assessments. This type of assessment involves

reporting the percentage of clients in continuous reports

who have previously relapsed since the beginning of their

treatment. This fails to take into account a participant's

status at the previous followup. Consequently, programs

report much higher rates of treatment success, making

treatment seem more effective. In addition, limitations in

relapse assessment are due to the fact that followup studies

include only participants who have completed treatment and

eliminate those who began but did not complete treatment.

This also inflates claims of success. Third, followup

periods are often too short and thus provide little










information about long-term relapse rates (Curry, Marlatt,

Peterson, & Lutton, 1988).

Finally, a problem exists with corporate advertising for

chemical-dependency treatment. Many of the ads "promise" a

cure. This is misinformation and sets the expectation that

treatment insures success whereas the truth is that

treatment is the beginning.

Support for the Approach to the Study

Gorski (1989) stated that chemical dependence is a

condition that creates long-term pain in return for short-

term gratification. It is an addiction accompanied by

obsession, compulsion, and loss of control. In the end

stages of addiction, the addict thinks about, plans, and

looks forward to using when abstinent. This is obsession;

there is an overwhelming urge to use again in spite of long-

term consequences. This is compulsion; this is addiction.

The person uses the drug to relieve the pain caused by the

drug (Johnson, 1980). Loss of control is obvious. It

affects and is affected by all areas of an addict's life.

The loss of control causes physical, psychological, and

social problems; the total person is affected. Accordingly,

Vaillant (1983) recommended a flexible, multimodel approach

to chemical-dependence treatment. The available research

data demonstrate the existence of multiple syndromes of

chemical-dependent use ( Ellis, McInerney, DiGuiseppe, &

Yeager, 1988; Gallant, 1987), a condition called bio-psycho-








37

social dependence (Gorski & Miller, 1986). The contribution

of each variable to the total clinical picture is presented

as follows. Milam theorized, in the book Don't help: A

positive guide to working with the Alcoholic (as cited in

Roger & McMillin, 1989), that the biological aspect of

addiction is the basis for the disease model. He provided

the reasons which explain the phenomenal growth of this

belief. One is that the disease model has the virtue of

simplicity. Recovery becomes less complicated because it is

understood that the problem stems from a disease that

affects ability to use rather than a complex problem

requiring the chemically-dependent person to root about in

the psyche for supposed causes. Another is that chemically-

dependent persons find much relief in the discovery that

they are not weak-willed, emotionally-inadequate, or

morally-defective persons. This realization relieves guilt

but bestows upon the person a personal responsibility to

recover. It eliminates outside blame for the problem. A

third is that the disease model can inspire the person to

change instead of depending on a therapist to "fix" the

problem. Abstinence is required and motivation needs to

come from within to ensure success. Finally, this model

provides a structure for treatment. The chemically-

dependent person can now be given practical and

understandable directions for recovery based on "proven"

experience.










Many researchers attest to the psychological component

of addiction as being both a trigger and a result of

addiction (Ellis et al., 1988; Marlatt & Gordon, 1985). In

a prospective study (n=38) using the Minnesota Multiphasic

Personality Inventory (MMPI) as a pre-and posttest

measurement, Vaillant (1983) reported that preatomic testing

suggested normal limits. However, when the subjects were

later hospitalized for alcoholism, the scores were

significantly elevated on the depression, psychosomatic

deviancy, and paranoia scales -- to pathologic levels.

Although it is widely believed that chemicals provide relief

from stresses in early stages of use, there is much evidence

to support the belief that severe psychological problems

manifest after the "line to addiction" is crossed.

Ellis et al. (1988) stated that the present review of

etymological factors in the development of alcoholism

suggested that chemically-dependent persons are not

necessarily premonitory different from nonaddicts in

personality traits such as dependence or their psychological

adjustments as children. Rogers and McMillen (1989) agreed

that psychological, social, and spiritual disasters of

chemical dependence can only be fully understood as

distortions and exaggerations of otherwise normal problems.

Bean and Zinberg (1981) concurred that alcoholism takes its

biological and psychological toll upon the personality. In

relatively healthy populations, alcohol abuse may be more










analogous to any intractable habit (such as smoking or

fingernail biting) than to mental illness. Such habits may

develop independently of preexisting psychological

vulnerability. This is not to say that addicts are not in

need of psychological treatment. Indeed, many are "adult

children of alcoholics" (ACOAs) and have family of origin

issues at all ranges of the spectrum from severe torture to

mild neglect. However, primary treatment for addiction

should focus on a period of detoxification to allow for drug

and alcohol-induced symptoms to subside. Accurate diagnosis

of secondary problems is difficult in early recovery because

symptoms often dissipate during the stabilization period.

Therefore, the issue of "timing" is vital in chemical-

dependence treatment--and in relapse prevention.

Because chemically-dependent persons often perceive

addiction as accusation rather than diagnosis, they

constantly reinterpret their symptoms, offering alternative

explanations which lead to conflict with and isolation from

others. For example, many addicts mistakenly blame their

wives and children for their problems. They defend their

position by "projecting" their problems onto others

(Johnson, 1980).

Recovery should include strategies designed to address

the social aspects of addiction. Techniques have been

developed for families and other supporters to help the










client to maintain abstinence and improve the quality of

relationships (McCrady, et al., 1985).

In summary, the biopsychosocial view of addiction

implies multiple casualty, involvement of multiple systems,

and multiple levels of analysis (Donovan & Chaney, 1985;

Maisto & McCollam, 1980; Marlatt & Donovan, 1981). This

model thus addresses the complex nature of addiction and can

be used to understand the various stages of addiction.

Clinicians have stressed the importance of viewing

growth as a developmental process (Erickson, 1959; Gazda,

1982; Mahler, Pine, & Bergman, 1975). It is especially

necessary for recovery from chemical dependence. Addicts do

not recover immediately. A developmental model consists of

stage specific steps or tasks (Brown, Beletsis & Cermak,

1989). Steps occur over a time period, each of which is

different for each recovering person. This process can be

changed or interrupted at any time.

Maintenance of non-use behavior involves full acceptance

of the need for abstinence. Sobriety can become elusive

after time as the memory of painful end-stage experiences

are forgotten. In addition, it can be easy to deny

awareness of the problem given enough time without

intoxication because it may seem as though a person who was

addicted would be using. Enjoyment of life comes through a

daily program of recovery which reminds the chemically-

dependent person of the good fortune which has been










bestowed. Gratitude is a very powerful means to long-term

sobriety. Action is another vehicle. Maintenance requires

positive changes. Without them, the disease of addiction

triggers a series of automatic, learned reactions which

create pain and make return to use palatable. The answer is

a well-planned recovery.

A commonality across addictions is the high rate of

relapse following (a period of) abstinence (Abrams, Niaura,

Cary, Monti, & Binkoff, 1986; Brownell, Marlatt,

Lichtenstein, & Wilson, 1986; Chaney, Roszell, & Cummings,

1982; Marlatt & Gordon, 1985; Tucker, Vuchinich, & Harris,

1985). Daley (1987) stated that relapse, like recovery, is

a process, not an event. Many events, behaviors, thought

patterns, feelings, and attitudes lead to relapse. Gorski

and Miller (1982) outlined several steps in the process of

relapse. It is failure to take the necessary action to

complete these recovery steps that leads to relapse.

Adherence to these recovery steps is called a recovery

program. Once a program becomes a low priority, the

progression of relapse begins. Complacency has begun and,

without a strong "program," the symptoms of relapse develop

spontaneously.

Relapse becomes a syndrome when the addict experiences

loss of control over behaviors. This occurs when the

symptoms of sobriety or post acute withdrawal symptoms (PAW)

are not managed. The symptoms progress to the point when,










if not interrupted, chemical use again occurs. During

periods of stress the chemically-dependent person has

difficulty in thinking clearly, identifying and managing

feelings, and remembering things. Psychomotor coordination

may become impaired, sleep disturbance may develop, and

difficulty with stress management may occur. These are not

unusual symptoms for a person who has used chemicals for a

prolonged period. The key to recovery, therefore, is to

recognize and manage the symptoms. This is prevention.

