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Personal Factors Influencing Impaired Professionals' Recovery from Addiction

Permanent Link: http://ufdc.ufl.edu/UFE0023846/00001

Material Information

Title: Personal Factors Influencing Impaired Professionals' Recovery from Addiction
Physical Description: 1 online resource (116 p.)
Language: english
Creator: Aissen, Kelly
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: 12step, aa, addiction, alcoholic, change, disease, doctors, ipn, na, nurses, prn, professionals, recovery, sobriety, spirituality, surrender, treatment, twelvesteps
Counselor Education -- Dissertations, Academic -- UF
Genre: Mental Health Counseling thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Alcohol and drug addiction are diseases that know no boundaries of profession, ethnicity, economics, gender, or age. This study examined the relationships among level of surrender, 12-step engagement, spirituality practices, and professional monitoring contract year among recovering impaired professionals and their stage of change. While professionals are often the last group of people suspected of alcohol and drug addiction, they are just as likely to suffer from this disease as are non-professionals. There is currently insufficient research discussing the unique needs of treating impaired professionals and the factors supporting post-treatment sobriety. The final sample consisted of 137 impaired professionals in recovery who had been diagnosed and treated for a substance abuse disorder, successfully completed substance abuse treatment, and were currently engaged in a five year contract with either the Intervention Project for Nurses (IPN) or the Professionals Resource Network (PRN) in the state of Florida. Participants completed an on-line survey that consisted of a demographic questionnaire, the University of Rhode Island Change Assessment (URICA), the Reinert S Surrender Scale, the Twelve-Step Participation Questionnaire (TSPQ), and the Spirituality and Beliefs Scale (SIBS). Findings suggested that 12-Step engagement was the most significant predictor of a participants? stage of change. Level of surrender, spirituality practices, and professional monitoring contract year were shown to be positively associated with stage of change. Therefore, discovering and achieving a balance of key personal factors that yield successful recovery practices and principles is the forefront for treating impaired professionals in recovery from addiction.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Kelly Aissen.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Amatea, Ellen S.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0023846:00001

Permanent Link: http://ufdc.ufl.edu/UFE0023846/00001

Material Information

Title: Personal Factors Influencing Impaired Professionals' Recovery from Addiction
Physical Description: 1 online resource (116 p.)
Language: english
Creator: Aissen, Kelly
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: 12step, aa, addiction, alcoholic, change, disease, doctors, ipn, na, nurses, prn, professionals, recovery, sobriety, spirituality, surrender, treatment, twelvesteps
Counselor Education -- Dissertations, Academic -- UF
Genre: Mental Health Counseling thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Alcohol and drug addiction are diseases that know no boundaries of profession, ethnicity, economics, gender, or age. This study examined the relationships among level of surrender, 12-step engagement, spirituality practices, and professional monitoring contract year among recovering impaired professionals and their stage of change. While professionals are often the last group of people suspected of alcohol and drug addiction, they are just as likely to suffer from this disease as are non-professionals. There is currently insufficient research discussing the unique needs of treating impaired professionals and the factors supporting post-treatment sobriety. The final sample consisted of 137 impaired professionals in recovery who had been diagnosed and treated for a substance abuse disorder, successfully completed substance abuse treatment, and were currently engaged in a five year contract with either the Intervention Project for Nurses (IPN) or the Professionals Resource Network (PRN) in the state of Florida. Participants completed an on-line survey that consisted of a demographic questionnaire, the University of Rhode Island Change Assessment (URICA), the Reinert S Surrender Scale, the Twelve-Step Participation Questionnaire (TSPQ), and the Spirituality and Beliefs Scale (SIBS). Findings suggested that 12-Step engagement was the most significant predictor of a participants? stage of change. Level of surrender, spirituality practices, and professional monitoring contract year were shown to be positively associated with stage of change. Therefore, discovering and achieving a balance of key personal factors that yield successful recovery practices and principles is the forefront for treating impaired professionals in recovery from addiction.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Kelly Aissen.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Amatea, Ellen S.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0023846:00001


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1 PERSONAL FACTORS INFLUENCING IMPAIRED PROFESSIONALS RECOVERY FROM ADDICTION By KELLY A. AISSEN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2008

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2 2008 Kelly A. Aissen

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3 To my maternal grandmother, Rosetta Powers Mackin GiGi, for showing me unconditional love and support.

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4 ACKNOWLEDGEMENTS I would like to thank my doctoral committee: Dr. Amatea, Dr. Sherrard, Dr. Smith, and Dr. Shehan for providing me with guidance a nd support in a variety of ways throughout my academic career at the University of Florida. I would like to thank my chairperson, Dr. Ellen Amatea, for her patience, support, and unwavering challenges to be a scholar. Dr. Amatea has been my mentor and role model for women in academia. Dr. Peter Sherrard has brought me strength and hope through his stories, has encourag ed and fostered my confidence as a clinician, and has taught me to believe in myself as is. Dr. Sondra Smith has been my mentor, supportive challenger, and model lib eral feminist. Dr. Smith has continued to encourage and mentor my roles as a clinician, an educator, and as a professiona l woman. Dr. Constance Shehan has been instrumental in all stages of my academ ic career at UF. Dr. Shehan has shaped my life since I took my first sociology course with her my freshman year in college throughout my masters and doctoral studies. Her guidance, wisd om, and mentorship will continue to help me throughout my career and life. I could not have completed this achievement w ithout my incredible village that is filled with family and friends. I am grateful to my parents, Kathleen & David Aissen for their continued support of my academic achievements and for instilling in me the importance of education. Id like to th ank my dad for cultivatin g the little scientist in me since day 1 and my mom for modeling the benefits of a village community. I am gr ateful to my brother Michael Aissen for his ability to make me laugh and serve as a constant re minder to take life a little less seriously. I am grateful to my maternal aunt, Dr Sara Lee Sanderson, for he r consistent belief in me and my academic pursuits. Id like to also thank my maternal grandmother, more affectionately known as Gigi to all, for showi ng me unconditional love and support. Gigi is an

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5 educated pioneering feminist before her time that has taught me more than she will ever know. I am grateful for her humble mentorsh ip and love throughout my life. My community of friends in Gainesville has been instrumental in the completion of my doctoral studies. I could not have completed this endeavor without their love and support. I am especially grateful to Shanaz & Mike Sawyer for their friendship and support as I completed this project. Shanazs spirit, laught er, and friendship have given me endless support as we have taken on this dissertation journey together. I am also extremely grateful for Joan Scully & Dan Ominski. Joan, Dan, & Jacob have provided me with a sense of family, lots of laughter, and endless emotional support. I am grateful for my friend and classmate, Jaime Jasser, for her endless chats on the trials of th e dissertation process, paving the way just a few steps before me to the finish line, her authenticity and candor as a friend, and offeri ng me another safe place to be just Kelly. As my best friend for the past 8 years Tracy Mi ller has continued to bring me support, laughter, and love. Tracy consistently fosters my spirit a nd allows me to be me as we share lifes joys and disappointment s. Last but not least, I would like to thank another friend of mine, Dr. Shannon Carter, for her unwavering friendship, role-modeling, love, laughter, and support. Shannon paved the way for me on my dissertation journey as I wa tched her achieve this amazing accomplishment and only hoped I would someday join her in this achievement. Shannon has been a key supporter in my life for th e past 10 years and I will be forever grateful for her guidance, love, and friendship. My or ange tabby Queso has provided love and support through his writing interruption reminders that its not all about me. I would also like to thank the following people for their varying role s of support and encour agement throughout my journey to professional and personal developmen t: Rachel Aissen, Razia & Andrew Ali-Hamm, Lisa Barlow, Earnestine Butler, Scott Carter, Elaine Casquarelli, Ginger Dodd, Pam Ellis, Kitty

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6 Fallon, Julie Giordano, Linda Goodwin, Peggy Gu in, Holly Henderson, Cassie Hessler-Smith, Rachel Hord, Nicole Karcinski, Deborah Kell ey, Michele King, Sherry Kitchens, Pat Korb, Virginia Leon, Arlene Leslie, Nancy Maas, Davi d Marshall, Brian Marshall, Esther Marshall, Tamara Martin, Helda Montero, Daryl Murvine, Alan Pappas, Julia Robbins, Deena Ruth, Christopher Sanderson, Elias Sarkis, Stephani e Sarkis, Meggen Sixbey, Tina Tannen, and Maryann Walker. I am thankful for my employm ent as a clinician in Shands Vistas Florida Recovery Center for the past 7 years. My career as a substance abuse therapist has encouraged my research agenda and allowed me to find the beauty and joy that recovery can offer. The knowledge, experience, and growth I have gain ed professionally and personally have been invaluable. I am grateful for Dr. Scott Teit elbaum and Dr. Kenneth Thompson, the current & former FRC medical directors, and Monica Guidry, director of addiction services, for their support of my research, allowing flexibility in my work throughout my doctoral program, and allowing me access to hospital services. Wit hout the support and encouragement from Dr. Raymond Pomm, the director of the Professionals Resource Network (PRN), and Jean DAprix, the director of the Intervention Project for Nurses (IPN) this study would not have been possible. Their support of my research allowed me access to the group leaders across Florida as I collected data. I am also thankful to the IPN and PR N group leaders who willingly gave my research materials to their professionals as a way to s upport addiction research and promote service back to the community. Most importantly, I am mo st indebted to the 137 recovering impaired professionals in Florida that took time out of thei r busy schedules to help foster research on the factors that are helping them stay in recovery from addiction. Lastly, I am grateful for my 10 year educationa l journey at the Univer sity of Florida, my eternal membership in the Gator Nation, and th e city of Gainesville for becoming home.

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7 TABLE OF CONTENTS page ACKNOWLEDGEMENTS.............................................................................................................4 LIST OF TABLES................................................................................................................. ..........9 ABSTRACT...................................................................................................................................10 CHAP TER 1 INTRODUCTION..................................................................................................................12 Statement of the Problem....................................................................................................... .12 Theoretical Framework.......................................................................................................... .17 Need for the Study..................................................................................................................19 Purpose of the Study........................................................................................................... ....20 2 REVIEW OF THE LITERATURE........................................................................................ 24 Introduction................................................................................................................... ..........24 Impaired Professionals......................................................................................................... ...24 Treatment of Impaired Professionals............................................................................... 27 Barriers to Impaired Profe ssionals S eeking Treatment...................................................29 Gender Differences among Im paired Professionals........................................................ 30 Monitoring Impaired Professionals................................................................................. 33 Transtheoretical Stage of Change Theory ............................................................................ 37 Surrender...................................................................................................................... ...........41 Twelve-Step Programs Alcoholics Anonymous.................................................................. 44 Summary of Relevant Research.............................................................................................. 58 3 METHODOLOGY................................................................................................................. 60 Research Variables.................................................................................................................61 Population..................................................................................................................... ..........62 Sampling Procedures..............................................................................................................63 Resultant Sample....................................................................................................................64 Instrumentation................................................................................................................ .......66 Stage of Change Scale University of Rhode Island Change Assessm ent (URICA)..... 66 Level of Surrender Reinert S Surrender Scale.............................................................. 67 Twelve-Step Engagement Twelve-ste p Participation Questionnaire (TSPQ) .............. 68 Spirituality Spirituality and Beliefs Scale (SIBS ).........................................................69 Contract Year of Professional Monitoring...................................................................... 69 Demographic Questionnaire............................................................................................ 70

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8 Data Collection Procedures....................................................................................................70 Research Hypotheses............................................................................................................ ..71 Data Analysis..........................................................................................................................71 Summary.................................................................................................................................72 4 RESULTS...............................................................................................................................75 Instrument Analyses............................................................................................................ ...75 Descriptive Statistics......................................................................................................... .....76 Hypothesis Testing............................................................................................................. ....77 Post-Hoc Analysis.............................................................................................................. ....84 Summary.................................................................................................................................85 5 DISCUSSION.........................................................................................................................87 Discussion of Study Findings................................................................................................. 87 Stage of Change...............................................................................................................87 Stage of Change and Surrender.......................................................................................89 Stage of Change and Twelve-Step Engagement............................................................. 90 Stage of Change and Spirituality..................................................................................... 93 Stage of Change and Professi onal Monitoring Contract Year ........................................ 95 Limitations of the Study....................................................................................................... ..97 Implications................................................................................................................... .........98 Theory..............................................................................................................................98 Research....................................................................................................................... ...99 Practice............................................................................................................................99 Recommendations for Future Research................................................................................100 Conclusion............................................................................................................................101 APPENDIX A INFORMED CONSENT......................................................................................................103 B PARTICIPANT POSTCARD..............................................................................................104 LIST OF REFERENCES.............................................................................................................105 BIOGRAPHICAL SKETCH.......................................................................................................116

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9 LIST OF TABLES Table Page 2-1 The Twelve Steps of Alcoholics Anonymous................................................................... 59 3-1 Resultant Sample Demographic Data N = 137................................................................72 4-1 Reliability Statistics, Mean s, and Standard Deviations ..................................................... 76 4-2 Descriptive Statistics for Inde pendent and Dependent Variables ......................................77 4-3 F statistics, p values, adjusted R2 values, and variances....................................................78 4-4 Regression Model #1 Pre-Contemplation Stage of Change (dependent variable) .......... 79 4-5 Correlation Matrix......................................................................................................... ....80 4-6 Regression Model #2 Contemplation St age of Change (dependent variable) ................. 81 4-7 Regression Model #3 Action Stage of Change (dependent variable) .............................. 82 4-8 Regression Model #4 Maintenance Stag e of Change (dependent variable) .................... 84 4-9 Regression Model #5 Action & Maintena nce com bined (dependent variables)............. 85 4-10 Results of Hypothesis Testing........................................................................................... 86

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10 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PERSONAL FACTORS INFLUENCING IM PAIRED PROFESSIONALS RECOVERY FROM ADDICTION By Kelly A. Aissen December 2008 Chair: Ellen S. Amatea Major: Mental Health Counseling Alcohol and drug addiction are diseases th at know no boundaries of profession, ethnicity, economics, gender, or age. While professionals are often the last group of people suspected of alcohol and drug addiction, they are just as likely to suffer fr om this disease as are nonprofessionals. The American Medical Associati on (AMA) defines an impaired professional as one who is unable to fulfill professional or personal responsibilities because of psychiatric illness, alcoholism, or drug dependency (AMA, 2006). This study examined the relationships among level of surrender, 12-step engagement, spir ituality practices, and professional monitoring contract year among impaired profes sionals in recovery from addiction and their stage of change. Prochaskas stage of change th eory offers a conceptualizati on of the changing beliefs and behaviors needed at various stages of the change process. The final sample consisted of 137 impaired professionals in recovery who had been diagnosed and treated for a substance abuse disorder, successfully completed substance abuse treatment, and were currently engaged in a five y ear contract with either the Intervention Project for Nurses (IPN) or the Professionals Resour ce Network (PRN) in the state of Florida. Participants completed an on-line survey that cons isted of an explanation of the study, directions, an informed consent, a demographic questionn aire, the University of Rhode Island Change

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11 Assessment (URICA), the Reinert S Surrende r Scale, the Twelve-Step Participation Questionnaire (TSPQ), and the Spirituality and Be liefs Scale (SIBS). Findings suggested that 12-Step engagement was the most significant predicto r of participants stage of change. Level of surrender, spirituality practices and professional monitoring cont ract year were shown to be positively associated with stage of change. Ther efore, discovering and achieving a balance of key personal factors that yield su ccessful recovery practices and pr inciples is the forefront for treating impaired professionals.

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12 CHAPTER 1 INTRODUCTION Alcohol and drug addiction are diseases th at know no boundaries of prof ession, ethnicity, economics, gender, or age. While professionals are often the last group of people suspected of alcohol and drug addiction, they are just as likely to suffer fr om this disease as are nonprofessionals. Forrest, Elman, Gizara, and V acha-Haase (1999) delineate professional impairment as having a diminished professional f unctioning attributable to personal distress, burnout, and/or substance abuse. Although the consequences for substance abusing professionals were once career debilitating, efforts to rehabilitate impaired professionals have grown with the implementation of programs such as the Intervention Project for Nurses (IPN) and the Professionals Resource Network (PRN). These programs are designed to monitor and support professionals as they reintegrate back into their careers follo wing their successful completion of substance abuse treatment programs. Statement of the Problem Addiction is endem ic in our society. According to the Nati onal Institute on Drug Addiction (NIDA) (2007), addictio n is defined as a chronic, re lapsing brain disease that is characterized by compulsive substance seeki ng and use, despite harmful consequences. Addiction to alcohol, nicotine, and illegal substances cost Americ ans upwards of half a trillion dollars a year when combining the medical, eco nomic, criminal, and social impacts (NIDA, 2007). Raia (2004) stated that approximately 20% of the population is at risk or is currently suffering from the disease of addiction. Each year more than 100,000 Americans die due to alcohol and drug related causes. Individuals who suffer from al cohol and drug addiction often have one or more additional me dical issues which often include lung and cardiovascular disease, stroke, cancer, and mental disorders (NIDA, 2007).

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13 Addiction is a complex disorder that involves every aspect of an individual's functioning. Increased knowledge about the etiology of the disease of addiction has allowed the public to view addictive disorders as t reatable (Cooper, 1989). Addic tion produces both psychological and physical symptoms. Regardless of whether th e alcohol and/or drug wa s obtained legally or illegally these substances still affect ones cr itical thinking, perceptions, attitudes, and skills (Adlersberg and MacKinnon, 2004). As the diseas e of addiction progres ses, there are common experiences throughout each stage. These stages encompass pers onal self-destructive behavior personally and socially, denial of current a nd future consequences, decreased levels of functioning, and negatively impacting families and friends as the cyclical patterns of addiction continue (Cooper, 1983; Johnson and Maddi, 1986; Zucker and Gomberg, 1986). The American Medical Association (AMA) defi nes an impaired professional as one who is unable to fulfill professional or personal resp onsibilities because of psychiatric illness, alcoholism, or drug dependency (AMA, 2006). Ex amples of warning signs of an impaired professional include but are not limited to: deterioration of personal hygiene, increased absence from professional functions or duties, emotiona lly lability, appears sleep deprived, increased incidence of professional errors, i.e. prescription s, dictations, clinical judgment, non-responsive to pages or telephone calls, shows a decreased concern for patient well being and unexplained personal problems to mask his or her defici ts in patient care, and/or increased patient complaints about the quality of care and bedside manner. In 1970, the Florida Legislature passed the Sick Doctor Statute which defined the inability to practice medicine with reasonable skill and safety and revised the grounds for professional discipline under the St ates Medical Practice Act. In the early 1970s, other states developed their own rules and regulations for impa ired professionals. In these early stages of

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14 professional monitoring, medical doctors were the primary focus. Professional monitoring systems were designed to protect the welfare of the public and support the in tegrity of healthcare systems (Hall, Pomm, Frost-Pineda, Gold, 2002). Addiction treatment for alc ohol and drug abuse is delivered in many different settings, using a variety of behavioral a nd pharmacological approaches. In the United States, more than 11,000 specialized drug treatment facilities provide rehabilitation, counseling, behavioral therapy, medication, case management, and other types of services to persons with addictive disorders. Research has documented the efficacy of substance abuse treatment, particularly those modeled after 12-step programs. Treatment cen ters throughout the United States often rely heavily upon Alcoholics Anonymous as a primary element of treatment and as an aftercare resource. Swora (2004) clarifies that Alcoholics Anonymous partic ipation and its principles are considered an effective treatment for alcohol ism, but Alcoholics Anonymous itself is not therapy. However, evidence as to the necessary components of successful addiction treatment for impaired professionals is lacking in the literature. Substance abuse treatment programs modeled after 12-step principles encourage clients to surrender to the process and needs of treatment and the devel opment of personal spirituality practices as components for living in healthy reco very. However, there is insufficient empirical data describing the nature of impaired professi onals recovery after completion of substance abuse treatment. More specifically, there is limited information about the surrender process, of 12-step engagement, of developing personal spiritual practices, and the influences of the general recovery process among impaired professionals. Surrender is assumed by many practitioners to be essential to addi ction recovery. Yet classifying, identifying, and/or defining surrender is often challenging. Th e surrender process is

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15 described as fundamental and carves its unique own path for each individual (Brown, 1995). Concepts of surrender are integr al components of active particip ation in 12-step programs. Brown (1985) asserts that recovery is a developmental proce ss with its own course which becomes pivotal when the individual accepts thei r loss of control and begins to accept their identity as an alcoholic. Reinert, Estadt, Fenzel, Allen, & Gilroy ( 1995) found that those who were more involved in Alcoholic s Anonymous scored higher on surrender scales compared to those with low levels of 12-step engagement a nd/or those involved in Rational Recovery, an alternate alcohol treatment group that does not advocate surrender or the benefits of spirituality practices in recovery. Speer a nd Reinert (1998) tested the relationship of surrender to the quality of ongoing recovery. Results i ndicated that those in the high surrender group had higher recovery scores; therefore, supporting the c onnection between surrende r and the quality of recovery (Speer and Reinert, 1998). Results also supported Browns (1985) theory that recovery is a developmental process. Hence the process of surrender is assumed to be an essential component of formal substance abuse treatment. This study examined the connection between a professionals level of surrender and the proc ess of self change from addiction. The foundational core tenets of Alcoholics Anonymous and other 12-step programs is that alcohol (or identified substa nce) is but a symptom of the di sease, and that recovery is dependent on much more than stopping the use of alcohol (Streifel and Servanty-Seib, 2006). Alcoholics Anonymous is the oldest, most well-known, and most successful mutual help organization on earth (Harvard, 2007). Alcoholics Anonymous is a worldwide fellowship of women and men who help each other maintain sobriety through sharing their experience, strength, and hope with each other at group meeti ngs and working the 12-steps. An important aspect of 12-step programs is the open-door po licy which allows entry to anyone who has a

