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Effectiveness of mental imagery for relapse prevention for recovering addicts

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Title:
Effectiveness of mental imagery for relapse prevention for recovering addicts
Creator:
Butkins, Peter A., 1945-
Copyright Date:
1994
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English

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Subjects / Keywords:
Addiction ( jstor )
Alcoholic beverages ( jstor )
Alcoholism ( jstor )
Demography ( jstor )
Diseases ( jstor )
Hats ( jstor )
Mental imagery ( jstor )
Psychological counseling ( jstor )
Psychotherapy ( jstor )
Relapse ( jstor )

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University of Florida
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EFFECTIVENESS OF MENTAL IMAGERY FOR
RELAPSE PREVENTION FOR RECOVERING ADDICTS












By

PETER A. BUTKINS


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

UNIVERSITY OF FLORIDA


1994

































Copyright 1994 by

Peter A. Butkins














DEDICATION

I dedicate this study to my mother, Rosemary, the

smartest woman I know; my sister, Tina; and my brother-inlaw, Hank, for their unconditional love, support, and wisdom.














ACKNOWLEDGMENTS

Many patient, tolerant, and loyal persons are

responsible for the completion of this research. I thank Dr. Larry Loesch for his expertise, guidance, and support. His dedication to his profession, clear-thinking, and willingness to lead have been an inspiration to me both personally and professionally.

I wish to thank the other members of my supervisory committee. Dr. Crocker has provided a great deal of expertise and direction. Dr. Gonzalez has been instrumental by adding an element of expertise and guidance in the area of chemical dependence. Dr. Ballet has been a mentor and inspiration even before this project was undertaken. I am deeply grateful to all of the above.

Without the assistance of Eileen Atkinson, this study would have been much more difficult. Pat Hill and Marie Winslow added an element of support as well as clerical work.

The facilitators, Mark Griffin, Larry Shyers, Virgil Bryant, and Michael Ladwig, were generous in giving their time, skills and professionalism.

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

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








time and helped me to learn and even prosper. I am grateful to them for teaching me gratitude, my greatest gift. Gratitude goes to AA for its help.

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

mother and father for their gifts of patience, intelligence, a success identity, and love. Without them I would be nothing. I thank my brothers and sisters who have helped to shape me since I was a child. My nieces and nephews are very special to me, and I am fortunate to have them. I am grateful for all of the above and their support both before and during this project.















TABLE OF CONTENTS

page

ACKNOWLEDGMENTS . iv

ABSTRACT . viii

CHAPTERS

1 INTRODUCTION . 1

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

2 REVIEW OF RELATED LITERATURE . 22

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

3 METHODOLOGY . 57

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

4 RESULTS . 78

Treatment History Information . 95 Followup . 96

5 DISCUSSION . 99

Limitations of the Study . 99 Conclusions . 101






























G

H


vii


Discussion .
Implications .
Recommendations .

APPENDICES


A

B

C

D


106 107 108



ill 115

120 121 128


129 135 161 162

164 166

184


RATIONALE FOR INTERVENTIONS . BRIEF WORKSHOPS AND THEIR EFFECTIVENESS . ABSTINENCE LIKELIHOOD INVENTORY (ALI) . ELEMENT (OR ITEM) REFERENCE SUPPORT FOR THE ALI . HELP-SEEKING LIKELIHOOD INVENTORY (HSLI) . ELEMENT (OR ITEM) REFERENCE SUPPORT FOR THE HSLI . DESCRIPTION OF TREATMENT . AGENDA . FOLLOWUP FORM . TREATMENT HISTORY FORM .


REFERENCES . BIOGRAPHICAL SKETCH .














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

EFFECTIVENESS OF MENTAL IMAGERY FOR
RELAPSE PREVENTION FOR RECOVERING ADDICTS By

Peter A. Butkins

August, 1994


Chairperson: Larry C. Loesch Major Department: Counselor Education

Relapse among recovering addicts is a common phenomenon which counselors frequently encounter. Relapse-prevention activities have not been tested that focused upon mental imagery within a strong theoretical framework. Therefore, the purposes of this study were to investigate (a) the effectiveness of such an approach and (b) how selected attributes related to treatment outcome variables.

A randomized, posttest only control group design was

used. Forty-nine persons in the experimental group provided data and were tested immediately after participating in a mental imagery relapse prevention workshop. Experimental group members were contacted six weeks after the workshop to assess their opinions of its effectiveness. The 36 control group members provided personal data and were assessed prior to participation in the workshop. Personal data collected viii







included age, gender, race, drug of choice, number of 12step meetings attended, and length of time in recovery. Outcome variables included level of self disclosure, perception of unmanageability, help-seeking behavior, and lifestyle behavior change.

Analyses of variance and multiple regression analyses using weighted, linear combinations yielded few statistically significant relationships or interactions among the demographic, treatment, and outcome variables. The major finding was that persons in the experimental group significantly increased their abstinence likelihood (i.e., perception of unmanageability) following participation in the workshop. At follow-up, a large majority of experimental group participants reported that the workshop was a positive and helpful experience.

It was concluded that the workshop generally was not successful in effecting immediate changes. Therefore, it was recommended that mental health counselors explore other methods to attempt to quickly facilitate and enhance relapse prevention. However, because feedback on the workshop was positive, it also was recommended that variations in the approach used in this study be explored.














CHAPTER 1

INTRODUCTION

F. Scott Fitzgerald complained that he could never get sober long enough to tolerate sobriety (Goodwin, 1988), suggesting that sobriety is not as easily attained as might be thought. In American society, it is evident that the problem of addiction includes not only alcohol but other drugs as well. The various drugs available today are just as cunning and lethal as Fitzgerald's drug of choice, yet they affect the body and mind much more quickly. However, for the purpose of this study, alcoholism and drug dependency are encompassed under the general rubric "chemical dependence" (CD). Talbott (1985) reported that the phenomena involved in alcohol and drug dependence are similar in that both have a set of symptoms including withdrawal and tendency to relapse. He noted that the standard definitions of alcoholism and drug addiction include compulsive use while experiencing adverse consequences. He continued, "In 1985 I hope we're not going to worry about whether we are talking about cocaineism, alcoholism, darvonism, quaaludism, fentanylism, valiumism or libriumism. we're talking about the disease of chemical dependence" (Talbott, 1985).








2
Researchers have found in numerous case studies that the psychological cravings characterizing chemical dependence can be satisfied by any mood-altering drug (Selby, 1985). Millham and Mason (1987) concurred in writing, "We keep coming back to the fact: Addiction is addiction is addiction, no matter what chemical is being abused" (p. 6).

Counseling for substance addiction is usually viewed as a difficult, often hopeless, clinical undertaking (Nace, 1987). Marlatt and Gordon (1985) added that it is a virtual truism that addictive disorders are characterized by high rates of relapse following initial treatment success. Thus, many attest to the severity and depth of addiction, alluding to the difficult problems in maintaining successful abstinence. Because of the frequency of relapse, there remains a need for effective approaches to preventive treatment for recovering addicts.

overview

Relapse (used here as synonymous with recidivism) is

defined as return to the compulsive use of drugs in the face of adverse consequences (Talbott, 1985). Recidivism occurs frequently among recovering persons; those who previously "stopped" use of the addictive substance. Many vow to stop, but make attempts to do so and fail--sometimes with tragic results. For example, Ohlms (1981) reported that 96% of alcoholics will die of their disease. The substance-abuse (chemical-dependence) problem in general is at epidemic










levels in the United States. Talbott (1985) noted that the great tragedy of the entire twentieth century in this country is that it is moving deeper and deeper into an addictive chemical culture. Chemical-dependence problems dramatically affect industry, youth, addicts, families, and counseling professionals among other groups. For example, alcohol abuse ranks third behind only cancer and heart disease in numbers afflicted. The casualty figures arising from abuse of alcohol on the highways, in crime, in hospitals, at the workplace, and in the family are staggering. Alcohol problems alone are costing the American society over $135 billion per year in medical expenses, time lost from work, and treatment costs. Moreover, there is a cost in human suffering that cannot be measured in dollars (Jacobson, 1990).

American industry has had to make major philosophical and operational changes because of employees' chemicaldependence problems. For example, the problem is so serious that the federal government has implemented several antidrug rules that apply to private-sector employers. These rules include the U.S. Department of Defense (DOD) policies, which require that defense contractors implement antidrug programs for employees in sensitive positions; the Drug-Free Workplace Act of 1988, which requires federal government contractors and employers receiving federal grants to maintain a drug-free workplace; and the U.S. Department of









Transportation regulations, which apply to the various transportation industries and call for, among other things, mandatory drug testing (Harrison & Simpler, 1989). To illustrate further, every employee with an alcohol or drug problem costs each citizen at least 25% of his/her salary each year in hidden expenses: absenteeism, mistakes, extra medical premiums, and more (Jacobson, 1990). Watkins (1989) reported that between 1% and 23% of all American workers use dangerous drugs--including alcohol--on the job. other employees may be under the influence when they arrive at work, or they may use alcohol and other drugs so extensively outside the workplace that their health and judgment are chronically impaired.

As many as 65% of young people entering the workforce have used illegal drugs. Jones (1988) reported that over 3 million of 50 million Americans who drink are under age 17. One in every five teenagers is experiencing, or has experienced, problems with alcohol. Up to 24% of teens nationwide reported alcohol abuse as being a "tremendous" problem in their schools. Nine of 10 teenagers and young adults have consumed alcohol at least once. Richmond and Peeples (1984) noted that substance abuse has been established as a part of the lives of many middle schoolaged children and is often quite extensive by adolescence.

Most people do not perceive addicts as being victims of addiction, including addicts themselves--a problem that










affects addicts in insidious ways. For example, chemical addiction is the third leading cause of suicide in the United States (Heilman, 1980). However, many of these deaths are disguised as "accidents." Kinney and Leaton (1987) cited half of all successful suicides and 67% of homicides as having involved the use of alcohol.

Many automobile-accident fatalities are the result of

substance abuse. Michael (1990) reported that (almost) one out of every four drivers between the ages of 16 and 45 who were killed in New York traffic accidents in recent years tested positive for cocaine use. Experts on cocaine use noted in the article that they were surprised by the large proportion of drivers using cocaine. However, in traffic fatalities in New York, as elsewhere, alcohol remains the number one substance abused by drivers. It was found that 11% of men 15 through 34 years old who were drivers in fatal accidents had tested positive for cocaine use. These'data were gathered before the cocaine epidemic "hit" the media. As noted, a newer study found that 23% of victims between 16 and 45 tested positive for cocaine use. About one-half of New York drivers who were killed had used alcohol, and about half of those using cocaine also had used alcohol.

Jones (1988) stated that although there are 23 million alcoholics in the U.S., over 90 million other people become affected by their disease. For example, over 30 million of those affected live in alcoholic homes or are closely










associated with alcoholic's children and/or adult children of alcoholics. Wegscheider-Cruse (1987) also explained that it is not just the abusers who suffer. Their problems affect family members, friends, and business associates. For example, cocaine is having devastating impacts on the lives of a booming generation of babies born to addicted women. The effects include stroke while babies are still in the womb, physical malformation, and increased risk of death during infancy. The number of repeated cases of cocaineexposed babies is growing explosively, doubling each year in major cities. Recent estimates placed the figure in the U.S. as high as 200,000 (Revkin, 1989). Also, fetal alcohol syndrome is widespread and producing alarming damage to infants.

Talbott (1985) has reported that, tragically, only 4% of alcoholics have an opportunity to recover. To make matters worse, many are "relapse prone." Gorski and Miller (1982) noted that recidivists are among the most desperate clients because they are caught in a trap of misunderstandings. They fail to recover in spite of their best efforts, and when the relapse takes its toll, they blame themselves. When they seek renewed treatment, they often feel the anger and misunderstanding of therapists; professionals often blame them for relapsing. This compounds the guilt and sense of helplessness, and reinforces the tendency to relapse.










On a somewhat more positive note, Gorski (1986)

observed that approximately one-half of alcoholics who "come to the door of sobriety" enter and stay. Of the remainder, many stay for a time, have one or more relapses, then grasp the sober life, and stay sober until death. Many others, however, go through "the revolving door" over and over again: drinking-sobriety, drinking-sobriety and so forth.

Kinney and Leaton (1987) wrote that reentry into

treatment after a relapse may be especially difficult for the alcoholic who has attained substantial recovery. In many cases, the family's involvement in the relapse syndrome is strongly influenced by co-dependence. Co-dependence is a primary condition that results from the debilitating physiological stress produced by living with an alcoholic or drug-dependent person. Co-dependent persons often develop physical, psychological, behavioral, and asocial symptoms resulting from attempts to adapt to and compensate for the debilitating effects of physiological stress (Gorski & Miller, 1983).

It is obvious that many problems confront the

counseling profession in attempts to help chemicallydependent persons, not the least of which is that relapsed addicts have great difficulty reentering treatment. Embarrassment and guilt sometimes delay treatment, and may even be used as reasons to avoid it if the addiction has been reactivated strongly. Gorski and Miller (1982) noted










that many persons who have achieved degrees of abstinence relapse in spite of their best efforts while skilled treatment professionals stand by helplessly because traditional approaches to counseling and treatment do not work. Trubo (1989) noted that, "Despite the proliferation of treatment centers and the millions spent on chemicaldependency research, professionals in the field still can't agree on the best therapy for alcoholism" (p. 56). Therefore, there is clearly need for specialized relapseprevention treatments.

Theoretical Framework of Relapse Prevention

Any theory of relapse prevention must develop from a theory of addiction. That is, in order to understand the process of relapse, it is necessary to know the condition to which the addict is relapsing. This section includes an overview of these two phenomena as well as an overview of the theories underlying the interventions to be used in this study: relaxation, mental imagery, and cognitive behavioral restructuring.

The biopsychosocial model, which is emerging from the area of behavioral medicine, provides a heuristic framework within which to understand and assess addictive behaviors (Donavan, 1988). Gorski and Miller (1986) defined addiction as a condition in which a person develops biopsychosocial dependence on any mood-altering substance. This means that it is a physical disease (bio) that also affects a person









psychologically and intellectually (psycho) and in relationships (social). In brief, all life areas are affected.

Both biological and nonbiological factors are

ingredients of addiction (Mueller & Ketcham, 1987). Such a model provides a metatheoretical framework in which the factors interact to determine a health status, which includes obsession, compulsion, and loss of control and is primary, chronic, progressive, and fatal (Ohlms, 1981).

There are also predictable stages of addiction with accompanying symptoms: early, middle, and chronic. The first stage is marked by a growing tolerance for dependence on the substance; larger and larger quantities are used without intoxication and/or harmful consequences. Symptoms are subtle, and diagnosis is difficult in this stage. The middle stage is marked by progressive loss of control. The addict is no longer able to use the same quantities without intoxication or adverse consequences. Pain develops as problems proliferate. The chronic stage of addiction is marked by physical, psychological, behavioral, social, and spiritual deterioration. All body systems can be, and usually are, affected. Loss of control becomes obvious to the addict and to others.

The recovery process develops through task-oriented

stages (Marlatt, 1985). The first involves the using stage and is marked by recognition of the addiction. The second








10
is the treatment decision stage and is marked by a conscious choice to seek help. The third stage is maintenance, marked by a quest for balanced living to achieve healthy biopsychosocial goals.

Gorski and Miller (1982) listed six recovery periods (developmental in nature) along with the goals for each. The first is pretreatment in which the goal is recognition of addiction. The second is stabilization, to achieve withdrawal and crisis management. The third period is early recovery and the goal therein is acceptance and nonchemical coping. The fourth is middle recovery in which the goal is balanced living. The fifth is late recovery, including the goal of personality change. The sixth period is maintenance, in which the goal is (further healthy) growth and development.

The process of relapse involves becoming dysfunctional in non-dependency. This can occur in any of Gorski and Miller's stages and in physical, psychological, or social health. Similar to the recovery process, it is developmental in nature, not an isolated event. Using the mood-altering chemical I'medicates" the dysfunction. Relapse prevention therefore is implementation of interventions to interrupt the potential, always impending, relapse process.

A recovering addict is likely to face a multitude of problems (Kinney & Leaton, 1987). one is a high level of stress, either temporary or chronic, for which the person








11
has low tolerance. Many alcoholics, for example, have used alcohol for the temporary but "quick" relief of anxiety. What is remembered (and longed for!) in sobriety is the almost instant relief of an intoxicant. When alcohol or drugs are no longer an option, the alcoholic has quite a problem: how to cope with stress. Some things can be done to alleviate this stress. One is relaxation therapy, based primarily on the assumption that when the body and breathing are relaxed, it is difficult to feel anxious. The mind rejects the paradox of a relaxed body and a "tense" mind.

Another technique often used is imagery. Witmer and Young (1985), for example, proffered use of visual imagery as an intervention which helps to reduce stress and also to overcome negative emotions. Pleasant mental images are used to evoke a relaxation response. Mental imagery, therefore, is the mental representation of a sensory--or perceptuallike--experience that occurs in the absence of the stimulus that would produce the genuine experience (Richardson, 1969). These images may be made to occur in any sense modality.

Sheikh and Jordon (1983) summarized a rationale for clinical use of imagery as a tool for therapeutic intervention. They reported that invoking mental images tends to bypass unconscious defenses and inhibitions. They further suggested that imagery has the power to produce a variety of physiological changes. Lazarus (1977) noted that










imagery may be the only practical way to develop control over the autonomic nervous system, indicating that goals and solutions rehearsed through imagery during therapy seem to apply outside the therapy session and are a motivation for future behavior. Finally, rational-emotive imagery changes "inappropriate" emotions to "appropriate" ones (Ellis & Dryden, 1987). Clinical research data support the contention that rehearsals of fantasy material through imagery produce cognitive restructuring (Beck, 1970). Behavioral therapies, as part of treatment programs for substance abuse, have gained clinical favor in recent years (Spitz & Spitz, 1987).

The basic assumption underlying cognitive-behavioral treatment is that maladaptive behaviors and feelings are mediated by distorted or maladaptive thinking and that clinical intervention should be used to alter cognitive processes (Garner & Bemis, 1985). Behavior therapy ' proponents advocate its use primarily as a method of symptom control with substance abusers. According to Spitz and Spitz (1987), the initial goal of behavioral therapies is to achieve abstinence rapidly. Treatment then focuses upon assessment of the stimuli that contribute to perpetuation of the substance abuse habit and upon alteration, interruption, or creation of (new) behaviors to replace dysfunctional ones. Notably, cognitive components are a major part of the method. Behavior rehearsal, cognitive restructuring, and










the creation of alternative behaviors other than drug ingestion are cardinal components of behavioral approaches.

Correcting cognitive distortions, or "mind traps," that generate maladaptive feelings and behaviors is an essential part of relapse prevention (Washton, 1989). Marlatt (1985) reported that cognitive restructuring has as its principal aim the countering of cognitive and affective components of the Abstinence Violation Effect (AVE). Annis and Davis (1988) also noted that cognitive appraisals can be effected at any point in the relapse process. Specific distortions in thinking and defensive tactics may inhibit more general coping patterns. Finally, Yalom (1985) reported that cognitive restructuring is necessary for the client to be able to generalize counseling experiences to other life arenas.

Statement of the Problem

A major problem to be addressed in this study is that the effectiveness of mental-imagery training intended to prevent relapse is unknown. Another significant concern is that it is unknown whether the effectiveness of mentalimagery training varies as a function of demographic factors, as well as factors particular to addiction. The demographic variables to be investigated include gender, race, age, and level of education. The addiction-related variables include length of recovery, drug of choice, and








14

number of weekly 12-step meetings because these factors may influence treatment effectiveness.

The specific dependent variables used in this study

include (a) self disclosure, (b) help-seeking behavior, (c) perception of unmanageability, and (d) lifestyle behavior change.

Giddan and Rollin (1975), Gorski (1989) and Spitz and Spitz (1987) suggested that cognitive-behavioral interventions are legitimate strategies to pursue in chemical-dependence relapse-prevention treatment. Similarly, Marlatt and Gordon (1985), Sheikh (1989), and Siegel (1986) all suggested that mental-imagery interventions are legitimate strategies to pursue in chemical-dependence relapse-prevention treatment. Relatedly, Gorski and Miller (1982), Kinney and Leaton (1987), and Knudson (1987) suggested that relaxation interventions are legitimate strategies to pursue in chemical-dependence relapse-prevention treatment. Therefore, there is good basis for the suggestion that this direction has potential for success.

Particularly needed are brief interventions. Long-term interventions are not practical and have not been found to be more effective. Also, Shorkey and Whiteman (1977), LaVecchia (1981), Crowley (1982), Brantlinger (1983), and Gillis (1986), among others, conducted studies which produced effective results using brief interventions










(Appendix B). Therefore, it is reasonable and appropriate to use a brief intervention in this study.

The measurements (i.e., surveys) to be used in this study have been shown to be valid and reliable. They include the Abstinence Likelihood Inventory (ALI), HelpSeeking Likelihood Inventory (HSLI), Jourard Self-Disclosure Questionnaire (JSDQ), and the Health Attribution Test (HAT). Their use is more exact than other forms of measurement, e.g., observation or interviews (Kerlinger, 1973). In addition, their use is cost effective and less time consuming than the alternatives. Therefore, this method is efficient.

The major disadvantage of this type of measurement lies in its lack of flexibility. Areas of investigation are limited to questions on the instruments. However, although behavioral observations and/or interviews might allow for more extensive investigation of respondents' opinions, the advantages of surveys outweigh the disadvantages when cost, time, and efficiency are considered.

Hypotheses

It is apparent in the research literature that

chemical-dependence relapse varies as functions of many variables, both demographic and substance-abuse related. The variables included in this study have not been empirically investigated previously in this context and therefore little is known about their interactions with








16

relapse. Accordingly, hypotheses addressed were as follows:

1. There is no significant relationship between ALI and

a weighted, linear combination of demographic variables (gender, race, age, and education).

2. There is no significant relationship between ALI and

a weighted, linear combination of demographic variables, treatment, and the interactions of

treatment with these demographic variables.

3. There is no significant relationship between ALI and

a weighted, linear combination of substance-abuse

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

meetings, and months of recovery).

4. There is no significant relationship between ALI and

a weighted, linear combination of substance-abuse

variables, treatment, and the interactions of

treatment with these substance-abuse variables.

5. There is no significant relationship between ALI and

a weighted, linear combination of treatment,

selected demographic variables, selected substanceabuse variables, and interactions of treatment with

the selected variables.

6. There is no significant relationship between HSLI

and a weighted, linear combination of demographic

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

7. There is no significant relationship between HSLI

and a weighted, linear combination of demographic










variables, treatment, and the interactions of

treatment with these demographic variables.

8. There is no significant relationship between HSLI and a weighted, linear combination of substanceabuse variables (drug of choice, number of weekly

12-step meetings, and months of recovery).

9. There is no significant relationship between HSLI and a weighted, linear combination of substanceabuse variables, treatment, and the interactions of

treatment with these substance-abuse variables.

10. There is no significant relationship between HSLI

and a weighted, linear combination of treatment,

selected demographic variables, selected substanceabuse variables, and interactions of treatment with

the selected variables.

11. There is no significant relationship between JSDQ

and a weighted, linear combination of demographic

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

12. There is no significant relationship between JSDQ

and a weighted, linear combination of demographic

variables, treatment, and the interactions of

treatment with these demographic variables.

13. There is no significant relationship between JSDQ

and a weighted, linear combination of substanceabuse variables (drug of choice, number of weekly

12-step meetings, and months of recovery).