Relapse prevention involves understanding, education,

and action. The addict needs to understand the relapse

syndrome, become educated as to the warning signs and

personal triggers, and take action to involve self, family,

friends, and a therapist in a plan of action which has been

pre-designed and pre-rehearsed. Such precautions allow for

interruption of the relapse syndrome and help prevent tragic

consequences. Planning should be an essential part of a

recovery program (Marlatt, 1985). Gorski and Miller (1986)

developed a model for relapse-prevention planning which

consists of nine steps.

First is stabilization. This step involves regaining

control of thoughts, emotions, memory, judgment, and

behavior after relapse has begun (i.e., after the drug has

been ingested). During this time of crisis, it is important

to turn to significant others for help to ameliorate the

negative emotions which accompany relapse. If stabilization










is not possible via this plan, professional help must be

sought.

The second stage involves assessment of the cause of the

relapse. A careful review of the history of addictive using

provides an opportunity to learn from the past.

Third, understanding is accomplished via education.

Because addiction is a disease of denial (Seixas & Youcha,

1985), it is imperative to review this step with a

professional who is trained in addictions, a sponsor, or a

sober friend. Mutuality is important for the addict because

it better insures that s/he will take responsibility for the

problem. Importance is placed upon learning about PAW

symptoms, what places the addict in high risk of developing

these symptoms, what can trigger them, and how to manage or

prevent them. Examples are needed to enhance accuracy and

clarity.

Fourth, relapse-warning-sign identification needs to be

undertaken. The signs are unique and personal, signalling a

need for an individualized approach. The signs are signals

that are apparent to self or others and may be internal or

external problems. Symptoms can be related to health,

thinking, emotions, memory, judgment, or appropriate

behavior. It is important to write a list of these warning

signs which are developed from past relapse experiences.

Fifth is warning sign management. This involves viewing

each warning sign as a problem which needs to be solved or









prevented upon onset. Of paramount importance is the

establishment of new responses. Problem resolution is the

key. Alternative behaviors should be explored, decided

upon, and practiced until habit. This should be done at

times of low stress.

Next, inventory training involves daily identification

of relapse-warning signs. Without this step, early warning

signs will be ignored and it may be very difficult to

interrupt the relapse symptom. It is advisable to develop

this daily inventory as a habit to be performed in a ritual-

like fashion two times each day. Journalling can be a

helpful adjunct in this step. It can help to monitor the

signs as well as function as a "barometer" for measuring

progress and be motivational.

The seventh step is a review of the recovery program.

An assumption inherent in this step is that a recovery

program is the best defense against relapse. In other

words, the addict needs a good recovery program in order to

prevent relapse. The recovery program as relapse strategy

is a learning process. Fingarette (1988) advocated a plan

wherein the drinker/addict not only addresses the slips, but

also how to overcome them and learn from mistakes. This

approach is supported by experimental and theoretical

research (Marlatt & Gordon, 1985). For every problem,

warning sign or symptom identified, there is a complementary

coping behavior.










Involvement of significant others (step eight) follows

the review of the recovery program. Help and support from

others is necessary because relapse is often an unconscious

process. Therefore, the addict may not be able to recognize

the process.

Step nine is followup and reinforcement. Addiction is a

chronic problem (Ohlms, 1981); it does not just go away.

Just as recovery is a "way of life," so is relapse

prevention. This planning must become an integral part of

the addict's life. There should be compatibility among all

factors of recovery such as the treatment program, AA

involvement, other support groups, family, school, friends,

and job involvement.

Structure is necessary to the entire process. Relapse

prevention must be practiced until it is habitual.

Willingness is another necessity. The plan usually involves

revision and updating at times as well as identification of

new problems which sabotage recovery. The result of relapse

prevention is a sense of confidence in recovery and a more

comfortable sobriety.

About two-thirds of all relapses occur within the first

90 days following treatment (Marlatt & Gordon, 1985). It is

important to consider the reasons addicts relapse as well as

the reasons they are prone to develop chemical dependence

(Vaillant, 1983). The precursors of alcoholism are often

triggers when the addict is sober. Research in this area










has shown that for many, alcohol can be a powerful

depressant, although, paradoxically, if taken in large

quantities for a prolonged period, it may actually elevate

anxiety levels (Stockwell & Town, 1989). Prolonged use also

can cause damage which persists long after abstinence and

may be responsible for stress symptoms stemming from central

nervous system damage (Gordis, 1976). Johnson (1980)

conducted an ex post fact study with alcoholics and

reported that, although their emotional backgrounds were

different before the onset of the disease, the pattern of

emotional distress after onset is (almost) universal.

Regardless of the cause of discomfort in sobriety, it is

apparent that chemically-dependent persons suffer from

stress-related symptomology. In assessing relapse crises,

the single most important factor to consider is the

affective tone of the situation (Shiffman, 1988). Stress is

a construct which subsumes many others, e.g., depression,

rage, fear, and guilt in general (Ellis et al., 1988).

According to Stockwell and Town (1989), the term stress

applies to the entire process of interactions between

external stresses (e.g., work demands, criticism, or

unrealistic demands) and the chemically-dependent person's

reactions or stress responses.

Vaillant (1983) reported that the sober addict's

predicament (i.e., being prone to relapse) is complicated by

the complexity of the disease. In addition to










pharmacological and emotional dependence, there is an

intricate learning process underlying seemingly

incomprehensible relapse. Craving for the drug, an

unconscious process, contributes to relapse in that it can

be aroused subsequent to psychological change (Ludwig &

Wikler, 1974). The craving thus can trigger learned

behavior (i.e., substance use). Further, alcohol

nonspecifically alters the chemically-dependent person's

feeling state, thus making it a powerful reinforcer

(Vaillant, 1983).

The change of affective state is an important

consideration in relapse prevention. Mello and Mendelson

(1972) demonstrated that many alcoholics do not maintain

stable concentrations of blood alcohol when drinking, but

instead attempt to induce variation in blood alcohol levels.

This suggests that continued changes in the addict's state

of consciousness may be as reinforcing as the relief of

physiological withdrawal. Mental imagery, cognitive

restructuring, and relaxation exercises are strategies which

can alter the state of the addict and are thus appropriate

interventions.

There are studies which suggest that the use of mental

imagery reduces stress. In one study, Beck (1967)

demonstrated that a catatonic imagery experience resulted in

an end to addiction. In another, the use of imagery in










alcoholism treatment to reduce stress showed it to be

effective (Pati, 1981).

Numerous authors have supported the use of mental

imagery as a vehicle for reducing stress. For example,

stress-inoculation training (SIT) uses imagery as a specific

means of attention diversion with stressed populations

(McCaffery, 1979; Meichenbaum, 1978; Turk, Meichenbaum, &

Genest, 1983). Wolpe (1958) developed a systematic

desensitization paradigm which is the predecessor to SIT.

His model also was designed to reduce stress. Others have

advised using mental-imagery exercises to reduce stress

(Davis, McKay, & Eshelman, 1982; Fezler, 1989; Gawain, 1982;

Miller & Leuth, 1986; Peale, 1982; Siegel, 1986; Singer,

1976) and claim high levels of effectiveness. More

specifically, many authors have recommended mental imagery

as treatment for stress-related symptoms which cause

relapse. Millham and Mason (1987) viewed it as a tool to

break free of the grasp of addiction. Nuckols (1987) held

mental imagery as a way to cope with high-risk situations.

Marlatt and Gordon (1985) pointed out that although studies

of this variable are scarce, future studies may reveal that

imagery techniques with addicts are a helpful adjunct to

treatment.

Images are mental representations of thought, usually

visual in nature, which enable people to record experiences,

fantasize, free associate, discover, construct, and problem-










solve without altering any of the environment (Witmer &

Young, 1985). Visual images also have the potential to

influence every cell, tissue, and organ in the body, a

concept vital in chemical-dependence relapse prevention.

For the addict, craving involves an unconscious process and

indicates a need to alter the mood (Vaillant, 1983). The

change or alteration of the mood is the important variable.

Mental imagery has the potential to alter the state of

consciousness to any possible combination of alternatives

(Bandler & Grinder, 1979).