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16 desire to stop drinking/using t oday. Therapies modeled after twelve-step practices and principles are the prevailing alcohol and drug treatment model in the United States for all genders and ethnicities (Hillhouse and Fiorenti ne, 2001). The main goal of hea ling is procured by relating to other members and their addiction experience. A majority of individuals receiving formal treatment usually attend Alcoholic s Anonymous (and/or other 12-step programs), even if for a limited time (Hillhouse and Fiorentine, 2001). Treatment centers throughout the United Stat es rely heavily upon Alcoholics Anonymous as an element of the treatment philosophy and as an aftercare resource. Twelve-step groups are attractive supplements to and sometimes alternatives to, formal treatment because they are easily accessible, free, and widely available in most communities across the world (Kahler, Kelly, Strong, Stuart, and Brown, 2006). An important delineation is that Alcoholics Anonymous participation and adherence to its principles are considered an e ffective treatment for alcoholism, but Alcoholics Anonymous itself is not therapy (Swora, 2004). Most treatment professionals will recommend Alcoholics Anonymous and/or add itional 12-step support in conjunction with formal treatment and therapy for all suffering fr om addiction. Addictio n specialists recommend simultaneous involvement in treatment and 12-st ep programs as an integral component of treatment and long-term recove ry success (Freimuth, 1996; Johnson and Chappel, 1994). Alcohol and drug use and spirituality have b een curiously intertwined throughout history (Miller and Bogenschultz, 2007). Di ctionaries define spirituality as concerned with or affecting the soul, not tangible or mate rial, and/or pertaining to God In practice, spirituality is experienced subjectively by any given individual (Morris, 197 0; Galanter, 2006). Currently, there is little known about the specific changes th at occur in an individua ls personal spirituality over the course of recovery. A ccording to Miller and Bogenschu ltz (2007), it is unclear whether

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17 an individuals spiritual developm ent is an antecedent, cause, or result of decreased substance abuse and dependence. While less is known about the actual effects of spiritual practices on those attempting sobriety from substance a buse, research on the practice of mindfulness meditation, an example of a spiritual practice, co ntinues to report an inve rse relationship to the abuse of alcohol, tobacco, and ot her drugs (Marlatt, 2007). Addiction medicine already encompasses in dividuals turning to alternative medicines rather than biomedical based treatments, a nd not only in Alcoholics Anonymous (Gallanter, 2006). Moreover, spirituality continues to be a central component in the treatment of and recovery from addiction. Researchers and clinic ians continue to provide testimonials from many individuals who have achieved sobriety both w ithin and outside of 12-step programs who report that spirituality is the driving force behind their sobriety. Literature across multiple disciplines supports the positive influence that spirituality ha s on the healing of an individual from a variety of diseases and disorders. The majority of treatment programs for addiction espouse spiritual progression (not perfection) as the primary goal for a healthy individual in recovery. The interface between spirituality and the treatment of substance abuse disorders has yet to be fully explored (Gallanter, 2006). This current st udy is designed to examin e the relationship of spirituality practices to the proce ss of self-change from addiction. Theoretical Framework The Transth eoretical Stage of Change th eory is an influential perspective for understanding the process of self change from substance abuse (Connors, Donovan, and DiClemente, 2001). The Transtheoretical Stage of Change theory hypothesizes that a person adopting a new behavior progresses through specif ic stages of change marked by distinct cognitive processes and behavior al indicators (Prochaska, 1991). This model represents an empirically derived multi-stag e sequential model of general change (Petrocelli, 2002). The

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18 structure of the Transtheoretical model ac knowledges the importance of a developmental perspective of change rather than a theoretical approach that exclusively focuses on personality characteristics or behaviors as predictors of change. This model also incorporates an understanding of the natural dynamic tendencies that individuals show regarding self-change (Petrocelli, 2002). The Transthe oretical Model has been applie d to addictions counseling and other health psychology research. Behavioral scientists recognized long ago that behavior was too complex to systematically and consistently respond to just one formal sc hool of interv ention (Samuelson, 2006). DiClemente (1991) and othe r behavioral scientists observe d that the vast majority of successful self-changers unconsciously follow an unwavering sequence of ac tivities and attitudes prior to finally extinguishing a pa rticular negative lifes tyle. These sequences of activities are now formulated into stages; the Transtheoretical approach is al so known as the Stage of Change Theory. These researchers believe that lifestyle changes occur by applying a mixture of motivation, facts, education, and action that vary in nature across the stages of change. Prochaska and DiClemente (1986) state that in adopting a new behavior people move through a series of four stages: 1. Pre-contemplation: The individual is not th inking about making a change. This stage is characterized by a lack of recognition of the problem. 2. Contemplation: The individual intends to make a change, but not in the immediate future. This stage is characterized by uncertainty. 3. Action: The individual actively a ttempts the change. The individual experiments with alternative behaviors. 4. Maintenance: The individual continues the changed behavior but it requires active or conscious effort to be sustai ned. A long-term reinforcement of the new healthier behaviors is need ed to stabilize the change in behavior.

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19 These stages were once considered linear, howev er now, each stage is viewed as part of a cyclical process that varies for each individual (Prochaska, 1994). Prochaska, DiClemente, and Norcross (1992) conceptualize the process of cha nge according to a spiral rather than a linear model, with relapse, regressi on to earlier stages, a nd recycling through the stages as change progresses. Need for the Study There is a substantial amount of research exam ining the pr evalence of addiction, the nature of addiction, and addiction treatment. Ho wever, there is insufficient research discussing the unique needs of treating impa ired professionals and the f actors supporting post-treatment sobriety. Impaired professionals are a growi ng sub-group of those diagnosed with addictive disorders. Professionals are just as likely to have addiction as non-professionals. The sub-group of impaired professionals is pa rticularly important to study as their impairment affects the welfare of others. Preventing harm to clients is vital regardless of the nature of the impairment as the results are similarly negative whether th e impairment is due to incompetence, unethical actions, or substance abuse (B issell, 1983; Emerson and Markos, 1996). Moreover, Verghese (2002) emphasizes the importance of upholding the moral obligation taken when becoming a licensed healthcare professional to do no harm. Impaired professionals enter treatmen t voluntarily, when mandated, or when experiencing disciplinary acti on (Monahan, 2003). When an indi vidual is progressing through the stages of the addiction process, ones career is usually the last sense of grounding one loses prior to intervention. Many impaired professionals will experience difficulty in their home life, other relationships, financially, and/or socially be fore admitting or recognizing that their ability to work is being threatened by the progression of the disease of addiction. Society puts professionals on a pedestal therefore professionals remain the leas t likely members of society to

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20 be suspected of substance abuse. The ability to maintain some le vel of functioning is one factor that allows the denial of impairment to cont inue within an impaired professional and their families. Externally well-functioning professionals find it difficult to admit and acknowledge that they have a problem that needs professional attention despit e being acutely aware of similar problems in others (Notman, Khantzian, and Ko uman, 1987). The concept of Physician, heal thyself, which originated biblically, has rema ined a prominent belief of many professionals (Jones, 1979). The concept of not needing help b ecause one is a helping professional, results in many impaired professionals not seeking treatment As a consequence, such professionals tend to be sicker and in greater danger when they finally do seek treatment. Relying on family support alone, fear that issues would not be kept confidential, fear of the stigma of addiction, denial about the severity of the addiction, and the beliefs th at they can fix themselves are common barriers to impaired professiona ls not seeking help (Deutch, 1985). Purpose of the Study Prochaskas stage of change th eory o ffers a conceptualizati on of the changing beliefs and behaviors needed at various stages of the change process. Hence the pur pose of this study was to examine the relationships between the level of surrender, 12-step engagement, spirituality practices, professional monitoring contract year, and recovering profession als reported stage of change. Research Questions 1. How does the participants leve l of surrender, 12-step engage ment, spirituality practices, and professional monitoring contract year predict the pre-contemplation stage of change? 2. How does the participants leve l of surrender, 12-step engage ment, spirituality practices, and professional monitoring contract year predict the contemplation stage of change? 3. How does the participants leve l of surrender, 12-step engage ment, spirituality practices, and professional monitoring cont ract year predict the action stage of change? 4. How does the participants leve l of surrender, 12-step engage ment, spirituality practices, and professional monitoring contract year predict the maintenance stage of change?

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21 Definition of Terms Abstinent Free from consuming any mind altering chemical substance. Action Stage of Change An individual actively attempts the change. The individual experiments with alternative behaviors. Addiction An addiction or dependence is a recurring compulsion by an individual to engage in som e specific activity, despite harmful consequences to the individual's health, mental state or social life. The term is often reserved for alcohol/ drug addictions but it is sometimes applied to other com pulsions, such as problem gambling, and compulsive overeating. Factors that have been suggested as causes of addiction include genetic, biological/ pharmacological and social factors (Lende and Sm ith, 2002). Addiction Medicine In the USA in the late 1980s, this became the preferred term for the branch of medicine dealing with alcohol and drug-related conditions. Contemplation Stage of Change An individual intends to make a change, but not in the immediate future. This stage is characterized by uncertainty. Disease Concept of Addiction The belief that alcoholism is a condition of primary biological causation and predictable natural history, conforming to accepted definitions of a disease. They lay perspective of Alcoholics Anonymous ( 1939)-that alcoholism, characterized by the individuals loss of control ove r drinking and thus over his or her life, was a "sickness"-was carried into the scholarly literatur e in the 1950s in the fo rm of the disease c oncept of alcoholism. (WHO, 2007). Impairment Diminished professional functioning at tributable to persona l distress, burnout, and/or substance abuse (F orrest et al., 1999). Impaired Professional A professional who is unable to de liver competent patient care due to alcoholism, chemical dependency, or mental illness. This also includes burnout or the sense of emotional depletion which comes from st ress (American Medical Association, 2006). Intervention Project for Nurses (IPN) the mission of IPN is to ensure public health and safety by providing an avenue for swift intervention/close monitoring and advocacy of nurses whose practice may be impaired due to the use, misuse, or abuse of alcohol and drugs, or a mental and/or physical condition. Maintenance Stage of Change An individual con tinues the changed behavior but requires an active or conscious effort to be sustained. A long-term reinforcement of the new healthier behaviors is needed to stabil ize the change in behavior.

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22 Professionals Resource Network (PRN) The purpose of the PRN Program is to ensure the public health and safety by assis ting the ill practitione rs who may suffer from one or more of the following: Chemical dependency, Psychiatric illn ess, Psychosexual illness, including boundary violations, Neurological/cognitive impairment, Phys ical illness, HIV infections/AIDS, and/or Behavioral disorders (Florida Department of Health). Pre-contemplation Stage of Change An individual is not thinking about making a change. This stage is characterized by a l ack of recognition of the problem. Professional A professional holding professional degrees (P h.D., MD, PharmD, DVM, LMHC) that most often require state licensure. Example careers: Doctors, Nurses, Pharmacists, Mental health Professionals, Prof essors, and Physician Assistants. Professional Monitoring Contract Year A professional holding a contract with either IPN or PRN will be in one of the five years of the contract. Year 0-1, 1-2, 2-3, 3-4, or 4-5. Spirituality Ones personalized experience and iden tity pertaining to a sense of worth, meaning, vitality, and connectedness to others and the universe. Spirituality Practices Examples: Praying, Meditation, Belief in a higher power, Journaling, being at one with nature, reading spiritual literature, engaging in intimate conversation with others. Each individual is able to define what practices are spiritual to them. This aspect of healing is inviting to those who s hy away from organized spirituality. Sponsor A more experienced member of a 12-step program who provides guidance to another member. Sponsors also have sponsors themselves Some of these relationships can last for years and become emotionally very close (Swora, 2004). Stage of Change A theory that represents an empirically derived multistage sequential model of general change (Petrocelli, 2002). Prochaskas stage of change theory is helpful when applied to changing risky lifestyle beha viors such as eating disorders, smoking, and excessive alcohol and/or drug consumption (Swora, 2004). Surrender The act of experiencing a nd participating in surrender involves an acceptance of ones limitations, giving up control to a power greater than onesel f, a shift from negative and aggressive feelings to more positive ones, and a sense of being at one with the world (Reinert, Allen, Fenzel, and Estadt, 1993). Transition Any event, or non-event, that result s in changed relationships, routines, assumptions, and roles (Schlossberg, 1984). Twelve-Step Program A twelve-step program is a set of guiding princi ples for recovery from addictive, compulsive, or other behavioral problems, originally developed by the fellowship of Alcoholics Anonymous for recovery from alcoholism (VandenBos, 2007).

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23 Twelve-Step Engagement Regular attendance at 12-step m eetings, has a home group they attend regularly, has a same gendered sponsor, spons ors others if applicable, provides service, willing to work the steps with their sponsor, and adheres to 12-step principles in ones daily affairs. Recovery Actively sober from all mind-altering subs tances. Being in recovery often includes active participation in 12-step programs a nd other forms of self improvement.

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24 CHAPTER 2 REVIEW OF THE LITERATURE Introduction There is a plethora of res earch on addiction; however, there is limited research detailing the intricacies of tr eating impaired professionals who are afflicted with addiction. Nevertheless, professionals are just as likely to be afflicted with this disease as the non-professional. A brief history of impaired professionals, their needs for treatment, and the treatment modalities, and post-treatment monitoring used with the impaired professional population are discussed in this chapter. In addition, literature on the influen ce of levels of surrender, 12-step engagement, spirituality practices, and Prochaskas transtheoret ical stage of change theory are discussed. Impaired Professionals When considering the issue of im pairment of pr ofessionals as a construct, it is crucial to define impairment precisely as there are severa l possible interpretations. On a broader level, Huprich and Rudd (2004) describe impairment as any thought, feeling, and/or behavior that leads to individual distress or dysf unction, that deviates from societ al norms, or that reduces the individuals level of adaptive control in his/ her environment (p. 45). According to the American Medical Association (2006), an impaired professional is defined as one who is unable to deliver competent patient care resulting from alcoholism, chemical dependency, or mental illness. Burnout and emotional depl etion which occurs from stress is also a part of impairment. Forrest, Elman, Gizara, and Vacha-Haase (1999) illustrate impairment as having diminished professional functioning attributab le to personal distress, burnout, and/or substance abuse, and unethical and incompetent professional functio ning (p. 632). Lamb, Presser, Pfost, Baum, Jackson, and Jarvis (1987) provide a comprehensive defi nition of impairment among professionals as interference in professional functi oning that is reflected in one or more of the

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25 following ways: (a) an inability and/or unw illingness to acquire and integrate professional standards into ones repertoire of professional be havior; (b) an inability to acquire professional skills in order to reach an acceptable level of comp etency; and (c) an inability to control personal stress and psychological dysfuncti on, and/or excessive emotional reactions that interfere with professional functioning (p. 598) Bissell (1983) outlines imp airment into incompetence, unethical actions or practice, and chemical depe ndency. Orr (1997) argues that constructs, such as impairment and ethical violations, may apply to the same individual, however, such constructs must be viewed as separate and distinct to work most effectively in each of the interventions. Preventing harm to clients is paramount, wh ether the cause is impairment, incompetence, or bad judgment. The distinctions of impair ment tend to blur, neve rtheless the results are similarly negative to clients (Emerson and Markos, 1996). Healthcare professionals have peoples welfare in their hands; therefore, their impairment is exponentially detrimental. McCrady (1989) discusses how alcohol and drug a buse may also lead to illegal and unethical activities, such as illegal procurement of prescriptions, taking patient medications, and stealing drugs from the office or hospital supplies. Verghese (2002) asserts that when becoming a licensed health professional one assumes a moral obligation to patients and fellow colleagues to help identify those who are tormented by the diseas e of addiction and take the appropriate action to help those in need get the he lp they deserve (p. 1510 ). Professionals are often protected from imme diate suspicion of impairment. Impaired professionals often possess a variet y of resources that allow them to continue in their disease such as money, job security, family support, and success in other areas their lives. While these resources may help an impaired professional no t experience as many consequences externally such as loss of employment, m oney, or family, the internal consequences such as depression,

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26 isolation, and negative se lf-esteem are still monumental. These resources inadvertently can become enabling factors, which can serve to dela y treatment and jeopardize eventual health for the impaired professional. Health care professionals expe rience a much higher risk of becoming impaired than other professionals. Wijesinghe and Dunne (2001) analyzed the nature and comorbidity of substance use and other psychiatric disorders in 157 impa ired practitioners reported to the Medical Practitioners Board in Victoria from 1983-1998. They found that comorbidity was much higher for alcohol (64%) than for drugs (26%). A nonsubstance induced psychiatric disorder coupled with an alcohol related diagnosis was most common when alcohol related diagnoses reached a recognizable threshold (Wijesinghe and Dunne 2001) Additional research findings show that 63% of the impaired practitioners were notified to the Board before the age of 45. This implies that if the impaired practitioners were left untreated, the community would be deprived of several years of service of highly trained and experienced professionals (Wijesinghe and Dunne 2001). A study of 375 physicians in California f ound that the largest source of physician discipline was negligence or incompetence, followed by alcohol/drug use (Dehlendorf and Wolfe, 1998). Wood, Klein, Cross, Lammers, and Elliot (1985) in a sample of licensed psychologists found that 38.5% of those surveyed reported being aware of a colleague whose work is affected by drugs and alcohol, 12.3% aw are of sexual inappropriateness, and 63% were aware of a colleague whose work is being affected by depression or bur nout. Thelan (1998) found in a study of 400 impaired health profession als that relationship problems, particularly divorce and major personal illness or injury, caused the most distress and impairment, and led to the use of maladaptive coping skil ls such as alcohol and drug a buse. Coombs (1997) described

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27 the signs and symptoms of alcohol and drug interference in an im paired professional as changes in appearance, failing to keep appointments, not meeting deadlines, experiencing ongoing interpersonal conflict with coworkers, disinterest in activities outside of work, social isolation, developing physical tolerance to drugs, and financial strain ca used by drug use expenses. Regier, Farmer, and Rae (1990) reported a high comorbidity between su bstance use disorders and other psychiatric disorders. Nace, Davis, and Hunter (1995) and Belts (1996) concurred on the existence of comorbidity be tween substance abuse disorders accompanying other psychiatric disorders among professionals who sought out treatment. Treatment of Impaired Professionals Im paired professionals may seek treatment on their own, but more often than not they seek treatment only after a disciplinary body or court has stipulated they must attend (Monahan, 2003). The United States and many other countr ies abide by a no tole rance policy when substance abusers are discovered. This no tole rance policy may prevent many impaired health professionals from seeking help. Health ca re professionals are viewed as pedestal professionals who are highly educated, responsib le people, and have earned their position of trust with patients and families. Health care professionals are one of the largest professional populations in need of substance abuse preven tion and treatment services. According to Monahan (2003), the behavior of im paired health professionals of ten has dire consequences for their social, financial, and ps ychological life. A unique n eed for impaired health care professionals to address in treat ment is the open access to drugs for those working in hospitals, pharmacies, and other medical settings. Monahan (2003) believes that health care professional impairment is frequently exacerbated by overwork, sleep deprivation, financial problems, and work settings providing access to drugs within th e context of a professional culture that views pharmacological agents as beneficial. Coombs (1997) discusses the heightened dramatic

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28 response and punitive responses to substance ab use among health care professionals compared to the general population. Until the implementation of diversion programs for impaired professionals arose in the 1970 s, the repercussions on the ca reers of substance-abusing professionals were severe. There was no rehabili tation available or supported for professionals disciplined for substance abuse; hence, when identified these professionals then lost their ability to practice. When developing substance abuse treatment fo r impaired professionals, certain features of their impairment must be considered. Wijesi nghe and Dunne (2001) describe five features of impairment that need to be addressed in treatment planning: (1) impa irments which are notified to Boards are the result of serious disorders that usually progress relentlessly to significant incompetence, (2) the majority of impaired pr ofessionals require expe rt on-going psychiatric care, (3) early engagement in treatment is imperative if risk to patient ca re is to be minimized, (4) in the absence of close monitoring the relaps e rate is high for substance abuse disorder, and (5) most impairments occur within the first two d ecades of a practitioners career and therefore if left untreated the economic loss to th e community can be heavy (p. 100). An initial assessment, detoxification, and st abilization are completed before a detailed treatment plan can be developed. The typical tr eatment for impaired professionals includes an initial assessment, an inpatient evaluation and stabilization, and 10-14 weeks in a PartialHospitalization Program (PHP) to address their physical, psychi atric, psychological, social, spiritual, and family needs (Talbott, 2007). Physicians, nurses, attorneys, professors, pharmacists, corporate executives and other profe ssionals are examples of those who may have unique issues that require specialized groups an d programming to address the shame, guilt, and recovery issues associated with their addicti on. The majority of impaired professionals in