14. There is no significant relationship between JSDQ

and a weighted, linear combination of substanceabuse variables, treatment, and the interactions of

treatment with these substance-abuse variables.

15. There is no significant relationship between JSDQ

and a weighted, linear combination of treatment,

selected demographic variables, selected substanceabuse variables, and interactions of treatment with

the selected variables.

16. There is no significant relationship between HAT

and a weighted, linear combination of demographic

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

17. There is no significant relationship between HAT and

a weighted, linear combination of demographic variables, treatment, and the interactions of

treatment with these demographic variables.

18. There is no significant relationship between HAT and

a weighted, linear combination of substance-abuse

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

meetings, and months of recovery).

19. There is no significant relationship between HAT and

a weighted, linear combination of substance-abuse

variables, treatment, and the interactions of

treatment with these substance-abuse variables.

20. There is no significant relationship between HAT and

a weighted, linear combination of treatment,








19

selected demographic variables, selected substanceabuse variables, and interactions of treatment with

the selected variables.

Definitions of Terms

The following definitions are used in this study:

Abstinence is a condition in which there is no chemical dependence (i.e., use) at all (Milam & Ketcham, 1981).

Addiction is a phenomenon characterized by tolerance changes for, physical dependence on, and loss of control over use of a drug (Mueller & Ketchman, 1987).

Alcoholism is a primary, progressive, chronic, often fatal disease which is characterized by a physical compulsion, obsessive thinking, and loss of control (Ohlms, 1981).

Chemical dependence is a generic term which encompasses alcoholism and drug-dependence characteristics and is synonymous with either for purposes of this study.

cognitive behaviorism is a theory which is recommended in the treatment of chemical dependence and mediates distorted thinking (Garner & Bemis, 1985).

Gender is self-designation as male or female by the respondent.

Help-seeking behavior is the score on the Help-Seeking Likelihood Inventory.

Length of education is self-reported as the last grade completed in number of years of schooling.








20

Length of recovery is defined by the respondent as the number of months abstinent from chemical (drug) use.

Lifestyle behavior change is defined as the score on the Health Attribution Test.

Mental imagery is the mental representation of a

sensory or perceptual-like experience that occurs in the absence of the stimulus that would produce the genuine experience (Richardson, 1969).

Powerlessness is defined as a score on the Help-Seeking Likelihood Inventory.

Progressive relaxation therapy is the reduction of

physiological tension so as to be incompatible with anxiety (Jacobson, 1929).

Race/ethnicity is defined through self-designation as Caucasian, Black, or Hispanic American by the respondent.

Relapse is a movement away from recovery which ends in a return to abuse of a mood-altering chemical after A period of abstinence (Gorski & Miller, 1986).

Self Disclosure is the score on the Jourard SelfDisclosure Questionnaire.

12-step meetings are closed meetings of Alcoholics Anonymous or Narcotics Anonymous.

Unmanaqeability is the score on the Abstinence Likelihood Inventory.








21

overview

Presented in Chapter 1 was the introduction to the

study. The review of the literature is presented in Chapter

2. The methodology of the study, including procedures and statistical methods, are covered in Chapter 3. Presented in Chapters 4 and 5, respectively, are the results and discussion of the study.














CHAPTER 2

REVIEW OF RELATED LITERATURE

People of the United States suffer from tragic

ramifications of chemical-dependence problems (Talbott, 1985). According to Lewis, Dana, and Blevins (1988), drug use and abuse is a mass phenomenon in the United States: 32 million Americans smoke marijuana at least once a year; 20 million smoke it at least once a month; annual cocaine abusers number over 12 million; and several million others take hallucinogens, stimulants, sedatives, and tranquilizers without medical supervision. And of course these figures are dwarfed by the number of people who use "legal drugs," including alcoholic beverages (125 million) and tobacco products (70 million) (Polich, Ellickson, Reuter, & Kahan, 1984).

Dr. Padraic Sweeny, Vice Chief of Emergency Services for Detroit Receiving Hospital, is but one reporting rapidly increasing drug-related shootings, stabbings, and assaults (Shannon, 1990). Relatedly, police make drug arrests in Los Angeles at a rate of 60,000 per year. It is readily evident beyond these examples that there would be far less drugrelated crime if jails, courts, and parole systems were not already strained to the breaking point. Thus, despite the








23

passage of stringent antidrug laws and police efforts, drugrelated crime continues to surge. For example, the nation's violent-crime rate rose 10% in the first six months of 1990. Murders were up 8% in the same six months and armed robbery rose 9%. Drug-related crime is perhaps the most obvious ramification of chemical-dependence problems in the United States.

cocaine has become one of the most debilitating

chemicals in history. Its epidemic use started among the upper middle class in the mid-1970s. Recently, "dealers" have touted a Caribbean import called crack (or rock) that sells for $10.00 or $20.00 a vial, compared to $50.00 to $100.00 for a gram of cocaine powder (Shannon, 1990). The result has been widespread use of cocaine even among the poor.

To date, the antidrug offensive's main accomplishment

has been to dissuade some experimenters and "weekend users" from increasing their dependencies. Unfortunately, however, the effort has not reached the millions of people so bereft of hope that they are willing to risk everything they have, or will have, for a few moments of psychological oblivion.

Alcoholism is perhaps still the most insidious offender. Lewis et al. (1988) noted that the use, misuse, and abuse of alcohol is one of the major health problems in the United States and is the third most prevalent public health problem. But the problems associated with alcohol abuse are










not limited to health problems because alcoholic behavior also leads to familial, social, vocational, and legal problems. Patterns of alcohol abuse also contribute to health impairment, vehicular and pedestrian accidents, criminal behavior, destructive social behavior, and other adverse consequences. Therefore, alcohol-related problems are not limited to the alcoholics themselves. Literally everyone encounters the ramifications of use, misuse, and abuse of alcohol in daily life (Pattison & Kaufman, 1982).

The financial costs of the chemical-dependence epidemic also are staggering. Jacobson (1990) reported that alcohol dependence alone costs the federal government about $25 billion a year. Overall, chemical dependence costs the nation an estimated $135 billion a year in medical expenses, time lost from work, treatment costs, and the like, yet state and federal governments combined collect only $12 billion in excise taxes to support remediation programs.

Unfortunately, the massive public health effects of

alcohol consumption in the United States are just beginning to be understood. Many Americans are shocked to learn that the economic costs associated with alcohol-related problems are even greater than those associated with problems due to cigarette smoking, cancer, or heart disease. one reason is that smoking-related diseases, e.g., cancer and heart disease, generally affect middle-aged or older people, but alcohol-related problems affect people of all ages. These










(and other forms of chemical dependence) are particularly prominent among children and youth. The earlier the age of onset, the longer the need for treatments and the greater the dispersion of negative effects; phenomena which greatly increase costs.

Support for the Need for the Study

An inherent problem in the chemical-dependence field centers around differences among professionals regarding legitimate treatment theory, models of treatment, and strategies and tasks/goals of therapy, all of which complicate treatment. Milam and Ketcham (1981) reported that thousands of alcoholics are seen every year by professionals--psychiatrists, psychologists, social workers, clergy, counselors, nurses, and doctors -- yet, tragically, they are almost always misdiagnosed and often harmfully treated. For example, Rogers and McMillin (1989) speculated that they have seen practically every form of group yet devised being used to treat alcoholism at some facility in America. It may not be "coincidental" that about two-thirds of all relapses occur within the first 90 days following treatment (Marlatt & Gordon, 1985).

Three different schools of thought seem to dominate

current directions in chemical-dependence treatment. One espouses that relapse need not be an either/or situation (Donovan, 1988; Marlatt & Gordon, 1985). Thus, the goal of treatment is not necessarily abstinence, but rather








26

improvement in drinking behavior. Another theory focuses on the absence of psychotherapy in early recovery due to neurological deficits, addictive instability, and the primacy of the need to focus on relapse prevention (Bean, 1984; Crewe, 1986; Flores, 1988). A third model would treat the character disorder along the road to recovery from addiction (Ellis & Dryden, 1987; Khantzian, Halliday, & McAuliffe, 1990). This approach is psychodynamically oriented.

A review of the family therapy for alcoholics literature indicates that clinicians are experimenting with at least three additional approaches to involvement of family members in the treatment process. These are conjoint family therapy (Esser, 1968, 1971; Meeks & Kelly, 1970), multiple couple therapy (Cadogan, 1973; Gallant, Rich, Bey, & Terranova, 1970; Steinglass, Davis, & Berensen, 1977) and conjoint hospitalization (McCrady, Paolino, Longabaugh, & Rossi, 1979; Steinglass et al., 1977). However, careful reading of this literature still supports the view that family systems approaches to alcoholism treatment have yet to mature fully (Steinglass et al., 1977).

There is also consensus in the literature that

chemical-dependence problems among American workers have risen significantly in the past decade (Dickman & Emener, 1982; Gerstein & Bayer, 1988; Michael, 1990). Investigators have suggested that 10% to 18% of those employed experience








27

such difficulties (Masi, 1984; Watkins, 1989). As a result, employees have begun to exhibit dysfunctional work behaviors which have become more and more prevalent and noticeable.

Bell (1988) also noted the severity of chemical dependence in the workplace and emphasized the high incidence of absenteeism and sick days taken, two variables not often recognized as symptoms of chemical dependence. Employees affected by chemical-dependence problems exhibit myriad dysfunctional work behaviors such as absenteeism, "on the job" absenteeism and high accident rates. They therefore have more insurance claims, spasmodic work patterns, difficulty in concentration, confusion, lack of task tenacity, coming to/returning to work in an obviously abnormal condition, generally lowered job efficiency, poor employee relations, misconduct, and poor supervisory relationships. Each of these behaviors usually results in significant personal and organizational costs (Management Writes, 1989). Chemical dependence has escalated to a major economic problem in the United States (Gold, 1988). Today, employee alcohol and drug use cost business and industry over $100 billion per year (Desmond, 1987).

In the handbook, What Works: Schools Without Drugs, former Secretary of Education, William J. Bennett (1986) stated that, "In America today, the most serious threat to the health and well-being of children is drug use" (p. v). California Attorney General, John Van De Kemp (1986)








28
explained that "It is a sad and sobering reality that trying drugs is the norm, not the exception among high school students" (p. iv). Other researchers and treatment providers concur that the problem of chemical dependence among youth has reached pandemic proportions (e.g., Gold, 1988; Guydish, 1982; Jones, 1988; Richmond & Peeples, 1984). Guydish (1982) suggested that one in every six adolescents had a problem with addiction. Nowinski (1990) reported that for the past decade, therapists have seen a marked increase in the number of youths to be treated for chemical dependence and/or increased severity of symptoms.

Gonzalez (1990) stated that alcohol abuse has long been recognized as a leading threat to the academic, social, and physical well-being of college students. Colleges have been confronting problem drinking by providing education and rehabilitation programs, alternatives to the campus "bar scene," and stricter regulation of on-campus parties. For example, Rutgers University set aside dorm rooms for recovering student alcoholics. However, Robert Hochstein, spokesman for the Carnegie Foundation for the Advancement of Teaching, issued a report saying that colleges are (generally) sidestepping the problem of chemical dependence (Rabinowitz, 1991).

A common phenomenon characteristic of chemical

dependence is recidivism. The danger of relapse is ever present in a chronic, addictive disorder (Johnson, 1980),








29

and the results of relapse are often tragic. Unfortunately, accurate relapse figures are difficult to obtain. In addition, there are few relapse studies covering any appreciable period of time (Weisman & Robe, 1983). Relapsers disappear not only from records, but also from sight. They are often lost in "geographic cures" (i.e., changing locales and hoping the problem will disappear), with no way for researchers to know whether disappearance was followed by relapse, recovery, or premature death. Thus, relapse-treatment approaches are difficult to develop. However, a classic survey of nearly 25,000 members in Alcoholics Anonymous revealed that relapse occurred in almost 60% of those who had been sober for only one year.

Reentry into recovery is difficult after relapse (Kinney & Leaton, 1987). Schrenck (1990) reported that it is much worse "the second time around" because the progression of adverse consequences occurs faster. Long-term followup data suggested that more than 90% of those who leave treatment will drink or use again at some time in the future (Heltzer, Robins, Taylor, Carey, Miller, Combs-Orme, & Farmer, 1985; Polich, Armor, & Braiker, 1981). Gorski (1989) reported that many chemically-dependent persons relapse many times before finding sobriety or freedom from addiction. Even they are fortunate, however. Others give up in despair and eventually die from their disease.








30
Within the context of the disease process, addiction is often referred to as a "chronically-relapsing" condition (Marlatt & Gordon, 1985). Relapse is always a possibility within chronic diseases, even after years of good health. Mueller and Ketcham (1987) stated that chemically-dependent persons are not safe from relapse even after 10, 15, or 20 years of sobriety, unless they continue to use the tools acquired in treatment. Previous treatment is an important component in this study. The participants all have been involved in a form of treatment, whether AA, NA, or inpatient or outpatient care.

The problem of recidivism in chemical-dependence

treatment leads to the need to provide effective relapseprevention approaches. Desmond (1987) suggested that addicts know how to get sober, but the problem lies in keeping them in that state. Relapse prevention is the latest attempt to help reduce the number of recovering persons who return to using.

Support for the Theoretical Framework

No one argues any longer with the fact that alcoholism is a disease (Chopra, 1987). The American Psychiatric Association (1975) defined alcoholism as a "chronic disease manifested by repeated drinking that produces injury to the drinker's health or to his social or economic functioning" (p.13). The term "suffer" and the concept of disease imply that the alcoholic is a victim of his/her demise.








31

Johnson (1980) agreed that these defenses are not selfimposed but occur as the disease progresses. Ohlms (1981) added that the disease has a specific set of defenses along with progressively escalating symptoms. One of the chief defenses which prohibits recognition of the problem is denial. Thus, alcoholics can't "see" what is happening to them. The reason for this is understandable. Johnson (1980) elaborated that, as their condition develops, the self-image continues to deteriorate and ego strength ebbs. For many reasons, alcoholics are progressively unable to keep track of their own behavior and begin to lose contact with emotions. Their defense systems continue to grow so that they can survive in the face of their problems. The greater the pain, the higher and more rigid the defenses become. This process is entirely unconscious.

Relapse is often a family concern. The family becomes afraid to upset the person and thus becomes victimized by the chemical-dependency system (Empry, 1990). These fears, coupled with a tendency to support the chemical-dependent behavior, lead many chemically-dependent persons back to fousing.11 This irony is supported by families at their own expense. Relatedly, Fish (1991) indicated that much of the responsibility for chemical-dependence problems often rests with parents who are drug users.

Chemical-dependence treatment is greatly affected by the lack of a sound theoretical base. There are many different










models of addiction, but little consistent thinking as to the most effective approach (Lewis et al., 1988). Within some models it is difficult to address the issues of relapse and relapse prevention. For example, the moral model of addiction holds the addict solely responsible for the relapse. This approach prohibits identification of relapse triggers.

Relatedly, chemical-dependence treatment is difficult at best because of the complicated nature of the problem. Denial and repression hinder acceptance of the reality of the situation; the chemically-dependent person usually goes back to the same environment. This exposes him/her to the very "cues" which preceded use (Donovan & Marlatt, 1988). The environment can be the job, school, neighborhood, friends, spouse, or family. complicating all this is the fact that many community role models are drug dealers and their role suggests (particularly financial) success, especially to teens (Fish, 1991). Further, the enticement of "easy money" makes it difficult for many users to avoid the drug culture. These complications have led experts to believe that success often depends on the individualized characteristics of the client rather than the treatment (Desmond, 1987).

The results of many studies (e.g., Hosie, West & Mackey, 1988; Richardson & Bradley, 1985) indicated that counselors are now established in the substance-abuse field. For








33

example, Hershenson and Power (1987) reported a substantial increase in community counseling centers specializing in the treatment of substance abuse. With this service comes a variety of problems for counselors. For example, although counselor education departments have acknowledged this specialization and counselor educators have been developing courses since 1980 to train counselors in chemical dependence (Hollis & Wantz, 1986), there are still confusing treatment guidelines and high counselor burnout to name only two apparent problems.

The problem of treatment effectiveness also exists in

the area of counselor education. Gonzalez (1990) noted that the efficacy of alcohol and other drug education to reduce the problems related to chemical dependence is questionable. other studies (e.g., Mauss, Hopkins, Weisheit, & Kearney, 1988) assessed the relative contribution that traditional variables such as self-esteem, attitude, and decision-making skills have made to drinking behavior. Suggested is that such variables make only a small contribution compared to other social and psychosocial variables not amenable to intervention. Therefore, researchers have expressed doubt that even a highly successful classroom intervention directed at traditional variables would do much to prevent alcohol use or abuse by youths.

Krestan (1989) found it necessary to provide a direction for counselors. She has admonished family (and other)








34
therapists to relinquish attempts to be totally in charge of treatment and/or all phases of treatment. She delineated different roles at different stages. Before sobriety, the family therapist should unbalance the system sufficiently for the family to enter chemical-dependence treatment. In early recovery, the family therapist should work to stabilize the family system around family members' participation in chemical-dependence treatment and self-help programs. The role in long-term recovery is more central, to establish resonance in the family in ways that are functional and satisfying for all family members.

misinformation and/or misdiagnosis is a major problem which leads to proliferation of chemical dependence. According to Aitchison (1990), in Alcoholism Briefs Newsletter (in "New York Intervention Program Helps Identify 850 Problem Drinkers") a minimum of 25% of all hospitalized patients reportedly have a significant alcohol problem, regardless of the admitting diagnosis. Misinformation comes in many different forms. Alcohol often mimics other diseases, including gastrointestinitis, colitis, depression, and stress-related illnesses. It often is the cause of stroke and heart attacks. It also is easy to confuse with certain psychological diagnoses such as conduct disorders, depression, and personality disorders.

The issue of prescribing medication to recovering

addicts is controversial. One school of thought contends










that mood-altering chemicals block the process of development needed to grow; another suggests that there are certain problems in recovery that warrant medication. For example, a frequent problem centers around the treatment of depression. Many medical doctors, including psychiatrists especially in hospital inpatient settings, medicate addicts for this problem. Talbott (1985) claimed that because alcohol is a depressant, depression in early recovery is normal and may dissipate with abstinence. This phenomenon leads to much stress for counselors who view indiscriminate medication as anathema, yet have to witness it frequently.

There is a problem in the misreporting of CD treatment

success. In many follow-up studies that include longitudinal assessments researchers report findings as cross-sectional or I'dipstick" assessments. This type of assessment involves reporting the percentage of clients in continuous reports who have previously relapsed since the beginning of their treatment. This fails to take into account a participant's status at the previous follow-up. Consequently, programs report much higher rates of treatment success, making treatment seem more effective. In addition, limitations in relapse assessment are due to the fact that follow-up studies include only participants who have completed treatment and eliminate those who began but did not complete treatment. This also inflates claims of success. Third, follow-up periods are often too short and thus provide little










information about long-term relapse rates (Curry, IMarlatt, Peterson, & Lutton, 1988).

Finally, a problem exists with corporate advertising for chemical-dependency treatment. Many of the ads "promise" a cure. This is misinformation and sets the expectation that treatment insures success whereas the truth is that treatment is the beginning.

Support for the Approach to the Study

Gorski (1989) stated that chemical dependence is a

condition that creates long-term pain in return for shortterm gratification. It is an addiction accompanied by obsession, compulsion, and loss of control. In the end stages of addiction, the addict thinks about, plans, and looks forward to using when abstinent. This is obsession; there is an overwhelming urge to use again in spite of longterm consequences. This is compulsion; this is addiction. The person uses the drug to relieve the pain caused by the drug (Johnson, 1980). Loss of control is obvious. It affects and is affected by all areas of an addict's life.

The loss of control causes physical, psychological, and social problems; the total person is affected. Accordingly, Vaillant (1983) recommended a flexible, multimodel approach to chemical-dependence treatment. The available research data demonstrate the existence of multiple syndromes of chemical-dependent use ( Ellis, Mclnerney, DiGuiseppe, & Yeager, 1988; Gallant, 1987), a condition called bio-psycho-








37
social dependence (Gorski & Miller, 1986). The contribution of each variable to the total clinical picture is presented as follows. Milam theorized, in the book Don't help: A positive guide to working with the Alcoholic (as cited in Roger & McMillin, 1989), that the biological aspect of addiction is the basis for the disease model. He provided the reasons which explain the phenomenal growth of this belief. One is that the disease model has the virtue of simplicity. Recovery becomes less complicated because it is understood that the problem stems from a disease that affects ability to use rather than a complex problem requiring the chemically-dependent person to root about in the psyche for supposed causes. Another is that chemicallydependent persons find much relief in the discovery that they are not weak-willed, emotionally-inadequate, or morally-defective persons. This realization relieves guilt but bestows upon the person a personal responsibility to recover. It eliminates outside blame for the problem. A third is that the disease model can inspire the person to change instead of depending on a therapist to "fix" the problem. Abstinence is required and motivation needs to come from within to ensure success. Finally, this model provides a structure for treatment. The chemicallydependent person can now be given practical and understandable directions for recovery based on "proven" experience.










Many researchers attest to the psychological component of addiction as being both a trigger and a result of addiction (Ellis et al., 1988; Marlatt & Gordon, 1985). In a prospective study (n=38) using the Minnesota Multiphasic Personality Inventory (MMPI) as a pre-and posttest measurement, Vaillant (1983) reported that preatomic testing suggested normal limits. However, when the subjects were later hospitalized for alcoholism, the scores were significantly elevated on the depression, psychosomatic deviancy, and paranoia scales -- to pathologic levels. Although it is widely believed that chemicals provide relief from stresses in early stages of use, there is much evidence to support the belief that severe psychological problems manifest after the "line to addiction" is crossed.

Ellis et al. (1988) stated that the present review of etymological factors in the development of alcoholism suggested that chemically-dependent persons are not necessarily premonitory different from nonaddicts in personality traits such as dependence or their psychological adjustments as children. Rogers and McMillen (1989) agreed that psychological, social, and spiritual disasters of chemical dependence can only be fully understood as distortions and exaggerations of otherwise normal problems. Bean and Zinberg (1981) concurred that alcoholism takes its biological and psychological toll upon the personality. In relatively healthy populations, alcohol abuse may be more










analogous to any intractable habit (such as smoking or fingernail biting) than to mental illness. Such habits may develop independently of preexisting psychological vulnerability. This is not to say that addicts are not in need of psychological treatment. Indeed, many are "adult children of alcoholics" (ACOAs) and have family of origin issues at all ranges of the spectrum from severe torture to mild neglect. However, primary treatment for addiction should focus on a period of detoxification to allow for drug and alcohol-induced symptoms to subside. Accurate diagnosis of secondary problems is difficult in early recovery because symptoms often dissipate during the stabilization period. Therefore, the issue of "timing" is vital in chemicaldependence treatment--and in relapse prevention.

Because chemically-dependent persons often perceive addiction as accusation rather than diagnosis, they constantly reinterpret their symptoms, offering alternative explanations which lead to conflict with and isolation from others. For example, many addicts mistakenly blame their wives and children for their problems. They defend their position by "projecting" their problems onto others (Johnson, 1980).

Recovery should include strategies designed to address the social aspects of addiction. Techniques have been developed for families and other supporters to help the










client to maintain abstinence and improve the quality of relationships (McCrady, et al., 1985).

In summary, the biopsychosocial view of addiction

implies multiple casualty, involvement of multiple systems, and multiple levels of analysis (Donovan & Chaney, 1985; Maisto & McCollam, 1980; Marlatt & Donovan, 1981). This model thus addresses the complex nature of addiction and can be used to understand the various stages of addiction.