Chopra (1989) also emphasized the necessity for a

"cellular" change in treating addiction because the memory

of the cravings and effects of the drugs remain after the

cell dies. This endocrinologist suggested that the process

is not volitional, but a product of unconscious thoughts and

memories. Mental imagery is powerful because it taps into

basic memory storage and retrieval processes (Fezler, 1989).

Mental imagery is therefore appropriate as a vehicle to

"counter" the process of relapse.

The scientific study of the ongoing imagery process was

spurred by sensory deprivation research in the 1960s

(Singer, 1974). The goal was to predict the possible

impacts of isolation on the mental functioning of astronauts

during flight. However, this research also has implications

for conditions such as social withdrawal, monotonous work

experiences, and hospitalization. One result was evidence








50

that an ongoing imagery process is an important variable in

human mental experience, particularly when perceptual

stimulation is reduced (Singer, 1974). This research was

vital because it began to offer scientific reasons why

imagery techniques in psychotherapy are so effective.

There are many justifications for incorporating imagery

into counseling practice. Among them are the power of

imagery to produce physiological change and the tendency of

imagery to provide motivation and to serve as a "rehearsal"

for new behaviors (Witmer & Young, 1985). Imagery used in

such clinical applications has been defined as a "sequence

of processing toward resolution" (Strosahl & Ascough, 1981,

p.423). It is a process leading toward insight into stored

associations. By assisting insight, imagery techniques are

more powerful than verbal inquiry. Kubie (1965) suggested

that there is a wealth of information which can be retrieved

through imagery techniques. Imagery also makes available

material such as early childhood experiences and thus

enhances treatment.

Skovholt and Thoen (1987) reported self-report and

anecdotal data using mental imagery as an intervention to

change behavior. Their data supported their beliefs that

imagery is sometimes a powerful counseling technique.

Mental imagery also has been demonstrated to be effective in

the treatment of a range of psychological problems (Witmer &

Young, 1985). Examples, as summarized by Sheikh and Jordan










(1983), include insomnia (Sheikh, 1976), depression

(Schultz, 1978), obesity (Bornstein & Sipprelli, 1973),

sexual malfunction (Singer & Switzer, 1980), chronic pain

(Joffe & Bresler, 1980), various phobias and anxieties

(Meichenbaum, 1977; Singer, 1974), and a host of

psychosomatic problems (Lazarus, 1977; Simonton, Matthews-

Simonton, & Creighton, 1978).

Other authors also have heralded the use of mental

imagery to produce behavioral change. For example,

Shiffman, Read, Maltese, Rapkin, and Jarvik (1985) claimed

that mental imagery reduced stress. Sheikh (1976) proposed

that mental imagery worked as a method to stop smoking

cigarettes. Michaud and Feinstein (1989) reported a study

which suggested that, after using mental imagery to

visualize blisters getting better, the blisters became

significantly smaller and white blood cells were positively

effected. Similarly, Epstein (1986) reported shrinkage in a

nodule after a rheumatoid patient used mental imagery.

Others have recommended the use of mental imagery with

chemically-dependent persons (e.g., Gawain, 1982; Johnson,

1980; Kritsberg, 1983; Small, 1982). Marlatt and Gordon

(1985) reported that although research on mental imagery is

generally lacking, future studies may reveal that this

technique is a helpful adjunct to treatment with addicted

clients. Finally, Ellis et al. (1988) recommended the use

of mental imagery with addicted clients. Adaptation of his








52

rational-emotive imagery made it more expressive and useful

for addicts (Maultsby, 1975; Maultsby & Ellis, 1974).

Relaxation is recommended as an antidote to stress and

as a preventive method in stress-management programs. There

is considerable research evidence that documents the

effectiveness of relaxation as a stress-reduction activity

(e.g., Bahrke & Morgan, 1978; Davidson & Schwartz, 1976;

English & Baker, 1983; Glaister, 1982; Lehner, Schoicket,

Carrington, & Woolfolk, 1980). Theoretically, there are a

number of explanations for the latter. Some authors have

focused on the physiological benefits of relaxation (e.g.,

Benson, 1975; Jacobson, 1929). Goleman (1971) focused on

the psychological and behavioral benefits of stress

reduction. Meichenbaum (1977) stressed the role of

relaxation in the excitation and exacerbation of anxiety

states.

Marlatt (1985) recommended relaxation as a lifestyle

modification procedure for addictive behavior problems and

other authors have supported this perspective (Glasser,

1976; Gold, 1988; Gorski, 1989; Strickler, Bigelow, Wells, &

Liebson, 1977). Weil (1972) suggested that this procedure

could be a substitute or "positive addiction," in lieu of

the addictive habit. Marlatt (1985) concurred that

addictive behaviors are strongly associated with relaxation

or escape. By replacing these behaviors, the sense of

deprivation may weaken. Levine (1979) contended that










relaxation tends to allow the addict to detach and can be

particularly effective in coping with urges and craving

experiences after cessation of the addictive experience.

In the alcoholism field, preliminary survey studies

disclosed that alcohol and drug use was reduced

substantially when subjects used relaxation methods (e.g.,

Benson & Wallace, 1972; Shafii, Lavely, & Jaffe, 1975).

However, Smith (1975) noted that most of these studies have

methodological problems and should be interpreted with

caution. For example, biases took the form of invalid self-

reports, lack of adequate control groups, and motivational

differences among subjects. Some studies also lacked true

alcoholic subjects. Overall, there exists little

consistency in research on the effect of relaxation

exercises (alone) on addictive patterns (Glasser, 1976;

Gold, 1988).

Two studies conducted at the University of Washington on

the effectiveness of relaxation procedures with heavy social

drinkers were aimed at reducing consumption (Marlatt &

Marques, 1977; Marlatt, Pagano, Rose, & Marques, 1984).

Results of the first study exhibited a significant reduction

in alcohol use (approximately a 50% reduction from

pretreatment rates) for subjects in three relaxation

conditions in comparison with a no-treatment control group.

Overall, results showed a significant reduction in drinking

rates after taking regular time-out periods to relax. The










second study showed significant decreases in drinking

compared to baseline drinking levels (Murphy, Pagano, &

Marlatt, 1984) in a relaxation (meditation) group. This

group returned to pretreatment levels of alcohol use shortly

afterwards, however.

In summary, research on relaxation as an intervention

for chemical-dependence reduction is both sparse and

conflicting. However, there are enough studies which

support the effectiveness of this technique to warrant its

use in conjunction with other techniques.

One of the primary focuses of cognitive restructuring is

to identify and decrease stress (Shiffman, Read, Maltese,

Rapkin, & Jarvik, 1985). This approach seeks to challenge

the irrational beliefs which cause discomfort (McMullin,

1986). The essence of this approach consists of three basic

steps, according to McMullin and Giles (1981). First, the

therapist helps the client recognize the thoughts, beliefs,

or schemata that are causing the negative emotions and

behaviors. Second, the clinician assists in helping the

client to analyze the validity and usefulness of the

negative processes. Last, the therapist helps to effect a

"shift" from irrationality to accurate, rational, and useful

behavior. There is considerable evidence showing that the

degree of stress that people experience depends mainly on

the labels and cognitions applied to physical states and are








55

not intrinsic properties of the state itself (Beecher, 1959;

Nisbett & Valino, 1971; Schachter & Singer, 1962).

Many studies have been conducted which support strongly

the use of cognitive restructuring with chemically-dependent

persons (Clark, 1986; Ellis, et al., 1988; McMullin, 1986).

For example, Oei and Jackson (1982) compared social skills

training, cognitive restructuring, and traditional

supportive therapy with inpatient alcoholics. At a three-

month followup, the cognitive-restructuring group was

evaluated as the most improved.

There is additional evidence to support the use of

cognitive restructuring specifically as a stress-reduction

strategy with chemically-dependent persons. Rohsenow,

Smith, and Johnson (1985) reported significant short-term

changes as a result of using cognitive restructuring as one

of the approaches to reduce stress in chemically-dependent

college males. McLellan, Woody, Luborsky, Obrien, and

Druley (1983) evaluated a sophisticated cognitive-behavior

study designed for chemically-dependent persons. This study

included a rigorous research design including random

assignment to groups and screening for subject motivation.

Findings suggested that cognitive restructuring was more

effective than traditional counseling.