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29 substance abuse treatment are trea ted in a partial-hosp italization setting. Partial Hospitalization Programs (PHP) for Impaired Professionals encompass medication management, individual therapy, implementing a 12-step way of life, and various groups that addr ess professional and profession-specific issues, relapse prevention, lif e skills, family therapy, spirituality, trauma, both mens and womens sexual issues, gender issues, meditation, and mindfulness trainings (Talbott, 2007). Partial-hosp italization programs are a unique blend of on-going effective therapies which emphasize the importance of lear ning sober-living skills while residing with peers. Integrating into local recovery mee tings while in treatment combine for an ideal environment for the newly recovering professiona l. Both men and women (26 years and older) struggling with addiction and/or a dual diagno sis are facing specific i ssues and challenges. Professionals who meet criteria for an impaired professional program come from a variety of fields including but are not limited to: medical doctors (MD), dentists (DDS), veterinarians (DVM), physicians assistants (PA), nurse s (ARNP, RN, LPN), pharmacists (PharmD), professors/teachers, therapists (Psychologists, LMHC, LMFT, LCSW), a ttorneys, and pilots. The criteria assessed when enrolling a professi onal in an impaired professionals program includes: (a) professional status/licensure, (b) impairme nt severity, and (c) individual treatment needs (psychiatrically, physically, and legally). Barriers to Impaired Professionals Seeking Treatment Thoreson and colleagues (1983) argue that impa ired professionals find it difficult to seek help because of their belief in their infinite power and invulnerability. This way of thinking creates and perpetuates the intern al views of being terminally unique, a term often used in 12step recovery literature. Tyseen, Rovik, Va glum, Gronwold, and Ekeberg (2004) surveyed 631 Norwegian medical students completing their last year in medical school throughout their third and fourth years of residency where they were practicing their specializations. Tyssen and

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30 colleagues (2004) reported findings that these young physicians gave a variety of reasons for not seeking help therefore suggesting the irrationality of s eeking help may be caused by shame, denial of psychological problems, re luctance to adapt to the role of a patient, and a lack of trust in psychiatry or the available mental health pr ofessional (p. 990). Thes e irrationalities connect to the identification concerns most unique to impa ired health care professionals. Most health care professionals recognize they will certainly face legal sanctions and lose the ability to practice if they are caught. Many impaired professionals will risk relationships with partners and families, become financially depleted and in de bt, and compromise their physical, emotional, and spiritual health before jeopard izing their ability to practice and support themselves (Boisaubin and Levine, 2001). Gender Differences among Impaired Professionals Barriers to accessing sub stance abuse treatmen t are gender specific. Lack of childcare resources, feelings of shame and guilt, and societal stigmas are some of the main obstacles for women. The stigma of being labeled an alcoholic and/or an a ddict continues to hinder many women from seeking appropriate treatment, especially those with children. Society judges such behaviors as deviant and not conforming to appropriate female, motherly, or professional behaviors. Gender specific treatment opportuni ties are a start to addressing the barriers professional women face. Notman, Khantzian, and Koumans (1987) repor ted that physicians we re usually keenly aware that substance abus e challenged their social legitimac y. Deutsch (1985) studied a diverse group of therapists to explore th e variety of reasons for not se eking professional help; results indicated a variety of justificati ons for not receiving any treatment: Therapists believed that an acceptable therapist was not available, they sought help from family members or friends, they feared exposure and the disclosu re of confidential information, they were concerned about the

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31 amount of effort required and about the cost, th ey had a spouse who was unwilling to participate in treatment, they failed to admit the seriousness of the problem, they believed that they should be able to work their problems out themselves, a nd/or they believed that therapy would not help them (p. 167). Bennet and ODonovan (2001) a nd Hughes (1992) suggested th at public image and even idealization may make it difficult for physicians and nurses to ask for help or admit problematic behaviors. Society puts prof essionals on a pedestal as do the professionals treating the identified impaired professionals. In the mi nd of the treating professi onal, the stereotypical substance abuser is most likely to be some one with different demographic and personal characteristics than the professi onal, particularly the physician (Notman et al., 1987). Pearson (1975) describes this process as professionals having blind spots, in which ascribing to the stereotyped views of addicts prev ented them from considering a ddiction as a possibility in a professional who is a patient. This constitutes one of many enabling factors experienced by an impaired professional. Emotional barriers appear to be more detr imental to professionals while the physical barriers appear more prevalent for the non-professional. Notman and colleagues (1987) reported that many individuals who become dependent on s ubstances also had a character structure that aligned with a reliance on denial, fantasies of ma gical rescue, or resoluti on and other defenses that make treatment difficult. Denial is a wi dely used mechanism when a physician (or any other professional) becomes ill or impaired (Waring, 1974). Notman and colleagues (1987) noted that it was common for well-functioning professionals to have difficulty acknowledging the extent of their own illness while being acutely sensit ive to similar problems in others.

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32 Shame is a common emotion felt by those attemp ting to achieve sobrie ty. According to Scheiber and Doyle (1983) the ac knowledgement of having a problem that is out of control threatened aspects of ones professional identi ty and personal vulnerability. For the impaired professional, disclosure of problem s often entails role reversal which in turn heightens the shame felt. Being the patient versus the expert often threatens the professionals self-esteem which intertwines back to professional identity (Notman et. al, 1987). A barrier to treatment that becomes apparent, particularly with impaired pr ofessionals, is the illusion that the problem remains under control by not revealing the de pth or severity of the challenges surrounding their addiction. Notman and colleagues (1987) views the concealment that is often attempted by impaired professionals in treatment as often de fensive, less conscious, and may become part of complicated positive or negative transference. Additionally, shame and embarrassment are integral emotions felt by impaired professionals. Role conflict is a constant struggle for the impaired professional as the embarrassment and shame that surrounds acceptance of addiction is not consistent with the im age of a professional. Fear of the stigma attached to addiction and other mental health disorders serves as another barrier to professiona ls seeking help. Tyssen and colleagues (1994) studied young physicians over a four year pe riod from medical school through residency. Results indicated trends of decreased help-seeki ng behaviors over time. The researchers hypothesized that the decrease in help-seeking behavior among young physicians was a re sult of believing they did not need help in addition to the fear of others knowing they needed help. Baxter, Singh, Standen, and Duggan (2001) and Givens and Tija (2002 ) concur that physicians shame is often compounded when the possibility of stigmatization for having a mental disorder is increased. King, Cockcroft, and Gooch (1992) studied the emotional stress factors of physicians and

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33 discovered decreases in help-seeking behavior s. Unfortunately, decreasing help-seeking behaviors frequently leads to inappropr iate health care use among physicians. With an increasing number of practitioners going into private pract ice, the opportunities for colleagues to observe unethical or inept practice decreases signifi cantly (Goleman, 1985 and Khinduka, 1987). The more isolated the impaired professional, the le ss likely they will get caught. Consequently, the offense must then become grave enough to get attention. Other enabling factors that prevent impaired professi onals from seeking or ending up in addiction treatment sooner include: money, enabling pa rtners (personal and business), children, reputation, and/or their ca reer itself. Due to these enabling fa ctors, impaired professionals suffer less from external consequences, which are the us ual impetus to enter treatment, voluntarily or not (Thompson, 2007). The lack of external conseque nces allows the impaired professional to be in denial about the severity of their disease. Hughes, Conrad, Baldwin, Storr, and Sheehan (1991) and Trinkoff and Storr ( 1999) reported that when heal th care professionals were perceived to be in distress, their families and co-workers often conspired with avoidant responses, thereby encouraging silence and withdrawal. Monitoring Impaired Professionals The m edical profession, and other professions working with people, mandate to do no harm which dates from the time of Hippocrates (D aniel, 1984). Reamer (1992) reported several organized efforts to identify and address the problems of impaired professionals. Organized efforts to address impaired workers have their historical roots in the late 1930s and early 1940s following the emergence of Alcoholics Anonymous (AA) and the need during World War II to retain a sound work force (Reamer, 1992). Earl y occupational alcoholis m programs developed in the early 1970s eventually l ead to the origin of Employee Assistance Programs (EAP).

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34 Employee Assistance Programs were originally designed to addr ess a broad range of problems experienced by workers. Strategies for dealing with professionals whose work is affected by problems such as substance abuse, mental illness, and emotional stress are more prevalent and visible today. The United States began diversion programs for heal th professionals in th e 1970s (Monahan, 2003). The United States and other countries abide by a no tolerance policy when substance abusers are discovered. The no tolerance policy may prevent many impaired health professionals from seeking help as they are unsure of the protection they will receive in order to get the help they need (Monahan, 2003). Diversion programs are view ed as a saving of suffering and dollars for health professionals and their families while they allow health professionals to stay on the job and continue meeting population health needs (Monahan, 2003). Professionals, particularly health care professionals, owe soci ety the degree of security that they are in safe care (Daniel, 1984). A study comprised of psychiatrists, non-psychiatric physicians, psyc hologists, and social workers seeking treatment found that 86% of the respondents said ab solutely yes or probably when answering if licensing boards should be able to require therapists who have violated professional standards to obtain therapy as a condition of their continuing or resuming practice (Katsavdakis, Ga bbard, and Athey, 2004). According to Boisaubin (2001), at least 39 stat es have sick doctor statutes that permit licensure suspension for medical doctors found to be unable to pr actice medicine with reasonable skill and safety because of illness or use of drugs or alcohol. Howe ver, a number of states have immunity for physicians, and other licensed prof essionals, who seek treatment voluntarily, and have adopted legislation requiring impaired doctors to get treatment and be monitored in order to keep their licenses. Hall and colleagues (2002) believed that physicia n treatment was unique

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35 because most treatment is involuntary or coerced. This implies that physicians tend to be sicker when they enter treatment. Physicians entering treatment have higher rate s of social dysfunction, more medical consequences, and are simply co mplicated to treat (H all et al., 2002). Florida is one of many states that have developed a diversion program for impaired professionals. There are two main Florida monitoring systems for impaired professionals; the Intervention Project for Nurses (IPN) and th e Professionals Resource Network (PRN). The Professionals Resource Networkwas established in the late 1970s after th e sick doctor statute was passed. The Florida Medical Practice Act allo ws the confidential treatment of physicians with impairments (Goetz, 1995). The Intervention Project for Nurses (IPN) was established in 1983 through legislative action to ensure public health and safety through a program that provides close monitoring of nurses who are unsafe to practice due to impair ment as a result of misuse/abuse of alcohol and/or dr ugs or due to a mental or physic al condition which could affect the licensee's ability to practice wi th skill and safety (IPN, 2007). Participation in PRN or IPN is confidential unless there is failure to progress in treatment. The PRN program was originally designed only for doctors until the need to monitor other health care professionals became evident. The Florida PRN program has grown from a program designed only for physicians to one that covers the entire spectrum of health care workers. The success of the Professionals Resource Networkled to similar programs being developed specifically for teachers and attorn eys. The Professionals Resource Networkgains approximately 200 new referrals each year. Appr oximately 84% of the referrals to PRN occur prior to any violation of the Me dical Practice Act or any evidence of patient harm (Goetz, 1995). The three medical specialties most represented are anesthesia, emergency medicine, and family medicine. The mission of Florid as IPN and PRN programs, connect ed to the Florida Boards of

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36 Nursing and Medicine, are to pr otect the welfare and safety of the public, while supporting the integrity of the healthcare system (Hall et al, 2002). The goal of PRN/ IPN and other diversion programs is to monitor these individuals under a fi ve-year contract as they reintegrate back to work and society as a recovering professional. Key components of an IPN/PRN contract require the impaired professional to participate fully in professional recovery meetings, 12-Step meetings, psychiatric assessments, follow-up appointments, and random urine drug screens throughout the entire length of the five year co ntract. The contract does not begin until the impaired professional has successfully completed addiction treatment. Other requirements that may be part of a professionals contract may include participation in individual and/or group therapy, medication monitoring, and work restri ctions surrounding access to narcotics (Roy, 1994). Hall and colleagues (2002) found that 91.4% of randomly selected PRN recovering physicians returned to work succes sfully after five years. Fact ors distinguishing those physicians who were unable to return to work from those that were able to work were frequently due to (a) opioid addiction, (b) had higher frequency of intr avenous (IV) drug use, (c) had more significant medical problems related to using, and (d) had more psychiatric comorbidity. According to Brooke, Edwards, and Taylor ( 1991), outcomes from Impaired Physician Programs in America have been encouraging, with about 75% of the participating physicians becoming drug free and practicing at follow-up periods ranging between two and eight years. Gold and Pomm (2001) analyzed data collected by the Florida Prof essionals Resource Netw orkon success rates of physicians in long-term treatment that are addicted to drugs and/or alcohol. Researchers selected case files of 24 doctors; 23 of the 24 were men, and ranged in age 30-63. Nearly 40% of the participants were once intrave nous drug users. This recovery was documented by counselors,

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37 psychiatrists, urine drug screens, and by records as to when they returned to work over the five year PRN monitoring period. Fi ndings reported that 22 of 24 Florida doctors who began treatment in a variety of inpatient and outpatient settings in 1995 were sober and leading a life of recovery in 2000 (Gold and Pomm, 2001). Gold (2001) states the five-year recovery rate among physicians is remarkable, 9 in 10 are alcohol and drug-free and have returned to work successfully. However, some medical profession als chose to leave the state when they were sanctioned or to give up their professional li censes once mandated (Gold, 2001). Thus data suggests once professionals commit to their cont ract with IPN/PRN, treatment becomes and continues to be effective. Transtheoretical Stage of Change Theory The Transth eoretical or Stag es of Change (SOC) theory has particular currency in contemporary health psychology (Prochaska and No rcross, 1998). The Transtheoretical model of change represents an empirically derived multistage sequential model of general change (Petrocelli, 2002). In seeking to understand how people change maladaptive patterns of behavior such as compulsive drinking, behavioral psychol ogists have developed a number of models over the years to explain and predict behavioral change, with the ultimate goal of creating psychotherapeutic interventions to assist in behavior change (Swora, 2004). Clinicians and researchers in health care and so cial services have found the Transtheoretical stage of change model helpful when applied to changing risky li festyle behaviors such as eating disorders, smoking, and excessive alcohol and/or drug consumption. When individuals are at different stages of change, they may have different attitudes, beliefs, and motivations with respect to the desired new behavior (Prochaska and DiClemente, 1986). According to Prochaska, Velicer, and Guadagnoli (1991), the Tr anstheoretical Model hypothesizes that a person adopti ng a new behavior progresses through specific stages of

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38 readiness to change marked by distinct cognitive processes and behavioral indicators. The Stage of Change theory may be applied to various disciplines and processe s of desired change. Although the Transtheoretical model of change theory has typically been inve stigated in the area of addictions counseling, the empirical base and implications for client readiness for change have tremendous potential for counseling in general (Petrocelli, 2002). Prochaska and Velicer (1997) discussed how the Transtheoretical model of change explains intentional behavior change along a temporal dimension that utilizes both cognitive and performance based components (p. 40). Three decades of research on this model validate that individuals move through a se ries of stages in the adoption of healthy behaviors or in the cessation of unhealthy ones. Prochaskas model entails six stages: (1) Pre-contemplation, (2) Contemplation, (3) Preparati on, (4) Action, (5) Maintenance, and (6) Termination. The Precontemplation Stage is noted by an individuals lack of awareness that life can be improved by a change in behavior. This indi vidual has no intent to change be havior in the near future, and is often characterized as resist ant, unmotivated, and avoiding of discussion around the behavior in need of change (Prochaska et al., 1992). Individuals in the Contemplation Stage are open in their intention to change within the next six m onths. These individuals are more aware of the benefits of changing but remain keenly aware of the costs and the actions needed to bring about change. Contemplators are often seen as ambivale nt to change or as procrastinators (Prochaska and DiClemente, 1984). Individuals who report that they intend to take action within the next month are categorized as in the Preparation Stage. The Preparation Stage is considered a transitional stage where introspection about the decision, reaffirmation of the need and desire to change, and the completion of the final pre-action steps are ta ken (Grimley, Prochaska, Velicer, Blais, and

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39 Diclemente, 1994). The Action stage is one in which an individual modifies their behavior, experiences, or environment in order to overcom e their problems (Proch aska et al., 1992). Action involves the most overt behavioral changes and requires considerable commitment of time and energy (Prochaska et al., 1992). Maintenance stages involve working to prevent relapse and to consolidate the gains made while in the Action Stage. Maintainers can be distinguished from persons in the Action Stage as they report higher levels of self-efficacy and are less tempted to relapse (Prochaska and DiCl emente, 1984). It is important to note that maintenance is a continuation of action, not an absence of change. For some behaviors, maintenance may be considered to last a lifetime. Prochaska and colleagues (1992) report s tabilizing behavior change and avoiding relapse are the hallmarks of maintenance (p. 1104). The Relapse stage is likely to occur if purposeful maintenance actions are not adhered to (Prochaska and Velicer, 1997). Gorski and Millers (1982) model of relapse states that behaviors and attitudes either lead to recovery or to relapse. Relapse is a common a nd often an expected occurrence in addiction recovery (Gerwe, 2000). DiClemente and colleagues (1991) suggest that each stage has interacting components which the individual will likely cycle through a nu mber of times before achieving the sustained behavior changes. McConnaughy, DiClemente, Prochaska, and Velicer (1989) cross-validated the Stages of Change Scales using a new clinical sample (N = 327). The scales consiste d of the: Stages of Change Scales, Symptom Checklist Battery, and the Millon Clinical Mu ltiaxial Inventory. McConnaughy and colleagues (1989) originally produced a pattern within the scales where adjacent stages correlated higher that the nonadj acent stages. This indicates when clients change, it is somewhat predictable from one stage to the next (Prochaska, 1979). A cluster

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40 analysis of the new data indica ted it was possible for clients to be simultaneously engaged in attitudes and behaviors descri bed by more than one stage at a time (McConnaughy et. al, 1989). Clients continue to move from one stage to the next in sequence; however fluctuation of stage involvement may occur more fluidly. The scales measure four of the distinct stages: Precontemplation, Contemplation, Action, and Maintena nce. The means and standard deviations were closely reproduced suggesting these descriptive statistics could be used for clinical norms (McConnaughy et. al, 1989). Results of the replicat ion study confirmed the original findings that the Stages of Change Scales provided a reliab le method of measuring stages of change in psychotherapy (McConnaughy et. al, 1989). OHea, Boudreaux, Jeffries, Carmack-Taylor, Scarinci, and Brantley (2004) examined the influence of self-efficacy in predicting stag e of change movement, without intervention, over a 1-month period for desired smoking cessation, exercise adoption, and dietar y fat reduction. In this longitudinal study, stage of change and self-e fficacy were assessed at baseline, and at the 1month follow-up. Validated stage of change and self-efficacy scales were administered to 554 low-income, predominantly African American in dividuals attending primar y care clinics in a large inner-city academic hospital in the southeas tern United States. Chi-square analyses were used to determine the ability of self-efficacy to predict stage movement at the 1-month followup. Results indicated that self-efficacy influenc es stage of change movement for all three outcomes. Statistically significant differences between predicted and actual stage of change movement were found for smoking cessation, exer cise adoption, and dietary fat reduction. Thirty-seven percent of smokers who were predicted to pr ogress on the basis of their selfefficacy scored progressed, as did 50% of exercise adopters, and 44% of dietary fat reducers.