Clinicians have stressed the importance of viewing

growth as a developmental process (Erickson, 1959; Gazda, 1982; Mahler, Pine, & Bergman, 1975). It is especially necessary for recovery from chemical dependence. Addicts do not recover immediately. A developmental model consists of stage specific steps or tasks (Brown, Beletsis & Cermak, 1989). Steps occur over a time period, each of which is different for each recovering person. This process can be changed or interrupted at any time.

Maintenance of non-use behavior involves full acceptance of the need for abstinence. Sobriety can become elusive after time as the memory of painful end-stage experiences are forgotten. In addition, it can be easy to deny awareness of the problem given enough time without intoxication because it may seem as though a person who was addicted would be using. Enjoyment of life comes through a daily program of recovery which reminds the chemicallydependent person of the good fortune which has been










bestowed. Gratitude is a very powerful means to long-term sobriety. Action is another vehicle. maintenance requires positive changes. Without them, the disease of addiction triggers a series of automatic, learned reactions which create pain and make return to use palatable. The answer is a well-planned recovery.

A commonality across addictions is the high rate of

relapse following (a period of) abstinence (Abrams, Niaura, Cary, Monti, & Binkoff, 1986; Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Chaney, Roszell, & Cummings, 1982; Marlatt & Gordon, 1985; Tucker, Vuchinich, & Harris, 1985). Daley (1987) stated that relapse, like recovery, is a process, not an event. Many events, behaviors, thought patterns, feelings, and attitudes lead to relapse. Gorski and Miller (1982) outlined several steps in the process of relapse. It is failure to take the necessary action to complete these recovery steps that leads to relapse. Adherence to these recovery steps is called a recovery program. once a program becomes a low priority, the progression of relapse begins. Complacency has begun and, without a strong "program," the symptoms of relapse develop spontaneously.

Relapse becomes a syndrome when the addict experiences loss of control over behaviors. This occurs when the symptoms of sobriety or post acute withdrawal symptoms (PAW) are not managed. The symptoms progress to the point when,










if not interrupted, chemical use again occurs. During periods of stress the chemically-dependent person has difficulty in thinking clearly, identifying and managing feelings, and remembering things. Psychomotor coordination may become impaired, sleep disturbance may develop, and difficulty with stress management may occur. These are not unusual symptoms for a person who has used chemicals for a prolonged period. The key to recovery, therefore, is to recognize and manage the symptoms. This is prevention.

Relapse prevention involves understanding, education, and action. The addict needs to understand the relapse syndrome, become educated as to the warning signs and personal triggers, and take action to involve self, family, friends, and a therapist in a plan of action which has been pre-designed and pre-rehearsed. Such precautions allow for interruption of the relapse syndrome and help prevent tragic consequences. Planning should be an essential part of a recovery program (Marlatt, 1985). Gorski and Miller (1986) developed a model for relapse-prevention planning which consists of nine steps.

First is stabilization. This step involves regaining control of thoughts, emotions, memory, judgment, and behavior after relapse has begun (i.e., after the drug has been ingested). During this time of crisis, it is important to turn to significant others for help to ameliorate the negative emotions which accompany relapse. If stabilization










is not possible via this plan, professional help must be sought.

The second stage involves assessment of the cause of the relapse. A careful review of the history of addictive using provides an opportunity to learn from the past.

Third, understanding is accomplished via education.

Because addiction is a disease of denial (Seixas & Youcha, 1985), it is imperative to review this step with a professional who is trained in addictions, a sponsor, or a sober friend. Mutuality is important for the addict because it better insures that s/he will take responsibility for the problem. Importance is placed upon learning about PAW symptoms, what places the addict in high risk of developing these symptoms, what can trigger them, and how to manage or prevent them. Examples are needed to enhance accuracy and clarity.

Fourth, relapse-warning-sign identification needs to be undertaken. The signs are unique and personal, signalling a need for an individualized approach. The signs are signals that are apparent to self or others and may be internal or external problems. Symptoms can be related to health, thinking, emotions, memory, judgment, or appropriate behavior. It is important to write a list of these warning signs which are developed from past relapse experiences.

Fifth is warning sign management. This involves viewing each warning sign as a problem which needs to be solved or










prevented upon onset. Of paramount importance is the establishment of new responses. Problem resolution is the key. Alternative behaviors should be explored, decided upon, and practiced until habit. This should be done at times of low stress.

Next, inventory training involves daily identification of relapse-warning signs. Without this step, early warning signs will be ignored and it may be very difficult to interrupt the relapse symptom. It is advisable to develop this daily inventory as a habit to be performed in a rituallike fashion two times each day. Journalling can be a helpful adjunct in this step. It can help to monitor the signs as well as function as a "barometer" for measuring progress and be motivational.

The seventh step is a review of the recovery program. An assumption inherent in this step is that a recovery program is the best defense against relapse. In other words, the addict needs a good recovery program in order to prevent relapse. The recovery program as relapse strategy is a learning process. Fingarette (1988) advocated a plan wherein the drinker/addict not only addresses the slips, but also how to overcome them and learn from mistakes. This approach is supported by experimental and theoretical research (Marlatt & Gordon, 1985). For every problem, warning sign or symptom identified, there is a complementary coping behavior.










Involvement of significant others (step eight) follows the review of the recovery program. Help and support from others is necessary because relapse is often an unconscious process. Therefore, the addict may not be able to recognize the process.

Step nine is follow-up and reinforcement. Addiction is a chronic problem (Ohlms, 1981); it does not just go away. Just as recovery is a "way of life," so is relapse prevention. This planning must become an integral part of the addict's life. There should be compatibility among all factors of recovery such as the treatment program, AA involvement, other support groups, family, school, friends, and job involvement.

Structure is necessary to the entire process. Relapse prevention must be practiced until it is habitual. Willingness is another necessity. The plan usually involves revision and updating at times as well as identification of new problems which sabotage recovery. The result of relapse prevention is a sense of confidence in recovery and a more comfortable sobriety.

About two-thirds of all relapses occur within the first 90 days following treatment (Marlatt & Gordon, 1985). It is important to consider the reasons addicts relapse as well as the reasons they are prone to develop chemical dependence (Vaillant, 1983). The precursors of alcoholism are often triggers when the addict is sober. Research in this area










has shown that for many, alcohol can be a powerful depressant, although, paradoxically, if taken in large quantities for a prolonged period, it may actually elevate anxiety levels (Stockwell & Town, 1989). Prolonged use also can cause damage which persists long after abstinence and may be responsible for stress symptoms stemming from central nervous system damage (Gordis, 1976). Johnson (1980) conducted an ex Post facto study with alcoholics and reported that, although their emotional backgrounds were different before the onset of the disease, the pattern of emotional distress after onset is (almost) universal.

Regardless of the cause of discomfort in sobriety, it is apparent that chemically-dependent persons suffer from stress-related symptomology. In assessing relapse crises, the single most important factor to consider is the affective tone of the situation (Shiffman, 1988). Stress is a construct which subsumes many others, e.g.1 depression, rage, fear, and guilt in general (Ellis et al., 1988). According to Stockwell and Town (1989), the term stress applies to the entire process of interactions between external stresses (e.g., work demands, criticism, or unrealistic demands) and the chemically-dependent person's reactions or stress responses.

Vaillant (1983) reported that the sober addict's

predicament (i.e., being prone to relapse) is complicated by the complexity of the disease. In addition to










pharmacological and emotional dependence, there is an intricate learning process underlying seemingly incomprehensible relapse. craving for the drug, an unconscious process, contributes to relapse in that it can be aroused subsequent to psychological change (Ludwig & Wikler, 1974). The craving thus can trigger learned behavior (i.e., substance use). Further, alcohol nonspecifically alters the chemically-dependent person's feeling state, thus making it a powerful reinforcer (Vaillant, 1983).

The change of affective state is an important

consideration in relapse prevention. Mello and Mendelson (1972) demonstrated that many alcoholics do not maintain stable concentrations of blood alcohol when drinking, but instead attempt to induce variation in blood alcohol levels. This suggests that continued changes in the addict's state of consciousness may be as reinforcing as the relief of physiological withdrawal. Mental imagery, cognitive restructuring, and relaxation exercises are strategies which can alter the state of the addict and are thus appropriate interventions.

There are studies which suggest that the use of mental imagery reduces stress. In one study, Beck (1967) demonstrated that a catatonic imagery experience resulted in an end to addiction. In another, the use of imagery in










alcoholism treatment to reduce stress showed it to be effective (Pati, 1981).

Numerous authors have supported the use of mental

imagery as a vehicle for reducing stress. For example, stress-inoculation training (SIT) uses imagery as a specific means of attention diversion with stressed populations (McCaffery, 1979; Meichenbaum, 1978; Turk, Meichenbaum, & Genest, 1983). Wolpe (1958) developed a systematic desensitization paradigm which is the predecessor to SIT. His model also was designed to reduce stress. Others have advised using mental-imagery exercises to reduce stress (Davis, McKay, & Eshelman, 1982; Fezler, 1989; Gawain, 1982; Miller & Leuth, 1986; Peale, 1982; Siegel, 1986; Singer, 1976) and claim high levels of effectiveness. More specifically, many authors have recommended mental imagery as treatment for stress-related symptoms which cause relapse. Millham and Mason (1987) viewed it as a tool to break free of the grasp of addiction. Nuckols (1987) held mental imagery as a way to cope with high-risk situations. Marlatt and Gordon (1985) pointed out that although studies of this variable are scarce, future studies may reveal that imagery techniques with addicts are a helpful adjunct to treatment.

Images are mental representations of thought, usually

visual in nature, which enable people to record experiences, fantasize, free associate, discover, construct, and problem-










solve without altering any of the environment (Witmer & Young, 1985). Visual images also have the potential to influence every cell, tissue, and organ in the body, a concept vital in chemical-dependence relapse prevention. For the addict, craving involves an unconscious process and indicates a need to alter the mood (Vaillant, 1983). The change or alteration of the mood is the important variable. Mental imagery has the potential to alter the state of consciousness to any possible combination of alternatives (Bandler & Grinder, 1979).

Chopra (1989) also emphasized the necessity for a

"cellular" change in treating addiction because the memory of the cravings and effects of the drugs remain after the cell dies. This endocrinologist suggested that the process is not volitional, but a product of unconscious thoughts and memories. Mental imagery is powerful because it taps into basic memory storage and retrieval processes (Fezler, 1989). Mental imagery is therefore appropriate as a vehicle to "counter" the process of relapse.

The scientific study of the ongoing imagery process was spurred by sensory deprivation research in the 1960s (Singer, 1974). The goal was to predict the possible impacts of isolation on the mental functioning of astronauts during flight. However, this research also has implications for conditions such as social withdrawal, monotonous work experiences, and hospitalization. one result was evidence








50

that an ongoing imagery process is an important variable in human mental experience, particularly when perceptual stimulation is reduced (Singer, 1974). This research was vital because it began to offer scientific reasons why imagery techniques in psychotherapy are so effective.

There are many justifications for incorporating imagery into counseling practice. Among them are the power of imagery to produce physiological change and the tendency of imagery to provide motivation and to serve as a "rehearsal" for new behaviors (Witmer & Young, 1985). Imagery used in such clinical applications has been defined as a "sequence of processing toward resolution" (Strosahl & Ascough, 1981, p.423). It is a process leading toward insight into stored associations. By assisting insight, imagery techniques are more powerful than verbal inquiry. Kubie (1965) suggested that there is a wealth of information which can be retrieved through imagery techniques. Imagery also makes available material such as early childhood experiences and thus enhances treatment.

Skovholt and Thoen (1987) reported self-report and

anecdotal data using mental imagery as an intervention to change behavior. Their data supported their beliefs that imagery is sometimes a powerful counseling technique. Mental imagery also has been demonstrated to be effective in the treatment of a range of psychological problems (Witmer & Young, 1985). Examples, as summarized by Sheikh and Jordan










(1983), include insomnia (Sheikh, 1976), depression (Schultz, 1978), obesity (Bornstein & Sipprelli, 1973), sexual malfunction (Singer & Switzer, 1980), chronic pain (Joffe & Bresler, 1980), various phobias and anxieties (Meichenbaum, 1977; Singer, 1974), and a host of psychosomatic problems (Lazarus, 1977; Simonton, MatthewsSimonton, & Creighton, 1978).

Other authors also have heralded the use of mental imagery to produce behavioral change. For example, Shiffman, Read, Maltese, Rapkin, and Jarvik (1985) claimed that mental imagery reduced stress. Sheikh (1976) proposed that mental imagery worked as a method to stop smoking cigarettes. Michaud and Feinstein (1989) reported a study which suggested that, after using mental imagery to visualize blisters getting better, the blisters became significantly smaller and white blood cells were positively effected. Similarly, Epstein (1986) reported shrinkage in a nodule after a rheumatoid patient used mental imagery.

Others have recommended the use of mental imagery with chemically-dependent persons (e.g., Gawain, 1982; Johnson, 1980; Kritsberg, 1983; Small, 1982). Marlatt and Gordon (1985) reported that although research on mental imagery is generally lacking, future studies may reveal that this technique is a helpful adjunct to treatment with addicted clients. Finally, Ellis et al. (1988) recommended the use of mental imagery with addicted clients. Adaptation of his








52

rational-emotive imagery made it more expressive and useful for addicts (Maultsby, 1975; Maultsby & Ellis, 1974).

Relaxation is recommended as an antidote to stress and

as a preventive method in stress-management programs. There is considerable research evidence that documents the effectiveness of relaxation as a stress-reduction activity (e.g., Bahrke & Morgan, 1978; Davidson & Schwartz, 1976; English & Baker, 1983; Glaister, 1982; Lehner, Schoicket, Carrington, & Woolfolk, 1980). Theoretically, there are a number of explanations for the latter. Some authors have focused on the physiological benefits of relaxation (e.g., Benson, 1975; Jacobson, 1929). Goleman (1971) focused on the psychological and behavioral benefits of stress reduction. Meichenbaum (1977) stressed the role of relaxation in the excitation and exacerbation of anxiety states.

Marlatt (1985) recommended relaxation as a lifestyle

modification procedure for addictive behavior problems and other authors have supported this perspective (Glasser, 1976; Gold, 1988; Gorski, 1989; Strickler, Bigelow, Wells, & Liebson, 1977). Weil (1972) suggested that this procedure could be a substitute or "positive addiction," in lieu of the addictive habit. Marlatt (1985) concurred that addictive behaviors are strongly associated with relaxation or escape. By replacing these behaviors, the sense of deprivation may weaken. Levine (1979) contended that










relaxation tends to allow the addict to detach and can be particularly effective in coping with urges and craving experiences after cessation of the addictive experience.

In the alcoholism field, preliminary survey studies disclosed that alcohol and drug use was reduced substantially when subjects used relaxation methods (e.g., Benson & Wallace, 1972; Shafii, Lavely, & Jaffe, 1975). However, Smith (1975) noted that most of these studies have methodological problems and should be interpreted with caution. For example, biases took the form of invalid selfreports, lack of adequate control groups, and motivational differences among subjects. Some studies also lacked true alcoholic subjects. Overall, there exists little consistency in research on the effect of relaxation exercises (alone) on addictive patterns (Glasser, 1976; Gold, 1988).

Two studies conducted at the University of Washington on the effectiveness of relaxation procedures with heavy social drinkers were aimed at reducing consumption (Marlatt & Marques, 1977; Marlatt, Pagano, Rose, & Marques, 1984). Results of the first study exhibited a significant reduction in alcohol use (approximately a 50% reduction from pretreatment rates) for subjects in three relaxation conditions in comparison with a no-treatment control group. Overall, results showed a significant reduction in drinking rates after taking regular time-out periods to relax. The










second study showed significant decreases in drinking compared to baseline drinking levels (Murphy, Pagano, & Marlatt, 1984) in a relaxation (meditation) group. This group returned to pretreatment levels of alcohol use shortly afterwards, however.

In summary, research on relaxation as an intervention for chemical-dependence reduction is both sparse and conflicting. However, there are enough studies which support the effectiveness of this technique to warrant its use in conjunction with other techniques.

One of the primary focuses of cognitive restructuring is to identify and decrease stress (Shiffman, Read, Maltese, Rapkin, & Jarvik, 1985). This approach seeks to challenge the irrational beliefs which cause discomfort (McMullin, 1986). The essence of this approach consists of three basic steps, according to McMullin and Giles (1981). First, the therapist helps the client recognize the thoughts, beliefs, or schemata that are causing the negative emotions and behaviors. Second, the clinician assists in helping the client to analyze the validity and usefulness of the negative processes. Last, the therapist helps to effect a "shift" from irrationality to accurate, rational, and useful behavior. There is considerable evidence showing that the degree of stress that people experience depends mainly on the labels and cognitions applied to physical states and are








55

not intrinsic properties of the state itself (Beecher, 1959; Nisbett & Valino, 1971; Schachter & Singer, 1962).

Many studies have been conducted which support strongly the use of cognitive restructuring with chemically-dependent persons (Clark, 1986; Ellis, et al., 1988; McMullin, 1986). For example, Oei and Jackson (1982) compared social skills training, cognitive restructuring, and traditional supportive therapy with inpatient alcoholics. At a threemonth followup, the cognitive-restructuring group was evaluated as the most improved.

There is additional evidence to support the use of

cognitive restructuring specifically as a stress-reduction strategy with chemically-dependent persons. Rohsenow, Smith, and Johnson (1985) reported significant short-term changes as a result of using cognitive restructuring as one of the approaches to reduce stress in chemically-dependent college males. McLellan, Woody, Luborsky, Obrien, and Druley (1983) evaluated a sophisticated cognitive-behavior study designed for chemically-dependent persons. This study included a rigorous research design including random assignment to groups and screening for subject motivation. Findings suggested that cognitive restructuring was more effective than traditional counseling.

Marlatt (1985) proposed that the chief purpose of

cognitive restructuring was to counter the cognitive and affective components of the Abstinence Violation Effect








56

(AVE). He proposed that relapse potential places much stress on the chemically-dependent person because of irrational thoughts which lead to feelings of hopelessness. Finally, several authors believe that an addict's relapse potential is strengthened when irrational conceptualizations which result in lowered self-efficacy and increased selfhelplessness are alleviated (Lazarus, Averill, & Opton, 1970).














CHAPTER 3

METHODOLOGY

There were two primary purposes of this study. The first purpose was to determine whether a mental-imagery workshop could change (i.e., improve) levels of self disclosure, help-seeking behavior, lifestyle behavior change, and perception of unmanageability over drugs and alcohol with recovering addicts. The second purpose was to determine how these outcome variables interacted with relevant independent (i.e., demographic and chemicaldependence related) variables.

Delineation of the Variables

Data were gathered for the following variables:

(a) group (experimental or control); (b) gender (male or female); (c) age (15 to 70); (d) race/ethnicity (Black (B), Caucasian (C), or Hispanic American (H)); (e) level of education (5 to 22); (f) length of recovery (4 to 96 months); (g) drug of choice (alcohol, sedative, marijuana, cocaine, amphetamine, or hallucinogen); (h) number of weekly 12-step meetings attended; (i) self disclosure (a score on the JSDQ); (j) help-seeking behavior (a score on the HSLI);

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

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










Population

The group of people to whom the results of this study were intended to apply (i.e., recovering chemicallydependent persons) have certain characteristics in common. However, the population was not intended to include those

(a) with less than a 5th grade reading level; (b) race other than Black, Caucasian, Native American, or Hispanic American; (c) persons with disabilities which prohibit them from completing the instruments; (d) younger than 15 or older than 70; (e) who do not read and write English; (f) who are chronic relapses because of severe mental and/or nervous disorders, pain, or other dual diagnoses; and (g) with less than four months or more than 96 months of abstinence from mood-altering chemicals.

Although an attempt was made to represent recovering

chemically-dependent persons in general, this goal was only partially achieved. Random sampling produced only three Blacks and only four Hispanic Americans. Likewise, only three subjects under 20 years of age participated. In addition, there were a predominance of alcohol abusers in the study. Therefore, the variable, drug of choice, was collapsed to alcohol and other. Finally, the sampling produced subjects having from 1 to 264 months of abstinence.

The psychological variables characteristic of this

population are primarily the result of prolonged substance abuse (Vaillant, 1983). There are psychological symptoms










(e.g., self-centeredness, resentment, self-deception, and fear) which progressively worsen as the person "uses" more of the chemical (Gorski, 1986). Thus, chemically-dependent persons generally are caught up in a "double-bind" wherein the psychological problems worsen and, in turn, perpetuate themselves. The self-centeredness prevents help-seeking behavior and the problems generate more problems. Resentments are born out of anger and disappointments as ingestion increases. The self-centeredness, coupled with this resentment, leads to exaggerated and overwhelming feelings of self-pity and alienation. Self-deception flourishes as the addict progressively defends his or her behavior by rationalization, intellectualization, projection, and justification. Honesty to self and others becomes more difficult to attain. Ultimately, fear begets paranoia. The self-deception aids the process and the other psychological variables also overlap to add to the confusion and eventual despair. Low self-esteem, depression, and a negative belief system follow.

There are other variables that merit reporting. The

male-to-female ratio of known substance abusers in the state of Florida was 76% to 24% as of 1989, including 62,609 males and 20,220 females. With an n of 15, 11.4 (11) males and

3.6 (4) females would have represented the chosen population. Percentages by race in the state of Florida were 71% Caucasian, 22% Black, 7% Hispanic American, and










less than 1% Other. Totals as of 1989 were 58,395 Caucasian, 18,406 Black, 5,690 Hispanic American, and 348 Other (i.e., Asian and Native American). With an n of 15, the totals would have been 10.6 (11), 3.3 (3), 1.05 (1), and 0, respectively.

The third variable, age, was reported as under 20 and over 20. The percentages of under 20 and 20 years of age and above were 12% and 88%, respectively. In Florida, there were 11,128 chemical-dependence admissions under 20 years of age and 82,387 20 years old and over in 1989. With an n of 15, there would have been 1.8 (2) persons under 20 and 13.2

(13) persons 20 years of age and over.

In summary, the National Association of State Alcohol and Drug Abuse Directors, Inc. reported characteristics and percentages for each of these three variables in the chemical-dependence population in Florida. These data were gleaned from reports from chemically-dependent client admissions to treatment centers in 1989. Representing them would have resulted in 11 males, 4 females; 11 Caucasians, 3 Blacks, 1 Hispanic American; 2 teenagers, and 13 persons over 20 years of age in each group, partitioned as shown in Table 1

Sampling Procedures

Subjects for this study were recruited primarily from

members of Alcoholics Anonymous (AA) and Narcotics Anonymous NA) groups. Nationally, members of these organizations










TABLE 1

Proposed Gender. Aae and Race/Ethnicity Percentacres for the Experimental and Control Groups


Race Male Female

Under 20 Over 20 Under 20 Over 20

Caucasian 11 11 11 11

Black 3 3 3 3

Hispanic 1 1 1 1

Total 15 15 15 15



represented over two million recovering chemically-dependent persons of all ages, races, and genders.

Presentations were made at eight different AA and NA

meetings in the central Florida area. The presenter stated that there would be five, day-long workshops at Quest Counseling Centre beginning the next Saturday and for the following four Saturdays for persons in chemical-dependence recovery. The focus of the workshops was to be on relapse prevention. The incentive for participation was described as self-improvement with an opportunity to strengthen the recovery process. After each presentation, interested persons were asked to write their names and phone numbers on a sheet of paper distributed by the presenter.