Marlatt (1985) proposed that the chief purpose of

cognitive restructuring was to counter the cognitive and

affective components of the Abstinence Violation Effect








56

(AVE). He proposed that relapse potential places much

stress on the chemically-dependent person because of

irrational thoughts which lead to feelings of hopelessness.

Finally, several authors believe that an addict's relapse

potential is strengthened when irrational conceptualizations

which result in lowered self-efficacy and increased self-

helplessness are alleviated (Lazarus, Averill, & Opton,

1970).














CHAPTER 3

METHODOLOGY

There were two primary purposes of this study. The

first purpose was to determine whether a mental-imagery

workshop could change (i.e., improve) levels of self

disclosure, help-seeking behavior, lifestyle behavior

change, and perception of unmanageability over drugs and

alcohol with recovering addicts. The second purpose was to

determine how these outcome variables interacted with

relevant independent (i.e., demographic and chemical-

dependence related) variables.

Delineation of the Variables

Data were gathered for the following variables:

(a) group (experimental or control); (b) gender (male or

female); (c) age (15 to 70); (d) race/ethnicity (Black (B),

Caucasian (C), or Hispanic American (H)); (e) level of

education (5 to 22); (f) length of recovery (4 to 96

months); (g) drug of choice (alcohol, sedative, marijuana,

cocaine, amphetamine, or hallucinogen); (h) number of weekly

12-step meetings attended; (i) self disclosure (a score on

the JSDQ); (j) help-seeking behavior (a score on the HSLI);

(k) perception of unmanageability (a score on the ALI); and

(1) lifestyle behavior change (a score on the HAT).










Population

The group of people to whom the results of this study

were intended to apply (i.e., recovering chemically-

dependent persons) have certain characteristics in common.

However, the population was not intended to include those

(a) with less than a 5th grade reading level; (b) race other

than Black, Caucasian, Native American, or Hispanic

American; (c) persons with disabilities which prohibit them

from completing the instruments; (d) younger than 15 or

older than 70; (e) who do not read and write English; (f)

who are chronic relapsers because of severe mental and/or

nervous disorders, pain, or other dual diagnoses; and (g)

with less than four months or more than 96 months of

abstinence from mood-altering chemicals.

Although an attempt was made to represent recovering

chemically-dependent persons in general, this goal was only

partially achieved. Random sampling produced only three

Blacks and only four Hispanic Americans. Likewise, only

three subjects under 20 years of age participated. In

addition, there were a predominance of alcohol abusers in

the study. Therefore, the variable, drug of choice, was

collapsed to alcohol and other. Finally, the sampling

produced subjects having from 1 to 264 months of abstinence.

The psychological variables characteristic of this

population are primarily the result of prolonged substance

abuse (Vaillant, 1983). There are psychological symptoms










(e.g., self-centeredness, resentment, self-deception, and

fear) which progressively worsen as the person "uses" more

of the chemical (Gorski, 1986). Thus, chemically-dependent

persons generally are caught up in a "double-bind" wherein

the psychological problems worsen and, in turn, perpetuate

themselves. The self-centeredness prevents help-seeking

behavior and the problems generate more problems.

Resentments are born out of anger and disappointments as

ingestion increases. The self-centeredness, coupled with

this resentment, leads to exaggerated and overwhelming

feelings of self-pity and alienation. Self-deception

flourishes as the addict progressively defends his or her

behavior by rationalization, intellectualization,

projection, and justification. Honesty to self and others

becomes more difficult to attain. Ultimately, fear begets

paranoia. The self-deception aids the process and the other

psychological variables also overlap to add to the confusion

and eventual despair. Low self-esteem, depression, and a

negative belief system follow.

There are other variables that merit reporting. The

male-to-female ratio of known substance abusers in the state

of Florida was 76% to 24% as of 1989, including 62,609 males

and 20,220 females. With an n of 15, 11.4 (11) males and

3.6 (4) females would have represented the chosen

population. Percentages by race in the state of Florida

were 71% Caucasian, 22% Black, 7% Hispanic American, and










less than 1% Other. Totals as of 1989 were 58,395

Caucasian, 18,406 Black, 5,690 Hispanic American, and 348

Other (i.e., Asian and Native American). With an n of 15,

the totals would have been 10.6 (11), 3.3 (3), 1.05 (1), and

0, respectively.

The third variable, age, was reported as under 20 and

over 20. The percentages of under 20 and 20 years of age

and above were 12% and 88%, respectively. In Florida, there

were 11,128 chemical-dependence admissions under 20 years of

age and 82,387 20 years old and over in 1989. With an n of

15, there would have been 1.8 (2) persons under 20 and 13.2

(13) persons 20 years of age and over.

In summary, the National Association of State Alcohol

and Drug Abuse Directors, Inc. reported characteristics and

percentages for each of these three variables in the

chemical-dependence population in Florida. These data were

gleaned from reports from chemically-dependent client

admissions to treatment centers in 1989. Representing them

would have resulted in 11 males, 4 females; 11 Caucasians, 3

Blacks, 1 Hispanic American; 2 teenagers, and 13 persons

over 20 years of age in each group, partitioned as shown in

Table 1

Sampling Procedures

Subjects for this study were recruited primarily from

members of Alcoholics Anonymous (AA) and Narcotics Anonymous

NA) groups. Nationally, members of these organizations










TABLE 1

Proposed Gender. Age and Race/Ethnicity Percentages for the
Experimental and Control Groups



Race Male Female

Under 20 Over 20 Under 20 Over 20

Caucasian 11 11 11 11

Black 3 3 3 3

Hispanic 1 1 1 1

Total 15 15 15 15



represented over two million recovering chemically-dependent

persons of all ages, races, and genders.

Presentations were made at eight different AA and NA

meetings in the central Florida area. The presenter stated

that there would be five, day-long workshops at Quest

Counseling Centre beginning the next Saturday and for the

following four Saturdays for persons in chemical-dependence

recovery. The focus of the workshops was to be on relapse

prevention. The incentive for participation was described

as self-improvement with an opportunity to strengthen the

recovery process. After each presentation, interested

persons were asked to write their names and phone numbers on

a sheet of paper distributed by the presenter.

This approach failed to enroll the desired 75

participants. Therefore, Lifeworks Center, Inc. was used to

recruit members from their chemical-dependence treatment








62

center. Subjects also were recruited from among outpatient

"graduates" of Quest Counseling Centre's Adult Treatment

Program. An n of 15 was the targeted number for each

treatment group. However, this number also was not reached

initially. Therefore, more treatment groups were added to

increase the numbers of subjects in the total experimental

group.

Numbers of persons needed to meet the proposed race,

gender, and age specifications were not achieved fully. The

gender distribution was relatively even instead of the

project three-to-one male-to-female ratio. The age variable

was changed to under 30 and over 30. Length of recovery was

from 1 month to 264 months. The characteristics of the

actual participants are delineated further in Chapter 4.

Subjects self-selected into groups based on their own

scheduling convenience. Designation of groups as either

experimental or control was done on a random basis. Thus

subjects were essentially randomly assigned to a group

because no experimenter-controlled factors were implemented.

Recovering CD persons typically are involved in

programs (e.g., AA or NA) intended to help them refrain from

renewed addiction. The motivation to participate in such

programs seemed to facilitate obtaining the initial sample

because the workshop participants were selected from among

those who had already demonstrated at least some inclination

not to relapse. That is, subjects came from among those










currently participating in abstinence-maintenance programs.

The conduct of the followup assessments and interviews,

however, presented additional considerations. Followup was

done with the experimental group six weeks after their

treatment. CD persons are known to relapse frequently.

Indeed, that is one of the reasons for the intervention (and

research) in the first place. Thus, it was likely that some

subjects would relapse before the followup activities. This

was true as 7 participants relapsed and were not available

to respond to followup questions. Therefore, followup data

were not obtained from all subjects.

Substantial effort was required to locate and obtain

data from the participants on individual bases. Their lives

seemed to be disordered and it was often difficult to obtain

followup data, even from those who initially agreed to

provide it. However, it appeared that the intervention was

perceived as helpful and therefore motivation to participate

in followup activities may have been increased. A total of

43 persons participated in the followup portion of the

study.