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41 This research also suggests that self-efficacy is central for behavior changes that involve an adoption of new behavior or the cessati on of old behaviors (OHea et. al., 2004). Henderson, Saules, and Galen (2004 ) investigated the efficacy of the stages of change scales of the University of Rhode Is land Change Assessment (URICA) (McConnaughy, Prochaska, and Velicer, 1983) questionnaire in a heroin-addicted poly-substance abusing treatment sample. At the begi nning of a 29 week treatment peri od, 96 participants completed the URICA assessment and three weekly urine drug sc reens. After controlling for demographic variables, substance abuse severity, and treatment assignment, multivariate multiple regression analyses revealed that the stages of change sc ales added significant pow er to the prediction of heroin and cocaine free urine samples (Henders on, Saules, and Galen, 2004). Additionally, selfreported readiness to change at the beginning of treatment is an important determinant of drug free treatment outcomes. Surrender Tiebouts (1961) clinical observations led him to theorize that the pr ocess of change in those suffering from addiction, particularly thos e exposed to the 12-step s, is one of hitting bottom, surrendering, ego reduction, and maintaining humility. Earlier studies indicate Tiebout (1953) made an important distinction between compliance and surrender. Compliance is engaging in the treatment process and doing all that is expected; however, unconscious forces seem to resist the process of change. Surrender, in contrast, is a complete engagement with reality, conscious and unconscious. Surrende r is the moment of accepting reality on the unconscious level where ones defenses no longer work. Surrender involves an acceptance of ones limitedness, giving up control to a higher power, a shift from aggressive and negative feelings to positive ones, and a sense of being at one with the world (Reinert, 1999). According

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42 to Reinert (1999), surrender appears to be characterized by an acceptance, a lack of resistance to change, and the person is no longer fi ghting the need for treatment. Harry Tiebout (1949, 1953, 1954, and 1961), a psychi atrist and avid researcher of the change process in alcoholics, opined that cha nge occurs when an individual hits bottom, surrenders, and has their ego reduced. Therefore, an individual no longer fights life but accepts it. The act of surrender is a moment when th e unconscious forces of defiance and grandiosity cease to function effectively and the individual begins to accept life (Tiebout, 1949). The recovery process involves a conve rsion that results in a positive attitude toward reality following an act of surrender (Tiebout, 1949). The importance for the distinction between compliance and surrender hails from skewed treatment outcomes. These distinctions serve to explain why some individuals who appear to engage in treatment are solely complia nt but do not experience lasting change whereas those individuals who truly su rrender respond more successfully (Reinert, 1999). Brown (1985) suggested that when an individual develops a con cept of a higher power they will have the ability to sustain surrender. Achieving surrender involv es the maintenance of humility. Reinert (1999) describes maintaining humility as acknowledging a power greater than oneself and turning ones life ove r to the care of a Higher Powe r. Speer and Reinert (1998) suggest that surrendering grandios ity and defiance, which resists the treatment process, is an important element. The challenge is in the early stage of the recovery pr ocess, the goal is to embrace an identity that includes a healthy sense of meaning and purpose, to develop a relationship with ones higher power in order to sustain surrender, and to find new ways to organize and interpret ones life and ones relationships (p. 28).

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43 There is a paucity of research utilizing surrender as a vari able. This study aims to provide more empirical data for its importance in the role of those in r ecovery from addiction. Reinert (1999) examined the relationship be tween surrender and narc issism while assessing change over alcohol treatment. Each of the 65 participants (16 = female, 49 = male) were given five instruments to complete, first at admission to treatment and then again a month later at the end of the participants treatment. The inst ruments used were the Surrender Scale, the Narcissistic Personality Invent ory, the Minnesota Multi-phasic Personality Inventory (MMPI-2), the Shipley Institute of Living Scale, and the Addi ction Severity Index (ASI). Indices were reassessed with the participants at admission to trea tment, one month into treatment, and at the end of their prescribed treatment. Results indicat ed that surrender scores improved over treatment for all of the 65 participants. Pathological narcissism decreased over treatment only within the high change group but not within the low change group. The mean surrender score at admission was 16.2 (SD = 3.6); one month later the mean surrender group was 19.2 (SD = 3.8). The shift in surrender was statistically si gnificant, according to the paired t -test procedure, t (64), 5.54 p < .001 (Reinert, 1999). These findings are congruent with Tiebouts (1961) theory, which believes the act of surrender helps reduce pat hological narcissism (Reinert, 1999). Speer and Reinert (1998) completed a pilot st udy comprised of 31 former clients (78% male, 22% female) of a Minnesota model treatmen t program in the rural mid-west who had been discharged from treatment at least one year prio r to the outset of the study. Two instruments were used, the Recovery Scale (Speer, 1995), designed to measure the qual ity of recovery of those who had experienced alcohol abuse or depe ndence, and the Reinert S Scale (1997) which was designed to measure surrender as defi ned by Tiebouts research (1944, 1949, 1953, 1954 & 1961). As hypothesized, those participants who were more involved in Alcoholics Anonymous

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44 (AA) scored higher on the surrend er scale than those participants with low involvement and those involved in Rational Recovery, an alcohol treatment group that does not advocate surrender to a higher power as a pa rt of their recovery process (R einert et al., 1995). Speer and Reinert (1998) reported that the High Surrender group had higher recovery scores consistent with the theory that there was a connection between su rrender and the quality of recovery. Those who maintained an attitude of surrender in this study appeared to have a highe r quality of recovery. However, the researchers noted th at a serious limitation of the study was the low response rate and lack of a representative sample. The results may not be indicative of anything beyond the current sample but it does suggest important implic ations for future resear ch (Speer and Reinert, 1998). Because there is a need fo r additional empirical research on the influence of concepts of surrender in addiction treatment this study seeks to determine whether an impaired professionals level of surrender is strongly rela ted to their stage of change. Twelve-Step Programs Alcoholics Anonymous It has been argued that Alcoholics Anonym ous (AA) is the most effective method to arrest alcoholism (Snyder, 1980). Founded in 1935, AA is the oldest, best known, and most successful mutual help organi zation available (Harvard, 2007) Alcoholics Anonymous is a worldwide fellowship of women and men who help each other maintain sobriety through sharing their experience, strength, and hope with each other at group meetings and working the 12-steps (see Table 2.1) designed for personal recovery of alcoholism (Streifel and Servanty-Seib, 2006). Alcoholics Anonymous does not engage in medical or psychiatric tr eatment and is selfsupporting through its own groups and memb ers (Alcoholics Anonymous, 1976, 1981). The only requirement for AA membership is a de sire to stop drinking (AA, 1976). Research estimates two million people are members of Alcoholics Anonymous and AA groups exist in over 150 countries across the worl d (AA fact file, 2003). Other twelve-step programs (ex: NA,

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45 OA, Al-Anon, SLA) were further developed and patterned after that of AA to help those recovering from other addictive substances such as narcotics, food/eating disorders, sex/relationships, gambling, overspending, and co dependency continue to benefit from the 12steps first outlined in AA. The founders of Alcoholics Anonymous believe that through participation in the AA program, individuals learn that they have a disease that prevents them from being able to predict and control their drin king in a consistent manner. They become aware of the destructive patterns of alcohol use, co me to acknowledge a loss of control over their drinking, and learn to understand that recovery is a lifelong pr ocess (AA, 1976). Twelve-step programs emphasize the acceptance of things over which there is no control, along with the development of the courage to change those things which can be controlled (Niebuhr, 1950). Individuals come to learn what it is they do ha ve control over, and learn how to use the tools available to them to control various aspects of their lives (ex: relations hips, emotions) (Streifel and Servanty-Seib, 2006). The premise of AA and other 12-step programs is that alcohol (or identified substance) is but a symptom of the disease, a nd that recovery is dependent on much more than stopping the use of alcohol (Streifel and Servanty-Seib, 2006). The guiding pr inciples of AA are the 12 steps disseminated in a volume called the Big Book as well as other lite rature. Twelve-step guidelines call for a spiritual transformation, taking responsibility for changing themselves, helping others, and acknowledging the loss of power over alcohol and other drugs and that their lives have become unmanageable (Harvard, 2007 ). Active members of AA seek a spiritual awakening by prayer/meditation practices, admitting doing wrong, making amends to those people they have hurt unless when to do so would injure them or others, and finally carrying the message of recovery to others. It is important to note it is only the first step of the entire twelve

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46 that includes the word alcohol. Core tenets of the program include principles such as honesty, hope, willingness, humility, spirituality, and servi ce to others. Although the 12-steps include reference to God, AA is not a relig ious organization; members may interpret the idea of a power greater than themselves in any way they see fit. There is no hierarchical organizational structure; there is no official doctrine, no declaration of faith (Swora, 2004). Alcoholics Anonymous members vehemently stress that the fellowship and program are spiritual rather than religious. Swora (2004) outlines the twelve steps through a rhetorical proc ess which moves the alcoholic from drinking to sobriety by means of a rhet oric predisposition, of empowerment, and of transformation (p. 187). Alcoho lics Anonymous discourse is spir itual, in that members are persuaded to interpret the world, th eir lives, and their affliction in re vered terms. Healing is not a cure, but a new way of attending to the world and engaging with others a power greater than oneself (Swora, 2004). Participation in Alcoholics Anonymous (a nd other 12-step programs) is the most frequently prescribed treatment for chemically dependent individuals (Fiorentine and Hillhouse, 2003). According to Tonigan (2001), a majority of clinicians consider 12-step programs to be an effective group intervention. F actors such as socio-economic st atus (SES), gender, family background, race, ethnicity, sexual orientation, financial status, along with other factors that typically influence ones accepta bility matter little to thos e involved in the program. Brown (2001) and Nowinski (1993) state th at although there is research evidence supporting the effectiveness of AA and various other 12-step program s. This research is not theory-driven. Emrick, Tonigan, Montgomery, and Little (1993) also criticized the existing AA research in terms of its inves tigator bias, homogeneity of samp les, and power and effect size considerations. According to St reifel and Servanty-S eib (2006), Schlossbergs (1984) transition

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47 theory and Randos (1995) theory on grief and mourning are two theoretical approaches that have been used to explain why the 12-step program of Alcoholics Anonymous is such an effective intervention for recovering alcoholics. These two theoretical approaches also provide direction for future research on AA. The transition from drinking to recovery is an unanticipated one that is both personal and interpersonal in natu re, and transcends all ar eas of life, resulting in a significant alteration in ones daily life (Streifel and Servan ty-Seib, 2006). Grief and loss issues are recognized as an active part of moving from alcoholism to recovery as they encompass a multitude of losses which are an essential part of the process. The impact to ones career, family, health, and financial lives are often deva stating. The concepts of transition theory and the grief and mourning theory run parallel to the concepts and steps of th e AA program. Streifel and Servanty-Seib (2006) propose th at (1) participation in AA he lps individuals cope with the difficult transition from active alcoholism to recovery and (2) participation in AA facilitates individuals working through the lo ss and grief issues associated with recovery from alcoholism (p.71). These two theories are applied together because the constructs of transition and loss are interconnected. In a treatment outcome study of 356 patients, Fiorentine and Hillhouse (2003) found confirmation as to why extensive partic ipation in recovery activities based on the Addicted-Self Model of recovery predicted abstin ence. This Addicted-Self Model of recovery involves and acknowledges that lo ss of control over alcohol and other drugs is only a partial explanation for why extensive participation in recovery activities pr omotes abstinence. Conclusions suggested that m ore is better; frequent couns eling, treatment completion, and weekly or more participation in 12-step progr ams promote abstinence independently (Fiorentine and Hillhouse, 2003).

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48 Stephenson and Zygouris (2007) performed a linguistic analysis of diary entries of 30 clients receiving Twelve-Step Facilitation Therap y in a treatment setting. They compared the progress of these clients with that of 60 clients in two matc hed control groups. One of the control groups received treatment before the intervention and th e second control group received treatment after the intervention was terminated. The controls were matched to the intervention group participants based on addictive substance (alcohol, drugs, or food), gender, and age. Linguistic and cluster analyses i ndicated that the clients in the intervention group referred more frequently to the vernacular associated with 12-step programming and spir ituality practices and responded in a more integrated way to the major aspects of treatment. This study confirmed that reviewing past diaries written at an earlier time in the course of 12-step based treatment, seems to enhance engagement in the treatment process, c onceived as it is in terms of moral and spiritual renewal (Stephenson and Zygouris, 2007). As hypothesized, by supporting self-reflection on progress in therapeutic settings there was an increase in 12-step program engagement. Zemore, Kaskutas, and Ammon (2004) research ed the helper principle which suggests that those who help others within self-help group s help themselves in th e process. This study examined whether clients in treatment for alcoho l and drug problems benefit from helping others and how it relates to 12-step involvement duri ng and post-treatment. Measures of 12-step involvement were taken at baseline and at a 6-month follow-ups and a helping checklist was utilized which measured the amount of time par ticipants spent helping, by sharing experiences, explaining how to get help, and giving advice on other living needs post-treatment. Twelve-step involvement at follow-up was predicted by client involvement levels at ba seline, helping levels during treatment, and the participan ts length of stay in treatment. Furthermore, helping and 12step involvement were found to be important, rela ted predictors of treatment outcomes. Total

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49 abstinence at follow-up was strongly and positivel y predicted by 12-step involvement at followup more than during the formal treatment. Zemo re and colleagues (2004) concluded that helping positively predicted subsequent 12-step involvement supported the helper therapy principle, and clarified the 12-step affiliation process. Hillhouse and Fiorentine (2001) examined gender and ethnic differences in 12-step program participation and effectiv eness. Analyzing data from the Los Angeles Target Cities Evaluation Project, 356 participan ts in the adult outpatient al cohol and drug treatment were followed for 24 months and rates of 12-step partic ipation and effectiveness were assessed for all gender and ethnic groups. Results indicated that 80% of those w ho report weekly participation in 12-step programs were alcohol and drug abstin ent during the six months prior to the last follow-up appointment. Thirty-nine percent of those who never engaged in 12-step programming were abstinent prior to the fina l follow-up. Results reported that women and ethnic minorities are equally as likely as Eur opean-American males to attend 12-step programs and to recover in conjunction with 12-step part icipation. Clinical implications for treatment providers and other addiction speci alists points to the benefits of integrating 12-step components into traditional treatment programs and recomme nding 12-step participation for clients of all gender and ethnic groups. Gallanter and Talbot (1989) combined the treatment philosophies of Alcoholics Anonymous with profes sional care for addicted physicia ns in a study of 100 impaired physicians currently in treatment. Results demonstrated that feelings of affiliation and intensity of commitment to AA, identification with thos e who had achieved stable sobriety, and having a shared belief in the 12-step programming all correlated with successful recovery. Cloud, Ziegler, and Blondell (2004) examined th e contribution of affiliation to successful participation in Alcoholics Anonymous. Outcom e data from 1,506 participants in the Project

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50 MATCH were analyzed at 1-year post-treatment. The Alc oholics Anonymous Involvement (AAI) Scale scores used to identify which as pects of AA affiliation predicted 1-year posttreatment sobriety outcomes. The sample of 1,506 was drawn from nine urban and nine suburban geographic sites across the United States. A stepwise regression was performed resulting in a three factor model: (1) sum of AA steps completed, (2) viewed self as an AA member, and (3) the number of me etings attended. The solution for the three factor analysis explained 35% of the variance. Working the steps of AA and attending meeti ngs emerged as powerful predictors both individually and collectively for pos itive affiliation. Results also revealed identification of self as an AA member to be a strong predictor of a ffiliation. The analysis revealed no statistical differences between males and females or between Whites and minorities in contributing to the three factors predicting abstinence (Cloud et al ., 2004). McIntyre (2000) analyzed published surveys of Alcoholics Anonymous from 19681996 from a perspective of analyzing the introductory interval of 90 days in AA as a determining factor of membership in the fellowship. The effectiveness of the AA progr am in terms of rete ntion rate, newcomer characteristics, introductory interval, and overa ll effectiveness or efficiency was researched through the Alcoholics Anonymous 1989 Membership Survey data. Findings report that once the introductory interval of 90 days is achieved, 55% of those who survived the first 90 days were sober at the end of the first year. In addi tion, the data revealed th at 50% of this group was sober at the end of five years. McIntyre (2000) denotes the age of this survey and the suggestions of recent data indicate increased percentages of success; this may be due to the rampant usage of 12-step programming as a core treatment philosophy across the majority of addiction treatment centers in the United States Moos (2005) studied the benefits of a two-

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51 pronged approach to treating al cohol (and other drug) dependence through his work with the U.S. Department of Veteran Affairs and Stan ford University. Moos and colleagues (2005) surveyed 362 men and women, half of whom had jointly experienced both forms of treatment (professional treatment combined with AA). Resu lts revealed that thos e with alcohol problems who sought professional help in addition to engaging in Alcoholics Anonymous were more likely to be sober at year one three, eight, and sixteen (Moo s, 2005). Researchers also found that while participation in treatment might temporarily strengthen affiliation with AA, the number of actual weeks of AA attendance had the most impact on remission (Moos, 2005). Additionally, the study results c ountered the concern that entry into treatment may reduce motivation to participate in AA. Johnson (2005) designed a survey to determine whether AA contact, as measured by the number of AA meetings attended by the alcoholic each week, (a) promoted improved levels of functioning in specif ied areas and (b) was a significant adjunct to formal treatment in the promotion of continuing sobriety. A Sobriety Screening Instrument for Alcoholics was administered to 150 alcoholics at three AA groups wh ich were representative of ethnicity, education, and social cl ass in Long Island, NY. Fifty-eight participants met criteria of having two or more years of sobriety and had attained significant im provement in areas of functioning. The remaining 58 participants were th en given a survey of Salient Factors in the Recovery of Alcoholics. Significant correlati ons were found between AA contact and improved levels of functioning in areas of abstinence, vocation, interpersonal re lations, and affect. Alcoholics Anonymous was also found to be a si gnificant adjunct to form al treatment in the promotion of continuing sobriety (Johnson, 2005).

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52 Spirituality Spirituality has been considered to be a critical f actor in recovery since the beginning of the contemporary alcohol and drug treatment movement. However, it remains poorly understood, understudied, and is not oriously difficult to define and operationalize (Swora, 2004, Eliason, Amodia, and Cano, 2006). The notion of sp irituality involves a co mplex combination of feelings, thoughts, and attitudes about oneself in the world. According to Miller (1999), because spirituality is associated w ith self-help recovery moveme nts, such as AA (Alcoholics Anonymous), and/or its conflati on with religion, there has been little scientific study of the concept of spirituality. Many experts are quick to point out that spiritua lity is separate from religion. Religion and spirituality are said to overlap but are not conceptually the same (Rowe & Allen, 2004). Literature across many disciplines discusses the positive influence and healing powers that spirituality has on an ailing person. However, while th e majority of treatment programs profess spiritual awakenings as a goal for those who want to be in recovery, there continues to be little empirical evidence supporting spirituality as a component of healing. Spirituality is not considered to exist as a single treatment method, but rather a ge neral orientation with which a person approaches alcohol and drug treatment. Western science continues to reduce the world to observable, measurable facts, rejecting the spiritual realm as un-measurable, therefore nonexistent (Wilbur, 1998). However, there are many reasons for studying spirituality from a scientific standpoint. The major ity of the United States population believes that spirituality is a component of the recovery process from a ny illness (McNichol, 1995), and individuals in recovery from alcohol and/or dr ugs frequently emphasize the importance of spirituality in their own recovery (Jarusiewicz, 1999; McMillen et al., 2001).