This approach failed to enroll the desired 75

participants. Therefore, Lifeworks Center, Inc. was used to recruit members from their chemical-dependence treatment








62

center. Subjects also were recruited from among outpatient "graduates" of Quest counseling Centre's Adult Treatment Program. An n of 15 was the targeted number for each treatment group. However, this number also was not reached initially. Therefore, more treatment groups were added to increase the numbers of subjects in the total experimental group.

Numbers of persons needed to meet the proposed race,

gender, and age specifications were not achieved fully. The gender distribution was relatively even instead of the project three-to-one male-to-female ratio. The age variable was changed to under 30 and over 30. Length of recovery was from 1 month to 264 months. The characteristics of the actual participants are delineated further in Chapter 4.

Subjects self-selected into groups based on their own scheduling convenience. Designation of groups as either experimental or control was done on a random basis. 'Thus subjects were essentially randomly assigned to a group because no experimenter-controlled factors were implemented.

Recovering CD persons typically are involved in

programs (e.g., AA or NA) intended to help them refrain from renewed addiction. The motivation to participate in such programs seemed to facilitate obtaining the initial sample because the workshop participants were selected from among those who had already demonstrated at least some inclination not to relapse. That is, subjects came from among those










currently participating in abstinence-maintenance programs. The conduct of the followup assessments and interviews, however, presented additional considerations. Followup was done with the experimental group six weeks after their treatment. CD persons are known to relapse frequently. Indeed, that is one of the reasons for the intervention (and research) in the first place. Thus, it was likely that some subjects would relapse before the followup activities. This was true as 7 participants relapsed and were not available to respond to followup questions. Therefore, followup data were not obtained from all subjects.

Substantial effort was required to locate and obtain

data from the participants on individual bases. Their lives seemed to be disordered and it was often difficult to obtain followup data, even from those who initially agreed to provide it. However, it appeared that the intervention was perceived as helpful and therefore motivation to participate in followup activities may have been increased. A total of 43 persons participated in the followup portion of the study.

Measurement Instruments

The instruments used in this study were the Jourard Self-Disclosure Questionnaire, Health Attribution Test, Abstinence Likelihood Inventory, and Help-Seeking Likelihood Inventory. These instruments have few items, are easily scored, and could be completed within 30 minutes. They also










are easy to comprehend and have brief, clear instructions for use. Appropriateness was determined via reliability and validity testing for each instrument.

The Jourard Self-Disclosure Questionnaire (JSDQ) was developed by Sidney Jourard. The questionnaire was published in an article by Jourard and Lasakow (1958). It was designed to measure the extent to which an individual is willing to reveal himself/herself to another (i.e., self disclosure). Subscales measure degree of self disclosure in regard to attitudes and opinions, tastes and interests, work, money, personality, and body. A respondent is asked to respond to a series of statements by indicating the target person (e.g., mother, father, male friend, female friend, or significant other) to whom she or he has revealed feelings and to what extent.

The JSDQ is a 60-item test which requires approximately 10 minutes to complete. It has a 0, 1, or 2 response format. Responses are written on the answer sheet. Although six subscale scores can be computed, only the total score was used in this study. Higher scores represent greater willingness and ability to self disclose. Research on the use of the questionnaire has shown that self disclosure is measurable and that this method of assessing it has validity (Jourard, 1971). The JSDQ has been used frequently as a self-inventory in personal growth laboratories or as an outcome measure in research on human









65

relations training or counseling. Panyard (1973) also found empirical support for the validity of the JSDQ.

The Health Attribution Test (HAT) was published in 1990 by the Institute for Personality and Abiltiy Testing, Inc. The HAT measures respondents' attitudes about responsibility for their own health maintenance or treatment programs (i.e., lifestyle behavior change). The HAT requires from 510 minutes to administer and can be hand-scored in less than five minutes. It also can be administered to groups or individuals. It contains three scales to predict behavioral reactions to illness and response to treatment.

In the original development of the HAT, 43 items were administered to 121 undergraduate students. Subjects responded to each question by marking one of six possible responses arranged in a Likert-type scale ranging from "Never" to "Always." Their responses were then factor analyzed. The marker variables from Levenson's (1973) locus of control measure suggested that there were three factors which measured Internal, Powerful Others, and Chance beliefs. Next, the 22 items having the highest factor loadings were selected to comprise the current version of the HAT.

Respondents mark an 11x11 in the box which represents the answer they choose on a Likert-type scale ranging from "Strongly Disagree" to "Strongly Agree." Higher scores indicate willingness to become responsible for one's health










maintenance or treatment program (i.e., lifestyle behavior change). The Internal subscale, which measures a person's attitude of personal responsibility for their health, was used as the score for this test.

The Abstinence Likelihood Inventory (ALI) (Appendix C) was developed in September, 1989, by the researcher for use in this study. The ALI measures perception of unmanageability, that is, the likelihood that a chemicallydependent person will remain abstinent. The ALI requires from 5-10 minutes to administer and can be hand-scored within 2-3 minutes. It can be administered to groups or individuals.

The ALI is a 26-item test. Respondents use a response scale ranging from 0 to 9. Scores represent the likelihood that the respondent will remain abstinent (i.e., perception of unmagageability). Scores range from 0 to 234, with higher scores indicating less likelihood of relapse. The total score is used.

The ALI was developed to measure likelihood to remain abstinent because no such measure was available. A pilot study was conducted to determine its reliability. A group equivalent to those to be studied was used. The 26-item ALI was administered to 35 (known) chemically-dependent persons, each of whom was (self-reported) abstinent from moodaltering chemicals for at least six months. Respondents were asked to write their age, gender, and social security










number (for matching purposes) on the form. Anonymity was emphasized. They were asked to complete the one-page form and return it in the self-addressed, stamped envelope provided. Instructions were to write the number from 0 to 9 which represented the extent to which each item was thought to be a trigger which precipitated "use." Thirty-two were returned.

Internal reliability was calculated by means of

Cronbach's coefficient alpha. The coefficient alpha is used when measures have multiple-scored items (Ary, Jacobs, & Razavieh, 1985). The coefficient alpha for the ALI was .92; a readily acceptable level of reliability. The split-half reliability coefficient was .87 (Table 1). The test-retest reliability coefficient following a 30-day period was .93.

Content validity was evaluated to determine the extent to which the ALI measures likelihood of abstinence. Content validity refers to the extent to which an instrument represents the content of interest (Ary et al., 1985). This type of validity is well-suited for tests used to measure psychological variables. The variable measured in the ALI is attitude toward different triggers associated with, and perhaps precipitating, a craving to "use." Each item was gleaned from an extensive literature search and is therefore multi-referenced, as shown in Appendix D.

The Help-Seekinq Likelihood Inventory (HSLI) (Appendix E) also was developed in September, 1989, by the researcher










for use in this study. The HSLI measures the likelihood that a chemically-dependent person will ask for help and, if so, from whom. This inventory takes from 5-10 minutes to administer and can be hand-scored within 2-3 minutes. It can be administered to groups or individuals.

The HSLI is a 20-item test on which respondents use a scale ranging from 0 to nine. Scores represent the likelihood that the subject will seek help while in recovery. Scores range from 0 to 180, with higher scores indicating greater likelihood of help-seeking behavior. The total score is used.

The HSLI was designed to measure this variable for this study because no such measurement was available. A pilot study was conducted to determine its reliability. A group equivalent to those being studied was used. The 20-item HSLI was administered to 35 (known) chemically-dependent persons each of whom was abstinent (self-reported) from mood-altering chemicals for at least six months. Respondents were asked to write their age, gender, and social security number (for matching purposes) on the form. Anonymity was emphasized. All were asked to complete the one-page form and return it in the self-addressed, stamped envelope provided. Written instructions were to write the number from 0 to nine which represented the extent to which each help-seeking behavior would be employed in recovery. Thirty-two were returned.










Internal reliability was calculated by means of the

Cronbach's coefficient alpha. The coefficient alpha for the HSLI was .77, an acceptable level of reliability. The split-half reliability coefficient was .88. (Table 2). A test-retest reliability coefficient following a 30-day period was .80.

Content validity is important and refers to the extent to which the inventory measures the content of interest, i.e., whether the subject will seek help with his/her recovery. The variable measured in the HSLI is willingness to seek help. Each item in the HSLI was gleaned from the literature. Item references are found in Appendix F. Table 2

Reliability Calculations for the ALT and HSLI



Coefficient alpha Test-retest Split-half



ALI .92 .93 .87

HSLI .77 .80 .88



Research Design

The design used in this study was a randomized,

posttest only control group with followup design. The original intent was to have one control group and one experimental group (composed of four treatment groups, each having an n of 15). However, random sampling produced less










than 15 subjects for each treatment group. This necessitated adding two more treatment groups to total six. The treatment groups were facilitated by different facilitators and on separate occasions. All groups except one were performed on Saturday. No other known differences existed between these groups. Preliminary analyses indicated no significant differences in the means for any of the dependent variables across the six treatment groups. Therefore, the data were pooled as a single experimental group.

The research covered six weeks. Initial assessments for the experimental group were completed immediately upon completion of the treatments. The experimental group was assessed again six weeks after the initial assessment. The control group received the treatment following completion of the initial assessments.

Treatment

The treatment (i.e., counseling intervention) used in this study was a day-long, approximately eight-contact hour workshop intended to help chemically-dependent persons be able to use mental-imagery techniques to prevent relapse. The treatment is described in detail in Appendix G. Support for the respective elements of the workshop is found in Chapter II.

The treatment workshop format used was common in the counseling profession in that day-long intervention








71

workshops have been used for a wide variety of purposes and for an equally-wide variety of clientele. Thus, the treatment had the advantage of being similar in format to frequently-used counseling interventions. In addition, many of the activities conducted have been used in other contexts and so their potential applicability was well-founded.

These commonalities notwithstanding, the treatment was unique and innovative in several regards. First, the treatment had a stronger, more integrated theoretical foundation than most used with CD persons. As shown in Chapter II, there existed theoretical commonality and coherence across the elements (i.e., activities) used. Theoretically integrated interventions have been used commonly in the counseling profession in general, but rarely has such theoretical integration been evident in interventions for CD persons. Second, the treatment was multifaceted in that a variety of activities, all focused upon mental-imagery training, were incorporated in it. Many of the activities used have been used in other contexts and generally with success. However, those that have been used with CD persons have only been used infrequently, often without demonstrated success and never within the context of a combination as was used in this research. Third, the treatment was based on a prevention perspective. Therefore, it was in accord with potentially far less costly approaches to treatment for CD persons. Finally, the treatment was










intended to effect a combination of (dependent) variables not heretofore studied in relapse-prevention efforts. In sum, the treatment was developed based upon a careful review and evaluation of the professional counseling literature on activities potentially appropriate for using mental imagery as a means to facilitate relapse prevention. It was developed so as to be both theoretically sound and professionally appropriate.

It should be noted that the intervention was an adjunct to treatment for those who were receiving, or had received, "standard" treatment. Standard treatment included inpatient, outpatient, NA, or AA approaches. Since the sample was derived from a population of recovering persons, it was assumed that these people were in recovery treatment of some sort. Relapse, by its very nature, occurs only after a person is exposed to recovery. Therefore, all participants had been or were involved in other treatment. A treatment history form (Appendix J) was designed to determine the type of treatment(s) to which the subjects were exposed.

Research Procedures

After participants in the control group entered the

group room at Quest Counseling Centre in Altamonte Springs, Florida, the facilitator said, "Good morning. Thank you for coming. My name is . I'm looking forward to a very

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










begin, I'd like you to complete four instruments which are necessary, important, and integral to the study. Please complete them conscientiously. The results will be coded and kept confidential.

on the forms which I will hand out, please write the last four digits of your social security number, your age, and M or F for male or female in the upper right corner. Also, write today's date as soon as I say to begin.

Complete one form at a time, respond to every item in order, and do not skip items. Instructions are written on each form. Read these carefully, relax, and respond to all questions as honestly as you can. Raise your hand when you finish all four forms. It should take you about 20 minutes but you are not being timed. Begin now."

The facilitator then gave each participant a pencil and the four forms. He stayed in the room, answered questions, and distributed more forms and/or pencils as needed. As participants finished, he checked the forms for social security digits, age, and gender information. He also checked for completion of all items. Forms were placed in a box marked C group.

When all forms were collected, the facilitator then

said, "Thank you for your cooperation. In six weeks, I will ask each of you to fill out follow-up forms. We have finished this phase and are ready to begin the workshop on relapse prevention."








74

At this point, the treatment procedure was implemented. In general, it was an eight-hour workshop on relapse prevention. The focus was on the use of mental imagery as the main intervention to raise levels of acceptance in four areas. Initially, time was given to the development of a "safe" atmosphere, followed by an introduction to imagery. The workshop proceeded with a series of imagery vignettes targeted to raise levels of acceptance. See Appendix G for a complete description of the treatment.

At the completion of the workshop, the facilitator

said, "It is now time to end. Thank you for participating. I wish you all much success. Lastly, in six weeks, I will contact you and ask you to complete four more forms. Thank you.11

Because this study incorporated a posttest only design, the experimental group received the instruments after the treatment. However, the format for the treatment was identical for both groups. After the participants in the experimental group entered the group room at Quest Counseling Centre in Altamonte Springs, Florida, the facilitator said, "Good morning. Thank you for coming. My name is . I'm looking forward to a very productive

day that is relaxing, fun, and helpful. We are ready to begin the workshop on relapse prevention. Please remember that we will end at 4:30 p.m. and then spend about one-half hour completing some forms." At this point the treatment










procedures were implemented. Upon completion of the workshop, the facilitator said, "It is now time to complete forms. Thank you for your cooperation. I wish you all much success. In six weeks I will ask each of you to fill out follow-up forms. This next part takes about one-half hour and involves completing four instruments necessary, important, and integral to the study. Please complete them conscientiously. The results will be coded and kept confidential. on the forms which I'll hand out please write the last four digits of your social security number, age, and M or F for male or female in the upper right corner. Also, write today's date as soon as I say to begin. Complete one form at a time, respond to every item in order, and do not skip items. Instructions are written on each form. Read these carefully, relax, and respond to all items as honestly as you can. Raise your hand when you finish all four forms. It should take you about 20 minutes but you are not being timed. Begin now."

The facilitator then gave each participant a pencil and the four forms. He stayed in the room, answered questions, and distributed more forms and or pencils as needed. As participants finished, he checked the forms for social security digits and gender information. He also checked for completion of all items. Forms were placed in a box marked E group.










Research participants

There were five trainers for the intervention.

originally, there were four trainers assigned, one to each group. However, as the number of subjects in each treatment group was smaller than intended, there was need to add more groups. One more trainer was added in order to facilitate this process. All of the trainers had been enrolled in post-master's graduate study, had master's degrees in counseling, possessed Florida State Licenses as either mental health or marriage and family counselors, were current practitioners in the field of counseling in the Central Florida area, had at least 15 years of experience in the counseling profession and were Caucasian males over 40 years of age.

The researcher had provided approximately 10 hours training to workshop leaders to explain the format, guidelines, and expected behaviors for the workshop. The imagery exercises, intended psychological environment for the day, and accompanying attitudes to be expressed to the participants were explained. Rehearsals of the tasks were completed. Imagery exercises were audiotapes beforehand and played during the workshop.

Data Analyses

The purpose of the workshop was to improve participant characteristics in ways known to be associated with successful recovery processes. Therefore, primary interest










was in differences in four selected outcome variables between those in the experimental and control groups. However, because a variety of variables were investigated, differences in or relationships to the selected variables as functions of demographic and other characteristics of both the participant and nonparticipant groups also were of interest.

The data analyses for the study were conducted in

steps. In the first step, four separate (i.e., one for each dependent variable) one-way analyses of variance (ANOVAs) across the six treatment groups were computed to determine if there were significant differences among the treatment groups. There were no significant differences and therefore the data from the respective treatment groups were combined for subsequent analyses.

Multiple regression analyses were used to determine significant differences and/or interactions among the demographic and each of the outcome variables. Similarly, multiple regression analyses were used to determine significance of relationships among the demographic variables and the each of the outcome variables. The general linear model was used for each of these analyses. It allowed for investigation of individual as well as linear, weighted combinations of relationships among the respective variables.














CHAPTER 4

RESULTS

This study examined the effects of a brief, relapseprevention intervention for chemically-dependent persons. A randomized, posttest only control group design, with follow-up, including multiple dependent and independent variables was used. Subjects in the treatment and control groups were measured across four dependent variables: helpseeking behavior, self disclosure, perception of unmanageability, and lifestyle behavior change.

Fifty subjects were recruited for the experimental

groups. It was necessary to have six groups because initial attempts to fill the four proposed treatment groups failed. Therefore, two additional groups were added. One of the participant's scores were discarded because the person was not in treatment for chemical dependence but rather for an over-eating problem. Thirty-seven subjects were recruited for the control group. one subject's data were discarded because of failure to complete the posttests. Therefore, there was a total of 85 participants.

An attempt was made to obtain a sample as presented in Table 1. However, the procedures yielded only an










approximation of that intention. The actual sample is presented in Table 3.

TABLE 3

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


Experimental Control

Age Male Female Male Female

Under 30 7 2 3 4

Over 30 20 20 18 11


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

Four one-way analyses of variance (ANOVA) were performed as a preliminary analysis to determine whether there were significant differences among the six treatment groups. The means and standard deviations by variable and TABLE 4

Mean and Standard Deviations for the Experimental and Control Group


El E2 E3 E4 E5 E6 All E Ctrl ALI M 155.5 174.0 165.0 159.9 129.2 178.0 158.5 130.3
SD 31.1 42.7 30.3 41.3 52.3 22.0 40.7 59.4

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

JSDQ M 275.7 242.4 237.0 285.6 307.1 197.0 264.5 268.4
SD 123.2 86.9 66.2 103.4 173.4 90.9 114.7 101.2 HAT M 12.0 11.7 14.1 12.7 11.6 13.5 12.4 11.4
SD 6.0 3.9 7.5 4.2 7.0 4.4 5.4 5.8








80

group are shown in Table 4. No significant differences were found among the six treatment group means for any of the four dependent variables. Therefore, the data from the six treatment groups were combined into a single experimental group for all subsequent analyses.

Multiple regression analyses, using the general linear model, were computed to evaluate all hypotheses. The .05 level of significance was used throughout. A standard, linear, weighted multiple regression approach was used. The demographic and substance-abuse related variables were added to the model in a stage-wise manner. In the first stage, only demographic variables were included. In the second stage, treatment was added to the model and interactions between treatment and the demographic variables were tested to determine whether the treatment had a differential impact on subjects with different demographic traits. In the third stage, substance-abuse history variables were used as the independent variables. In the fourth stage, treatment was added to the model and its interactions with substance-abuse history variables were examined. In the final stage, the original intent was to combine only variables shown to be significantly related to the dependent variables in the preceding models to determine their combined effects. These stages of analyses were to have been applied to all four dependent variables. However, because prior analyses
























evaluation of this hypothesis is shown in Table 5. There TABLE 5

Multiple Regression Results for the ALI and Demographic Variables

Source DF Sum of Squares Mean Square F Value Pr > F Model 6 22698.8169 3783.1362 0.14 0.1895

Gender 1 99.7387 99.7387 0.04 0.8429

Race 3 6258.0956 2086.0319 0.83 0.4832

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

*p < .05

was not a significant relationship between the ALI and a weighted combination of the demographic variables. Therefore, hypothesis 1 was not rejected. However, there was a significant and positive relationship between ALI scores and age.

Hypothesis 2 stated that there was no significant relationship between ALI scores and a weighted, linear combination of the demographic variables, treatment, and the interactions of treatment with these demographic variables.


did not yield sufficient variables to evaluate these hypotheses, no statistical analyses were conducted.

Abstinence Likelihood Inventory

Hypothesis I stated that there was no significant relationship between ALI scores and a weighted, linear combination of the demographic variables (i.e., gender,


race, age, and education)


The data analyses summary for









82

The data analysis summary for evaluation of this hypothesis is shown in Table 6. There was a significant difference by group, with the experimental group having the higher mean. There also was a relationship between the ALI scores and the demographic variable age. In addition, there was a TABLE 6


Variables Source

Model Gender

Race Age

Education Group G*Group R*Group Aqe*Group Ed*Group

*< .05


and Treatment Interactions with the Demoaranhic


Sum of Squares

59885.3344

0.8676

6203.2854 19741.5559

54.3569 20374.1557 1684.2818

21.9130

893.9556

9796.6603


Mean Square 5444. 1213 0.8676 2067.7618 19741.5559

54 .3569 20374. 1557 1684.2818 21.9130

893.9556 9796.6603


F Value

2.49 0. 00

0.95 9.03

0.02 9.32 0.77 0.01

0.41 4.48


Pr > F

0. 0103 *

0.9842 0. 4232

0.0036 *

0. 8752

0.0032 *
0.3831 0.9205

0.5246

0.0377 *


significant group-by-education level interaction. There were uneven distributions across grade levels of those in the experimental and control groups. Therefore, hypothesis

2 was rejected.

Hypothesis 3 stated that there was no significant relationship between ALI scores and a weighted, linear combination of substance-abuse related variables (i.e., drug


DF


MultiDle Rearession Results for the ALI Demonranhit-










of choice, number of weekly meetings, and months of recovery). The data analysis summary for evaluation of this hypothesis is shown in Table 7. There was a significant relationship between the ALI and only length of time in recovery. Therefore, hypothesis 3 was rejected, but only length of recovery was related to ALI scores. TABLE 7

Multiple Regression Results for the ALI and Substance-abuse Variables

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


Model 3 24835.2176 8278.4059 3.44 0.0205 *

Drug of C 1 629.0992 629.0992 0.26 0.6103

Meetings 1 8121.4021 8121.4021 3.38 0.0697

Len of Rec 1 9999.7785 9999.7785 4.16 0.0446 *

*p < .05

Hypothesis 4 stated that there was no significant relationship between ALI scores and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. The data analysis summary for evaluation of this hypothesis is shown in Table 8. There was a significant relationship between ALI scores and only length of time in recovery. Therefore, although hypothesis 4 was rejected, it yielded redundant information with hypothesis 3 in that only length of recovery was a significant predictor of ALI scores.










TABLE 8

Multiple Reqression Results for the ALI, Substance-abuse Variables, and Treatment Interactions with the Substanceabuse Variables

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


Model 3 24835.2176 8278.4059 .44 0.0205 *

Drug of C 1 629.0992 629.0992 0.26 0.6103

Meetings 1 8121.4021 8121.4021 3.38 0.0697

Len of Rec 1 9999.7785 9999.7785 4.16 0.0446 *

Group 1 2216.7339 2216.7339 0.98 0.3253

DC*Group 1 5872.2433 5872.2433 2.60 0.1113

Mtgs*Group 1 75.6972 75.6972 0.03 0.8553

Len*Group 1 2559.6044 2559.6044 1.13 0.2908

*p< .05

Hypothesis 5 stated that there was no significant relationship between ALI scores and a weighted, linear combination of treatment, selected demographic variables, selected substance-abuse variables, and the interactions of treatment with the selected variables. Because prior analyses did not yield sufficient variables to evaluate this hypothesis, no statistical analysis was conducted for it. Therefore, hypothesis 5 was not tested.