Measurement Instruments

The instruments used in this study were the Jourard

Self-Disclosure Questionnaire, Health Attribution Test,

Abstinence Likelihood Inventory, and Help-Seeking Likelihood

Inventory. These instruments have few items, are easily

scored, and could be completed within 30 minutes. They also










are easy to comprehend and have brief, clear instructions

for use. Appropriateness was determined via reliability and

validity testing for each instrument.

The Jourard Self-Disclosure Questionnaire (JSDQ) was

developed by Sidney Jourard. The questionnaire was

published in an article by Jourard and Lasakow (1958). It

was designed to measure the extent to which an individual is

willing to reveal himself/herself to another (i.e., self

disclosure). Subscales measure degree of self disclosure in

regard to attitudes and opinions, tastes and interests,

work, money, personality, and body. A respondent is asked

to respond to a series of statements by indicating the

target person (e.g., mother, father, male friend, female

friend, or significant other) to whom she or he has revealed

feelings and to what extent.

The JSDQ is a 60-item test which requires approximately

10 minutes to complete. It has a 0, 1, or 2 response

format. Responses are written on the answer sheet.

Although six subscale scores can be computed, only the total

score was used in this study. Higher scores represent

greater willingness and ability to self disclose. Research

on the use of the questionnaire has shown that self

disclosure is measurable and that this method of assessing

it has validity (Jourard, 1971). The JSDQ has been used

frequently as a self-inventory in personal growth

laboratories or as an outcome measure in research on human








65

relations training or counseling. Panyard (1973) also found

empirical support for the validity of the JSDQ.

The Health Attribution Test (HAT) was published in 1990

by the Institute for Personality and Abiltiy Testing, Inc.

The HAT measures respondents' attitudes about responsibility

for their own health maintenance or treatment programs

(i.e., lifestyle behavior change). The HAT requires from 5-

10 minutes to administer and can be hand-scored in less than

five minutes. It also can be administered to groups or

individuals. It contains three scales to predict behavioral

reactions to illness and response to treatment.

In the original development of the HAT, 43 items were

administered to 121 undergraduate students. Subjects

responded to each question by marking one of six possible

responses arranged in a Likert-type scale ranging from

"Never" to "Always." Their responses were then factor

analyzed. The marker variables from Levenson's (1973) locus

of control measure suggested that there were three factors

which measured Internal, Powerful Others, and Chance

beliefs. Next, the 22 items having the highest factor

loadings were selected to comprise the current version of

the HAT.

Respondents mark an "x" in the box which represents the

answer they choose on a Likert-type scale ranging from

"Strongly Disagree" to "Strongly Agree." Higher scores

indicate willingness to become responsible for one's health










maintenance or treatment program (i.e., lifestyle behavior

change). The Internal subscale, which measures a person's

attitude of personal responsibility for their health, was

used as the score for this test.

The Abstinence Likelihood Inventory (ALI) (Appendix C)

was developed in September, 1989, by the researcher for use

in this study. The ALI measures perception of

unmanageability, that is, the likelihood that a chemically-

dependent person will remain abstinent. The ALI requires

from 5-10 minutes to administer and can be hand-scored

within 2-3 minutes. It can be administered to groups or

individuals.

The ALI is a 26-item test. Respondents use a response

scale ranging from 0 to 9. Scores represent the likelihood

that the respondent will remain abstinent (i.e., perception

of unmagageability). Scores range from 0 to 234, with

higher scores indicating less likelihood of relapse. The

total score is used.

The ALI was developed to measure likelihood to remain

abstinent because no such measure was available. A pilot

study was conducted to determine its reliability. A group

equivalent to those to be studied was used. The 26-item ALI

was administered to 35 (known) chemically-dependent persons,

each of whom was (self-reported) abstinent from mood-

altering chemicals for at least six months. Respondents

were asked to write their age, gender, and social security










number (for matching purposes) on the form. Anonymity was

emphasized. They were asked to complete the one-page form

and return it in the self-addressed, stamped envelope

provided. Instructions were to write the number from 0 to 9

which represented the extent to which each item was thought

to be a trigger which precipitated "use." Thirty-two were

returned.

Internal reliability was calculated by means of

Cronbach's coefficient alpha. The coefficient alpha is used

when measures have multiple-scored items (Ary, Jacobs, &

Razavieh, 1985). The coefficient alpha for the ALI was .92;

a readily acceptable level of reliability. The split-half

reliability coefficient was .87 (Table 1). The test-retest

reliability coefficient following a 30-day period was .93.

Content validity was evaluated to determine the extent

to which the ALI measures likelihood of abstinence. Content

validity refers to the extent to which an instrument

represents the content of interest (Ary et al., 1985). This

type of validity is well-suited for tests used to measure

psychological variables. The variable measured in the ALI

is attitude toward different triggers associated with, and

perhaps precipitating, a craving to "use." Each item was

gleaned from an extensive literature search and is therefore

multi-referenced, as shown in Appendix D.

The Help-Seeking Likelihood Inventory (HSLI) (Appendix

E) also was developed in September, 1989, by the researcher










for use in this study. The HSLI measures the likelihood

that a chemically-dependent person will ask for help and, if

so, from whom. This inventory takes from 5-10 minutes to

administer and can be hand-scored within 2-3 minutes. It

can be administered to groups or individuals.

The HSLI is a 20-item test on which respondents use a

scale ranging from 0 to nine. Scores represent the

likelihood that the subject will seek help while in

recovery. Scores range from 0 to 180, with higher scores

indicating greater likelihood of help-seeking behavior. The

total score is used.

The HSLI was designed to measure this variable for this

study because no such measurement was available. A pilot

study was conducted to determine its reliability. A group

equivalent to those being studied was used. The 20-item

HSLI was administered to 35 (known) chemically-dependent

persons each of whom was abstinent (self-reported) from

mood-altering chemicals for at least six months.

Respondents were asked to write their age, gender, and

social security number (for matching purposes) on the form.

Anonymity was emphasized. All were asked to complete the

one-page form and return it in the self-addressed, stamped

envelope provided. Written instructions were to write the

number from 0 to nine which represented the extent to which

each help-seeking behavior would be employed in recovery.

Thirty-two were returned.










Internal reliability was calculated by means of the

Cronbach's coefficient alpha. The coefficient alpha for the

HSLI was .77, an acceptable level of reliability. The

split-half reliability coefficient was .88. (Table 2). A

test-retest reliability coefficient following a 30-day

period was .80.

Content validity is important and refers to the extent

to which the inventory measures the content of interest,

i.e., whether the subject will seek help with his/her

recovery. The variable measured in the HSLI is willingness

to seek help. Each item in the HSLI was gleaned from the

literature. Item references are found in Appendix F.

Table 2

Reliability Calculations for the ALI and HSLI



Coefficient alpha Test-retest Split-half



ALI .92 .93 .87

HSLI .77 .80 .88



Research Design

The design used in this study was a randomized,

posttest only control group with followup design. The

original intent was to have one control group and one

experimental group (composed of four treatment groups, each

having an n of 15). However, random sampling produced less










than 15 subjects for each treatment group. This

necessitated adding two more treatment groups to total six.

The treatment groups were facilitated by different

facilitators and on separate occasions. All groups except

one were performed on Saturday. No other known differences

existed between these groups. Preliminary analyses

indicated no significant differences in the means for any of

the dependent variables across the six treatment groups.

Therefore, the data were pooled as a single experimental

group.

The research covered six weeks. Initial assessments

for the experimental group were completed immediately upon

completion of the treatments. The experimental group was

assessed again six weeks after the initial assessment. The

control group received the treatment following completion of

the initial assessments.

Treatment

The treatment (i.e., counseling intervention) used in

this study was a day-long, approximately eight-contact hour

workshop intended to help chemically-dependent persons be

able to use mental-imagery techniques to prevent relapse.

The treatment is described in detail in Appendix G. Support

for the respective elements of the workshop is found in

Chapter II.

The treatment workshop format used was common in the

counseling profession in that day-long intervention








71

workshops have been used for a wide variety of purposes and

for an equally-wide variety of clientele. Thus, the

treatment had the advantage of being similar in format to

frequently-used counseling interventions. In addition, many

of the activities conducted have been used in other contexts

and so their potential applicability was well-founded.