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53 Brown and Petersen (1991) describe spirituality as participating in daily action of living spiritual principles and defini ng religion as conforming to a belief, doctrine, or theology. Dollard (1983) defines spirituality as con cerned with our ability, through our attitudes and actions, to relate to others, to ourselves, and to a God, as we understand him. Mikulas (1987) uses the term spiritual to refer to practices, insights, states of be ing, and frames of reference that are most influenced by forces beyond and in clusive of the individual and his personal, interpersonal, and suprapersonal, or transc endent experiences. Brown and Peterson (1991) define spiritual progress as advancement toward or in the development, experience, integration, or acquisition of those ego-tran scending behaviors, cognitions, va lues, attitudes, practices, or beliefs that are manifested in the personality ch ange sufficient to bring about recovery from a previously maladaptive state of being. Alt hough varied, the commonality among the definitions is that spirituality transcends all aspects of treatment and therefore provides a common link for integrating treatment components and a develo ping lifestyle supportive of alcohol and drug abstinence. Although spirituality consists of a myriad of practices and lifestyles, the majority of substance abuse treatment programs espouse a sp iritual approach embrace the specific steps suggested within the twelve steps of Alcoholic s Anonymous (AA). The concept of a Higher Power need not represent God or indeed any form of religion, but rather is defined by the individual as his/her source of support in over coming and abstaining from problematic alcohol and drug abuse. The founder of Alcoholics An onymous, Bill W., wrote that spirituality in regards to the twelve steps only requires faith an d therefore allows for a nearly unlimited choice of spiritual belief and action. Strachan (1982) sugg ests that spirituality is a type of lifestyle necessary for whole recovery of the alcoholic/addict According to Whitfield (1985), the

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54 physical, mental, and spiritual recovery in a prog ram is a way out of needless suffering for all humankind. Twerski (1997) points out that the spir itual life of an individu al includes the ability of the person to be responsible, to be trusting, to achieve deeper levels of intimacy, and to realize his or her potential for growt h. The Buddhist Monk, Thich Nhat Hanh, describes spirituality as keeping our appointment with life (Alexander, 1997). Vencil (2006) is fascinated by the popularity of faith or spiritually based programs available to individuals with substance abuse disorders in the United States. Individuals with chronic illnesses often deal with intense physical and psychological stressors as a consequence of living with an illness; the same is tr ue for the disease of addiction. Rowe and Allen (2004) explored the relationship between spiritu ality and coping ability. Two hundred and one participants completed the Spir itual Involvement and Belief Scale (SIBS), the Coping Styles Scale, and a demographics que stionnaire. A multiple regression analysis conducted on four factors of coping indicated a positive correlation between spirituality and the ability to cope. Participants who scored high in spirituality practices tended to show higher overall coping scores. Results al so showed a significant correlati on between spirituality and age, therefore increasing spirituality becomes a function of age. Researchers suggested that the correlation between spirituality and age is a wa y to cope with the re alization of ones own mortality (Hunglemann et al., 1996). Pardini, Plante, Sherman, and Stumps (2000) research aimed to determine the mental health benefits of religious faith and spir ituality when applied to substance abuse recovery. Results reported high levels of religious beliefs and high levels of spirituality were intercorrelated, but that when re ligious beliefs were controlled, spirituality was associated with greater optimism, more social su pport, and less anxiety. Spiritual practices not associated with formal religion, were found to benefi cial to the recovery pr ocess. Greater levels

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55 of spirituality were found in those participants w ho remained in recovery for two years compared with those who relapsed, and had lower levels of spirituality than people in the general population. Jarusiewicz (2000) expl ored the relationship between an individuals level of faith and spirituality within a population experiencing success in recover y. Two groups were solicited from local AA groups in central New Jersey. On e group represented those who were continually relapsing after a prior treatment and those who we re successfully recovering (two or more years abstinent). Two instruments were administered to each member of the two groups. The first instrument was the Spiritual Belief Scale (S BS) based on the Alcoho lics Anonymous (AA) model and the second instrument was the Fowler Interview Process (FIP) which showed the growth of faith as a part of the maturation process. A two sample t-test was used to establish that a difference in spirituality levels exists between the recovering and relapsing groups. Results revealed that individuals who had at least two years of recovery demonstrated significantly greater levels of spirituality than those who continued to relapse. While the research is becoming clearer as to the benefits of sp iritual engagement for those in recovery from addiction, it is difficult to determine if spirituality helps the reco very process directly, or if spiritual engagement is a result of recove ry (Jarusiewicz, 2000). Walsh, King, Jones, Tookman, and Blizard (2002) explored the relationship between spiritual beliefs and resolution of bereavement in a three part longitudinal study. The population consisted of 135 relatives and close friends of patients admitted to th e Marie Curie Palliative Care Center for the terminally ill in London. Th e Core Bereavement scale was administered to the participants at one, nine, and fourteen months post death of their loved one. People reporting no spiritual belief continued to have unresolved grief 14 months after the death of their loved one. Participants with strong spiritual beliefs re solved their grief progres sively throughout the 14

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56 months. People with low levels of belief showed little change in the first nine months but thereafter resolved their grief. These differen ces approached significance in a repeated measures analysis of variance (F = 2.42; p = 0.058). Strength of spiritual belief remained an important predictor after the relevant confounding variables were accounted for. Walsh and colleagues (2002) concluded that people who professed stronger spiritual beli efs seemed to resolve their grief more rapidly and comple tely than did people with no spiritual beliefs. According to Miller and Kurtz (1994), Alc oholics Anonymous (AA) has been described as a spiritual program for living as there is no dogma, theology, or creed to be learned. Galanter, Dermatis, Bunt, Williams, Trujillo, and Steinke (2007) discuss how the prominence of Twelve-Step programs have led to increased attention on the putative role of spirituality in recovery from addictive disorder s. A series of cross-sectiona l studies were completed by two cohorts: Cohort 1, the identified substance abusers were selected from dually diagnosed psychiatric patients, residents of a therapeutic comm unity, patients on methadone maintenance, and members of Methadone Anonymous (patterned after that of Alcoholics Anonymous). Cohort 2, the non substance abusing group, consisted of medical students at NYU, Medical Addiction Faculty, Chaplaincy tr ainees, and university students that obtain services from the NYU counseling center. The studies were designed to assess the spiritual orientation and its relationship to attitudes toward addiction treatmen t, and their views on AA. The Spirituality Self Rating Scale (SSRS) in addition to other scales measuring demographic, drug use, employment, and prior treatment related items were administ ered to both cohort groups. The SRSS scale was developed to assess connotations of spirituality that are typically reflected in AA members views (Galanter, 2005). An inde pendent t-test was conducted to compare the two groups on the SRSS. The substance abusers (M = 22.63, SD = 5.8) in cohort 1 were significantly more

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57 spiritual than were the students (M = 17.49, SD = 6.2) in cohort 2. Both spiritual orientation (paired t-test 4.04, df = 100, p < .001) and AA (paired t-test = 5.02, df = 100, p < .0001) were scored as more valuable than a job when paired t-tests were carried out to determine the degree to which the substance abusers considered the two types of experiences to be valuable for their personal recoveries. Galanter and colleagues (2007) conclude d that spirituality, however difficult to define in operational terms, consti tutes an important motivator for recovery among many substance dependent people. Beitel, Genova, Schuman-Olivier, Arnold, Av ants, and Margolin (2007) developed a manual-guided spirituality focused intervention, the Spiritual Self-Schema therapy (3-S Therapy) for the treatment of addiction and HIV-risk behavi or as a part of a Stage I behavioral therapies development project. Marlett (2002) and Miller (1998) concurred that there were few manual guided spirituality focused interventions that have been developed, subjected to empirical evaluation, and made available for use by co mmunity-based treatment programs. Their qualitative study was theoretically grounded in cognitive and Buddhist psychologies. Focus groups with clients in treatment fo r addiction were formed in orde r to explore the perceived need for a spirituality-focused intervention in treat ment facilities serving substance dependent populations. The focus group was comprised of 21 HIV-positive methadone-maintained individuals. The majority of the group confirmed a belief that spirituality based interventions would be helpful in reducing both drug cravi ng and HIV-risk behavi or (Arnold, Avants, Margolin, & Marcotte, 2002). Th irty-nine participants enrolled in an inner-city methadone maintenance program participated in post-trea tment interviews on the completion of the 3-S therapy. Sixty-two percent were women and 24% were men with a mean age of 43 for both genders. Post-treatment questionnaires (PTQ ) and post-treatment interviews (PTI) were

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58 conducted; the majority of the sample (62%) re ported that their inte rpersonal/intrapersonal functioning had improved as a result of therapy. Twenty-six percent stated that they became more mindful as a result of the treatment interv entions. The majority of participants reported making significant changes in their lives as a consequence of ther apy. The majority specifically cited improvement in daily functioning and was ab le to give clear examples, outside of the therapy context, in support of spirituality evoking these chan ges (Beitel et. al., 2007). In conclusion, most participants indicated that th eir new mindfulness practi ces would help them sustain their gains made from these therapy interventions. Summary of Relevant Research This literature supports the need to exam ine the impact of levels of surrender, 12-step engagement, spirituality practices, on the proce ss of recovery in impaired professionals. Research on spiritual involvement has consistently been associated with positive mental and physical health, and a reduction of substance abuse disorders (Miller an d Thoreson, 1998). The 12-step approach is extensively utilized in subs tance abuse treatment in the United States (Moos, Finney, Ouimette, and Suchinsky, 1999). Twelve-s tep programs have stressed the importance of spiritual practices since its de velopment in 1935. Brown (1985) asserts that recovery is a developmental process with its own course and th e core of recovery involves acceptance of loss of control and acceptance of an identity as an alcoholic. The Transtheoretical model (TTM) of change conceptualizes behavior change as a progression through five stages. This sequence characterizes different types of cognitive, behavioral, and affective transitions (Miller, 1996). Prochaskas stages of change include Precontemplation, Contemplation, Pr eparation, Action, and Maintenan ce. It is not uncommon for individuals to cycle through theses stages of chan ge multiple times before acquiring the ability to remain in the action and maintenance stages of change. This study assessed the relationships

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59 among level of surrender, 12-step engagement, sp irituality practices, length of time under professional monitoring post-treatment (in IPN/PR N), and the stage of change of impaired professionals recovery from addiction. Table 2-1 The Twelve Steps of Alcoholics Anonymous 1. We admitted we were powerless over alcohol a nd that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives ov er to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God rem ove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory and when we were wrong promptly admitted it. 11. Sought through prayer and meditation to impr ove our conscious contact with God as we understood Him, praying only for knowledge of Hi s will for us and the power to carry that out. 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

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60 CHAPTER 3 METHODOLOGY The purpose of this study was to exam ine the relationships among the levels of surrender, 12-step program engagement, spirituality practices, and stage of self-change as reported by impaired professionals enrolled in professiona l monitoring with the Intervention Project for Nurses (IPN) or the Professionals Resource Netw ork (PRN). In this chapter the following aspects of the study are described: (a) research design, (b) depende nt and independent variables, (c) population, (d) sampling procedures, (e) procedur es for data collection and analysis, and (f) the research hypotheses. Research Design A survey research design was implemented for this study. Survey rese arch is designed to obtain information from members of a population or sample to determine the current status of that particular population with respect to one or more variab les (Fraenkel and Wallen, 2006). An on0line survey was developed to assess the stag e of change, level of surrender, 12-step engagement, spirituality, and professional monitori ng contract year of the study participants. The benefits of using an online survey include the elimin ation of paper, postage, mailout, and data entry costs, as well as the re duced time required for survey implementation (Dillman, 2000; Murray & Fisher, 2002). One di sadvantage of using on-line surveys includes the inaccessibility to a comput er for some populations; however, since the population was solely comprised of professionals, access to computers and the internet was most probable and it was assumed that participants had a basic knowledge of internet usage. Quantitative researchers have found that response rates for postal mail surveys and internet surveys are e quivalent (Schaefer & Dillman, 1998). Responses to email surveys are received more quickly, and the it em non-response rate is lower for internet surveys (Schaefer &

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61 Dillman, 1998; Murray & Fisher, 2002). Truell, Ba rtlett, and Alexander (2002) also determined that the response speed and rate of completed questionnaires is higher for internet based surveys as compared to pencil/paper questionnaires. Pettit (2002) found that random response, item nonresponse, extreme response, and acquiescent re sponse are not statistic ally different when comparing internet based survey to pencil/paper questionnaire formats. Furthermore, participant responses to a paper and pencil qu estionnaire format had statistica lly higher rates of un-codable responses. Research Variables It is im portant to define th e study variables to ensure a similar understanding of meaning. Stage of Change theory represents an empirical ly derived multistage sequential model of general change (Petrocelli, 2002). Prochaskas stage of change theory is helpful when applied to changing risky lifestyle behavi ors such as eating disorders, smoking, and excessive alcohol and/or drug consumption (Swora, 2004). Surrender is defined as the act of experiencing and participating in surrender involves an acceptan ce of ones limitations, giving up control to a power greater than oneself, a shift from negative and aggressive feelings to more positive ones, and a sense of being at one with the world (Rei nert, Allen, Fenzel, and Estadt, 1993). Twelvestep engagement is conceptualized as regular attendance at 12-step meetings, having a home group one attends regularly, has a sponsor, sponsors others if applicable, provides service, has willingness to work the steps with their sponsor, and adheres to 12-step principles in daily affairs. Spirituality has many definitions, fo r this study spirituality is defined as ones personalized experience and identity pertaining to a sense of worth, meaning, vitality, and connectedness to others and the universe.

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62 Population The population, and subsequent sam ple, for this study consisted of impaired professionals who had been diagnosed and treated for a subs tance abuse disorder, successfully completed substance abuse treatment, and were currently enga ged in a five year contract with either the Intervention Project for Nurses (IPN) or the Pr ofessionals Resource Network (PRN) in the state of Florida. To be under contract with a monitori ng system such as IPN or PRN, participants are required to currently hold an active license with the Department of Health (primarily a medical one) and to have successfully completed treatm ent from an IPN/PRN approved substance abuse treatment facility. After a safe detoxification and stabilization has occurred in either an inpatient or outpatient setting, impaired pr ofessionals are typically treated either in residential treatment, partial-hospitalization treatment, and/or inte nsive outpatient (IOP). Once an impaired professional has successfully completed treatment, they are required to commit to a five year monitoring contract with IPN or PRN if the professional chooses to keep an active license and be allowed to continue practicing in their careers. While under the five year contract with IP N or PRN, each impaired professional is required to attend weekly support groups comprised of other impaired professionals in recovery. These groups are led by mental health professionals. Each individual is al so required to attend multiple twelve-step meetings offered through either Alcoholics Anonymous (AA) and/or Narcotics Anonymous (NA) weekly. Professionals are also require d to call in daily for potential random drug screening, and to complete any other personalized requirements recommended by their treatment provider. Such personalized requirements to ones cont ract with IPN/PRN may include combinations of individu al counseling, psychiatric evalua tions, and/or continued medical management.

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63 Sampling Procedures A snowball sam pling procedure was used in this study. Snowball sampling is a particular non-probability method used when the desired samp le characteristic is rare (Statpac, 2007). Snowball sampling is a technique for developing a research sample where existing study subjects recruit future subjects from among their acquainta nces, peers, and/or colleagues. This sampling technique is often used to access populations who are difficult for researchers to locate (Salganik and Heckathorn, 2004), and was most appropriate to use in this study as the potential participants also had access to friends/peers who mi ght qualify as possible participants. To access this sample, the directors of the In tervention Project for Nurses (IPN) and the Professionals Resource Network (PRN) were info rmed of the study and access to each IPN/PRN group facilitator was requested. The medical direct or of PRN agreed to provide the researcher with the contact information on the PRN group leader s within the stat e of Florida. Participants were informed of the study and provided w ith a postcard by their PRN group facilitator containing the information to access and complete th e survey online. Each PRN group facilitator was mailed a packet of postcards to distribute to their groups and a letter containing a description of the study. Approximately 675 postcards were sent to the 26 chemical dependency PRN facilitators across Florida. The director of the Intervention Project for Nurses (IPN) was also contacted to obtain facilitator contact info rmation. However, the IPN system was not willing to provide the researcher direct access to their group facilitators Instead, the IPN director sent a mass email to the IPN facilitators reque sting that they contact the researcher with thei r contact information. When the facilitators responded, th e researcher was then able to ask for their contact information and group size. Approximately one-third (24) of the IPN facilitators indicated a willingness to assist with distributing participant requests. Ap proximately 550 survey po stcards were sent to

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64 IPN facilitators in Florida. While the research er had less overall access to the IPN participants the number of final responses from both IPN and PRN was approximately equivalent. Resultant Sample Although a total of 165 study participants bega n the on-line survey, 33 were eliminated due to providing incomplete survey data. Theref ore, the final sample consisted of 137 impaired professionals under current contract with either the Intervention Pr oject for Nurses (IPN) or the Professionals Resource Network (PRN) in the state of Florida. Table 3.1 depicts the demographic data collected in terms of frequencies and percentages for the following categories of information: gender, race, age, sexual orient ation, marital status, monitoring system, contract year, highest level of education, professional license held, career identity, number of times in treatment prior to current sobriety date, level of care while in addiction treatment, length of personal awareness of addiction problem, length of time in career, and length of time in career prior to addiction treatment. As can be seen in Table 3-1, the fina l resultant sample was comprised of 137 professionals, 61 contracted with IPN and 76 contracted with PRN. There was nearly an equal distribution among participants curr ent contract year; 34 were in years 0-1, 26 were in years 1-2, 32 were in years 2-3, 15 were in years 3-4, and 30 were in years 4-5. The gender representation was nearly equal with 67 females res ponding and 70 males responding. Out of the 137 participants, 128 identified as Caucasian/White, 5 identified as Latina/Hispanic, 2 identified as African American/Black, 2 identified as Asian, and 0 identified as Multi-racial. The mean age of the participants was 47 with the range being 25 75. One hundred and twen ty-seven participants identified themselves as heterosexual, 8 identified as bi-sexual, and 2 identified as homosexual. The marital status varied among the sample w ith 15 single, 61married, 8 partnered/coupled, 9 still married but currently separated, 41 divorced and 3 widowed. The highest level of education

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65 varied with 34 professionals with medical doctor degrees, 4 with a Ph.D., Ed.D, or Psy.D, 7 with a Doctor of Pharmacy, 3 with a Doctor of Vete rinary Medicine, 8 with a Doctor of Dental Surgery/medicine, 2 Physician Assistants, 8 with Masters degrees, 35 with Bachelors degrees, 34 with Associates degrees, and 3 did not spec ify their education leve l. The career field represented most frequently was nursing with 63 partic ipants, 33 identified as Medical Doctors, 13 identified as Pharmacists, 2 identified as Phys ician Assistants, 3 identified as Mental Health Professionals, 9 identified as Dentists, 3 identified as Veterinarians, and 11 did not identify with choices given. Other professions included were respiratory therapists, massage therapists, and radiographic technologists. Fifty-two participants had not b een in treatment prior to this sobriety date, 37 had been in treatment 1 other time besides thei r current sobriety date, 26 had b een in treatment twice before their current sobriety date, and 5 had been in tr eatment three and four times respectively prior to their current sobriety date, and 12 participants ha d been in treatment 5 or more times prior to their current sobriety date. The majority of pa rticipants completed a type of formal substance abuse treatment; 39 completed residential treatment, 26 completed Partial-Hospitalization treatment (PHP), 41 completed Intensive Outp atient treatment (IOP), and 19 completed a combination of both PHP and IOP, 3 completed treatment combined with a housing component such as a way or house, 9 stated they did no t participate in formal treatment prior to their IPN/PRN contract. Professionals were aske d to identify how long they had admitted to themselves they had a problem with alcohol and/or drugs prior to their cu rrent sobriety date; 28 acknowledged their problem within 1 year, 20 within 1-2 years, 24 within 3-5 years, 23 in 5-10 years, and 42 had acknowledged to themselves problematic use for 10 or more years prior to their current sobriety date. The mean numbers of years participants were in current professional

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66 practice was 18.5 with a range of practice from 1 year to 50 years. The mean number of years participants were in practice pr ior to their first or only substa nce abuse treatment was 13.3 years with the range of years being 0-33. This data is found in chart form in Table 3-1. Instrumentation Stage of Change Scale University of Rhode Island Chang e Assessment (URICA) Stage of change was the dependent variable for this study and was measured using the University of Rhode Island Change Assessment S cale (URICA). The URICA is a 32-item scale that assesses attitudes toward changing problem behaviors and four stages of change: precontemplation, contemplation, action, and mainte nance (Dozois, Westra, Collins, Fung, and Garry 2004). URICA scores may be used to select treatment strategies and also to measure stage of change pre and post treatment. The URICA ha s demonstrated reliability and validity in an alcoholism treatment population; researchers have only begun to examine responses to this measure in other disorders (Dozois et al., 2004) The stage of change scale (URICA) was designed to be a continuous meas ure therefore participants receive a score for each of the four stages of change. Adults are the target populat ion for use of the URICA and can be used to measure process and outcome variables for a variety of health and addictive behaviors (DiClemente and Hughes, 1990). Henderson, Galen, and Saules (2004) examined the predictive validity of the stages of change scales of the University of Rhode Isla nd Change Assessment (URICA) questionnaire in a heroin-addicted poly-substance-abusing treatment sa mple. Ninety-six participants completed the URICA at the beginning of a 29week treatment period which included drug screens three times a week. Multivariate multiple regression analysis indicated that after controlling for demographic variables, substance abuse severity, and treatment assignment, the stages of change

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67 scales added significant variance to the predic tion of heroin and coca ine free urine samples (Henderson et al, 2004). Level of Surrender Reinert S Surrender Scale Level of surrender was one of the independent variables assessed in this study. Surrender involves an acceptance of ones limitations, giving up control to a power greater than oneself, shifting from aggressive and nega tive feelings to more positive one s, and a sense of being at one with the world (Reinert, 1999). Reinert (1997 ) developed the Surrender Scale, which was designed to measure the concept of surrender as it relates to Alc oholics Anonymous. The Surrender scale consists of 25 quest ions, 19 pairs of sentences in a forced-choice format, and six items in a Yes, No, or Dont Know format. On e point accrues for each ite m marked in a positive surrender direction; theref ore, the possible range is 0 to 25. In the three separate studies reported by Reinert (1997), reliability coefficients for the scale ranged from .70 to .80. Several studies have employed the use of the Surrender Scale. Scores have been found to be associated with the degree of AA involvement with higher involvement in AA associated with increased levels of surre nder among participants in Rationa l Recovery, a peer support group with a very different philosophical orientati on than AA (Reinert, Allen, Fenzel, and Estadt, 1993). Reinert (1997) completed thr ee studies to assess the reliabil ity, factor structure, and the validity of the Surrender Scale. In the first study, the internal fact or structure with 190 alcoholics as respondents was explored. Using a principa l components analysis, evidence confirmed the general construct of surrender wa s theoretically consistent with Tiebouts concepts of surrender (Reinert, 1997). The validity of the surrender scale was examined in studies 2 and 3 using 130 clients engaged in treatment for alcoholism. Among the participants, higher levels of surrender were positively correlated with less psychopathology, an increased internal locus of control, and a sense of God-mediated control.