Help-Seekinq Likelihood Inventory

Hypothesis 6 stated that there was no significant

relationship between HSLI scores and a weighted, linear combination of the demographic variables (i.e., gender, race, age, and education). The data analyses summary for










evaluation of this hypothesis is shown in Table 9. There was not a significant relationship between the HSLI and a weighted combination of the demographic variables. Therefore, hypothesis 6 was not rejected. TABLE 9

Multiple Regression Results for the HSLI and Demographic Variables

Source DF Sum of Squares Mean Square F Value Pr > F Model 6 5029.7498 838.2916 1.50 0.1900

Gender 1 1136.8021 1136.8021 2.03 0.1581

Race 3 4102.3386 1367.4462 2.44 0.0704

Age 1 56.9640 56.9640 0.10 0.7506

Education 1 289.2033 289.2033 0.52 0.4744


Hypothesis 7 stated that there was no significant

relationship between HSLI scores and a weighted, linear combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. The data analysis summary for evaluation of this hypothesis is shown in Table 10. There were no significant relationships, differences, or interactions. Therefore, hypothesis 7 was not rejected.

Hypothesis 8 stated that there was no significant

relationship between HSLI scores and a weighted, linear combination of substance-abuse variables (i.e., drug of choice, number of weekly meetings, and months of recovery).











The data analysis summary for evaluation of this hypothesis is shown in Table 11. There was not a significant TABLE 10

Multiple Reqression Results for the HSLI, Demographic


Variables Variables


and Treatment Interactions with the


Demoaranh ir - cI--


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


Model 11 6468.3852 588.0350 1.02 0.4407

Gender 1 1608.2802 1608.2803. 2.78 0.0997

Race 3 4070.4012 1356.8004 2.35 0.0798

Age 1 26.0763 26.0763 0.05 0.8324

Education 1 402.8410 402.8410 0.70 0.4067

Group 1 123.8208 123.8208 0.21 0.6450

G*Group 1 311.3700 311.3700 0.54 0.4655

R*Group 1 225.4763 225.4763 0.39 0.5343

Age*Group 1 641.9961 641.9961 1.11 0.2956

Ed*Group 1 0.1300 0.1300 0.00 0.9881



TABLE 11

Multiple Reqression Results for the HSLI and Substance-abuse Variables

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

Model 3 1461.1696 487.0565 0.84 0.478

Drug of C 1 424.3183 424.3183 0.73 0.3961

Meetings 1 0.6879 0.6879 0.00 0.9727

Len of Rec 1 1206.8233 1206.8233 2.07 0.1541


Demoaraphic








87

relationship between the USLI and a weighted combination of variables. Therefore, hypothesis 8 was not rejected.

Hypothesis 9 stated that there was no significant

relationship between HSLI scores and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. The data analysis summary for evaluation of this hypothesis is shown in Table 12. There were no significant relationships, differences, or interactions. Therefore, hypothesis 9 was not rejected. TABLE 12

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


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


Model 7 2953.7396 421.9628 0.71 0.6633

Drug of C 1 259.2825 259.2825 0.44 0.5108

Meetings 1 88.2745 88.2745 0.15 0.7009

Len of Rec 1 730.2304 730.2304 1.23 0.2710

Group 1 18.4745 18.4745 0.03 0.8605

DC*Group 1 454.0910 454.0910 0.76 0.3847

Mtgs*Group 1 178.5050 178.5050 0.30 0.5851

Len*Group 1 456.9829 456.9829 0.77 0.3831


Hypothesis 10 stated that there was no significant relationship between HSLI scores and a weighted, linear combination of treatment, selected demographic variables,








88

selected substance abuse-variables, and the interactions of treatment with the selected variables. Because prior analyses did not yield sufficient variables to evaluate this hypothesis, no statistical analysis was conducted for it. Therefore, hypothesis 10 was not tested.

Jourard Self-Disclosure Questionnaire

Hypothesis 11 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of the demographic variables (i.e., gender, race, age, and education). The data analyses summary for evaluation of this hypothesis is shown in Table 13. There was not a significant relationship between the JSDQ scores and a weighted combination of the demographic variables. Therefore, hypothesis 11 was not rejected. TABLE 13

Multiple Regression Results for JSDO and Democrraphic Variables

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


Model 6 34177.1734 5696.1956 0.46 0.8325

Gender 1 0.2334 0.2334 0.00 0.9965

Race 3 26463.2649 8821.0883 0.72 0.5433

Age 1 10662.0471 10662.0471 0.87 0.3539

Education 1 2855.0173 2855.0173 0.23 0.6308



Hypothesis 12 stated that there was no significant relationship between JSDQ scores and a weighted, linear










combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. The data analysis summary for evaluation of this hypothesis is shown in Table 14. There were few significant relationships, differences, or interactions. Hypothesis 12 was rejected, however, because there was a significant gender-by-group interaction. The experimental group had a mean of 280 for males and 246 for females. The control group had a mean of 288 for females and 249 for males. TABLE 14

Multiple Recrression Results for the JSDO, Demociraphic Variables, and Treatment Interactions with the Democrraphic Variables


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


Model 11 128992.4560 11726.5869 0.99 0.4604

Gender 1 1007.7209 1007.7209 0.09 0.7709

Race 3 32514.7906 10838.2635 0.92 0.4363

Age 1 3794.6139 3794.6139 0.32 0.5724

Education 1 7349.9551 7349.9551 0.62 0.4326

Group 1 8747.3831 8747.3831 0.74 0.3921

G*Group 1 56562.5408 56562.5408 4.79 0.0318*

R*Group 1 3232.5934 3232.5934 0.27 0.6023

Age*Group 1 24710.9606 24710.9606 2.09 0.1522

Ed*Group 1 43166.2425 43166.2425 3.66 0.0697

*p< .05










Hypothesis 13 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of substance-abuse variables (i.e., drug of choice, number of weekly meetings, and months of recovery). The data analysis summary for evaluation of this hypothesis is shown in Table 15. There was not a significant relationship between the JSDQ and a weighted combination of variables. Therefore, hypothesis 13 was not rejected. TABLE 15

Multiple Regression Results for the JSDO and Substance-abuse Variables


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


Model 3 6055.2707 2018.4236 0.17 0.9189

Drug of C 1 115.2378 115.2378 0.01 0.9227

Meetings 1 5528.5037 5528.5037 0.45 0.5019

Len of Rec 1 0.8808 0.8808 0.00 0.9932



Hypothesis 14 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. The data analysis summary for evaluation of this hypothesis is shown in Table 16. There were no significant relationships, differences, or interactions. Therefore, hypothesis 14 was not rejected.










TABLE 16

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


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


Model 7 64029.2202 9147.0315 0.76 0.6221

Drug of C 1 47.6030 47.6030 0.00 0.9500

Meetings 1 25052.4009 25052.4009 2.08 0.1531

Len of Rec 1 6802.0190 6802.0190 0.57 0.4544

Group 1 3546.7267 3546.7267 0.29 0.5887

DC*Group 1 2722.1913 2722.1913 0.23 0.6357

Mtgs*Group 1 30781.3856 30781.3856 2.56 0.1138

Len*Group 1 46200.0447 46200.0447 3.84 0.0537


Hypothesis 15 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of treatment, selected demographic variables, selected substance-abuse variables, and the interactions of treatment with the selected variables. Because prior analyses did not yield sufficient variables to evaluate this hypothesis, no statistical analysis was conducted for it. Therefore, hypothesis 15 was not tested.

Health Attribution Test

Hypothesis 16 stated that there was no significant relationship between HAT scores and a weighted, linear combination of the demographic variables (i.e., gender, race, age, and education). The data analyses summary for




Full Text

PAGE 1

EFFECTIVENESS OF MENTAL IMAGERY FOR RELAPSE PREVENTION FOR RECOVERING ADDICTS By PETER A. BUTKINS A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1994

PAGE 2

Copyright 1994 by Peter A. Butkins

PAGE 3

DEDICATION I dedicate this study to my mother, Rosemary, the smartest woman I know; my sister, Tina; and my brother-in law, Hank, for their unconditional love, support, and wisdom.

PAGE 4

ACKNOWLEDGMENTS Many patient, tolerent, and loyal persons are responsible for the completion of this research. I thank Dr. Larry Loesch for his expertise, guidance, and support. His dedication to his profession, clear-thinking, and willingness to lead have been an inspiration to me both personally and professionally. I wish to thank the other members of my supervisory committee. Dr. Crocker has provided a great deal of expertise and direction. Dr. Gonzalez has been instrumental by adding an element of expertise and guidance in the area of chemical dependence. Dr. Bollet has been a mentor and inspiration even before this project was undertaken. I am deeply grateful to all of the above. Without the assistance of Eileen Atkinson, this study would have been much more difficult. Pat Hill and Marie Winslow added an element of support as well as clerical work. The facilitators, Mark Griffin, Larry Shyers, Virgil Bryant, and Michael Ladwig, were generous in giving their time, skills and professionalism. I have special friends, Tom L., Bob D., Scott G., and Scott D., and many others, who were there for me time after iv

PAGE 5

time and helped me to learn and even prosper. I am grateful to them for teaching me gratitude, my greatest gift. Gratitude goes to AA for its help. My family has always been there for me. I thank my mother and father for their gifts of patience, intelligence, a success identity, and love. Without them I would be nothing. I thank my brothers and sisters who have helped to shape me since I was a child. My nieces and nephews are very special to me, and I am fortunate to have them. I am grateful for all of the above and their support both before and during this project. V

PAGE 6

TABLE OF CONTENTS ACKNOWLEDGMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv ABSTRACT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Viii CHAPTERS 1 2 3 4 5 INTRODUCTION . ................................... . Overview . ................................... . Theoretical Framework of Relapse Prevention ... Statement of the Problem ...... . Hypotheses ......... . Definition of Terms. Overview ............ . REVIEW OF RELATED LITERATURE ...............•...•. Support Support Support for for for the the the Need for the Theoretical Approach to Study .... Framework. the Study .. METHODOLOGY Delineation of the Variables ... Population .....•.............. Sampling Procedures ....•. Measurement Instruments .. Research Design ..... Treatment .......•... Research Procedures. Research Participants .•. Data Analyses ................ . RESULTS . .................. . Treatment History Information. Followup ..................... . DISCUSSION .. Limitations of the Study .. Conclusions ............. . vi 1 2 8 13 15 19 21 22 25 30 36 57 57 58 60 63 69 70 72 76 76 78 95 96 99 99 101

PAGE 7

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 APPENDICES A RATIONALE FOR INTERVENTIONS ........•.....•.•.. 111 B BRIEF WORKSHOPS AND THEIR EFFECTIVENESS .•....• 115 C ABSTINENCE LIKELIHOOD INVENTORY (ALI) ......... 120 D ELEMENT (OR ITEM) REFERENCE SUPPORT FOR THE ALI....................................... 121 E HELP-SEEKING LIKELIHOOD INVENTORY (HSLI) 128 F ELEMENT (OR ITEM} REFERENCE SUPPORT FOR THE HSLI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 9 G DESCRIPTION OF TREATMENT ...........••......... 135 H AGENDA........................................ 161 I FOLLOWUP FORM................................. 162 J TREATMENT HISTORY FORM........................ 164 REFERENCES. . . . . . . . . . 16 6 BIOGRAPHICAL SKETCH.................................... 184 vii

PAGE 8

Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy EFFECTIVENESS OF MENTAL IMAGERY FOR RELAPSE PREVENTION FOR RECOVERING ADDICTS By Peter A. Butkins August, 1994 Chairperson: Larry c. Loesch Major Department: Counselor Education Relapse among recovering addicts is a common phenomenon which counselors frequently encounter. Relapse-prevention activities have not been tested that focused upon mental imagery within a strong theoretical framework. Therefore, the purposes of this study were to investigate (a) the effectiveness of such an approach and (b) how selected attributes related to treatment outcome variables. A randomized, posttest only control group design was used. Forty-nine persons in the experimental group provided data and were tested immediately after participating in a mental imagery relapse prevention workshop. Experimental group members were contacted six weeks after the workshop to assess their opinions of its effectiveness. The 36 control group members provided personal data and were assessed prior to participation in the workshop. Personal data collected viii

PAGE 9

included age, gender, race, drug of choice, number of 12step meetings attended, and length of time in recovery. Outcome variables included level of self disclosure, perception of unmanageability, help-seeking behavior, and lifestyle behavior change. Analyses of variance and multiple regression analyses using weighted, linear combinations yielded few statistically significant relationships or interactions among the demographic, treatment, and outcome variables. The major finding was that persons in the experimental group significantly increased their abstinence likelihood (i.e., perception of unmanageability) following participation in the workshop. At followup, a large majority of experimental group participants reported that the workshop was a positive and helpful experience. It was concluded that the workshop generally was not successful in effecting immediate changes. Therefore, it was recommended that mental health counselors explore other methods to attempt to quickly facilitate and enhance relapse prevention. However, because feedback on the workshop was positive, it also was recommended that variations in the approach used in this study be explored. ix

PAGE 10

CHAPTER 1 INTRODUCTION F. Scott Fitzgerald complained that he could never get sober long enough to tolerate sobriety (Goodwin, 1988), suggesting that sobriety is not as easily attained as might be thought. In American society, it is evident that the problem of addiction includes not only alcohol but other drugs as well. The various drugs available today are just as cunning and lethal as Fitzgerald's drug of choice, yet they affect the body and mind much more quickly. However, for the purpose of this study, alcoholism and drug dependency are encompassed under the general rubric "chemical dependence" (CD). Talbott (1985) reported that the phenomena involved in alcohol and drug dependence are similar in that both have a set of symptoms including withdrawal and tendency to relapse. He noted that the standard definitions of alcoholism and drug addiction include compulsive use while experiencing adverse consequences. He continued, "In 1985 I hope we're not going to worry about whether we are talking about cocaineism, alcoholism, darvonism, quaaludism, fentanylism, valiumism or libriumism. We're talking about the disease of chemical dependence" (Talbott, 1985). 1

PAGE 11

2 Researchers have found in numerous case studies that the psychological cravings characterizing chemical dependence can be satisfied by any mood-altering drug (Selby, 1985). Millham and Mason (1987) concurred in writing, "We keep coming back to the fact: Addiction is addiction is addiction, no matter what chemical is being abused" (p. 6). Counseling for substance addiction is usually viewed as a difficult, often hopeless, clinical undertaking (Nace, 1987). Marlatt and Gordon (1985) added that it is a virtual truism that addictive disorders are characterized by high rates of relapse following initial treatment success. Thus, many attest to the severity and depth of addiction, alluding to the difficult problems in maintaining successful abstinence. Because of the frequency of relapse, there remains a need for effective approaches to preventive treatment for recovering addicts. overview Relapse (used here as synonymous with recidivism) is defined as return to the compulsive use of drugs in the face of adverse consequences (Talbott, 1985). Recidivism occurs frequently among recovering persons; those who previously "stopped" use of the addictive substance. Many vow to stop, but make attempts to do so and fail--sometimes with tragic results. For example, Ohlms (1981) reported that 96% of alcoholics will die of their disease. The substance-abuse (chemical-dependence) problem in general is at epidemic

PAGE 12

3 levels in the United States. Talbott (1985) noted that the great tragedy of the entire twentieth century in this country is that it is moving deeper and deeper into an addictive chemical culture. Chemical-dependence problems dramatically affect industry, youth, addicts, families, and counseling professionals among other groups. For example, alcohol abuse ranks third behind only cancer and heart disease in numbers afflicted. The casualty figures arising from abuse of alcohol on the highways, in crime, in hospitals, at the workplace, and in the family are staggering. Alcohol problems alone are costing the American society over $135 billion per year in medical expenses, time lost from work, and treatment costs. Moreover, there is a cost in human suffering that cannot be measured in dollars (Jacobson, 1990). American industry has had to make major philosophical and operational changes because of employees' chemical dependence problems. For example, the problem is so serious that the federal government has implemented several antidrug rules that apply to private-sector employers. These rules include the U.S. Department of Defense (DOD) policies, which require that defense contractors implement antidrug programs for employees in sensitive positions; the Drug-Free Workplace Act of 1988, which requires federal government contractors and employers receiving federal grants to maintain a drug-free workplace; and the U.S. Department of

PAGE 13

4 Transportation regulations, which apply to the various transportation industries and call for, among other things, mandatory drug testing (Harrison & Simpler, 1989). To illustrate further, every employee with an alcohol or drug problem costs each citizen at least 25% of his/her salary each year in hidden expenses: absenteeism, mistakes, extra medical premiums, and more (Jacobson, 1990). Watkins (1989) reported that between 1% and 23% of all American workers use dangerous drugs--including alcohol--on the job. Other employees may be under the influence when they arrive at work, or they may use alcohol and other drugs so extensively outside the workplace that their health and judgment are chronically impaired. As many as 65% of young people entering the workforce have used illegal drugs. Jones (1988) reported that over 3 million of 50 million Americans who drink are under age 17. One in every five teenagers is experiencing, or has experienced, problems with alcohol. Up to 24% of teens nationwide reported alcohol abuse as being a "tremendous" problem in their schools. Nine of 10 teenagers and young adults have consumed alcohol at least once. Richmond and Peeples (1984) noted that substance abuse has been established as a part of the lives of many middle school aged children and is often quite extensive by adolescence. Most people do not perceive addicts as being victims of addiction, including addicts themselves--a problem that

PAGE 14

affects addicts in insidious ways. For example, chemical addiction is the third leading cause of suicide in the United States (Heilman, 1980). However, many of these deaths are disguised as "accidents." Kinney and Leaton (1987) cited half of all successful suicides and 67% of homicides as having involved the use of alcohol. 5 Many automobile-accident fatalities are the result of substance abuse. Michael (1990) reported that (almost) one out of every four drivers between the ages of 16 and 45 who were killed in New York traffic accidents in recent years tested positive for cocaine use. Experts on cocaine use noted in the article that they were surprised by the large proportion of drivers using cocaine. However, in traffic fatalities in New York, as elsewhere, alcohol remains the number one substance abused by drivers. It was found that 11% of men 15 through 34 years old who were drivers in fatal accidents had tested positive for cocaine use. These data were gathered before the cocaine epidemic "hit" the media. As noted, a newer study found that 23% of victims between 16 and 45 tested positive for cocaine use. About one-half of New York drivers who were killed had used alcohol, and about half of those using cocaine also had used alcohol. Jones (1988) stated that although there are 23 million alcoholics in the U.S., over 90 million other people become affected by their disease. For example, over 30 million of those affected live in alcoholic homes or are closely

PAGE 15

6 associated with alcoholic's children and/or adult children of alcoholics. Wegscheider-Cruse (1987) also explained that it is not just the abusers who suffer. Their problems affect family members, friends, and business associates. For example, cocaine is having devastating impacts on the lives of a booming generation of babies born to addicted women. The effects include stroke while babies are still in the womb, physical malformation, and increased risk of death during infancy. The number of repeated cases of cocaine exposed babies is growing explosively, doubling each year in major cities. Recent estimates placed the figure in the U.S. as high as 200,000 (Revkin, 1989). Also, fetal alcohol syndrome is widespread and producing alarming damage to infants. Talbott (1985) has reported that, tragically, only 4% of alcoholics have an opportunity to recover. To make matters worse, many are "relapse prone." Gorski and Miller (1982) noted that recidivists are among the most desperate clients because they are caught in a trap of misunderstandings. They fail to recover in spite of their best efforts, and when the relapse takes its toll, they blame themselves. When they seek renewed treatment, they often feel the anger and misunderstanding of therapists; professionals often blame them for relapsing. This compounds the guilt and sense of helplessness, and reinforces the tendency to relapse.

PAGE 16

7 on a somewhat more positive note, Gorski (1986) observed that approximately one-half of alcoholics who "come to the door of sobriety" enter and stay. Of the remainder, many stay for a time, have one or more relapses, then grasp the sober life, and stay sober until death. Many others, however, go through "the revolving door" over and over again: drinking-sobriety, drinking-sobriety and so forth. Kinney and Leaton (1987) wrote that reentry into treatment after a relapse may be especially difficult for the alcoholic who has attained substantial recovery. In many cases, the family's involvement in the relapse syndrome is strongly influenced by co-dependence. Co-dependence is a primary condition that results from the debilitating physiological stress produced by living with an alcoholic or drug-dependent person. co-dependent persons often develop physical, psychological, behavioral, and asocial symptoms resulting from attempts to adapt to and compensate for the debilitating effects of physiological stress (Gorski & Miller, 1983). It is obvious that many problems confront the counseling profession in attempts to help chemically dependent persons, not the least of which is that relapsed addicts have great difficulty reentering treatment. Embarrassment and guilt sometimes delay treatment, and may even be used as reasons to avoid it if the addiction has been reactivated strongly. Gorski and Miller (1982) noted

PAGE 17

that many persons who have achieved degrees of abstinence relapse in spite of their best efforts while skilled treatment professionals stand by helplessly because traditional approaches to counseling and treatment do not work. Trubo (1989) noted that, "Despite the proliferation of treatment centers and the millions spent on chemical dependency research, professionals in the field still can't agree on the best therapy for alcoholism" (p. 56). Therefore, there is clearly need for specialized relapse prevention treatments. Theoretical Framework of Relapse Prevention 8 Any theory of relapse prevention must develop from a theory of addiction. That is, in order to understand the process of relapse, it is necessary to know the condition to which the addict is relapsing. This section includes an overview of these two phenomena as well as an overview of the theories underlying the interventions to be used in this study: relaxation, mental imagery, and cognitive behavioral restructuring. The biopsychosocial model, which is emerging from the area of behavioral medicine, provides a heuristic framework within which to understand and assess addictive behaviors (Donovan, 1988). Gorski and Miller (1986) defined addiction as a condition in which a person develops biopsychosocial dependence on any mood-altering substance. This means that it is a physical disease (bio) that also affects a person

PAGE 18

psychologically and intellectually (psycho) and in relationships (social). In brief, all life areas are affected. Both biological and nonbiological factors are ingredients of addiction (Mueller & Ketcham, 1987). Such a model provides a metatheoretical framework in which the factors interact to determine a health status, which includes obsession, compulsion, and loss of control and is primary, chronic, progressive, and fatal (Ohlms, 1981). There are also predictable stages of addiction with accompanying symptoms: early, middle, and chronic. The first stage is marked by a growing tolerance for dependence on the substance; larger and larger quantities are used without intoxication and/or harmful consequences. Symptoms are subtle, and diagnosis is difficult in this stage. The middle stage is marked by progressive loss of control. The addict is no longer able to use the same quantities without intoxication or adverse consequences. Pain develops as problems proliferate. The chronic stage of addiction is marked by physical, psychological, behavioral, social, and spiritual deterioration. All body systems can be, and usually are, affected. Loss of control becomes obvious to the addict and to others. The recovery process develops through task-oriented stages (Marlatt, 1985). The first involves the using stage and is marked by recognition of the addiction. The second 9

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10 is the treatment decision stage and is marked by a conscious choice to seek help. The third stage is maintenance, marked by a quest for balanced living to achieve healthy biopsychosocial goals. Gorski and Miller (1982) listed six recovery periods (developmental in nature) along with the goals for each. The first is pretreatment in which the goal is recognition of addiction. The second is stabilization, to achieve withdrawal and crisis management. The third period is early recovery and the goal therein is acceptance and nonchemical coping. The fourth is middle recovery in which the goal is balanced living. The fifth is late recovery, including the goal of personality change. The sixth period is maintenance, in which the goal is (further healthy) growth and development. The process of relapse involves becoming dysfunctional in non-dependency. This can occur in any of Gorski and Miller's stages and in physical, psychological, or social health. Similar to the recovery process, it is developmental in nature, not an isolated event. Using the mood-altering chemical ''medicates" the dysfunction. Relapse prevention therefore is implementation of interventions to interrupt the potential, always impending, relapse process. A recovering addict is likely to face a multitude of problems (Kinney & Leaton, 1987). One is a high level of stress, either temporary or chronic, for which the person