These commonalities notwithstanding, the treatment was

unique and innovative in several regards. First, the

treatment had a stronger, more integrated theoretical

foundation than most used with CD persons. As shown in

Chapter II, there existed theoretical commonality and

coherence across the elements (i.e., activities) used.

Theoretically integrated interventions have been used

commonly in the counseling profession in general, but rarely

has such theoretical integration been evident in

interventions for CD persons. Second, the treatment was

multifaceted in that a variety of activities, all focused

upon mental-imagery training, were incorporated in it. Many

of the activities used have been used in other contexts and

generally with success. However, those that have been used

with CD persons have only been used infrequently, often

without demonstrated success and never within the context of

a combination as was used in this research. Third, the

treatment was based on a prevention perspective. Therefore,

it was in accord with potentially far less costly approaches

to treatment for CD persons. Finally, the treatment was










intended to effect a combination of (dependent) variables

not heretofore studied in relapse-prevention efforts. In

sum, the treatment was developed based upon a careful review

and evaluation of the professional counseling literature on

activities potentially appropriate for using mental imagery

as a means to facilitate relapse prevention. It was

developed so as to be both theoretically sound and

professionally appropriate.

It should be noted that the intervention was an adjunct

to treatment for those who were receiving, or had received,

"standard" treatment. Standard treatment included

inpatient, outpatient, NA, or AA approaches. Since the

sample was derived from a population of recovering persons,

it was assumed that these people were in recovery treatment

of some sort. Relapse, by its very nature, occurs only

after a person is exposed to recovery. Therefore, all

participants had been or were involved in other treatment.

A treatment history form (Appendix J) was designed to

determine the type of treatments) to which the subjects

were exposed.

Research Procedures

After participants in the control group entered the

group room at Quest Counseling Centre in Altamonte Springs,

Florida, the facilitator said, "Good morning. Thank you for

coming. My name is I'm looking forward to a very

productive day that is relaxing, fun, and helpful. To










begin, I'd like you to complete four instruments which are

necessary, important, and integral to the study. Please

complete them conscientiously. The results will be coded

and kept confidential.

On the forms which I will hand out, please write the

last four digits of your social security number, your age,

and M or F for male or female in the upper right corner.

Also, write today's date as soon as I say to begin.

Complete one form at a time, respond to every item in

order, and do not skip items. Instructions are written on

each form. Read these carefully, relax, and respond to all

questions as honestly as you can. Raise your hand when you

finish all four forms. It should take you about 20 minutes

but you are not being timed. Begin now."

The facilitator then gave each participant a pencil and

the four forms. He stayed in the room, answered questions,

and distributed more forms and/or pencils as needed. As

participants finished, he checked the forms for social

security digits, age, and gender information. He also

checked for completion of all items. Forms were placed in a

box marked C group.

When all forms were collected, the facilitator then

said, "Thank you for your cooperation. In six weeks, I will

ask each of you to fill out followup forms. We have

finished this phase and are ready to begin the workshop on

relapse prevention."








74
At this point, the treatment procedure was implemented.

In general, it was an eight-hour workshop on relapse

prevention. The focus was on the use of mental imagery as

the main intervention to raise levels of acceptance in four

areas. Initially, time was given to the development of a

"safe" atmosphere, followed by an introduction to imagery.

The workshop proceeded with a series of imagery vignettes

targeted to raise levels of acceptance. See Appendix G for

a complete description of the treatment.

At the completion of the workshop, the facilitator

said, "It is now time to end. Thank you for participating.

I wish you all much success. Lastly, in six weeks, I will

contact you and ask you to complete four more forms. Thank

you."

Because this study incorporated a posttest only design,

the experimental group received the instruments after the

treatment. However, the format for the treatment was

identical for both groups. After the participants in the

experimental group entered the group room at Quest

Counseling Centre in Altamonte Springs, Florida, the

facilitator said, "Good morning. Thank you for coming. My

name is I'm looking forward to a very productive

day that is relaxing, fun, and helpful. We are ready to

begin the workshop on relapse prevention. Please remember

that we will end at 4:30 p.m. and then spend about one-half

hour completing some forms." At this point the treatment










procedures were implemented. Upon completion of the

workshop, the facilitator said, "It is now time to complete

forms. Thank you for your cooperation. I wish you all much

success. In six weeks I will ask each of you to fill out

followup forms. This next part takes about one-half hour and

involves completing four instruments necessary, important,

and integral to the study. Please complete them

conscientiously. The results will be coded and kept

confidential. On the forms which I'll hand out please write

the last four digits of your social security number, age,

and M or F for male or female in the upper right corner.

Also, write today's date as soon as I say to begin.

Complete one form at a time, respond to every item in order,

and do not skip items. Instructions are written on each

form. Read these carefully, relax, and respond to all items

as honestly as you can. Raise your hand when you finish all

four forms. It should take you about 20 minutes but you are

not being timed. Begin now."

The facilitator then gave each participant a pencil and

the four forms. He stayed in the room, answered questions,

and distributed more forms and or pencils as needed. As

participants finished, he checked the forms for social

security digits and gender information. He also checked for

completion of all items. Forms were placed in a box marked

E group.










Research participants

There were five trainers for the intervention.

Originally, there were four trainers assigned, one to each

group. However, as the number of subjects in each treatment

group was smaller than intended, there was need to add more

groups. One more trainer was added in order to facilitate

this process. All of the trainers had been enrolled in

post-master's graduate study, had master's degrees in

counseling, possessed Florida State Licenses as either

mental health or marriage and family counselors, were

current practitioners in the field of counseling in the

Central Florida area, had at least 15 years of experience in

the counseling profession and were Caucasian males over 40

years of age.

The researcher had provided approximately 10 hours

training to workshop leaders to explain the format,

guidelines, and expected behaviors for the workshop. The

imagery exercises, intended psychological environment for

the day, and accompanying attitudes to be expressed to the

participants were explained. Rehearsals of the tasks were

completed. Imagery exercises were audiotaped beforehand and

played during the workshop.

Data Analyses

The purpose of the workshop was to improve participant

characteristics in ways known to be associated with

successful recovery processes. Therefore, primary interest










was in differences in four selected outcome variables

between those in the experimental and control groups.

However, because a variety of variables were investigated,

differences in or relationships to the selected variables as

functions of demographic and other characteristics of both

the participant and nonparticipant groups also were of

interest.

The data analyses for the study were conducted in

steps. In the first step, four separate (i.e., one for each

dependent variable) one-way analyses of variance (ANOVAs)

across the six treatment groups were computed to determine

if there were significant differences among the treatment

groups. There were no significant differences and therefore

the data from the respective treatment groups were combined

for subsequent analyses.

Multiple regression analyses were used to determine

significant differences and/or interactions among the

demographic and each of the outcome variables. Similarly,

multiple regression analyses were used to determine

significance of relationships among the demographic

variables and the each of the outcome variables. The

general linear model was used for each of these analyses.

It allowed for investigation of individual as well as

linear, weighted combinations of relationships among the

respective variables.














CHAPTER 4

RESULTS

This study examined the effects of a brief, relapse-

prevention intervention for chemically-dependent persons. A

randomized, posttest only control group design, with

followup, including multiple dependent and independent

variables was used. Subjects in the treatment and control

groups were measured across four dependent variables: help-

seeking behavior, self disclosure, perception of

unmanageability, and lifestyle behavior change.

Fifty subjects were recruited for the experimental

groups. It was necessary to have six groups because initial

attempts to fill the four proposed treatment groups failed.

Therefore, two additional groups were added. One of the

participant's scores were discarded because the person was

not in treatment for chemical dependence but rather for an

over-eating problem. Thirty-seven subjects were recruited

for the control group. One subject's data were discarded

because of failure to complete the posttests. Therefore,

there was a total of 85 participants.

An attempt was made to obtain a sample as presented in

Table 1. However, the procedures yielded only an










approximation of that intention. The actual sample is

presented in Table 3.

TABLE 3

Actual Gender. Age, and Race\Ethnicitv Percentages for the
Experimental and Control Groups


Experimental Control

Age Male Female Male Female

Under 30 7 2 3 4

Over 30 20 20 18 11


Note: Only three Blacks, four Hispanic Americans, and two
American Indians were involved in the study.