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68 Reinert (1999) also studied the levels of Surrender and Narcissism across the course of alcohol treatment. He administ ered a series of five instruments which included: the Surrender Scale, the Narcissistic Personality Inventory, the Minnesota Multiphasic Personality Inventory (MMPI-2), the Shipley Institute of Living Scales estimate of intelligence, and the Addiction Severity Index. Surrender scores improved over treatment for the 49 male and 16 female alcoholics who participated. Pathological narcissism decreased over treatment within the High Change surrender group, but not within the Low Change surrender group (Reinert 1999). Tiebouts (1961) theory continues to be s upported which suggests th at making an act of surrender helps reduce pathological narcissism. This is a nece ssary precursor to successful treatment outcomes. Twelve-Step Engagement Twelve-step Participation Questionnaire (TSPQ) Twelve-step engagem ent is an independent variable measured in this study. Snyder (1980) argues that 12-step programs, particul arly Alcoholics Anonymous (AA), are the most effective method to arrest alcoholism. Alc oholics Anonymous is a worldwide fellowship of women and men who help each other maintain sobriety through sharing their experience, strength, and hope with each other at group mee tings and working the 12-steps designed for personal recovery of alcoholism (Streifel and Servanty-Seib, 2006). In this study, the Twelvestep Participation Ques tionnaire was used to measure the de gree of connection and engagement as a member of a 12-step program. Impaired pr ofessionals under contract are required to attend Alcoholics Anonymous (AA) and/ or Narcotics Anonymous (NA) as part of their weekly requirements. However, mere attendance in 12-step meetings does not indicate level of engagement therefore the scale also asks not only the frequency of attendance of 12-step meetings weekly, monthly, and at 90 day intervals but also asks if partic ipants have a current sponsor and/or if they have ever been a 12-st ep sponsor to someone else in the program.

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69 Participants are also asked to report which of the 12 steps they have worked while being a member of a 12-step program. There is no availa ble validity data provided on this scale. Spirituality Spirituality and Beliefs Scale (SIBS) The field of addiction medicine endorses the im portance of balance between ones physical, emotional, and spiritual health. Spirituality practices were measured by means of the Spiritual Involvement and Belief Scale (SIBS ) (Hatch, Burg, Naberhaus, and Hellmich, 1998). This instrument was designed to be widely app licable across religious traditions and to assess actions and beliefs. The instrument is comprise d of 26 Likert scale items Reliability, validity, and internal consistency are reported to be high, Cronbachs alpha = .92, strong test-retest reliability (r = .92), and a high correlation (r = .80 ). The SIBS was chosen because it avoids the cultural and religious biases i nherent in many measures of its type and it operationalizes spirituality more broadly than other measures of religiosity (Atkinson, Wishart, Bushra, and Robinson, 2004). Contract Year of Professional Monitoring Each participant was currently contracted with either the Intervention Pro ject for Nurses (IPN) or the Professionals Resource Network (PRN) in the state of Florida. After successful completion of an approved substance abuse treatment program, each identified impaired professional was given a five year contract for which they were to be monitored for alcohol and drug use, required to have consistent attendance and participation at weekly therapy support groups with other impaired professionals, ma ndatory random alcohol and drug screening, and any potential tailored contract requirements such as psychiatric care, medicine management, and any other follow-up individual needs. In this st udy, each participants current contract year was also examined for its predictive value. Each su rvey participant was asked to identify the year in

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70 which they were currently under contract. Prof essionals were asked to identify one of the following options for their current contract year : between years 0-1, 12, 2-3, 3-4, or 4-5. Demographic Questionnaire By m eans of a demographic questionnaire, each participant was asked their gender, race, age, marital status, sexual orient ation, highest level of education, professional license currently held, career most identified w ith, number of years working in field, number of years working in the field before their first substance abuse treatment, number of times in treatment prior to most recent sobriety date, level of care during most re cent substance abuse treatment, name of last treatment center, length of awaren ess time of addiction problem prior to getting help, and which monitoring system are they currently contracted with, IPN or PRN. Data Collection Procedures Once the participants accessed the on-line survey (www.tiny.cc/ recovery), th ey read the inform ed consent information describing the study. The informed consent explained that all participants results would be confidential and anonymous; in dicating IPN/PRN or their group facilitators would not have access to their responses. If they agr eed to participate, they clicked on the I have read the above document and agree to participate box. Profe ssionals were then directed to the on-line survey. Participants were not able to acc ess the survey unless they agreed to the terms of the informed consent. The info rmed consent form may be read in Appendix A*. The on-line survey consisted of an explanation of the st udy, directions, an informed consent, a demographic questionnaire, the Univ ersity of Rhode Island Change Assessment (URICA), the Reinert S Surrender Scale, the Tw elve-Step Participation Questionnaire (TSPQ), and the Spirituality and Beliefs Scale (SIBS).

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71 Research Hypotheses The following hypotheses were tested in this study: Ho (1): There are no significant c ontributions of the participants level of surrender, 12-step engagement, spirituality practices, and professional monitoring contract year in the prediction of their pre-contemplation stage of change. Ho (2): There are no significant c ontributions of the participants level of surrender, 12-step engagement, spirituality practices, and professional monitoring contract year in the prediction of their contemplation stage of change. Ho (3): There are no significant c ontributions of the participants level of surrender, 12-step engagement, spirituality practices, and professional monitoring contract year in the predic tion of their action stage of change. Ho (4): There are no significant c ontributions of the participants level of surrender, 12-step engagement, spirituality practices, and professional monitoring contract year in the prediction of their maintenance stage of change. Data Analysis The purpose of this study was to assess the relationships am ong the dependent variable, stage of change, and the four independent variab les: level of surrender, 12-step engagement, spirituality practices, and number of years under professional monitoring. In the first phase of the analysis, simple descriptive statistics were computed for the four stages of change scales and th e four independent variables. The second phase of the analysis, four hierarchical regression anal yses were conducted to assess the contribution of each of the four independent variables to each of the four stages of change. The hierarchical regression models assess the individual relati onships between the dependent variable (Stage of change) and each of the independent variables (level of surrender, 12-step e ngagement, spirituality practices, and number of years under professional monitori ng) while holding the remaining independent variables constant. Phase three of the analysis assessed the relationships between the stages of change and each of the four independent vari ables, calculated using correlation statistics (Pearsons r).

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72 Summary The purpose of this study was to assess the relationship betw een levels of surrender, 12step engagement, spirituality practices, and th e length of time under professional monitoring in relation to stage of change within impaired professionals in rec overy from addiction. A snowball sample of impaired professionals was drawn from th e state of Florida. Participants completed an on-line survey that includes the Reinert Surr ender Scale, the Twel ve-Step Participation Questionnaire (TPQ), the Spiritua l Involvement and Beliefs Scal e, the University of Rhode Island Change Assessment (URICA), and a series of demographic questions. Data was analyzed by computing multiple regression and correlationa l analyses. The results of the study are presented in Chapter 4. Table 3-1 Resultant Sample Demographic Data N = 137 Demographic Frequency (N) Percent (%) Gender Female 67 48.9 Male 70 51.1 _____________________________________________________________________________ Race Caucasian/White 128 93.4 Latina/Hispanic 5 3.6 African American/Black 2 1.5 Asian 2 1.5 Multi-Racial/Other 0 0 ______________________________________________________________________________ Age in Decades 20 29 11 8.0 (Mean age = 47) 30 39 19 13.9 40 49 41 29.9 50 59 56 40.9 60 69 9 6.6 70 79 1 0.7 ______________________________________________________________________________ Sexual Orientation Heterosexual 127 92.7 Bi-sexual 8 5.8 Homosexual 2 1.5

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73 Table 3-1. Continued Demographic Frequency (N) Percent (%) Marital Status Single 15 10.9 Married 61 44.5 Partnered/Coupled 8 5.8 Separated 9 6.6 Divorced 41 29.9 Widowed 3 2.2 ______________________________________________________________________________ Monitoring System IPN 61 44.5 PRN 76 55.5 ______________________________________________________________________________ IPN/PRN Contract Year 0-1 34 24.8 1-2 26 19.0 2-3 32 23.4 3-4 15 10.9 4-5 30 21.9 ______________________________________________________________________________ Highest Level of Education Medical Doctor/Doctor of Osteopathy 34 24.9 Doctor of Philosophy (Ph.D./Psy.D/Ed.D.) 4 2.9 Doctor of Pharmacy 7 5.1 Doctor of Veterinary Medicine 3 2.2 Doctor of Dental Surgery/Medicine 8 5.8 Physician Assistant 1 0.7 Masters Degree 8 5.8 Bachelors Degree 35 25.5 Associates Degree 34 24.8 Other 3 2.2 Professional License Held MD/DO 32 23.4 PA 2 1.5 Pharm.D/R.Ph. 13 9.5 ARNP 4 2.9 RN 52 38.0 LPN 5 3.6 LMHC, LMFT, LCSW, or 3 2.2 Licensed Psychologist DDS 8 5.8 DVM 3 2.2 Other 5 3.6 None 10 7.3 ______________________________________________________________________________

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74 Table 3-1. Continued Demographic Frequency (N) Percent (%) Career Field Identity Medical Doctor 33 24.1 Nurse 63 46.0 Pharmacist 13 9.5 Physician Assistant 2 1.5 Mental Health Professional 3 2.2 Dentist 9 6.6 Veterinarian 3 2.2 Other 11 8.0 Number of times in Substance Abuse Treatment prior to current sobriety date 0 52 38.0 1 37 27.0 2 26 19.0 3 5 3.6 4 5 3.6 5 or more 12 8.8 ______________________________________________________________________________ Level of care during last Substance Abuse Treatment Residential 39 28.5 Partial-Hospitalization (PHP) 26 19.0 Intensive Outpatient (IOP) 41 29.9 PHP/IOP Combination 19 13.9 Never been in treatment 9 6.6 Other 3 2.2 ______________________________________________________________________________ Approximate number of m onths/years participant admitted to themselves they had a problem with alcohol and/or drugs pr ior to their current sobriety date 0 12 months 28 20.4 1 2 years 20 14.6 3 5 years 24 17.5 5 10 years 23 16.8 10 or more years 42 30.7 ______________________________________________________________________________ N Mean SD Minimum-Maximum Statistic Age 137 47.09 9.9 24 75 ______________________________________________________________________________ Years in practice 137 18.71 10.2 1 50 ______________________________________________________________________________ Years in practice prior to 135 13.30 9.4 0 33 first addiction treatment

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75 CHAPTER 4 RESULTS The purpose of this study was to investig ate the relationship of four predictor independent variables (level of surrender, twelve-step engagem e nt, spirituality practices, and current professional monitoring contract year to the dependent variable (stage of change) of recovering impaired professiona ls. In this chapter, the results of this study are presented in four sections: Instrument analyses descriptive statisti cs, hypothesis results, and the summary of current findings. Instrument Analyses Previous studies have confirm ed that the original scales and subscales were reliable and measured the identified constructs except for the Twelve-step participation questionnaire. However, validity and reliability have shown to be situation and person specific. Hence, prior to analyzing the data and testi ng the hypotheses for this study, the reliability of the study instruments was determined. Internal consistency estimates were calculated for the following four instruments: the University of Rhode Is land Change Assessment (URICA), the Reinert S Surrender Scale, the Twelve-step participation questionnaire (T SPQ), and the Spirituality and beliefs scale (SIBS). Cronbachs alpha was used to calculate the in ternal consistency of the four instruments administered to the participants. In addition, th e means and standard deviations were computed on the study sample and are presented below in Table 4-1.

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76 Table 4-1 Reliability Statistics, Means, and Standard Deviations Scale # of Items Cronbachs Alpha Mean Standard Deviation SIBS 39 0.964 220 36.3 ______________________________________________________________________________ Surrender 25 0.487 21.25 3.25 _____________________________________________________________________________ TSPQ 11 0.851 9 2.39 ______________________________________________________________________________ URICA Pre-Contemplative 8 0.841 13.33 4.48 Contemplative 8 0.779 31.66 4.32 Action 8 0.778 32.87 3.99 Maintenance 8 0.784 24.68 5.69 Total scale 32 0.716 ______________________________________________________________________________ N = 137 Descriptive Statistics The data for this study was analyzed usi ng SPSS version 16.0. The survey developed for this study was comprised of four instruments and a demographic questionnaire. Descriptive statistics were computed for the dependent variable Stage of Change (URICA), as well as for the four independent variables (level of surrender (Reinert S Scale), 12-step engagement (TSPQ), spirituality (SIBS), and year of current IPN/PRN monitoring contract). The participants with missing data were deleted from the overall data used in each analysis. Th e mean scores, standard deviations, and confidence intervals for each inst rument are reported for each of the dependent and independent variables (See Table 4-2).

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77 Table 4-2 Descriptive Statistics fo r Independent and Dependent Variables Range of Mean Standard 95% Confidence Variables Scores Score Deviation Interval 1. Surrender 6 25 21.3 3.3 20.7 21.8 2. TSPQ 0 11 9.0 2.4 8.6 9.4 3. SIBS 77 272 220.2 36.4 214.0 226.3 4. Contract Year 0 5 2.9 1.5 2.6 3.1 5. URICA Pre-Contemplative 8 30 13.3 4.5 12.6 14.1 Contemplative 16 40 31.7 4.3 30.9 32.4 Action 20 40 32.9 4.0 32.2 33.3 Maintenance 9 36 24.7 5.7 23.7 25.6 Action & Maintenance 29 76 57.6 8.4 33.8 51.5 _____________________________________________________________________________ NOTE: TSPQ = 12-step engagement scale, SIBS = Spirituality scale, URICA = Stage of Change scale Hypothesis Testing Hierarchical multiple regression analyses a nd correlational statis tics were conducted in order to test the study hypothese s and one post-hoc analysis in this study. Hypotheses 1-4 were tested using a sequence of four hierarchical multiple regression analyses to determine what, if any, relationships existed between the four inde pendent variables (level of surrender, 12-step engagement, spirituality practices, and professional monitoring contract year) and the dependent variable, each of the four stages of change (pre-contemplation, contemplation, action, and maintenance). Level of Surrender, 12-Step engagement, Spirituality Practices, and Professional Monitoring Contract Year was the order the variab les were placed in the hierarchical regression models. Correlational results are described for each hypothesis. Tables 4-4 4-9 depict the regression and correlati onal results. A Wilks Lambda is a test st atistic used in Mul tivariate analysis of variance (MANOVA) to determine whether there are differences among the means of identified groups of subjects on a combination of dependent variab les (Crichton, 2000). The Wilks Lambda value is a number

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78 equivalent to F in the analysis of variance (ANOVA) test (Fraenkel and Wallen, 2006). After performing a Wilks Lambda test, the results su ggest that there are significant differences. ~ F (16, 394.74) = 4.98, = 0.57, p < .001. The univariate F tests are significant for each stage of change indicated below in Table 4.3 with the corresponding p values, adjusted R2 values, and shared variance percentages. Table 4-3 F statistics, p values, adjusted R2 values, and variances Variable Univariate F test p value R2 Variance Pre-contemplation F (191.08, 14.90) = 12.83 p < .001 .258 28.0% Contemplation F (118.81, 15.62) = 7.61 p < .001 .163 18.7% Action F (145.35, 12.03) = 12.03 p < .001 .246 26.8% Maintenance F (223.64, 26.61) = 8.40 p < .001 .179 20.3% Action & Maintenance F (4, 132) = 11.79 p < .001 .241 26.3% Hypothesis 1 states there are no significant contribu tions of the participants level of surrender, 12-step engagement, spirituality prac tices, and professional monitoring contract year in the prediction of th eir pre-contemplation stage of change. Regr ession results supported rejecting the null hypothesis. Table 4-4 depicts the hierarchic al regression results. The surrender score is a significant predictor of the pre-contempla tion stage of change with a p value = .049. On average, and holding the other predictors cons tant, a one-point increase th e surrender score predicts a 0.279 point decrease in the pre-contemplation score. The twelve step pa rticipation score was a significant predictor of the pre-cont emplation stage of change with a p value = .001. While holding the other predictors cons tant, a one-point incr ease in the 12-step participation score predicts a 0.748 point decrease in the pre-contemplation score. Spirituality and professional

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79 monitoring contract year were not significant predictors of the pre-contemplation stage of change. The correlation matrix for this study is de picted in Table 4-5 below. There was a negative correlation between level of surrender and the pre-cont emplation stage of change (r = -40, p < .001). The inverse relati onship suggests the higher th e pre-contemplation stage of change score, the lower th e level of surrender score. There was a negative correlation between the level of twelve-step engagement and the pre-contemplation stage of change (r = -.50; p < .001). The inverse relationship suggests as twelve-step engagement scores incr eases the pre-contemplation stage of change score decreases. There was a negative correlation between the level of spirituality and the precontemplation stage of change (r = -.31; p < .001). The inverse relationship suggests the higher the pre-contemplation score the lower le vel of spirituality is present. There was a negative correla tion between the number of years under contract with IPN/PRN and the pre-contemplation stage of cha nge (r = -.06; p < .001). This inverse relationship suggests as higher precontemplation scores occur the more likely a participant is in an early year of their professional monitoring contract. Table 4-4 Regression Model #1 Pre-Contemplation Stage of Change (dependent variable) Standardized 95% Confidence Independent Coefficients Interval Variables Beta (Standard Error) t-value p-value Lower Upper Surrender -.203 (.140) -1.99 .049 -.557 -.002 12-Step -.399 (.161) -4.64 .001 -1.07 -.429 Spirituality -.008 (.012) -.087 .931 -.025 .023 Contract Year .019 (.228) .258 .797 -.392 .509

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80 Table 4-5 Correlation Matrix Variable________________ 1 2 3 4 5 6 7 8__________ 1. P-URICA -2. C-URICA -.77*** -3. A-URICA -.71*** .71*** -4. M-URICA -.44*** .60*** .50*** -5. Surrender -.40*** .30*** .37*** .15 -6. TSPQ -.50*** .39*** .48*** .36** .48*** -7. SIBS -.31*** .24** .35*** .05 .65*** .44*** -8. Contract Year -.06 -.08 .02 -.19* .11 .14 .12 -*p < .05, **p < .01 (two-tailed); ***p < .001 (two-tailed); N = 137 NOTE: P-URICA= Pre-contemplation; C-URIC A = Contemplation; A-URICA = Action; MURICA = Maintenance; TSPQ = 12-step engageme nt scale; SIBS = Spirituality and Beliefs scale. Hypothesis 2 states there are no significant contribu tions of the participants level of surrender, 12-step engagement, spirituality prac tices, and professional monitoring contract year in the prediction of their contemplation stage of change. Regressi on results supported rejecting the null hypothesis. Table 4-6 depicts the hierarch ical regression results for the contemplation stage of change. The twelve-step particip ation score was the only statistica lly significant predictor of the contemplation stage of change score with a p value = .001. While holding the other predictors constant, a one-point increase in the 12-step participation score pr edicted a 0.59 point increase in the contemplation score. Add itionally, the relationship between the contemplation stage of change and contract year a pproached significance with a p value = .075. In an inverse relationship, predicted contemplation score de creases by -0.42 points for each one-year increase in contract year. Level of surrender and spirituality were not significant predictors of the contemplation stage of change. The correlation matrix for this study is de picted in Table 4-5. There was a positive correlation between the level of surrender and the contemplat ion stage of change (r = .30, p <

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81 .001). Therefore, as the level of surrender increases the contemplation stage of change scores increase. There was a positive correlation between the le vel of twelve-step engagement and the contemplation stage of change (r = .39; p < .001). Therefore, the hi gher the level of 12-step engagement, the contemplation stage of change scores also increased. There was a positive correlation between the le vel of spirituality and the contemplation stage of change score (r = .24; p < .01). Therefore, the greater th e extent of spirituality practices and beliefs of each impaired professional, the hi gher the contemplation stage of change scores were. There was a negative correla tion between the number of years under contract with IPN/PRN and the contemplation stag e of change score (r = -.08; p < .01). This inverse relationship suggests as contemplati on scores increase the more likely a participant is in an early year of their professiona l monitoring contract. Table 4-6 Regression Model #2 Contemplati on Stage of Change (dependent variable) Standardized 95% Confidence Independent Coefficients Interval Variable Beta (Standard Error) t-value p-value Lower Upper Surrender .161 (.144) 1.49 .138 -.070 -.498 12-Step .327 (.165) 3.58 .001 .264 .918 Spirituality -.005 (.013) .046 .964 -.024 .025 Contract Year -1.43 (.233) -1.80 .075 -.880 .042 Hypothesis 3 states there are no significant contribu tions of the participants level of surrender, 12-step engagement, spirituality prac tices, and professional monitoring contract year in the prediction of their action stage of change. Regression re sults supported re jecting the null hypothesis. Table 4-7 depicts the hierarchic al regression results for the action stage of change. The twelve-step participation score was the only statistically significant predictor of the action stage