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11 has low tolerance. Many alcoholics, for example, have used alcohol for the temporary but "quick" relief of anxiety. What is remembered (and longed for!) in sobriety is the almost instant relief of an intoxicant. When alcohol or drugs are no longer an option, the alcoholic has quite a problem: how to cope with stress. Some things can be done to alleviate this stress. One is relaxation therapy, based primarily on the assumption that when the body and breathing are relaxed, it is difficult to feel anxious. The mind rejects the paradox of a relaxed body and a "tense" mind. Another technique often used is imagery. Witmer and Young (1985), for example, proffered use of visual imagery as an intervention which helps to reduce stress and also to overcome negative emotions. Pleasant mental images are used to evoke a relaxation response. Mental imagery, therefore, is the mental representation of a sensory--or perceptual like--experience that occurs in the absence of the stimulus that would produce the genuine experience (Richardson, 1969). These images may be made to occur in any sense modality. Sheikh and Jordon (1983) summarized a rationale for clinical use of imagery as a tool for therapeutic intervention. They reported that invoking mental images tends to bypass unconscious defenses and inhibitions. They further suggested that imagery has the power to produce a variety of physiological changes. Lazarus (1977) noted that

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12 imagery may be the only practical way to develop control over the autonomic nervous system, indicating that goals and solutions rehearsed through imagery during therapy seem to apply outside the therapy session and are a motivation for future behavior. Finally, rational-emotive imagery changes "inappropriate" emotions to "appropriate" ones (Ellis & Dryden, 1987). Clinical research data support the contention that rehearsals of fantasy material through imagery produce cognitive restructuring (Beck, 1970). Behavioral therapies, as part of treatment programs for substance abuse, have gained clinical favor in recent years (Spitz & Spitz, 1987). The basic assumption underlying cognitive-behavioral treatment is that maladaptive behaviors and feelings are mediated by distorted or maladaptive thinking and that clinical intervention should be used to alter cognitive processes (Garner & Bemis, 1985). Behavior therapy proponents advocate its use primarily as a method of symptom control with substance abusers. According to Spitz and Spitz (1987), the initial goal of behavioral therapies is to achieve abstinence rapidly. Treatment then focuses upon assessment of the stimuli that contribute to perpetuation of the substance abuse habit and upon alteration, interruption, or creation of (new) behaviors to replace dysfunctional ones. Notably, cognitive components are a major part of the method. Behavior rehearsal, cognitive restructuring, and

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13 the creation of alternative behaviors other than drug ingestion are cardinal components of behavioral approaches. Correcting cognitive distortions, or "mind traps," that generate maladaptive feelings and behaviors is an essential part of relapse prevention (Washton, 1989). Marlatt (1985) reported that cognitive restructuring has as its principal aim the countering of cognitive and affective components of the Abstinence Violation Effect (AVE). Annis and Davis (1988) also noted that cognitive appraisals can be effected at any point in the relapse process. Specific distortions in thinking and defensive tactics may inhibit more general coping patterns. Finally, Yalom (1985) reported that cognitive restructuring is necessary for the client to be able to generalize counseling experiences to other life arenas. Statement of the Problem A major problem to be addressed in this study is that the effectiveness of mental-imagery training intended to prevent relapse is unknown. Another significant concern is that it is unknown whether the effectiveness of mental imagery training varies as a function of demographic factors, as well as factors particular to addiction. The demographic variables to be investigated include gender, race, age, and level of education. The addiction-related variables include length of recovery, drug of choice, and

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14 number of weekly 12-step meetings because these factors may influence treatment effectiveness. The specific dependent variables used in this study include (a) self disclosure, (b) help-seeking behavior, (c) perception of unmanageability, and (d) lifestyle behavior change. Giddan and Rollin (1975), Gorski (1989) and Spitz and Spitz (1987) suggested that cognitive-behavioral interventions are legitimate strategies to pursue in chemical-dependence relapse-prevention treatment. Similarly, Marlatt and Gordon (1985), Sheikh (1989), and Siegel (1986) all suggested that mental-imagery interventions are legitimate strategies to pursue in chemical-dependence relapse-prevention treatment. Relatedly, Gorski and Miller (1982), Kinney and Leaton (1987), and Knudson (1987) suggested that relaxation interventions are legitimate strategies to pursue in chemical-dependence relapse-prevention treatment. Therefore, there is good basis for the suggestion that this direction has potential for success. Particularly needed are brief interventions. Long-term interventions are not practical and have not been found to be more effective. Also, Shorkey and Whiteman (1977), Lavecchia (1981), Crowley (1982), Brantlinger (1983), and Gillis (1986), among others, conducted studies which produced effective results using brief interventions

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15 (Appendix B). Therefore, it is reasonable and appropriate to use a brief intervention in this study. The measurements (i.e., surveys) to be used in this study have been shown to be valid and reliable. They include the Abstinence Likelihood Inventory (ALI), Help Seeking Likelihood Inventory (HSLI), Jourard Self-Disclosure Questionnaire (JSDQ), and the Health Attribution Test (HAT). Their use is more exact than other forms of measurement, e.g., observation or interviews (Kerlinger, 1973). In addition, their use is cost effective and less time consuming than the alternatives. Therefore, this method is efficient. The major disadvantage of this type of measurement lies in its lack of flexibility. Areas of investigation are limited to questions on the instruments. However, although behavioral observations and/or interviews might allow for more extensive investigation of respondents' opinions, the advantages of surveys outweigh the disadvantages when cost, time, and efficiency are considered. Hypotheses It is apparent in the research literature that chemical-dependence relapse varies as functions of many variables, both demographic and substance-abuse related. The variables included in this study have not been empirically investigated previously in this context and therefore little is known about their interactions with

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16 relapse. Accordingly, hypotheses addressed were as follows: 1. There is no significant relationship between ALI and a weighted, linear combination of demographic variables (gender, race, age, and education). 2. There is no significant relationship between ALI and a weighted, linear combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. 3. There is no significant relationship between ALI and a weighted, linear combination of substance-abuse variables (drug of choice, number of weekly 12-step meetings, and months of recovery). 4. There is no significant relationship between ALI and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. 5. There is no significant relationship between ALI and a weighted, linear combination of treatment, selected demographic variables, selected substance abuse variables, and interactions of treatment with the selected variables. 6. There is no significant relationship between HSLI and a weighted, linear combination of demographic variables (gender, race, age, and education). 7. There is no significant relationship between HSLI and a weighted, linear combination of demographic

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variables, treatment, and the interactions of treatment with these demographic variables. 8. There is no significant relationship between HSLI and a weighted, linear combination of substance abuse variables (drug of choice, number of weekly 12-step meetings, and months of recovery). 17 9. There is no significant relationship between HSLI and a weighted, linear combination of substance abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. 10. There is no significant relationship between HSLI and a weighted, linear combination of treatment, selected demographic variables, selected substance abuse variables, and interactions of treatment with the selected variables. 11. There is no significant relationship between JSDQ and a weighted, linear combination of demographic variables (gender, race, age, and education). 12. There is no significant relationship between JSDQ and a weighted, linear combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. 13. There is no significant relationship between JSDQ and a weighted, linear combination of substance abuse variables (drug of choice, number of weekly 12-step meetings, and months of recovery).

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18 14. There is no significant relationship between JSDQ and a weighted, linear combination of substance abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. 15. There is no significant relationship between JSDQ and a weighted, linear combination of treatment, selected demographic variables, selected substance abuse variables, and interactions of treatment with the selected variables. 16. There is no significant relationship between HAT and a weighted, linear combination of demographic variables (gender, race, age, and education). 17. There is no significant relationship between HAT and a weighted, linear combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. 18. There is no significant relationship between HAT and a weighted, linear combination of substance-abuse variables (drug of choice, number of weekly 12-step meetings, and months of recovery). 19. There is no significant relationship between HAT and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. 20. There is no significant relationship between HAT and a weighted, linear combination of treatment,

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19 selected demographic variables, selected substance abuse variables, and interactions of treatment with the selected variables. Definitions of Terms The following definitions are used in this study: Abstinence is a condition in which there is no chemical dependence (i.e., use) at all (Milam & Ketcham, 1981). Addiction is a phenomenon characterized by tolerance changes for, physical dependence on, and loss of control over use of a drug (Mueller & Ketchman, 1987). Alcoholism is a primary, progressive, chronic, often fatal disease which is characterized by a physical compulsion, obsessive thinking, and loss of control (Ohlms, 1981). Chemical dependence is a generic term which encompasses alcoholism and drug-dependence characteristics and is synonymous with either for purposes of this study. Cognitive behaviorism is a theory which is recommended in the treatment of chemical dependence and mediates distorted thinking (Garner & Bemis, 1985). Gender is self-designation as male or female by the respondent. Help-seeking behavior is the score on the Help-Seeking Likelihood Inventory. Length of education is self-reported as the last grade completed in number of years of schooling.

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20 Length of recovery is defined by the respondent as the number of months abstinent from chemical (drug) use. Lifestyle behavior change is defined as the score on the Health Attribution Test. Mental imagery is the mental representation of a sensory or perceptual-like experience that occurs in the absence of the stimulus that would produce the genuine experience (Richardson, 1969). Powerlessness is defined as a score on the Help-Seeking Likelihood Inventory. Progressive relaxation therapy is the reduction of physiological tension so as to be incompatible with anxiety (Jacobson, 1929). Race/ethnicity is defined through self-designation as Caucasian, Black, or Hispanic American by the respondent. Relapse is a movement away from recovery which ends in a return to abuse of a mood-altering chemical after a period of abstinence (Gorski & Miller, 1986). Self Disclosure is the score on the Jourard Self Disclosure Questionnaire. 12-step meetings are closed meetings of Alcoholics Anonymous or Narcotics Anonymous. Unmanageability is the score on the Abstinence Likelihood Inventory.

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21 Overview Presented in Chapter 1 was the introduction to the study. The review of the literature is presented in Chapter 2. The methodology of the study, including procedures and statistical methods, are covered in Chapter 3. Presented in Chapters 4 and 5, respectively, are the results and discussion of the study.

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CHAPTER 2 REVIEW OF RELATED LITERATURE People of the United states suffer from tragic ramifications of chemical-dependence problems (Talbott, 1985). According to Lewis, Dana, and Blevins (1988), drug use and abuse is a mass phenomenon in the United States: 32 million Americans smoke marijuana at least once a year; 20 million smoke it at least once a month; annual cocaine abusers number over 12 million; and several million others take hallucinogens, stimulants, sedatives, and tranquilizers without medical supervision. And of course these figures are dwarfed by the number of people who use "legal drugs," including alcoholic beverages (125 million) and tobacco products (70 million) (Polich, Ellickson, Reuter, & Kahan, 1984) . Dr. Padraic Sweeny, Vice Chief of Emergency Services for Detroit Receiving Hospital, is but one reporting rapidly increasing drug-related shootings, stabbings, and assaults (Shannon, 1990). Relatedly, police make drug arrests in Los Angeles at a rate of 60,000 per year. It is readily evident beyond these examples that there would be far less drug related crime if jails, courts, and parole systems were not already strained to the breaking point. Thus, despite the 22

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23 passage of stringent antidrug laws and police efforts, drug related crime continues to surge. For example, the nation's violent-crime rate rose 10% in the first six months of 1990. Murders were up 8% in the same six months and armed robbery rose 9%. Drug-related crime is perhaps the most obvious ramification of chemical-dependence problems in the United States. Cocaine has become one of the most debilitating chemicals in history. Its epidemic use started among the upper middle class in the mid-1970s. Recently, "dealers" have touted a Caribbean import called crack (or rock) that sells for $10.00 or $20.00 a vial, compared to $50.00 to $100.00 for a gram of cocaine powder (Shannon, 1990). The result has been widespread use of cocaine even among the poor. To date, the antidrug offensive's main accomplishment has been to dissuade some experimenters and "weekend users" from increasing their dependencies. Unfortunately, however, the effort has not reached the millions of people so bereft of hope that they are willing to risk everything they have, or will have, for a few moments of psychological oblivion. Alcoholism is perhaps still the most insidious offender. Lewis et al. (1988) noted that the use, misuse, and abuse of alcohol is one of the major health problems in the United States and is the third most prevalent public health problem. But the problems associated with alcohol abuse are

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24 not limited to health problems because alcoholic behavior also leads to familial, social, vocational, and legal problems. Patterns of alcohol abuse also contribute to health impairment, vehicular and pedestrian accidents, criminal behavior, destructive social behavior, and other adverse consequences. Therefore, alcohol-related problems are not limited to the alcoholics themselves. Literally everyone encounters the ramifications of use, misuse, and abuse of alcohol in daily life (Pattison & Kaufman, 1982). The financial costs of the chemical-dependence epidemic also are staggering. Jacobson (1990) reported that alcohol dependence alone costs the federal government about $25 billion a year. Overall, chemical dependence costs the nation an estimated $135 billion a year in medical expenses, time lost from work, treatment costs, and the like, yet state and federal governments combined collect only $12 billion in excise taxes to support remediation programs. Unfortunately, the massive public health effects of alcohol consumption in the United States are just beginning to be understood. Many Americans are shocked to learn that the economic costs associated with alcohol-related problems are even greater than those associated with problems due to cigarette smoking, cancer, or heart disease. One reason is that smoking-related diseases, e.g., cancer and heart disease, generally affect middle-aged or older people, but alcohol-related problems affect people of all ages. These

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25 (and other forms of chemical dependence) are particularly prominent among children and youth. The earlier the age of onset, the longer the need for treatments and the greater the dispersion of negative effects; phenomena which greatly increase costs. support for the Need for the study An inherent problem in the chemical-dependence field centers around differences among professionals regarding legitimate treatment theory, models of treatment, and strategies and tasks/goals of therapy, all of which complicate treatment. Milam and Ketcham (1981) reported that thousands of alcoholics are seen every year by professionals--psychiatrists, psychologists, social workers, clergy, counselors, nurses, and doctors -yet, tragically, they are almost always misdiagnosed and often harmfully treated. For example, Rogers and McMillin (1989) speculated that they have seen practically every form of group yet devised being used to treat alcoholism at some facility in America. It may not be "coincidental" that about two-thirds of all relapses occur within the first 90 days following treatment (Marlatt & Gordon, 1985). Three different schools of thought seem to dominate current directions in chemical-dependence treatment. One espouses that relapse need not be an either/or situation (Donovan, 1988; Marlatt & Gordon, 1985). Thus, the goal of treatment is not necessarily abstinence, but rather

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26 improvement in drinking behavior. Another theory focuses on the absence of psychotherapy in early recovery due to neurological deficits, addictive instability, and the primacy of the need to focus on relapse prevention (Bean, 1984; Crewe, 1986; Flores, 1988). A third model would treat the character disorder along the road to recovery from addiction (Ellis & Dryden, 1987; Khantzian, Halliday, & McAuliffe, 1990). This approach is psychodynamically oriented. A review of the family therapy for alcoholics literature indicates that clinicians are experimenting with at least three additional approaches to involvement of family members in the treatment process. These are conjoint family therapy (Esser, 1968, 1971; Meeks & Kelly, 1970), multiple couple therapy (Cadogan, 1973; Gallant, Rich, Bey, & Terranova, 1970; steinglass, Davis, & Berensen, 1977) and conjoint hospitalization (Mccrady, Paolino, Longabaugh, & Rossi, 1979; steinglass et al., 1977). However, careful reading of this literature still supports the view that family systems approaches to alcoholism treatment have yet to mature fully (Steinglass et al., 1977). There is also consensus in the literature that chemical-dependence problems among American workers have risen significantly in the past decade (Dickman & Emener, 1982; Gerstein & Bayer, 1988; Michael, 1990). Investigators have suggested that 10% to 18% of those employed experience

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27 such difficulties (Masi, 1984; Watkins, 1989). As a result, employees have begun to exhibit dysfunctional work behaviors which have become more and more prevalent and noticeable. Bell (1988) also noted the severity of chemical dependence in the workplace and emphasized the high incidence of absenteeism and sick days taken, two variables not often recognized as symptoms of chemical dependence. Employees affected by chemical-dependence problems exhibit myriad dysfunctional work behaviors such as absenteeism, "on the job" absenteeism and high accident rates. They therefore have more insurance claims, spasmodic work patterns, difficulty in concentration, confusion, lack of task tenacity, coming to/returning to work in an obviously abnormal condition, generally lowered job efficiency, poor employee relations, misconduct, and poor supervisory relationships. Each of these behaviors usually results in significant personal and organizational costs (Management Writes, 1989). Chemical dependence has escalated to a major economic problem in the United States (Gold, 1988). Today, employee alcohol and drug use cost business and industry over $100 billion per year (Desmond, 1987). In the handbook, What Works: Schools Without Drugs, former Secretary of Education, William J. Bennett (1986) stated that, "In America today, the most serious threat to the health and well-being of children is drug use" (p. v). California Attorney General, John Van De Kemp (1986)

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28 explained that "It is a sad and sobering reality that trying drugs is the norm, not the exception among high school students" (p. iv). Other researchers and treatment providers concur that the problem of chemical dependence among youth has reached pandemic proportions (e.g., Gold, 1988; Guydish, 1982; Jones, 1988; Richmond & Peeples, 1984). Guydish (1982) suggested that one in every six adolescents had a problem with addiction. Nowinski (1990) reported that for the past decade, therapists have seen a marked increase in the number of youths to be treated for chemical dependence and/or increased severity of symptoms. Gonzalez (1990) stated that alcohol abuse has long been recognized as a leading threat to the academic, social, and physical well-being of college students. Colleges have been confronting problem drinking by providing education and rehabilitation programs, alternatives to the campus "bar scene," and stricter regulation of on-campus parties. For example, Rutgers University set aside dorm rooms for recovering student alcoholics. However, Robert Hochstein, spokesman for the Carnegie Foundation for the Advancement of Teaching, issued a report saying that colleges are (generally} sidestepping the problem of chemical dependence (Rabinowitz, 1991). A common phenomenon characteristic of chemical dependence is recidivism. The danger of relapse is ever present in a chronic, addictive disorder (Johnson, 1980),

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29 and the results of relapse are often tragic. Unfortunately, accurate relapse figures are difficult to obtain. In addition, there are few relapse studies covering any appreciable period of time (Weisman & Robe, 1983). Relapsers disappear not only from records, but also from sight. They are often lost in "geographic cures" (i.e., changing locales and hoping the problem will disappear), with no way for researchers to know whether disappearance was followed by relapse, recovery, or premature death. Thus, relapse-treatment approaches are difficult to develop. However, a classic survey of nearly 25,000 members in Alcoholics Anonymous revealed that relapse occurred in almost 60% of those who had been sober for only one year. Reentry into recovery is difficult after relapse (Kinney & Leaton, 1987). Schrenck (1990) reported that it is much worse "the second time around" because the progression of adverse consequences occurs faster. Long-term followup data suggested that more than 90% of those who leave treatment will drink or use again at some time in the future (Heltzer, Robins, Taylor, Carey, Miller, Combs-Orme, & Farmer, 1985; Polich, Armor, & Braiker, 1981). Gorski (1989) reported that many chemically-dependent persons relapse many times before finding sobriety or freedom from addiction. Even they are fortunate, however. Others give up in despair and eventually die from their disease.

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30 Within the context of the disease process, addiction is often referred to as a "chronically-relapsing" condition (Marlatt & Gordon, 1985). Relapse is always a possibility within chronic diseases, even after years of good health. Mueller and Ketcham {1987) stated that chemically-dependent persons are not safe from relapse even after 10, 15, or 20 years of sobriety, unless they continue to use the tools acquired in treatment. Previous treatment is an important component in this study. The participants all have been involved in a form of treatment, whether AA, NA, or inpatient or outpatient care. The problem of recidivism in chemical-dependence treatment leads to the need to provide effective relapse prevention approaches. Desmond (1987) suggested that addicts know how to get sober, but the problem lies in keeping them in that state. Relapse prevention is the latest attempt to help reduce the number of recovering persons who return to using. Support for the Theoretical Framework No one argues any longer with the fact that alcoholism is a disease (Chopra, 1987). The American Psychiatric Association (1975) defined alcoholism as a "chronic disease manifested by repeated drinking that produces injury to the drinker's health or to his social or economic functioning" (p.13). The term "suffer" and the concept of disease imply that the alcoholic is a victim of his/her demise.