Four one-way analyses of variance (ANOVA) were performed

as a preliminary analysis to determine whether there were

significant differences among the six treatment groups. The

means and standard deviations by variable and

TABLE 4

Mean and Standard Deviations for the Experimental and
Control Group


El E2 E3 E4 E5 E6 All E Ctrl


ALI M 155.5 174.0 165.0 159.9 129.2 178.0 158.5 130.3
SD 31.1 42.7 30.3 41.3 52.3 22.0 40.7 59.4

HSLI M 109.8 118.5 114.7 110.7 99.0 104.3 110.0 105.5
SD 23.3 19.6 15.1 21.9 20.2 32.1 21.4 27.4

JSDQ M 275.7 242.4 237.0 285.6 307.1 197.0 264.5 268.4
SD 123.2 86.9 66.2 103.4 173.4 90.9 114.7 101.2

HAT M 12.0 11.7 14.1 12.7 11.6 13.5 12.4 11.4
SD 6.0 3.9 7.5 4.2 7.0 4.4 5.4 5.8








80
group are shown in Table 4. No significant differences were

found among the six treatment group means for any of the

four dependent variables. Therefore, the data from the six

treatment groups were combined into a single experimental

group for all subsequent analyses.

Multiple regression analyses, using the general linear

model, were computed to evaluate all hypotheses. The .05

level of significance was used throughout. A standard,

linear, weighted multiple regression approach was used. The

demographic and substance-abuse related variables were added

to the model in a stage-wise manner. In the first stage,

only demographic variables were included. In the second

stage, treatment was added to the model and interactions

between treatment and the demographic variables were tested

to determine whether the treatment had a differential impact

on subjects with different demographic traits. In the third

stage, substance-abuse history variables were used as the

independent variables. In the fourth stage, treatment was

added to the model and its interactions with substance-abuse

history variables were examined. In the final stage, the

original intent was to combine only variables shown to be

significantly related to the dependent variables in the

preceding models to determine their combined effects.

These stages of analyses were to have been applied to all

four dependent variables. However, because prior analyses










did not yield sufficient variables to evaluate these

hypotheses, no statistical analyses were conducted.

Abstinence Likelihood Inventory

Hypothesis 1 stated that there was no significant

relationship between ALI scores and a weighted, linear

combination of the demographic variables (i.e., gender,


race, age, and education)


The data analyses summary for


evaluation of this hypothesis is shown in Table 5. There

TABLE 5

Multiple Regression Results for the ALI and Demographic
Variables

Source DF Sum of Squares Mean Square F Value Pr > F

Model 6 22698.8169 3783.1362 0.14 0.1895

Gender 1 99.7387 99.7387 0.04 0.8429

Race 3 6258.0956 2086.0319 0.83 0.4832

Age 1 16376.8264 16376.8264 6.49 0.0128 *
Education 1 1507.5353 1507.5353 0.60 0.4419

*p < .05

was not a significant relationship between the ALI and a

weighted combination of the demographic variables.

Therefore, hypothesis 1 was not rejected. However, there

was a significant and positive relationship between ALI

scores and age.

Hypothesis 2 stated that there was no significant

relationship between ALI scores and a weighted, linear

combination of the demographic variables, treatment, and the

interactions of treatment with these demographic variables.









82

The data analysis summary for evaluation of this hypothesis

is shown in Table 6. There was a significant difference by

group, with the experimental group having the higher mean.

There also was a relationship between the ALI scores and the

demographic variable age. In addition, there was a

TABLE 6

MultiDle Rearession Results for the ATT. Demn~ranhkir


Variables
Variables

Source

Model

Gender

Race

Age

Education

Group
G*Group

R*Group

Age*Group

Ed*Group

*p < .05


and Treatment Interactions with the Demoaranhic


Sum of Squares

59885.3344

0.8676

6203.2854

19741.5559

54.3569

20374.1557
1684.2818

21.9130

893.9556

9796.6603


Mean Square

5444.1213

0.8676

2067.7618

19741.5559

54.3569

20374.1557
1684.2818

21.9130

893.9556

9796.6603


F Value

2.49

0.00

0.95

9.03

0.02

9.32
0.77

0.01

0.41

4.48


Pr > F

0.0103 *

0.9842

0.4232

0.0036 *

0.8752

0.0032 *
0.3831

0.9205

0.5246

0.0377 *


significant group-by-education level interaction. There

were uneven distributions across grade levels of those in

the experimental and control groups. Therefore, hypothesis

2 was rejected.

Hypothesis 3 stated that there was no significant

relationship between ALI scores and a weighted, linear

combination of substance-abuse related variables (i.e., drug


DF


MultiDle Rearession Results for the ALI Demonranhit-


,










of choice, number of weekly meetings, and months of

recovery). The data analysis summary for evaluation of this

hypothesis is shown in Table 7. There was a significant

relationship between the ALI and only length of time in

recovery. Therefore, hypothesis 3 was rejected, but only

length of recovery was related to ALI scores.

TABLE 7

Multiple Regression Results for the ALI and Substance-abuse
Variables

Source DF Sum of Squares Mean Square F Value Pr > F


Model 3 24835.2176 8278.4059 3.44 0.0205 *

Drug of C 1 629.0992 629.0992 0.26 0.6103

Meetings 1 8121.4021 8121.4021 3.38 0.0697

Len of Rec 1 9999.7785 9999.7785 4.16 0.0446 *

*p < .05

Hypothesis 4 stated that there was no significant

relationship between ALI scores and a weighted, linear

combination of substance-abuse variables, treatment, and the

interactions of treatment with these substance-abuse

variables. The data analysis summary for evaluation of this

hypothesis is shown in Table 8. There was a significant

relationship between ALI scores and only length of time in

recovery. Therefore, although hypothesis 4 was rejected, it

yielded redundant information with hypothesis 3 in that only

length of recovery was a significant predictor of ALI

scores.










TABLE 8

Multiple Regression Results for the ALI. Substance-abuse
Variables, and Treatment Interactions with the Substance-
abuse Variables

Source DF Sum of Squares Mean Square F Value Pr > F


Model 3 24835.2176 8278.4059 .44 0.0205 *

Drug of C 1 629.0992 629.0992 0.26 0.6103

Meetings 1 8121.4021 8121.4021 3.38 0.0697

Len of Rec 1 9999.7785 9999.7785 4.16 0.0446 *

Group 1 2216.7339 2216.7339 0.98 0.3253

DC*Group 1 5872.2433 5872.2433 2.60 0.1113

Mtgs*Group 1 75.6972 75.6972 0.03 0.8553

Len*Group 1 2559.6044 2559.6044 1.13 0.2908

*p < .05

Hypothesis 5 stated that there was no significant

relationship between ALI scores and a weighted, linear

combination of treatment, selected demographic variables,

selected substance-abuse variables, and the interactions of

treatment with the selected variables. Because prior

analyses did not yield sufficient variables to evaluate this

hypothesis, no statistical analysis was conducted for it.

Therefore, hypothesis 5 was not tested.

Help-Seeking Likelihood Inventory

Hypothesis 6 stated that there was no significant

relationship between HSLI scores and a weighted, linear

combination of the demographic variables (i.e., gender,

race, age, and education). The data analyses summary for










evaluation of this hypothesis is shown in Table 9. There

was not a significant relationship between the HSLI and a

weighted combination of the demographic variables.

Therefore, hypothesis 6 was not rejected.

TABLE 9

Multiple Regression Results for the HSLI and Demographic
Variables

Source DF Sum of Squares Mean Square F Value Pr > F


Model 6 5029.7498 838.2916 1.50 0.1900

Gender 1 1136.8021 1136.8021 2.03 0.1581

Race 3 4102.3386 1367.4462 2.44 0.0704

Age 1 56.9640 56.9640 0.10 0.7506

Education 1 289.2033 289.2033 0.52 0.4744


Hypothesis 7 stated that there was no significant

relationship between HSLI scores and a weighted, linear

combination of demographic variables, treatment, and the

interactions of treatment with these demographic variables.

The data analysis summary for evaluation of this hypothesis

is shown in Table 10. There were no significant

relationships, differences, or interactions. Therefore,

hypothesis 7 was not rejected.