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82 of change score. While holding th e other predictors constant, a one -point increase in the 12-step participation score predicts a 0.65 point increase in the action score, with p value = .001. Level of surrender, spirituality, and pr ofessional monitoring contract y ear did not significantly predict the contemplation stage of change. The correlation matrix for this study is de picted in Table 4-5. There was a positive correlation between the level of surrender and the action stage of change (r = .37, p < .001). Therefore, as the level of surrender scores increase, the action stage of cha nge scores increase. There was a positive correlation between the le vel of twelve-step engagement and the action stage of change (r = .48; p < .001). Therefore, as the level of 12-step engagement increases, the action stage of change scores also increase. There was a positive correlation between the leve l of spirituality and the action stage of change (r = .35; p < .001). Therefore, the greater the exte nt of spirituality practices and beliefs of each impaired professional, the action stage of change scores increase. There was a positive correlation between th e number of years under contract with IPN/PRN and the action st age of change (r = .02; p < .05). A high action stage of change score increases with longer length of time under IPN/PRN contract. Table 4-7 Regression Model #3 Action St age of Change (dependent variable) Standardized 95% Confidence Independent Coefficients Interval Variable Beta (Standard Error) t-value p-value Lower Upper Surrender .126 (.126) 1.23 .220 -.094 .405 12-Step .387 (.145) 4.46 .001 .359 .933 Spirituality .102 (.011) 1.02 .310 -.012 .033 Contract Year -.061 (.205) -.813 .417 -.572 .238 Hypothesis 4 states there are no significant contribu tions of the participants level of surrender, 12-step engagement, spirituality prac tices, and professional monitoring contract year

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83 in the prediction of their maintenance stage of change. Regression results supported rejecting the null hypothesis. Table 4-8 depicts the hierarchic al regression results for the maintenance stage of change. The twelve-step participation score is a statistical ly significant predictor of the maintenance stage of change score. While holdi ng the other predictors constant a one point increase in the participation predicts a 1.01 point increase in the maintenance score with p = .001. The contract year is also a statistically significant pred ictor of the maintenance stage of change score. While holding the other predictors constant, a one-year increase in contract year predicts a 0.94 point decrease in the maintenance score, with p = .002. Level of surrender and spirituality were not significant predic tors of the maintenance stage of change. The correlation matrix for this study is de picted in Table 4-5. There was a positive correlation between the level of surrender and the maintenanc e stage of change (r = .15, p > .05). Therefore, as the level of surrender scores increas e, the maintenance stage of change scores also increase. There was a positive correlation between the level of twelve-step engagement and maintenance stage of change (r = .36; p < .01). The findings show a significant relationship between twelve-step engagement and stage of change Therefore, the higher the level of 12-step engagement, the higher the maintenance stage of change scores are. There was a positive correlation between the level of spirituality and maintenance stage of change (r = .05; p < .05). Therefore, the greater the exte nt of spirituality pr actices and beliefs of each impaired professional, maintenan ce stage of change scores increase. There was a negative correla tion between the number of years under contract with IPN/PRN and the maintenance (r = .05; p > .05) stage of change. The inverse relationship

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84 suggests that there is an invers e relationship between the maintena nce stage of change score and the impaired professionals year under IPN/PRN contract. Table 4-8 Regression Model #4 Maintenanc e Stage of Change (dependent variable) Standardized 95% Confidence Independent Coefficients Interval Variable Beta (Standard Error) t-value p-value Lower Upper Surrender .080 (.187) .743 .459 -.231 .510 12-Step .426 (.216) 4.70 .001 .587 1.44 Spirituality -.162 (.016) -1.54 .125 -.058 .007 Contract Year -.244 (.304) -3.10 .002 -1.55 .341 Post-Hoc Analysis Post-hoc analyses were conduc ted to investigate the relati onship between the following independent variables: level of surrender, 12-step engagem ent, spirituality practices, and professional monitoring contract year, and the combined composite scores of the action and maintenance stages of change (dependent va riables) as reported by recovering impaired professionals. The results of the post-hoc regres sion analysis provided ev idence of a significant association, which supported reje cting the null hypothesis. Table 4-9 depicts the hierar chical regression results for the combined action and maintenance stages of change. The twelve-s tep participation and c ontract year are both significant predictors of the combin ed action/maintenance score with p values equaling .001 and .012 respectively. Comparing standa rdized regression coefficients, we find that the twelve step participation score is by far the strongest predicto r of the set. Specifical ly, a one-point increase in this score, holding th e other variables constant, is associated with a 1.67 point increase in the action/maintenance score. Contract year has a negative relationship su ch that a one-year increase, holding other variables constant, is associated with a 1.11 decrease in the action/maintenance score.

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85 Table 4-9 Regression Model #5 Action & Main tenance combined (dependent variables) Standardized 95% Confidence Independent Coefficients Interval Variable Beta (Standard Error) t-value p-value Lower Upper Surrender .114 (.267) 1.10 .272 -.234 -.823 12-Step .470 (.307) 5.40 .001 1.05 2.27 Spirituality -.061 (.023) -.601 .549 -.060 .032 Contract Year -.193 (.434) -2.56 .012 -1.97 -.251 Summary In this chapter, the resu lts of a survey on impaired professionals in recovery from addiction who are currently under a Florida professional monitori ng contract with either the Intervention Project for Nurses (IPN) or th e Professionals Resource Network (PRN) were presented. Descriptive statistics for the research variables, multiple regressions, and correlations between the variables were presented. The re search questions were answered by providing a detailed explanation of the results of the data an alyses. The hypotheses results are articulated in Table 4.10. In chapter 5, the regression re sults, study limitations, implications, and recommendations for future research are discussed.

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86 Table 4-10 Results of Hypothesis Testing Number Hypothesis Decision Ho (1): There are no significant contributions of the participants level of Reject surrender, 12-step engagement, spirituality practices, and professional monitoring contract year in the pr ediction of their pre-contemplation stage of change. ______________________________________________________________________________ Ho (2): There are no significant contributions of the participants level of Reject surrender, 12-step engagement, spirituality practices, and professional monitoring contract year in the prediction of their contemplation stage of change.. ______________________________________________________________________________ Ho (3): There are no significant contributions of the participants level of Reject surrender, 12-step engagement, spirituality practices, and professional monitoring contract year in the prediction of their action stage of change. ______________________________________________________________________________ Ho (4): There are no significant contributions of the participants level of Reject surrender, 12-step engagement, spirituality practices, and professional monitoring contract year in the prediction of their maintenance stage of change. ______________________________________________________________________________

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87 CHAPTER 5 DISCUSSION There is an abundance o f research on alc ohol and drug addiction and the facets of the recovery process. However, there has been limited research on impaired professionals recovering from alcohol and drug addiction. This study examined the influences of surrender, of 12-step engagement, and of spiritu ality practices in the recovery of 137 impaired professionals currently under contract with either the Intervention Project for Nurses (IPN) or the Physicians Resource Network (PRN) in the state of Florida. Each professional completed an online survey comprised of the University of Rhode Island Change Assessment (U RICA), the Reinert S Surrender Scale (Reinert, 1997), the Twelve-Ste p Participation Questionnaire (TSPQ), the Spirituality and Beliefs Scale (SIBS), and a dem ographic questionnaire. This chapter discussed the major findings of the study, the study limitations, implications for theory, research, and practice, and recommendations for future research. Discussion of Study Findings Stage of Change The Transth eoretical or Stag es of Change (SOC) theory has particular currency in contemporary health psychology (Prochaska and Norcross, 1998). When individuals are at different stages of change, they may have di fferent attitudes, beliefs, and motivations with respect to the desired new behavior (Prochaska and DiClemente, 1986). The Transtheoretical Model hypothesized that a person adopting a new be havior progresses through specific stages of readiness to change marked by distinct cognitive processes and behavioral indicators (Prochaska, Velicer, and Guadagnoli, 1991). The Stage of Change theory may be applied to various disciplines and processes of desired change. Although the Transtheoreti cal stage of change

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88 theory has been used to investig ate persons engaged in substance abuse treatment, this is the first use of this process with the impaired professional population. Results from regression calculations reported there was somewhat low shared variance. Hence, 28% of the variance was explained for th e pre-contemplation stage of change score in relation to the four independe nt variables, 18.7% of the variance was explained for the contemplation stage of change score, 26.8% of the variance was explained for the action stage of change score, and 20.3% was explained for the main tenance stage of change score. There were substantial significant differences in the relati onships between stage of change and the four independent variables (level of surrender, 12-step engagement, spirituality, and professional monitoring contract year). Callaghan, Hathaway, Cunningham, Vettese, Wya tt, and Taylor (2005) researched the stage of change predictive quali ties of 130 adolescents in an inpa tient adolescent substance abuse treatment facility. Callaghan and colleagues (200 5) developed a hierarchical logistic regression model of treatment dropout using the subscales of the University of Rhode Island Change Assessment (URICA), demographic variables, an d subscales of the Addiction Severity Index (ASI). A chi-square analysis was conducted and researchers found the best predictive model of dropout included only the Pre-contemplation subscale of the URIC A. Adolescents assigned to the Pre-contemplation stage manifested significan tly higher rates of treatment attrition than adolescents in the Contemplati on or Preparation/Action stages Findings provided important empirical support for the predictive utility of the stage of change theory when implemented with a culturally diverse sample of a dolescents admitted to an inpatient substance-abuse treatment program. Similarly to this study, through hi erarchical multiple regressions, the precontemplation stage of change provided predictive validity in relation to level of surrender and

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89 12-Step engagement. The URICA change assessmen t continues to provide statistical support for the predictive validity the stages of change have in predicting various treatment outcomes with varying substance abusing populations. Stage of Change and Surrender Surrender involves an acceptanc e of ones lim itedness, giving up control to a higher power, a shift from aggressive and negative feelings to positive ones, and a sense of being at one with the world (Reinert, 1999). According to Reinert (1999), surrender appears to be characterized by an acceptance, a lack of resistance to change, and the person no longer fighting the need for treatment. Speer and Reinert (1998) completed a pilot study comprised of 31 former clients (78% male, 22% female) of a Minnesota model treatment program in the rural mid-west who had been discharged from treat ment at least one year prior to the outset of the study. The Recovery Scale (Speer, 1995), designed to meas ure the quality of recovery of those who had experienced alcohol abuse or dependence, and th e Reinert S Scale (1997) which was designed to measure surrender as defined by Tiebouts research (1944, 1949, 1953, 1954 & 1961) were given. Similarly to the results of this study, participants who were more actively involved in Alcoholics Anonymous (AA) scored higher on the surrender scale th an those participants with low involvement and those involved in Rational Recovery, an alcohol treatment group that does not advocate surrender to a higher power as a part of their recovery process (Reinert et al., 1995). Speer and Reinert (1998) reporte d that the High Surrender group ha d higher recovery scores consistent with the theory that there was a connecti on between surrender and the quality of ones recovery from alcohol and drug addiction. Hypotheses 1-4 stated that th ere were no significant contri butions of the participants level of surrender to their stage of change score. Results from th e four regression models and the post-hoc analysis resulted in rejecting the null hypot heses. Overall, level of surrender was

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90 indicated to be associated with stage of change. More specif ically, there was a significant inverse relationship between level of surrender a nd the pre-contemplation stage of change. A one-point increase in the surrender score predicted a 0.279 point decrease in the precontemplation score. These results revealed that the higher the pre-c ontemplation scores, the lower the levels of surrender scores. Therefore, it appeared th at the less an individual is willing to surrender to the need and/or process of change, the more likel y their behaviors and actions are consistent with being in the precontemplation stage of change. In contrast, there was a positive correlation between the level of surrender scores and the scores on the contemplation, action, and maintenan ce stage of change scores. Therefore, it appeared that the level of su rrender increased as the scores on the contemplation, action, and maintenance stage of change increased. Resu lts imply that as persons move through the sequential stages of change, th e level of surrender scores incr ease. This studys findings are congruent with Speer and Reiner t (1998) who found that levels of surrender were directly correlated to ones quality of recovery. Stage of Change and Twelve-Step Engagement Participation in Alcoholics Anonym ous (a nd other 12-step programs) is the most frequently prescribed treatment for chemically dependent individuals (Fiorentine and Hillhouse, 2003). A majority of clinicians consider 12-step programs to be an effective group intervention. Factors such as socio-economic status (SES), ge nder, family background, race, ethnicity, sexual orientation, financial status, along with other factors that typically influence ones acceptability, matter little to those involved in the program (Tonigan, 2001). The premise of AA and other 12-step programs is that alcohol (o r the identified substance) is but a symptom of the disease, and that recovery is dependent on much more than stopping the use of alcohol (Streifel and Servanty-Seib, 2006). Core tenets of the program include principles such as

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91 honesty, hope, willingness, humility, spirituality, and service to others. Although the 12-steps include reference to God, AA is not a religious organization; memb ers may interpret the idea of a power greater than themselves in any way they see fit. There is no hierarchical organizational structure; there is no official doctrine, no declaration of faith (Swora, 2004). Alcoholics Anonymous members vehemently stress that the fe llowship and program are spiritual rather than religious. Hypotheses 1-4 stated there were no significant contributions of the participants level of 12-Step engagement to predicting their stage of change scores. Results from the four multiple regressions models, including the post-hoc analyses, supported re jecting the null hypothesis. Overall, 12-Step engagement was indicated to be a significant predictor of all four stages of change (pre-contemplation, contempl ation, action, and maintenance). More specifically, there wa s a significant inverse relati onship between twelve-step engagement and the pre-contemplation stage of change. A one-point increase in the twelve-step participation score predicted a 0.748 point decrea se in the pre-contemplation score. These results suggest that as 12-Step engagement scores increased, readiness for change increased resulting in a decrease in pre-co ntemplation scores. Similarly, th e twelve-step participation score is a significant predictor of the contemplation stag e of change score. A one-point increase in the twelve-step participation score predicted a 0.59 point in crease in the contemplation stage of change scores. The twelve-step participation score was the only statistically significant predictor of the action stage of change score. A one-poi nt increase in the tw elve-step participation predicted a 0.65 point increase in th e action stage of change score. The twelve-step participation score was a statistically significan t predictor of the maintenance stage of change score. A onepoint increase in the tw elve-step participation predicted a 1.0 1 point increase in the maintenance

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92 stage of change score. Twelve-Step engagement scores increased as stage of change scores for the contemplation, action, and maintenance stages of change increased. This implies the more actively engaged in 12-Step programming one is, the hi gher the scores in stage of change occur. Correlational results also indicated a negativ e correlation between the level of twelvestep engagement and the pre-contemplation stage of change. That is, the higher ones scores in the pre-contemplation stage of change, the less engaged the person was in 12-step programming. In contrast, there was a positive correlation betw een the level of twelve-step engagement and the contemplation, action, and the maintenance stages of change. Therefore, it appeared that the higher the level of 12-step engagement, the higher the contemplation, action, and maintenance stage of change scores. These findings are similar to those repor ted by Fiorentine and Hillhouse (2003) who analyzed a treatment outcome study of 356 patient s and found confirmation as to why extensive participation in recovery activities based on th e Addicted-Self Model of recovery predicted abstinence. Conclusions suggested that mor e is better; frequent counseling, treatment completion, and weekly or more participati on in 12-step programs promote abstinence independently (Fiorentine and Hillhouse, 2003). The findings from this study are also consiste nt with those reported by Zemore, Kaskutas, and Ammon (2004) who examined whether client s in treatment for alcohol and drug problems benefited from helping others and how their recovery related to their 12-step involvement during and post-treatment. Measures of 12-step involve ment were taken at ba seline and at a 6-month follow-ups; a helping checklist measured the amount of time particip ants spent helping, by sharing experiences, explaining how to get he lp, and giving advice on other living needs posttreatment in a non-professional specific population. Tw elve-step involvement at follow-up was

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93 predicted by client involvement levels at ba seline, helping levels during treatment, and the participants length of stay in treatment. He lping and 12-step involvement were found to be important, related predictors of treatment outco mes. Total abstinence at follow-up was strongly and positively predicted by 12-st ep involvement at follow-up more than during the formal treatment. Zemore and colleague s (2004) concluded that helping positively predicted subsequent 12-step involvement, and clarified the 12-step affiliation process. Thus results from this current study are consistent with current research evidence on the positive affects of engagement in 12Step programming on the recovery process. Stage of Change and Spirituality Spiritu ality has been considered to be a critical fact or in recovery since the beginning of the contemporary alcohol and drug treatment movement. However, it remains poorly understood, understudied, and is not oriously difficult to define and operationalize (Swora, 2004, Eliason, Amodia, and Cano, 2006). Spirituality i nvolves a complex combination of feelings, thoughts, and attitudes about oneself in the world. According to Miller (1999), because spirituality is associated w ith self-help recovery moveme nts, such as AA (Alcoholics Anonymous), and/or its conflati on with religion, there has been little scientific study of the concept of spirituality. Religion and spirituality are said to overlap but are not conceptually the same (Rowe & Allen, 2004). The majority of the United States population believes that spirituality is a component of the recovery process from any illness (McNichol, 1995), and individuals in recovery from alcohol and/or drugs frequently emphasize the importance of spirituality in their own recovery (Jarusiewicz, 1999; McMillen et al., 2001). This study also revealed the correlational prevalence of 12-St ep engagement and heightened spirituality practices.

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94 Individuals with chronic illnesses often deal with intense physical and psychological stressors as a consequence of living with an illness; the same is tr ue for the disease of addiction. Rowe and Allen (2004) explored the relationship between spiritu ality and coping ability after 201 participants completed the Spiritual Involv ement and Belief Scale (SIBS) and the Coping Styles Scale. Regression an alyses conducted on four factors of coping indicated a positive correlation between spirituality and the ability to cope. Participants who scored high in spirituality practices tended to show higher overall coping scores. In regards to recovery from addiction, spirituality growth is assumed to be an important coping skill. In another study, two groups were formed from local AA groups in New Jersey. One group represented those who were continually relapsing. The Spiritual Belief Scale (SBS) based on the Alcoholics Anonymous (AA) model and the Fo wler Interview Process (FIP) s cale which showed the growth of faith as a part of the maturation process were administered; results re vealed that individuals who had at least two years of recovery demonstrated significantly greater levels of spirituality than those who continued to relaps e. While the research is becomi ng clearer as to the benefits of spiritual engagement for those in recovery fr om addiction, it is difficult to determine if spirituality helps the recovery process directly, or if spiritual engagement is a result of recovery (Jarusiewicz, 2000). While the results of the cu rrent study reveal a posi tive relationship between spirituality and stage of change scores, it was not a significant predictor of the change score. Hypotheses 1-4 stated there were no significant contributions of the participants level of spirituality and stage of change. Results from the four multiple regressions models and the posthoc analyses did not reveal that spirituality was a significant predicto r of stage of change scores. However, correlational results show ed a negative correlation between the level of spirituality and the pre-contemplation stage of change. That is the higher the pre-contem plation score the lower

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95 the level of spirituality is present. Moreover, there was a positive correlation between the level of spirituality and the contempla tion, action, and maintenance stage of change. In addition, there was a significant association between stage of ch ange scores and 12-Step engagement scores indicating that they shared a common pool of variance. Stage of Change and Profession al Monitoring Contract Year The m edical profession, and other professions working with people, mandate to do no harm which dates from the time of Hippocrates (Daniel, 1984). Organized efforts to address impaired workers have their historical roots in the late 1930s and early 1940s following the emergence of Alcoholics Anonymous (AA) and th e need during World War II to retain a sound work force (Reamer, 1992). Early occupational alcoholism progr ams developed in the early 1970s eventually lead to the origin of Employee Assistance Programs (EAP). Employee Assistance Programs were origin ally designed to address a broa d range of problems experienced by workers. Florida is one of many states that have developed a diversion program for impaired professionals. There are two main Florida monitoring systems for impaired professionals; the Intervention Project for Nurses (IPN) and th e Professionals Resource Network (PRN). The Professionals Resource Networkwas established in the late 1970s after th e sick doctor statute was passed. The Florida Medical Practice Act allo ws the confidential treatment of physicians with impairments (Goetz, 1995). The Intervention Project for Nurses (IPN) was established in 1983 through legislative action to ensure public health and safety through a program that provides close monitoring of nurses who are unsafe to practice due to impair ment as a result of misuse/abuse of alcohol and/or dr ugs or due to a mental or physic al condition which could affect the licensee's ability to practice wi th skill and safety (IPN, 2007). Participation in PRN or IPN is confidential unless there is failure to progress in treatment.

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96 The goal of PRN/IPN and other diversion progr ams is to monitor th ese individuals under a five-year contract as they rein tegrate back to work and society as a recovering professional. Key components of an IPN/PRN contract require the impaired professional to participate fully in professional recovery meetings, 12-Step m eetings, psychiatric assessments, follow-up appointments, and random urine drug screens th roughout the entire length of the five year contract. The contract does not begin until th e impaired professional has successfully completed addiction treatment. Hall and colleagues (2002) found that 91.4% of randomly selected PRN recovering physicians returned to work successful ly after five years. Factors distinguishing those physicians who were unable to return to wo rk from those that were able to work were frequently due to (a) opioid addiction, (b) had higher frequency of intravenous (IV) drug use, (c) had more significant medical problems relate d to using, and (d) had more psychiatric comorbidity. According to Brooke, Edwards, and Taylor (1991), outcomes from Impaired Physician Programs in America have been enc ouraging, with about 75% of the participating physicians becoming drug free and practicing at follow-up periods ranging between two and eight years. Hypotheses 1-4 stated there were no significant contributions of the participants professional monitoring contract year and stage of change. Overall, professional monitoring contract year was minimally associ ated with the prediction of partic ipants stage of change score. While there was not a significant association found between professional monitoring contract year and the pre-contemplation, contemplation, and maintenance st ages of change scores there was a positive correlation betw een the number of years under c ontract with IPN/PRN and the action stage of change. That is the participants action stage of change score increased the longer the length of time they reported being under IPN/PRN contract.