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31 Johnson (1980) agreed that these defenses are not self imposed but occur as the disease progresses. Ohlms (1981) added that the disease has a specific set of defenses along with progressively escalating symptoms. One of the chief defenses which prohibits recognition of the problem is denial. Thus, alcoholics can't "see" what is happening to them. The reason for this is understandable. Johnson (1980) elaborated that, as their condition develops, the self-image continues to deteriorate and ego strength ebbs. For many reasons, alcoholics are progressively unable to keep track of their own behavior and begin to lose contact with emotions. Their defense systems continue to grow so that they can survive in the face of their problems. The greater the pain, the higher and more rigid the defenses become. This process is entirely unconscious. Relapse is often a family concern. The family becomes afraid to upset the person and thus becomes victimized by the chemical-dependency system (Empry, 1990). These fears, coupled with a tendency to support the chemical-dependent behavior, lead many chemically-dependent persons back to ''using." This irony is supported by families at their own expense. Relatedly, Fish (1991) indicated that much of the responsibility for chemical-dependence problems often rests with parents who are drug users. Chemical-dependence treatment is greatly affected by the lack of a sound theoretical base. There are many different

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32 models of addiction, but little consistent thinking as to the most effective approach (Lewis et al., 1988). Within some models it is difficult to address the issues of relapse and relapse prevention. For example, the moral model of addiction holds the addict solely responsible for the relapse. This approach prohibits identification of relapse triggers. Relatedly, chemical-dependence treatment is difficult at best because of the complicated nature of the problem. Denial and repression hinder acceptance of the reality of the situation; the chemically-dependent person usually goes back to the same environment. This exposes him/her to the very "cues" which preceded use (Donovan & Marlatt, 1988). The environment can be the job, school, neighborhood, friends, spouse, or family. complicating all this is the fact that many community role models are drug dealers and their role suggests (particularly financial) success, especially to teens (Fish, 1991). Further, the enticement of "easy money" makes it difficult for many users to avoid the drug culture. These complications have led experts to believe that success often depends on the individualized characteristics of the client rather than the treatment (Desmond, 1987). The results of many studies (e.g., Hosie, West & Mackey, 1988; Richardson & Bradley, 1985) indicated that counselors are now established in the substance-abuse field. For

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33 example, Hershenson and Power (1987) reported a substantial increase in community counseling centers specializing in the treatment of substance abuse. With this service comes a variety of problems for counselors. For example, although counselor education departments have acknowledged this specialization and counselor educators have been developing courses since 1980 to train counselors in chemical dependence (Hollis & Wantz, 1986), there are still confusing treatment guidelines and high counselor burnout to name only two apparent problems. The problem of treatment effectiveness also exists in the area of counselor education. Gonzalez (1990) noted that the efficacy of alcohol and other drug education to reduce the problems related to chemical dependence is questionable. Other studies (e.g., Mauss, Hopkins, Weisheit, & Kearney, 1988) assessed the relative contribution that traditional variables such as self-esteem, attitude, and decision-making skills have made to drinking behavior. Suggested is that such variables make only a small contribution compared to other social and psychosocial variables not amenable to intervention. Therefore, researchers have expressed doubt that even a highly successful classroom intervention directed at traditional variables would do much to prevent alcohol use or abuse by youths. Krestan (1989) found it necessary to provide a direction for counselors. She has admonished family (and other)

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34 therapists to relinquish attempts to be totally in charge of treatment and/or all phases of treatment. She delineated different roles at different stages. Before sobriety, the family therapist should unbalance the system sufficiently for the family to enter chemical-dependence treatment. In early recovery, the family therapist should work to stabilize the family system around family members' participation in chemical-dependence treatment and self-help programs. The role in long-term recovery is more central, to establish resonance in the family in ways that are functional and satisfying for all family members. Misinformation and/or misdiagnosis is a major problem which leads to proliferation of chemical dependence. According to Aitchison (1990), in Alcoholism Briefs Newsletter (in "New York Intervention Program Helps Identify 850 Problem Drinkers") a minimum of 25% of all hospitalized patients reportedly have a significant alcohol problem, regardless of the admitting diagnosis. Misinformation comes in many different forms. Alcohol often mimics other diseases, including gastrointestinitis, colitis, depression, and stress-related illnesses. It often is the cause of stroke and heart attacks. It also is easy to confuse with certain psychological diagnoses such as conduct disorders, depression, and personality disorders. The issue of prescribing medication to recovering addicts is controversial. One school of thought contends

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35 that mood-altering chemicals block the process of development needed to grow; another suggests that there are certain problems in recovery that warrant medication. For example, a frequent problem centers around the treatment of depression. Many medical doctors, including psychiatrists especially in hospital inpatient settings, medicate addicts for this problem. Talbott (1985) claimed that because alcohol is a depressant, depression in early recovery is normal and may dissipate with abstinence. This phenomenon leads to much stress for counselors who view indiscriminate medication as anathema, yet have to witness it frequently. There is a problem in the misreporting of CD treatment success. In many followup studies that include longitudinal assessments researchers report findings as cross-sectional or "dipstick" assessments. This type of assessment involves reporting the percentage of clients in continuous reports who have previously relapsed since the beginning of their treatment. This fails to take into account a participant's status at the previous followup. Consequently, programs report much higher rates of treatment success, making treatment seem more effective. In addition, limitations in relapse assessment are due to the fact that followup studies include only participants who have completed treatment and eliminate those who began but did not complete treatment. This also inflates claims of success. Third, followup periods are often too short and thus provide little

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36 information about long-term relapse rates (Curry, Marlatt, Peterson, & Lutton, 1988). Finally, a problem exists with corporate advertising for chemical-dependency treatment. Many of the ads "promise" a cure. This is misinformation and sets the expectation that treatment insures success whereas the truth is that treatment is the beginning. Support for the Approach to the study Gorski (1989) stated that chemical dependence is a condition that creates long-term pain in return for short term gratification. It is an addiction accompanied by obsession, compulsion, and loss of control. In the end stages of addiction, the addict thinks about, plans, and looks forward to using when abstinent. This is obsession; there is an overwhelming urge to use again in spite of long term consequences. This is compulsion; this is addiction. The person uses the drug to relieve the pain caused by the drug (Johnson, 1980). Loss of control is obvious. It affects and is affected by all areas of an addict's life. The loss of control causes physical, psychological, and social problems; the total person is affected. Accordingly, Vaillant (1983) recommended a flexible, multimodel approach to chemical-dependence treatment. The available research data demonstrate the existence of multiple syndromes of chemical-dependent use ( Ellis, Mcinerney, DiGuiseppe, & Yeager, 1988; Gallant, 1987), a condition called bio-psycho

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37 social dependence (Gorski & Miller, 1986). The contribution of each variable to the total clinical picture is presented as follows. Milam theorized, in the book Don't help: A positive guide to working with the Alcoholic (as cited in Roger & McMillin, 1989), that the biological aspect of addiction is the basis for the disease model. He provided the reasons which explain the phenomenal growth of this belief. One is that the disease model has the virtue of simplicity. Recovery becomes less complicated because it is understood that the problem stems from a disease that affects ability to use rather than a complex problem requiring the chemically-dependent person to root about in the psyche for supposed causes. Another is that chemically dependent persons find much relief in the discovery that they are not weak-willed, emotionally-inadequate, or morally-defective persons. This realization relieves guilt but bestows upon the person a personal responsibility to recover. It eliminates outside blame for the problem. A third is that the disease model can inspire the person to change instead of depending on a therapist to "fix" the problem. Abstinence is required and motivation needs to come from within to ensure success. Finally, this model provides a structure for treatment. The chemically dependent person can now be given practical and understandable directions for recovery based on "proven" experience.

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38 Many researchers attest to the psychological component of addiction as being both a trigger and a result of addiction (Ellis et al., 1988; Marlatt & Gordon, 1985). In a prospective study (n=38) using the Minnesota Multiphasic Personality Inventory (MMPI) as a pre-and posttest measurement, Vaillant (1983) reported that preatomic testing suggested normal limits. However, when the subjects were later hospitalized for alcoholism, the scores were significantly elevated on the depression, psychosomatic deviancy, and paranoia scales -to pathologic levels. Although it is widely believed that chemicals provide relief from stresses in early stages of use, there is much evidence to support the belief that severe psychological problems manifest after the "line to addiction" is crossed. Ellis et al. (1988) stated that the present review of etymological factors in the development of alcoholism suggested that chemically-dependent persons are not necessarily premonitory different from nonaddicts in personality traits such as dependence or their psychological adjustments as children. Rogers and McMillen (1989) agreed that psychological, social, and spiritual disasters of chemical dependence can only be fully understood as distortions and exaggerations of otherwise normal problems. Bean and Zinberg (1981) concurred that alcoholism takes its biological and psychological toll upon the personality. In relatively healthy populations, alcohol abuse may be more

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39 analogous to any intractable habit (such as smoking or fingernail biting) than to mental illness. Such habits may develop independently of preexisting psychological vulnerability. This is not to say that addicts are not in need of psychological treatment. Indeed, many are "adult children of alcoholics" (ACOAs) and have family of origin issues at all ranges of the spectrum from severe torture to mild neglect. However, primary treatment for addiction should focus on a period of detoxification to allow for drug and alcohol-induced symptoms to subside. Accurate diagnosis of secondary problems is difficult in early recovery because symptoms often dissipate during the stabilization period. Therefore, the issue of "timing" is vital in chemical dependence treatment--and in relapse prevention. Because chemically-dependent persons often perceive addiction as accusation rather than diagnosis, they constantly reinterpret their symptoms, offering alternative explanations which lead to conflict with and isolation from others. For example, many addicts mistakenly blame their wives and children for their problems. They defend their position by "projecting" their problems onto others (Johnson, 1980) . Recovery should include strategies designed to address the social aspects of addiction. Techniques have been developed for families and other supporters to help the

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40 client to maintain abstinence and improve the quality of relationships (Mccrady, et al., 1985). In summary, the biopsychosocial view of addiction implies multiple casualty, involvement of multiple systems, and multiple levels of analysis (Donovan & Chaney, 1985; Maisto & Mccollam, 1980; Marlatt & Donovan, 1981). This model thus addresses the complex nature of addiction and can be used to understand the various stages of addiction. Clinicians have stressed the importance of viewing growth as a developmental process (Erickson, 1959; Gazda, 1982; Mahler, Pine, & Bergman, 1975). It is especially necessary for recovery from chemical dependence. Addicts do not recover immediately. A developmental model consists of stage specific steps or tasks (Brown, Beletsis & Cermak, 1989). Steps occur over a time period, each of which is different for each recovering person. This process can be changed or interrupted at any time. Maintenance of non-use behavior involves full acceptance of the need for abstinence. Sobriety can become elusive after time as the memory of painful end-stage experiences are forgotten. In addition, it can be easy to deny awareness of the problem given enough time without intoxication because it may seem as though a person who was addicted would be using. Enjoyment of life comes through a daily program of recovery which reminds the chemically dependent person of the good fortune which has been

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41 bestowed. Gratitude is a very powerful means to long-term sobriety. Action is another vehicle. Maintenance requires positive changes. Without them, the disease of addiction triggers a series of automatic, learned reactions which create pain and make return to use palatable. The answer is a well-planned recovery. A commonality across addictions is the high rate of relapse following (a period of) abstinence (Abrams, Niaura, Cary, Monti, & Binkoff, 1986; Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Chaney, Roszell, & Cummings, 1982; Marlatt & Gordon, 1985; Tucker, Vuchinich, & Harris, 1985). Daley (1987) stated that relapse, like recovery, is a process, not an event. Many events, behaviors, thought patterns, feelings, and attitudes lead to relapse. Gorski and Miller {1982) outlined several steps in the process of relapse. It is failure to take the necessary action to complete these recovery steps that leads to relapse. Adherence to these recovery steps is called a recovery program. Once a program becomes a low priority, the progression of relapse begins. Complacency has begun and, without a strong "program," the symptoms of relapse develop spontaneously. Relapse becomes a syndrome when the addict experiences loss of control over behaviors. This occurs when the symptoms of sobriety or post acute withdrawal symptoms (PAW) are not managed. The symptoms progress to the point when,

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42 if not interrupted, chemical use again occurs. During periods of stress the chemically-dependent person has difficulty in thinking clearly, identifying and managing feelings, and remembering things. Psychomotor coordination may become impaired, sleep disturbance may develop, and difficulty with stress management may occur. These are not unusual symptoms for a person who has used chemicals for a prolonged period. The key to recovery, therefore, is to recognize and manage the symptoms. This is prevention. Relapse prevention involves understanding, education, and action. The addict needs to understand the relapse syndrome, become educated as to the warning signs and personal triggers, and take action to involve self, family, friends, and a therapist in a plan of action which has been pre-designed and pre-rehearsed. Such precautions allow for interruption of the relapse syndrome and help prevent tragic consequences. Planning should be an essential part of a recovery program (Marlatt, 1985). Gorski and Miller (1986) developed a model for relapse-prevention planning which consists of nine steps. First is stabilization. This step involves regaining control of thoughts, emotions, memory, judgment, and behavior after relapse has begun (i.e., after the drug has been ingested). During this time of crisis, it is important to turn to significant others for help to ameliorate the negative emotions which accompany relapse. If stabilization

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43 is not possible via this plan, professional help must be sought. The second stage involves assessment of the cause of the relapse. A careful review of the history of addictive using provides an opportunity to learn from the past. Third, understanding is accomplished via education. Because addiction is a disease of denial (Seixas & Youcha, 1985), it is imperative to review this step with a professional who is trained in addictions, a sponsor, or a sober friend. Mutuality is important for the addict because it better insures thats/he will take responsibility for the problem. Importance is placed upon learning about PAW symptoms, what places the addict in high risk of developing these symptoms, what can trigger them, and how to manage or prevent them. Examples are needed to enhance accuracy and clarity. Fourth, relapse-warning-sign identification needs to be undertaken. The signs are unique and personal, signalling a need for an individualized approach. The signs are signals that are apparent to self or others and may be internal or external problems. Symptoms can be related to health, thinking, emotions, memory, judgment, or appropriate behavior. It is important to write a list of these warning signs which are developed from past relapse experiences. Fifth is warning sign management. This involves viewing each warning sign as a problem which needs to be solved or

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44 prevented upon onset. Of paramount importance is the establishment of new responses. Problem resolution is the key. Alternative behaviors should be explored, decided upon, and practiced until habit. This should be done at times of low stress. Next, inventory training involves daily identification of relapse-warning signs. Without this step, early warning signs will be ignored and it may be very difficult to interrupt the relapse symptom. It is advisable to develop this daily inventory as a habit to be performed in a ritual like fashion two times each day. Journalling can be a helpful adjunct in this step. It can help to monitor the signs as well as function as a "barometer" for measuring progress and be motivational. The seventh step is a review of the recovery program. An assumption inherent in this step is that a recovery program is the best defense against relapse. In other words, the addict needs a good recovery program in order to prevent relapse. The recovery program as relapse strategy is a learning process. Fingarette (1988) advocated a plan wherein the drinker/addict not only addresses the slips, but also how to overcome them and learn from mistakes. This approach is supported by experimental and theoretical research (Marlatt & Gordon, 1985). For every problem, warning sign or symptom identified, there is a complementary coping behavior.

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45 Involvement of significant others (step eight) follows the review of the recovery program. Help and support from others is necessary because relapse is often an unconscious process. Therefore, the addict may not be able to recognize the process. Step nine is followup and reinforcement. Addiction is a chronic problem (Ohlms, 1981); it does not just go away. Just as recovery is a "way of life," so is relapse prevention. This planning must become an integral part of the addict's life. There should be compatibility among all factors of recovery such as the treatment program, AA involvement, other support groups, family, school, friends, and job involvement. Structure is necessary to the entire process. Relapse prevention must be practiced until it is habitual. Willingness is another necessity. The plan usually involves revision and updating at times as well as identification of new problems which sabotage recovery. The result of relapse prevention is a sense of confidence in recovery and a more comfortable sobriety. About two-thirds of all relapses occur within the first 90 days following treatment (Marlatt & Gordon, 1985). It is important to consider the reasons addicts relapse as well as the reasons they are prone to develop chemical dependence (Vaillant, 1983). The precursors of alcoholism are often triggers when the addict is sober. Research in this area

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46 has shown that for many, alcohol can be a powerful depressant, although, paradoxically, if taken in large quantities for a prolonged period, it may actually elevate anxiety levels (Stockwell & Town, 1989). Prolonged use also can cause damage which persists long after abstinence and may be responsible for stress symptoms stemming from central nervous system damage (Gordis, 1976). Johnson (1980) conducted an ex post facto study with alcoholics and reported that, although their emotional backgrounds were different before the onset of the disease, the pattern of emotional distress after onset is (almost) universal. Regardless of the cause of discomfort in sobriety, it is apparent that chemically-dependent persons suffer from stress-related symptomology. In assessing relapse crises, the single most important factor to consider is the affective tone of the situation (Shiffman, 1988). Stress is a construct which subsumes many others, e.g., depression, rage, fear, and guilt in general (Ellis et al., 1988). According to Stockwell and Town (1989), the term stress applies to the entire process of interactions between external stresses (e.g., work demands, criticism, or unrealistic demands} and the chemically-dependent person's reactions or stress responses. Vaillant (1983) reported that the sober addict's predicament (i.e., being prone to relapse) is complicated by the complexity of the disease. In addition to

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pharmacological and emotional dependence, there is an intricate learning process underlying seemingly incomprehensible relapse. Craving for the drug, an unconscious process, contributes to relapse in that it can be aroused subsequent to psychological change (Ludwig & Wikler, 1974). The craving thus can trigger learned behavior (i.e., substance use). Further, alcohol nonspecifically alters the chemically-dependent person's feeling state, thus making it a powerful reinforcer (Vaillant, 1983). 47 The change of affective state is an important consideration in relapse prevention. Mello and Mendelson (1972) demonstrated that many alcoholics do not maintain stable concentrations of blood alcohol when drinking, but instead attempt to induce variation in blood alcohol levels. This suggests that continued changes in the addict's state of consciousness may be as reinforcing as the relief of physiological withdrawal. Mental imagery, cognitive restructuring, and relaxation exercises are strategies which can alter the state of the addict and are thus appropriate interventions. There are studies which suggest that the use of mental imagery reduces stress. In one study, Beck (1967) demonstrated that a catatonic imagery experience resulted in an end to addiction. In another, the use of imagery in

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48 alcoholism treatment to reduce stress showed it to be effective (Pati, 1981). Numerous authors have supported the use of mental imagery as a vehicle for reducing stress. For example, stress-inoculation training (SIT) uses imagery as a specific means of attention diversion with stressed populations (Mccaffery, 1979; Meichenbaum, 1978; Turk, Meichenbaum, & Genest, 1983). Wolpe (1958) developed a systematic desensitization paradigm which is the predecessor to SIT. His model also was designed to reduce stress. Others have advised using mental-imagery exercises to reduce stress (Davis, McKay, & Eshelman, 1982; Fezler, 1989; Gawain, 1982; Miller & Leuth, 1986; Peale, 1982; Siegel, 1986; Singer, 1976) and claim high levels of effectiveness. More specifically, many authors have recommended mental imagery as treatment for stress-related symptoms which cause relapse. Millham and Mason (1987) viewed it as a tool to break free of the grasp of addiction. Nuckols (1987) held mental imagery as a way to cope with high-risk situations. Marlatt and Gordon (1985) pointed out that although studies of this variable are scarce, future studies may reveal that imagery techniques with addicts are a helpful adjunct to treatment. Images are mental representations of thought, usually visual in nature, which enable people to record experiences, fantasize, free associate, discover, construct, and problem

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49 solve without altering any of the environment (Witmer & Young, 1985). Visual images also have the potential to influence every cell, tissue, and organ in the body, a concept vital in chemical-dependence relapse prevention. For the addict, craving involves an unconscious process and indicates a need to alter the mood (Vaillant, 1983). The change or alteration of the mood is the important variable. Mental imagery has the potential to alter the state of consciousness to any possible combination of alternatives (Bandler & Grinder, 1979). Chopra (1989) also emphasized the necessity for a "cellular" change in treating addiction because the memory of the cravings and effects of the drugs remain after the cell dies. This endocrinologist suggested that the process is not volitional, but a product of unconscious thoughts and memories. Mental imagery is powerful because it taps into basic memory storage and retrieval processes {Fezler, 1989). Mental imagery is therefore appropriate as a vehicle to "counter" the process of relapse. The scientific study of the ongoing imagery process was spurred by sensory deprivation research in the 1960s (Singer, 1974). The goal was to predict the possible impacts of isolation on the mental functioning of astronauts during flight. However, this research also has implications for conditions such as social withdrawal, monotonous work experiences, and hospitalization. One result was evidence

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50 that an ongoing imagery process is an important variable in human mental experience, particularly when perceptual stimulation is reduced (Singer, 1974). This research was vital because it began to offer scientific reasons why imagery techniques in psychotherapy are so effective. There are many justifications for incorporating imagery into counseling practice. Among them are the power of imagery to produce physiological change and the tendency of imagery to provide motivation and to serve as a "rehearsal" for new behaviors (Witmer & Young, 1985). Imagery used in such clinical applications has been defined as a "sequence of processing toward resolution" (Strosahl & Ascough, 1981, p.423). It is a process leading toward insight into stored associations. By assisting insight, imagery techniques are more powerful than verbal inquiry. Kubie (1965) suggested that there is a wealth of information which can be retrieved through imagery techniques. Imagery also makes available material such as early childhood experiences and thus enhances treatment. Skovholt and Thoen (1987) reported self-report and anecdotal data using mental imagery as an intervention to change behavior. Their data supported their beliefs that imagery is sometimes a powerful counseling technique. Mental imagery also has been demonstrated to be effective in the treatment of a range of psychological problems (Witmer & Young, 1985). Examples, as summarized by Sheikh and Jordan

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51 (1983), include insomnia (Sheikh, 1976), depression (Schultz, 1978), obesity (Bornstein & Sipprelli, 1973), sexual malfunction (Singer & Switzer, 1980), chronic pain (Joffe & Bresler, 1980), various phobias and anxieties (Meichenbaum, 1977; singer, 1974), and a host of psychosomatic problems (Lazarus, 1977; Simonton, MatthewsSimonton, & Creighton, 1978). Other authors also have heralded the use of mental imagery to produce behavioral change. For example, Shiffman, Read, Maltese, Rapkin, and Jarvik (1985) claimed that mental imagery reduced stress. Sheikh (1976) proposed that mental imagery worked as a method to stop smoking cigarettes. Michaud and Feinstein (1989) reported a study which suggested that, after using mental imagery to visualize blisters getting better, the blisters became significantly smaller and white blood cells were positively effected. Similarly, Epstein (1986) reported shrinkage in a nodule after a rheumatoid patient used mental imagery. Others have recommended the use of mental imagery with chemically-dependent persons (e.g., Gawain, 1982; Johnson, 1980; Kritsberg, 1983; Small, 1982). Marlatt and Gordon (1985) reported that although research on mental imagery is generally lacking, future studies may reveal that this technique is a helpful adjunct to treatment with addicted clients. Finally, Ellis et al. (1988) recommended the use of mental imagery with addicted clients. Adaptation of his

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52 rational-emotive imagery made it more expressive and useful for addicts (Maultsby, 1975; Maultsby & Ellis, 1974). Relaxation is recommended as an antidote to stress and as a preventive method in stress-management programs. There is considerable research evidence that documents the effectiveness of relaxation as a stress-reduction activity (e.g., Bahrke & Morgan, 1978; Davidson & Schwartz, 1976; English & Baker, 1983; Glaister, 1982; Lehner, Schoicket, Carrington, & Woolfolk, 1980). Theoretically, there are a number of explanations for the latter. Some authors have focused on the physiological benefits of relaxation (e.g., Benson, 1975; Jacobson, 1929). Goleman (1971) focused on the psychological and behavioral benefits of stress reduction. Meichenbaum (1977) stressed the role of relaxation in the excitation and exacerbation of anxiety states. Marlatt (1985) recommended relaxation as a lifestyle modification procedure for addictive behavior problems and other authors have supported this perspective (Glasser, 1976; Gold, 1988; Gorski, 1989; Strickler, Bigelow, Wells, & Liebson, 1977). Weil (1972) suggested that this procedure could be a substitute or "positive addiction," in lieu of the addictive habit. Marlatt (1985) concurred that addictive behaviors are strongly associated with relaxation or escape. By replacing these behaviors, the sense of deprivation may weaken. Levine (1979) contended that

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53 relaxation tends to allow the addict to detach and can be particularly effective in coping with urges and craving experiences after cessation of the addictive experience. In the alcoholism field, preliminary survey studies disclosed that alcohol and drug use was reduced substantially when subjects used relaxation methods (e.g., Benson & Wallace, 1972; Shafii, Lavely, & Jaffe, 1975). However, Smith (1975) noted that most of these studies have methodological problems and should be interpreted with caution. For example, biases took the form of invalid self reports, lack of adequate control groups, and motivational differences among subjects. Some studies also lacked true alcoholic subjects. Overall, there exists little consistency in research on the effect of relaxation exercises (alone) on addictive patterns (Glasser, 1976; Gold, 1988). Two studies conducted at the University of Washington on the effectiveness of relaxation procedures with heavy social drinkers were aimed at reducing consumption (Marlatt & Marques, 1977; Marlatt, Pagano, Rose, & Marques, 1984). Results of the first study exhibited a significant reduction in alcohol use (approximately a 50% reduction from pretreatment rates) for subjects in three relaxation conditions in comparison with a no-treatment control group. Overall, results showed a significant reduction in drinking rates after taking regular time-out periods to relax. The

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54 second study showed significant decreases in drinking compared to baseline drinking levels (Murphy, Pagano, & Marlatt, 1984) in a relaxation (meditation) group. This group returned to pretreatment levels of alcohol use shortly afterwards, however. In summary, research on relaxation as an intervention for chemical-dependence reduction is both sparse and conflicting. However, there are enough studies which support the effectiveness of this technique to warrant its use in conjunction with other techniques. One of the primary focuses of cognitive restructuring is to identify and decrease stress (Shiffman, Read, Maltese, Rapkin, & Jarvik, 1985). This approach seeks to challenge the irrational beliefs which cause discomfort (McMullin, 1986). The essence of this approach consists of three basic steps, according to McMullin and Giles (1981). First, the therapist helps the client recognize the thoughts, beliefs, or schemata that are causing the negative emotions and behaviors. Second, the clinician assists in helping the client to analyze the validity and usefulness of the negative processes. Last, the therapist helps to effect a "shift" from irrationality to accurate, rational, and useful behavior. There is considerable evidence showing that the degree of stress that people experience depends mainly on the labels and cognitions applied to physical states and are