Hypothesis 8 stated that there was no significant

relationship between HSLI scores and a weighted, linear

combination of substance-abuse variables (i.e., drug of

choice, number of weekly meetings, and months of recovery).











The data analysis summary for evaluation of this hypothesis

is shown in Table 11. There was not a significant

TABLE 10

Multiple Regression Results for the HSLI, Demoaraphic


Variables
Variables


and Treatment Interactions with the


Demoaranhic


Source DF Sum of Squares Mean Square F Value Pr > F


Model 11 6468.3852 588.0350 1.02 0.4407

Gender 1 1608.2802 1608.2803. 2.78 0.0997

Race 3 4070.4012 1356.8004 2.35 0.0798

Age 1 26.0763 26.0763 0.05 0.8324

Education 1 402.8410 402.8410 0.70 0.4067

Group 1 123.8208 123.8208 0.21 0.6450

G*Group 1 311.3700 311.3700 0.54 0.4655

R*Group 1 225.4763 225.4763 0.39 0.5343

Age*Group 1 641.9961 641.9961 1.11 0.2956

Ed*Group 1 0.1300 0.1300 0.00 0.9881



TABLE 11

Multiple Regression Results for the HSLI and Substance-abuse
Variables

Source DF Sum of Squares Mean Square F Value Pr > F

Model 3 1461.1696 487.0565 0.84 0.478

Drug of C 1 424.3183 424.3183 0.73 0.3961

Meetings 1 0.6879 0.6879 0.00 0.9727

Len of Rec 1 1206.8233 1206.8233 2.07 0.1541


Demoaraphic


m _m K








87

relationship between the HSLI and a weighted combination of

variables. Therefore, hypothesis 8 was not rejected.

Hypothesis 9 stated that there was no significant

relationship between HSLI scores and a weighted, linear

combination of substance-abuse variables, treatment, and the

interactions of treatment with these substance-abuse

variables. The data analysis summary for evaluation of this

hypothesis is shown in Table 12. There were no significant

relationships, differences, or interactions. Therefore,

hypothesis 9 was not rejected.

TABLE 12

Multiple Regression Results for the HSLI, Substance-abuse
Variables, and Treatment Interactions with the Substance-
abuse Variables


Source DF Sum of Squares Mean Square F Value Pr > F


Model 7 2953.7396 421.9628 0.71 0.6633

Drug of C 1 259.2825 259.2825 0.44 0.5108

Meetings 1 88.2745 88.2745 0.15 0.7009

Len of Rec 1 730.2304 730.2304 1.23 0.2710

Group 1 18.4745 18.4745 0.03 0.8605

DC*Group 1 454.0910 454.0910 0.76 0.3847

Mtgs*Group 1 178.5050 178.5050 0.30 0.5851

Len*Group 1 456.9829 456.9829 0.77 0.3831


Hypothesis 10 stated that there was no significant

relationship between HSLI scores and a weighted, linear

combination of treatment, selected demographic variables,








88

selected substance abuse-variables, and the interactions of

treatment with the selected variables. Because prior

analyses did not yield sufficient variables to evaluate this

hypothesis, no statistical analysis was conducted for it.

Therefore, hypothesis 10 was not tested.

Jourard Self-Disclosure Questionnaire

Hypothesis 11 stated that there was no significant

relationship between JSDQ scores and a weighted, linear

combination of the demographic variables (i.e., gender,

race, age, and education). The data analyses summary for

evaluation of this hypothesis is shown in Table 13. There

was not a significant relationship between the JSDQ scores

and a weighted combination of the demographic variables.

Therefore, hypothesis 11 was not rejected.

TABLE 13

Multiple Regression Results for JSDQ and Demographic
Variables


Source DF Sum of Squares Mean Square F Value Pr > F


Model 6 34177.1734 5696.1956 0.46 0.8325

Gender 1 0.2334 0.2334 0.00 0.9965

Race 3 26463.2649 8821.0883 0.72 0.5433

Age 1 10662.0471 10662.0471 0.87 0.3539

Education 1 2855.0173 2855.0173 0.23 0.6308



Hypothesis 12 stated that there was no significant

relationship between JSDQ scores and a weighted, linear










combination of demographic variables, treatment, and the

interactions of treatment with these demographic variables.

The data analysis summary for evaluation of this hypothesis

is shown in Table 14. There were few significant

relationships, differences, or interactions. Hypothesis 12

was rejected, however, because there was a significant

gender-by-group interaction. The experimental group had a

mean of 280 for males and 246 for females. The control

group had a mean of 288 for females and 249 for males.

TABLE 14

Multiple Regression Results for the JSDQ, Demographic
Variables, and Treatment Interactions with the Demographic
Variables


Source DF Sum of Squares Mean Square F Value Pr > F


Model 11 128992.4560 11726.5869 0.99 0.4604

Gender 1 1007.7209 1007.7209 0.09 0.7709

Race 3 32514.7906 10838.2635 0.92 0.4363

Age 1 3794.6139 3794.6139 0.32 0.5724

Education 1 7349.9551 7349.9551 0.62 0.4326

Group 1 8747.3831 8747.3831 0.74 0.3921

G*Group 1 56562.5408 56562.5408 4.79 0.0318 *

R*Group 1 3232.5934 3232.5934 0.27 0.6023

Age*Group 1 24710.9606 24710.9606 2.09 0.1522

Ed*Group 1 43166.2425 43166.2425 3.66 0.0697

*p < .05










Hypothesis 13 stated that there was no significant

relationship between JSDQ scores and a weighted, linear

combination of substance-abuse variables (i.e., drug of

choice, number of weekly meetings, and months of recovery).

The data analysis summary for evaluation of this hypothesis

is shown in Table 15. There was not a significant

relationship between the JSDQ and a weighted combination of

variables. Therefore, hypothesis 13 was not rejected.

TABLE 15

Multiple Regression Results for the JSDQ and Substance-abuse
Variables


Source DF Sum of Squares Mean Square F Value Pr > F


Model 3 6055.2707 2018.4236 0.17 0.9189

Drug of C 1 115.2378 115.2378 0.01 0.9227

Meetings 1 5528.5037 5528.5037 0.45 0.5019

Len of Rec 1 0.8808 0.8808 0.00 0.9932



Hypothesis 14 stated that there was no significant

relationship between JSDQ scores and a weighted, linear

combination of substance-abuse variables, treatment, and the

interactions of treatment with these substance-abuse

variables. The data analysis summary for evaluation of this

hypothesis is shown in Table 16. There were no significant

relationships, differences, or interactions. Therefore,

hypothesis 14 was not rejected.










TABLE 16

Multiple Regression Results for the JSDO. Substance-abuse
Variables, and Treatment Interactions with the Substance-
abuse Variables


Source DF Sum of Squares Mean Square F Value Pr > F


Model 7 64029.2202 9147.0315 0.76 0.6221

Drug of C 1 47.6030 47.6030 0.00 0.9500

Meetings 1 25052.4009 25052.4009 2.08 0.1531

Len of Rec 1 6802.0190 6802.0190 0.57 0.4544

Group 1 3546.7267 3546.7267 0.29 0.5887

DC*Group 1 2722.1913 2722.1913 0.23 0.6357

Mtgs*Group 1 30781.3856 30781.3856 2.56 0.1138

Len*Group 1 46200.0447 46200.0447 3.84 0.0537


Hypothesis 15 stated that there was no significant

relationship between JSDQ scores and a weighted, linear

combination of treatment, selected demographic variables,

selected substance-abuse variables, and the interactions of

treatment with the selected variables. Because prior

analyses did not yield sufficient variables to evaluate this

hypothesis, no statistical analysis was conducted for it.

Therefore, hypothesis 15 was not tested.

Health Attribution Test

Hypothesis 16 stated that there was no significant

relationship between HAT scores and a weighted, linear

combination of the demographic variables (i.e., gender,

race, age, and education). The data analyses summary for




University of Florida Home Page
© 2004 - 2010 University of Florida George A. Smathers Libraries.
All rights reserved.

Acceptable Use, Copyright, and Disclaimer Statement
Last updated October 10, 2010 - Version 2.9.7 - mvs