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97 Limitations of the Study There were a num ber of limitations in the design of this study which include the nature of the sample, the sampling procedures, the instrume ntation, and the data collection procedures. The study participants were a voluntary sample which induced difficulty when generalizing this sample to the whole population of impaired prof essionals. A larger sample size would have enhanced the generalizabili ty of the findings. One of the primary concerns was the sampling procedures. Due to state privacy laws, the researcher was unable to access a random sample of IPN/PRN contracted impaired professionals in recovery; therefore, a convenience sample was used. By using a convenience sample, particularly to gather information on a subject as personal as factors infl uencing a professionals recovery from addiction, the type of respondent s who participated in the study may have been affected. Since the potential for self-selecti on bias existed, a profe ssional attending their IPN/PRN groups who was not atte nding to their recovery needs, may have chosen not to participate as they are aware of their disinter est in their personal re covery, struggling with surrender and lack of engagement in 12-step progra mming and/or spirituality practices. Another limitation of the sampling procedure involved the recruitment of particip ants through both the IPN and PRN organizations and subsequent variable access to participants. Since the researcher relied on the IPN/PRN facilitators to distribute information about the study, the response rate and details about who the information reached was unclear. A second limitation concerns the studys in strumentation. The su rrender, twelve-step engagement, and the spirituality scale were lacking validity data. As this population and field of interest increase, there will be more opportunity to find reliability and validity with varying populations. Future studies could benefit from th e results of validity stud ies on these instruments as more populations with addiction are studied.

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98 Another research concern was the nature and influence of se lf-report instruments. Social desirability responding by the impaired profe ssionals sampled was a concern. Although the directions explicitly dir ected participants to respond to thei r thoughts, actions, and feelings of that current time, it is not uncommon for persons to respond to questions in a manner that they aspire to. Once again, a larger sample could potentially combat th ese potential effects of social desirability responding. Implications Theory The results of this study have im plications fo r theory, practice, and research. This study was based on Prochaskas Transtheoretical St age of Change Theory which represents an empirically derived multistage sequential model of general change (Petrocelli, 2002). In seeking to understand how people change maladaptive patte rns of behavior such as compulsive drinking, behavioral psychologists have developed a number of models over the years to explain and predict behavioral change, with the ultimate goal of creating psychotherapeutic interventions to assist in behavior change (Swora, 2004). Clinic ians and researchers in health care and social services have found the Transtheoretical stage of change model helpful when applied to changing risky lifestyle behavi ors such as eating disorders, smoking, and excessive alcohol and/or drug consumption. The use of Prochaskas St age of Change theory in this study adds to the growing research interest in addiction, and professionals in particular, when examining the personal factors of a healthy recovery process. Th is studys results support ed the use of the four stages of change model to describe the behavi ors characterizing an impaired professionals recovery from alcohol and drug addiction.

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99 Research The m ajority of previous research on addiction has attempted to understand why treatment does not work, what helps persons not be addicted, and the nature versus nurture influences on the societal impact of addicti on. Researchers have not focused their efforts specifically on professionals and other sectored members of soci ety who are responsible for the well being of others. Communities cannot afford to lose gifted professionals due to the disease of addiction. The more accepting society become s of receiving help the less impact shame will have on people not getting the help they need. Further research on the impact of successful recovery behaviors will allow cl inicians and treatment centers to tailor their programming to specific needs of impaired professionals and decreas e the recidivism rate of relapse. There is a limited amount of data supported research on th e level of surrender, 12-step engagement, and spirituality practices directly re lated to the process of recovery from addiction. These personal factors alone could benefit from further research with all populations suffering from addiction, not just impaired professionals. These concep ts are not new to recovery; however, current research has primarily been anecdotal thus far. Practice The results of this research contribute to som e understanding of th e role of surrender, 12step engagement, and spirituality in impaired pr ofessionals recovery from addiction. Results from this study indicated the presence of varyi ng stages of change expe rienced by professionals recovering from alcohol and drug addiction. The majority of addiction research implies that persons move through the different st ages of change as they conti nue in recovery. Moreover, the majority of treatment centers for chemical depende ncy espouse the integral role of surrender, 12step engagement, and spirituality practice developm ent in the varying levels of treatment. This

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100 studys findings suggest the impact of these variables specifically and how to continue to endorse these options for success in the multifaceted stage a pproaches to substance abuse treatment. Treatment centers today have detailed treatm ent plans for persons in recovery from addiction. There are specific stages of treatment th at parallel the stages of change. For example, in the early stages of addict ion treatment in both inpatient and outpatient treatment settings, gaining an understanding the disease process and surrender process were the primary focus. This correlates with the study findings A negative association was found between level of surrender and the pre-contemplation stage of change. This implied that those in th e early treatment stages, often characterized as the pre-contemplation stage, also have decreased level of surrender scores. Treatment plan strategies shift as clients pr ogress through the stages of treatment. Thus strategies such as modeling and teaching the importance of building a sober support system and developing personal spirituality practices, characterize more advanced treatment stages. Results from this study support the use of clinical strate gies such as 12-Step engagement and developing personal spirituality practices as behaviors characteristic of more advanced stages of change. Recommendations for Future Research The findings of this research confirm the use of particular be haviors that support impaired professionals recovery from addiction. This study found significant relationships between the use of surrender, 12-step engageme nt, building personal spir ituality practices, and the participants stage of change. Future resear ch is necessary to gain a greater understanding of other personal factors cont ributing to the recovery of impaired professionals. To increase the external validity of the resu lts, it will be important for researchers to replicate this study using differe nt sampling methods (i.e. using a random sample rather than a convenience sample), and gathering data from a la rger overall sample. In order to learn more about the relationships among the stages of change and personal recovery factors, it is important

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101 that researchers employ a similar research de sign using impaired professionals from all monitored professions, and a grea ter representation from all of Floridas IPN/PRN contract members. Future studies on the personal recovery factors of impaired professionals would include utilizing other research designs. Qualitative rese arch would an asset to this research. There would be a benefit to further re search with the impaired professi onal population to discover what personal factors were represente d in the 65% of the variance not accounted for by surrender, 12step engagement, spirituality, and professional mon itoring contract year in this study. In addition to further quantitative research, this populat ion would benefit from qualitative research. Interviewing impaired professiona ls in recovery on a 1:1 basis would allow for a more intimate exposure to the intricacies of a healthy recovery program in ones life. Personal interviewing would also allow for greater understanding of th e personal factors that influence recovery not just concepts understood in th eory. Varying research methods may highlight research and clinical implications that are not able to be assessed in self-rep orting survey scales. Conclusion This chapter provided a discussion of the re sults, the study lim itations, implications for research, theory and practice, a nd recommendations for future rese arch. The results of this study showed significant rela tionships among surrender, 12-step engagement, spirituality, professional monitoring contract year, and st age of change among impaired professionals. However, 12-step engagement proved to be the most significant predic tor of the four stage of change scores (precontemplation, contemplation, action, and maintena nce). Once again, 12-step engagement is more than attendance at these community m eetings. Engagement in 12-step programming involves consistent attendance and participation, reading recovery litera ture, developing personal spirituality practices, connecting with other memb ers in 12-step groups, obtaining a sponsor to

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102 work the 12-steps of recovery with, and a dedication to the process of change. These results supported hypotheses and clinical implications of the positive a ssociations surrender, 12-step engagement, and the development of personal spirituality practices has on the impaired professional in recovery. Therefore, discovering which pers onal recovery practices are successful at which stage of change is the forefr ont for treating impaired professionals diagnosed with the disease of addiction.

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103 APPENDIX A INFORMED CONSENT Dear Professional: In a better effort to understand the recovery of Impaired Professionals, a research study is being conducted on the personal factors that influence the recovery of professionals currently holding a contract with either the Inte rvention Project for Nurs es (IPN) or the Professionals Resource Network (PRN) in the state of Florida. As a doctoral candidate in the Counselor Education Department at the University of Florid a, I am inviting you to participate in this study. Participation in this survey will require a pproximately 10-15 minutes. You will be asked to complete a series of questionnaires about factors influencing your recovery from addiction in an online survey. Lastly, a demographic ques tionnaire will include an opportunity for you to share any additional information you think would be helpful to me. Your identity and responses will be kept confidential and anonymous to the extent provided by the law. Questions or concerns about your rights as a research participant may be di rected to the UF IRB office, University of Florida, P.O. Box 112250, Gainesville, FL 32611, (352) 392-0433. Your participation in this study is completely voluntary. You may withdraw at any time. There are no known risks; however, if you feel th at you need to speak with someone regarding issues stimulated by these survey s, you may contact me about a re ferral. No immediate benefits are anticipated, however, you w ill be contributing to an important study on Impaired Professionals and the factors that go into a healthy solid recovery. There will be no compensation for participating in this study. If you have any questions about this research, you may contact me at kaissen@ufl.edu or at (352) 281-6242. My faculty advisor, Dr Ellen S. Am atea, may be contacted at eamatea@coe.ufl.edu or (352) 392-0731. Either of us m ay be contacted in writing at 1215 Norman Hall, University of Florida, P.O. Box 117046, Gainesville, FL 32611-7046. Sincerely, Kelly A. Aissen Ed.S. Doctoral Candidate Licensed Mental Health Counselor Principal Investigator I have read the procedure described above for th e study on factors of recovery from addiction. I voluntarily agree to participate in the survey. Click one response: YES NO

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104 APPENDIX B PARTICIPANT POSTCARD IPN or PRN? Survey: Professionals in Recovery Dear Professional: (currently unde r contract with IPN or PRN only) I am grateful for your willingness to part icipate in my University of Florida IRB approved dissertation research aiming to bett er understand the fact ors that influence professionals in recovery. Survey will take approximately 10 minutes to complete (go to link below) and is 100% anonymous Forwarding this web address to any friends, co-workers, or weekly group members in IPN or PRN would be greatly appreciated as well. Thank you in advance for your time, contributing to further re search in addiction, and helping me earn my PhD! Please feel free to contact me with any questions, thoughts, or interest in study results. Sincerely, Kelly A. Aissen Ed.S., NCC, LMHC Doctoral Candidate University of Florida kaissen@ufl.edu www.tiny.cc/recovery

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105 LIST OF REFERENCES Aach, R. D., Girard, D. E., Hum phrey, H., McCue, J. D., Reuben, D. B., Smith, J. W., Wallenstein, L., and Ginsburg, J. (1992). Alcohol and other substance abuse and impairment among physicians in residency training. Ann Internal Medicine, Vol. 1; 116(3), 245-254. Adlersberg, M. and MacKinnon, J. (2004). Registered Nurses and Substance Misuse or Abuse: RN ABCs Role. Nurse to Nurse, April, 2004. Alcoholics Anonymous Worl d Services (1976). Alcoholics Anonymous (4th ed.). New York: Author (Originally published in 1939). American Medical Association (2006). Helping Doctors Help Patients. http://www.ama-assn.org/ Arnold, R. M., Avants, S. K., Margolin, A., and Marcotte, D. (2002). Patient attitudes regarding the incorporation of spir ituality into addiction treatment. Journal of Substance Abuse Treatment, 23, 319-326. Atkinson, M., Wishart, P., Bushra, W., and R obinson, J. (2004). The self-perception and relationship tool (S-PRT): A novel approach to the measurement of subjective healthrelated quality of life Health and Quality of Life Outcomes, 2004. 2 (36). http://www.hqlo.com/content/2/1/36 Avants, S. K., W arburton, L. A. and Margolin, A. (2001). Spiritual and religious support in recovery from addiction among HIV-positive injection drug users. Journal of Psychoactive Drugs, 33, 39-46. Baxter, H., Singh, S. P., Standen, P., and Dugga n, C. (2001). The attitudes of tomorrows doctors towards mental illness and psychiatry: changes during the final undergraduate year. Medical Education Vol. 35, 381-383. Beitel, M., Genova, M., Schuman-O livier, Z., Arnold, R., Avants, K., and Margolin, A. (2007). Reflections by Inner-City Drug Users on a Buddhist-Based Spirituality-Focused Therapy: A Qualitative study. American Journal of Orthops ychiatry, Vol. 77(1), 1-9. Belts, W. C. (1996). Psychiatric diagnoses in North Carolina Physic ians Health Program participants. North Carolina Medical Journal 57:214-215. Bennet J. and ODonovan, D. (2001). Substance misu se by doctors, nurses, and other health care workers. Current opinion in Psychiatry, 14(3), 195-199. Bissell, L. (1983). Alcoholism in Physicians: Tactics to improve the salvage rate. Postgraduate Medicine 74, 177-230.

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106 Bogenshutz, M. P., Tonigan, J. S., and Miller, W. R. (2006). Examining the Effects of Alcoholism Typology and AA Attendance on Self-Efficacy as a Mechanism of Change. Journal of Studies on Alcohol, July 2006. Bohigian, G. M., Croughan, J. L., and Bondurant, R. (2002). Substance abuse and dependence in physicians: the Missouri Physicians Health Program, Vol. 99, 161-165. Boisaubin, E. V. and Levine, R. E. (2001). Id entifying and assisting th e impaired physician. American Journal of Medical Science 322(1): 31-36. Brooke, D., Edwards, G., and Taylor, C. (1991). Addiction as an occupational hazard: 144 doctors with drugs and alcohol problems. British Journal of Addiction, Vol. 86, 10111016. Brown, H. and Peterson, J., (1991). Assessing Spirituality in Addi ctions Treatment and Follow-up: Development of the Brown-Peterson Recovery Progress Inventory (B-PRPI). Alcoholism Treatment Quarterly, 8(2), 21-45. Brown, S. (1985). Treating the Alcoholic: A developmental model of recovery. New York: John Wiley & Sons. Callaghan R. C., Hathaway, A., Cunningham, J. A ., Vettese, L. C., Wyatt, S., and Taylor, L. (2005). Does stage-of-change predict dr opout in a culturally diverse sample of adolescents admitted to inpatient substance-abuse treatment? A test of the Transtheoretical Model. Addictive Behaviors; Oct2005, Vol. 30 Issue 9, p1834-1847, 14p Connors, G. J., Donovan, D. M, and DiClem ente, C. C. (2001). Substance abuse and the stages of change. Selecting an d planning interventions. New York: Guilford. Coombs, R. H. (1997). Drug-Impaired Professionals. Cambridge: Harvard University Press. Cooper, S. E. (1983). Survey on studies on alcoholism. The International Journal of the Addictions, 18, 971-985. Cooper, S. E. (1989). Chemical Dependency and Eati ng Disorders: Are they really so different? Journal of Counseling and Development, Vol. 68, 102-105. Crichton, N. (2000). Defining and assessing compet ence: issues and debates. A comparison of nursing competence. Journal of Clinical Nursing, 9, 369-381 Daniel, I. Q. (1984). Impaired Profe ssionals: Responsibilities and Roles. Journal of Nursing Economics, May-June, Vol. 2 Deutsch, C. (1985). A survey of therapists personal problems and treatment. Professional Psychology: Research and Practice, 1p6, 305-315.

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108 Freimuth, M. (1996). Psychotherapists beliefs about the benefits of 12-step groups. Alcoholism Treatment Quarterly, 14, 95-102. Galanter, M. and Talbot, D. (1989). Combining Alcoholics Anony mous and Professional Care for Addicted Physicians. American Journal of Psychiatry, 149, 64-68. Galanter, M. (2002). Healing through social and spiritual affiliation. Psychiatric Services, 53, 1072 1074. Galanter, M. (2005). Spiritualit y and the healthy mind: Scien ce, therapy, and the need for personal meaning. New York: Oxford University Press. Galanter, M. (2006). Spiritualit y and Addiction: A Research and Clinical Perspective. The American Journal on Addictions, 15, 286-292. Galanter, M., Dermatis, H., Bunt, G., Willia ms, C., Trujillo, M., Steinke, P. (2007). Assessment of spirituality and its relevance to addiction treatment. Journal of Substance Abuse Treatment, Vol. 33, 257-264. Gerwe, C. F. (2000). Chronic Addiction Relaps e Treatment: The Study of the Effectiveness of The High Risk Identification and Pr ediction Treatment Method, Part II. The Journal of Substance Abuse Treatment 19 (2) 429-438. Givens, J. L. and Tija, J. (2002). Depresse d medical students use of mental health services and barriers to use. Academic Medical Journal, Vol. 77, 918-921. Gold, M. S. and Pomm, R. (2001) UF Study: Physicians Addict ed To Drugs Or Alcohol Do Well In Long-Term Treatment. University of Florida Resear ch News, Gainesville, FL. Goleman, D. (1985). Social workers vault into a leading role in psychotherapy. New York Times, C1-C9. Gorski, T. T. and Miller, M. (1982). Counseling for relapse prevention. Independence, MO: Independence Press. Grimley, Prochaska, Velicer, Blais, and Diclemente, (1994). The Transtheoretical Model of Change. Chapter 7. In: Brinthaupt, T. M. and Lipka R. P. (1994). Changing the Self: Philosophies, Techniques, and Experiences. SUNY Press. Guy, J. D., Poelstra, P. L., and Stark, M. (1989). Personal distress and therapeutic effectiveness: National survey of ps ychologists practicing psychotherapy. Professional Psychology: Research and Practice, 20, 48-50. Hatch, R. L., Burg, M. A., Naberhaus, D. S., a nd Hellmich, L. K. (1998). The Spirituality and Beliefs Scale. Journal of Family Practice.

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109 Hall (2002). JAMA: Journal of the American Medical Association 288( 6): 756-64. Hall, J., Pomm, R., Frost-Pineda, K ., and Gold, M.S. (2002). Treatment of Alcohol Dependent Physicians: Impact of Alc ohol Use during Medical School. Journal of Biology Psychology, 51(8S), 197S-573. Henderson, M. J., Saules, K. K., and Galen, L. W. (2004). The Predictive Validity of the University of Rhode Island Change Asse ssment Questionnaire in a Heroin-Addicted Polysubstance Abuse Sample. Psychology of Addictive Behaviors, 18 (2), 106-112. Hillhouse, M. and Fiorentine, R. (2001). 12-step Program Participation and Effectiveness: Do gender and ethnic differences exist? Journal of Drug Issues, 31(3), 767-780. Hobbs, N. (1962). Sources of gain in psychotherapy. American Psychologist, 17, 741-747 Hughes, P., Conrad, S., Baldwin, D., Storr C., and Sheehan, D. (1991). Resident physician substance use in the United States. Journal of the Americ an Medical Association 265, 2069-2073. Hughes, P., Brandenberg, N., Baldwin, D., Storr C., and Williams, K., Anthony, J., and Sheehan, D. (1992). Prevalence of substance use among U.S. physicians. Journal of the American Medical Association, 267, 2333-2339. Hunglemann, J., Kenkel-Rossi, E., Klassen, L., and Strollenwe rk, R. (1996). Focusing on spiritual well-being; Harmonious interc onnectedness of mind-body spirit use of the JAREL well-being scale. Geriatric Nursing, 17 (6), 262-266. Huprich, S. K. and Rudd M. (2004). A national survey of train ee im pairment in clinical, counseling, and school psychology doctor al programs and internships. Journal of Clinical Psychology, Vol. 60 Issue 1, p. 43-52. Jarusiewicz, B. (2000). Spiritual ity and Addiction: Relationship to Recovery and Relapse. Alcoholism Treatment Quarterly, Vol. 18 (4). The Hawthorne Press, Inc. Jellineck, E. M. (1952). Ph ase of alcohol addiction. Quarterly Journal of Studies on Alcohol, 13, 673-684. Johnson, C. and Maddi, K. L. (1986). The etiology of bulimia: Biopsychosocial perspectives. Adolescent Psychiatry, 15, 253-273. Johnson, N. P. and Chappel, J. N. (1994). Using AA and other 12-step programs more effectively. Journal of Substance Abuse Treatment, 11, 137-142. Johnson, Z. (2004). The relationship between AA participation and le vel of functioning. Dissertation Abstracts Inter national: Section B: The Scie nces and Engineering, Vol. 65(6-B), p. 3165.

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116 BIOGRAPHICAL SKETCH Kelly Anne Aissen was born in June of 1978 in Miami, Florida. She graduated from Miami Killian Senior High in 1996. She earned he r Bachelor of Science degree in psychology in 2000, earned her Master of Educa tion and Specialist in Education degrees in mental health counseling in 2002, and earned her Doctor of Philo sophy in mental health counseling in 2008 all from the University of Florida. She has been a Licensed Mental Health Counselor (LMHC) in the state of Florida since 2005. Ke lly will continue working clinical ly in addition to her work in academia.