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55 not intrinsic properties of the state itself (Beecher, 1959; Nisbett & Valine, 1971; Schachter & Singer, 1962). Many studies have been conducted which support strongly the use of cognitive restructuring with chemically-dependent persons (Clark, 1986; Ellis, et al., 1988; McMullin, 1986). For example, Oei and Jackson (1982) compared social skills training, cognitive restructuring, and traditional supportive therapy with inpatient alcoholics. At a three month followup, the cognitive-restructuring group was evaluated as the most improved. There is additional evidence to support the use of cognitive restructuring specifically as a stress-reduction strategy with chemically-dependent persons. Rohsenow, Smith, and Johnson (1985) reported significant short-term changes as a result of using cognitive restructuring as one of the approaches to reduce stress in chemically-dependent college males. McLellan, Woody, Luborsky, Obrien, and Druley (1983) evaluated a sophisticated cognitive-behavior study designed for chemically-dependent persons. This study included a rigorous research design including random assignment to groups and screening for subject motivation. Findings suggested that cognitive restructuring was more effective than traditional counseling. Marlatt (1985) proposed that the chief purpose of cognitive restructuring was to counter the cognitive and affective components of the Abstinence Violation Effect

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56 (AVE). He proposed that relapse potential places much stress on the chemically-dependent person because of irrational thoughts which lead to feelings of hopelessness. Finally, several authors believe that an addict's relapse potential is strengthened when irrational conceptualizations which result in lowered self-efficacy and increased self helplessness are alleviated (Lazarus, Averill, & Opton, 1970)

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CHAPTER 3 METHODOLOGY There were two primary purposes of this study. The first purpose was to determine whether a mental-imagery workshop could change (i.e., improve) levels of self disclosure, help-seeking behavior, lifestyle behavior change, and perception of unmanageability over drugs and alcohol with recovering addicts. The second purpose was to determine how these outcome variables interacted with relevant independent (i.e., demographic and chemical dependence related) variables. Delineation of the Variables Data were gathered for the following variables: (a) group (experimental or control); (b) gender {male or female); {c) age {15 to 70); (d) race/ethnicity (Black (B), Caucasian (C), or Hispanic American (H)); (e) level of education (5 to 22); (f) length of recovery (4 to 96 months); (g) drug of choice (alcohol, sedative, marijuana, cocaine, amphetamine, or hallucinogen); (h) number of weekly 12-step meetings attended; (i) self disclosure (a score on the JSDQ); (j) help-seeking behavior (a score on the HSLI); {k) perception of unmanageability {a score on the ALI); and (1) lifestyle behavior change (a score on the HAT). 57

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58 Population The group of people to whom the results of this study were intended to apply (i.e., recovering chemically dependent persons) have certain characteristics in common. However, the population was not intended to include those (a) with less than a 5th grade reading level; (b) race other than Black, Caucasian, Native American, or Hispanic American; (c) persons with disabilities which prohibit them from completing the instruments; (d) younger than 15 or older than 70; (e) who do not read and write English; (f) who are chronic relapsers because of severe mental and/or nervous disorders, pain, or other dual diagnoses; and (g) with less than four months or more than 96 months of abstinence from mood-altering chemicals. Although an attempt was made to represent recovering chemically-dependent persons in general, this goal was only partially achieved. Random sampling produced only three Blacks and only four Hispanic Americans. Likewise, only three subjects under 20 years of age participated. In addition, there were a predominance of alcohol abusers in the study. Therefore, the variable, drug of choice, was collapsed to alcohol and other. Finally, the sampling produced subjects having from 1 to 264 months of abstinence. The psychological variables characteristic of this population are primarily the result of prolonged substance abuse (Vaillant, 1983). There are psychological symptoms

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59 (e.g., self-centeredness, resentment, self-deception, and fear) which progressively worsen as the person "uses" more of the chemical (Gorski, 1986). Thus, chemically-dependent persons generally are caught up in a "double-bind" wherein the psychological problems worsen and, in turn, perpetuate themselves. The self-centeredness prevents help-seeking behavior and the problems generate more problems. Resentments are born out of anger and disappointments as ingestion increases. The self-centeredness, coupled with this resentment, leads to exaggerated and overwhelming feelings of self-pity and alienation. Self-deception flourishes as the addict progressively defends his or her behavior by rationalization, intellectualization, projection, and justification. Honesty to self and others becomes more difficult to attain. Ultimately, fear begets paranoia. The self-deception aids the process and the other psychological variables also overlap to add to the confusion and eventual despair. Low self-esteem, depression, and a negative belief system follow. There are other variables that merit reporting. The male-to-female ratio of known substance abusers in the state of Florida was 76% to 24% as of 1989, including 62,609 males and 20,220 females. With an n of 15, 11.4 (11) males and 3.6 (4) females would have represented the chosen population. Percentages by race in the state of Florida were 71% Caucasian, 22% Black, 7% Hispanic American, and

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60 less than 1% Other. Totals as of 1989 were 58,395 Caucasian, 18,406 Black, 5,690 Hispanic American, and 348 Other (i.e., Asian and Native American). With an n of 15, the totals would have been 10.6 (11), 3.3 (3), 1.05 (1), and o, respectively. The third variable, age, was reported as under 20 and over 20. The percentages of under 20 and 20 years of age and above were 12% and 88%, respectively. In Florida, there were 11,128 chemical-dependence admissions under 20 years of age and 82,387 20 years old and over in 1989. With an n of 15, there would have been 1.8 (2) persons under 20 and 13.2 (13) persons 20 years of age and over. In summary, the National Association of State Alcohol and Drug Abuse Directors, Inc. reported characteristics and percentages for each of these three variables in the chemical-dependence population in Florida. These data were gleaned from reports from chemically-dependent client admissions to treatment centers in 1989. Representing them would have resulted in 11 males, 4 females; 11 Caucasians, 3 Blacks, 1 Hispanic American; 2 teenagers, and 13 persons over 20 years of age in each group, partitioned as shown in Table 1 Sampling Procedures Subjects for this study were recruited primarily from members of Alcoholics Anonymous (AA) and Narcotics Anonymous NA) groups. Nationally, members of these organizations

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61 TABLE 1 Proposed Gender. Age and Race/Ethnicity Percentages for the Experimental and Control Groups Race Male Female Under 20 over 20 Under 20 Over 20 Caucasian 11 11 11 11 Black 3 3 3 3 Hispanic 1 1 1 1 Total 15 15 Is 15 represented over two million recovering chemically-dependent persons of all ages, races, and genders. Presentations were made at eight different AA and NA meetings in the central Florida area. The presenter stated that there would be five, day-long workshops at Quest Counseling Centre beginning the next Saturday and for the following four Saturdays for persons in chemical-dependence recovery. The focus of the workshops was to be on relapse prevention. The incentive for participation was described as self-improvement with an opportunity to strengthen the recovery process. After each presentation, interested persons were asked to write their names and phone numbers on a sheet of paper distributed by the presenter. This approach failed to enroll the desired 75 participants. Therefore, Lifeworks Center, Inc. was used to recruit members from their chemical-dependence treatment

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62 center. Subjects also were recruited from among outpatient ''graduates" of Quest Counseling Centre's Adult Treatment Program. Ann of 15 was the targeted number for each treatment group. However, this number also was not reached initially. Therefore, more treatment groups were added to increase the numbers of subjects in the total experimental group. Numbers of persons needed to meet the proposed race, gender, and age specifications were not achieved fully. The gender distribution was relatively even instead of the projecd three-to-one male-to-female ratio. The age variable was changed to under 30 and over 30. Length of recovery was from 1 month to 264 months. The characteristics of the actual participants are delineated further in Chapter 4. Subjects self-selected into groups based on their own scheduling convenience. Designation of groups as either experimental or control was done on a random basis. ' Thus subjects were essentially randomly assigned to a group because no experimenter-controlled factors were implemented. Recovering CD persons typically are involved in programs (e.g., AA or NA) intended to help them refrain from renewed addiction. The motivation to participate in such programs seemed to facilitate obtaining the initial sample because the workshop participants were selected from among those who had already demonstrated at least some inclination not to relapse. That is, subjects came from among those

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63 currently participating in abstinence-maintenance programs. The conduct of the followup assessments and interviews, however, presented additional considerations. Followup was done with the experimental group six weeks after their treatment. CD persons are known to relapse frequently. Indeed, that is one of the reasons for the intervention (and research) in the first place. Thus, it was likely that some subjects would relapse before the followup activities. This was true as 7 participants relapsed and were not available to respond to followup questions. Therefore, followup data were not obtained from all subjects. Substantial effort was required to locate and obtain data from the participants on individual bases. Their lives seemed to be disordered and it was often difficult to obtain followup data, even from those who initially agreed to provide it. However, it appeared that the intervention was perceived as helpful and therefore motivation to participate in followup activities may have been increased. A total of 43 persons participated in the followup portion of the study. Measurement Instruments The instruments used in this study were the Jourard Self-Disclosure Questionnaire, Health Attribution Test, Abstinence Likelihood Inventory, and Help-Seeking Likelihood Inventory. These instruments have few items, are easily scored, and could be completed within 30 minutes. They also

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64 are easy to comprehend and have brief, clear instructions for use. Appropriateness was determined via reliability and validity testing for each instrument. The Jourard Self-Disclosure Questionnaire (JSDQ) was developed by Sidney Jourard. The questionnaire was published in an article by Jourard and Lasakow (1958). It was designed to measure the extent to which an individual is willing to reveal himself/herself to another (i.e., self disclosure). Subscales measure degree of self disclosure in regard to attitudes and opinions, tastes and interests, work, money, personality, and body. A respondent is asked to respond to a series of statements by indicating the target person (e.g., mother, father, male friend, female friend, or significant other) to whom she or he has revealed feelings and to what extent. The JSDQ is a 60-item test which requires approximately 10 minutes to complete. It has a o, 1, or 2 response format. Responses are written on the answer sheet. Although six subscale scores can be computed, only the total score was used in this study. Higher scores represent greater willingness and ability to self disclose. Research on the use of the questionnaire has shown that self disclosure is measurable and that this method of assessing it has validity (Jourard, 1971). The JSDQ has been used frequently as a self-inventory in personal growth laboratories or as an outcome measure in research on human

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65 relations training or counseling. Panyard (1973) also found empirical support for the validity of the JSDQ. The Health Attribution Test (HAT) was published in 1990 by the Institute for Personality and Abiltiy Testing, Inc. The HAT measures respondents' attitudes about responsibility for their own health maintenance or treatment programs (i.e., lifestyle behavior change). The HAT requires from 510 minutes to administer and can be hand-scored in less than five minutes. It also can be administered to groups or individuals. It contains three scales to predict behavioral reactions to illness and response to treatment. In the original development of the HAT, 43 items were administered to 121 undergraduate students. Subjects responded to each question by marking one of six possible responses arranged in a Likert-type scale ranging from "Never" to "Always." Their responses were then factor analyzed. The marker variables from Levenson's (1973) locus of control measure suggested that there were three factors which measured Internal, Powerful Others, and Chance beliefs. Next, the 22 items having the highest factor loadings were selected to comprise the current version of the HAT. Respondents mark an "x" in the box which represents the answer they choose on a Likert-type scale ranging from "Strongly Disagree" to "Strongly Agree." Higher scores indicate willingness to become responsible for one's health

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66 maintenance or treatment program (i.e., lifestyle behavior change). The Internal subscale, which measures a person's attitude of personal responsibility for their health, was used as the score for this test. The Abstinence Likelihood Inventory (ALI) (Appendix C) was developed in September, 1989, by the researcher for use in this study. The ALI measures perception of unmanageability, that is, the likelihood that a chemically dependent person will remain abstinent. The ALI requires from 5-10 minutes to administer and can be hand-scored within 2-3 minutes. It can be administered to groups or individuals. The ALI is a 26-item test. Respondents use a response scale ranging from Oto 9. Scores represent the likelihood that the respondent will remain abstinent (i.e., perception of unmagageability). Scores range from Oto 234, with higher scores indicating less likelihood of relapse. The total score is used. The ALI was developed to measure likelihood to remain abstinent because no such measure was available. A pilot study was conducted to determine its reliability. A group equivalent to those to be studied was used. The 26-item ALI was administered to 35 (known) chemically-dependent persons, each of whom was (self-reported) abstinent from mood altering chemicals for at least six months. Respondents were asked to write their age, gender, and social security

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67 number (for matching purposes) on the form. Anonymity was emphasized. They were asked to complete the one-page form and return it in the self-addressed, stamped envelope provided. Instructions were to write the number from o to 9 which represented the extent to which each item was thought to be a trigger which precipitated "use." Thirty-two were returned. Internal reliability was calculated by means of Cronbach's coefficient alpha. The coefficient alpha is used when measures have multiple-scored items (Ary, Jacobs, & Razavieh, 1985). The coefficient alpha for the ALI was .92; a readily acceptable level of reliability. The split-half reliability coefficient was .87 {Table 1). The test-retest reliability coefficient following a JO-day period was .93. Content validity was evaluated to determine the extent to which the ALI measures likelihood of abstinence. Content validity refers to the extent to which an instrument represents the content of interest (Ary et al., 1985). This type of validity is well-suited for tests used to measure psychological variables. The variable measured in the ALI is attitude toward different triggers associated with, and perhaps precipitating, a craving to ''use." Each item was gleaned from an extensive literature search and is therefore multi-referenced, as shown in Appendix D. The Help-Seeking Likelihood Inventory (HSLI) (Appendix E) also was developed in September, 1989, by the researcher

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68 for use in this study. The HSLI measures the likelihood that a chemically-dependent person will ask for help and, if so, from whom. This inventory takes from 5-10 minutes to administer and can be hand-scored within 2-3 minutes. It can be administered to groups or individuals. The HSLI is a 20-item test on which respondents use a scale ranging from Oto nine. Scores represent the likelihood that the subject will seek help while in recovery. Scores range from o to 180, with higher scores indicating greater likelihood of help-seeking behavior. The total score is used. The HSLI was designed to measure this variable for this study because no such measurement was available. A pilot study was conducted to determine its reliability. A group equivalent to those being studied was used. The 20-item HSLI was administered to 35 (known) chemically-dependent persons each of whom was abstinent (self-reported) from mood-altering chemicals for at least six months. Respondents were asked to write their age, gender, and social security number (for matching purposes) on the form. Anonymity was emphasized. All were asked to complete the one-page form and return it in the self-addressed, stamped envelope provided. Written instructions were to write the number from Oto nine which represented the extent to which each help-seeking behavior would be employed in recovery. Thirty-two were returned.

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69 Internal reliability was calculated by means of the Cronbach's coefficient alpha. The coefficient alpha for the HSLI was .77, an acceptable level of reliability. The split-half reliability coefficient was .88. (Table 2). A test-retest reliability coefficient following a 30-day period was .80. Content validity is important and refers to the extent to which the inventory measures the content of interest, i.e., whether the subject will seek help with his/her recovery. The variable measured in the HSLI is willingness to seek help. Each item in the HSLI was gleaned from the literature. Item references are found in Appendix F. Table 2 Reliability Calculations for the ALI and HSLI ALI HSLI Coefficient alpha .92 .77 Test-retest .93 .80 Research Design Split-half .87 .88 The design used in this study was a randomized, posttest only control group with followup design. The original intent was to have one control group and one experimental group (composed of four treatment groups, each having an n of 15). However, random sampling produced less

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70 than 15 subjects for each treatment group. This necessitated adding two more treatment groups to total six. The treatment groups were facilitated by different facilitators and on separate occasions. All groups except one were performed on Saturday. No other known differences existed between these groups. Preliminary analyses indicated no significant differences in the means for any of the dependent variables across the six treatment groups. Therefore, the data were pooled as a single experimental group. The research covered six weeks. Initial assessments for the experimental group were completed immediately upon completion of the treatments. The experimental group was assessed again six weeks after the initial assessment. The control group received the treatment following completion of the initial assessments. Treatment The treatment (i.e., counseling intervention) used in this study was a day-long, approximately eight-contact hour workshop intended to help chemically-dependent persons be able to use mental-imagery techniques to prevent relapse. The treatment is described in detail in Appendix G. Support for the respective elements of the workshop is found in Chapter II. The treatment workshop format used was common in the counseling profession in that day-long intervention

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71 workshops have been used for a wide variety of purposes and for an equally-wide variety of clientele. Thus, the treatment had the advantage of being similar in format to frequently-used counseling interventions. In addition, many of the activities conducted have been used in other contexts and so their potential applicability was well-founded. These commonalities notwithstanding, the treatment was unique and innovative in several regards. First, the treatment had a stronger, more integrated theoretical foundation than most used with CD persons. As shown in Chapter II, there existed theoretical commonality and coherence across the elements (i.e., activities) used. Theoretically integrated interventions have been used commonly in the counseling profession in general, but rarely has such theoretical integration been evident in interventions for CD persons. Second, the treatment was multifaceted in that a variety of activities, all focused upon mental-imagery training, were incorporated in it. Many of the activities used have been used in other contexts and generally with success. However, those that have been used with CD persons have only been used infrequently, often without demonstrated success and never within the context of a combination as was used in this research. Third, the treatment was based on a prevention perspective. Therefore, it was in accord with potentially far less costly approaches to treatment for CD persons. Finally, the treatment was

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72 intended to effect a combination of {dependent) variables not heretofore studied in relapse-prevention efforts. In sum, the treatment was developed based upon a careful review and evaluation of the professional counseling literature on activities potentially appropriate for using mental imagery as a means to facilitate relapse prevention. It was developed so as to be both theoretically sound and professionally appropriate. It should be noted that the intervention was an adjunct to treatment for those who were receiving, or had received, "standard" treatment. Standard treatment included inpatient, outpatient, NA, or AA approaches. Since the sample was derived from a population of recovering persons, it was assumed that these people were in recovery treatment of some sort. Relapse, by its very nature, occurs only after a person is exposed to recovery. Therefore, all participants had been or were involved in other treatment. A treatment history form {Appendix J) was designed to determine the type of treatment{s) to which the subjects were exposed. Research Procedures After participants in the control group entered the group room at Quest Counseling Centre in Altamonte Springs, Florida, the facilitator said, "Good morning. Thank you for coming. My name is___ I'm looking forward to a very productive day that is relaxing, fun, and helpful. To

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begin, I'd like you to complete four instruments which are necessary, important, and integral to the study. Please complete them conscientiously. The results will be coded and kept confidential. on the forms which I will hand out, please write the last four digits of your social security number, your age, and Mor F for male or female in the upper right corner. Also, write today's date as soon as I say to begin. 73 Complete one form at a time, respond to every item in order, and do not skip items. Instructions are written on each form. Read these carefully, relax, and respond to all questions as honestly as you can. Raise your hand when you finish all four forms. It should take you about 20 minutes but you are not being timed. Begin now." The facilitator then gave each participant a pencil and the four forms. He stayed in the room, answered questions, and distributed more forms and/or pencils as needed. As participants finished, he checked the forms for social security digits, age, and gender information. He also checked for completion of all items. Forms were placed in a box marked C group. When all forms were collected, the facilitator then said, "Thank you for your cooperation. In six weeks, I will ask each of you to fill out followup forms. We have finished this phase and are ready to begin the workshop on relapse prevention."

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74 At this point, the treatment procedure was implemented. In general, it was an eight-hour workshop on relapse prevention. The focus was on the use of mental imagery as the main intervention to raise levels of acceptance in four areas. Initially, time was given to the development of a ''safe" atmosphere, followed by an introduction to imagery. The workshop proceeded with a series of imagery vignettes targeted to raise levels of acceptance. See Appendix G for a complete description of the treatment. At the completion of the workshop, the facilitator said, "It is now time to end. Thank you for participating. I wish you all much success. Lastly, in six weeks, I will contact you and ask you to complete four more forms. Thank you." Because this study incorporated a posttest only design, the experimental group received the instruments after the treatment. However, the format for the treatment was identical for both groups. After the participants in the experimental group entered the group room at Quest counseling Centre in Altamonte Springs, Florida, the facilitator said, "Good morning. Thank you for coming. My name is_____ I'm looking forward to a very productive day that is relaxing, fun, and helpful. We are ready to begin the workshop on relapse prevention. Please remember that we will end at 4:30 p.m. and then spend about one-half hour completing some forms." At this point the treatment

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75 procedures were implemented. Upon completion of the workshop, the facilitator said, "It is now time to complete forms. Thank you for your cooperation. I wish you all much success. In six weeks I will ask each of you to fill out followup forms. This next part takes about one-half hour and involves completing four instruments necessary, important, and integral to the study. Please complete them conscientiously. The results will be coded and kept confidential. On the forms which I'll hand out please write the last four digits of your social security number, age, and Mor F for male or female in the upper right corner. Also, write today's date as soon as I say to begin. Complete one form at a time, respond to every item in order, and do not skip items. Instructions are written on each form. Read these carefully, relax, and respond to all items as honestly as you can. Raise your hand when you finish all four forms. It should take you about 20 minutes but you are not being timed. Begin now." The facilitator then gave each participant a pencil and the four forms. He stayed in the room, answered questions, and distributed more forms and or pencils as needed. As participants finished, he checked the forms for social security digits and gender information. He also checked for completion of all items. Forms were placed in a box marked E group.

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76 Research participants There were five trainers for the intervention. Originally, there were four trainers assigned, one to each group. However, as the number of subjects in each treatment group was smaller than intended, there was need to add more groups. One more trainer was added in order to facilitate this process. All of the trainers had been enrolled in post-master's graduate study, had master's degrees in counseling, possessed Florida State Licenses as either mental health or marriage and family counselors, were current practitioners in the field of counseling in the Central Florida area, had at least 15 years of experience in the counseling profession and were Caucasian males over 40 years of age. The researcher had provided approximately 10 hours training to workshop leaders to explain the format, guidelines, and expected behaviors for the workshop. The imagery exercises, intended psychological environment for the day, and accompanying attitudes to be expressed to the participants were explained. Rehearsals of the tasks were completed. Imagery exercises were audiotaped beforehand and played during the workshop. Data Analyses The purpose of the workshop was to improve participant characteristics in ways known to be associated with successful recovery processes. Therefore, primary interest

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77 was in differences in four selected outcome variables between those in the experimental and control groups. However, because a variety of variables were investigated, differences in or relationships to the selected variables as functions of demographic and other characteristics of both the participant and nonparticipant groups also were of interest. The data analyses for the study were conducted in steps. In the first step, four separate (i.e., one for each dependent variable) one-way analyses of variance (ANOVAs) across the six treatment groups were computed to determine if there were significant differences among the treatment groups. There were no significant differences and therefore the data from the respective treatment groups were combined for subsequent analyses. Multiple regression analyses were used to determine significant differences and/or interactions among the demographic and each of the outcome variables. Similarly, multiple regression analyses were used to determine significance of relationships among the demographic variables and the each of the outcome variables. The general linear model was used for each of these analyses. It allowed for investigation of individual as well as linear, weighted combinations of relationships among the respective variables.

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CHAPTER 4 RESULTS This study examined the effects of a brief, relapse prevention intervention for chemically-dependent persons. A randomized, posttest only control group design, with followup, including multiple dependent and independent variables was used. Subjects in the treatment and control groups were measured across four dependent variables: help seeking behavior, self disclosure, perception of unmanageability, and lifestyle behavior change. Fifty subjects were recruited for the experimental groups. It was necessary to have six groups because initial attempts to fill the four proposed treatment groups failed. Therefore, two additional groups were added. One of the participant's scores were discarded because the person was not in treatment for chemical dependence but rather for an over-eating problem. Thirty-seven subjects were recruited for the control group. One subject's data were discarded because of failure to complete the posttests. Therefore, there was a total of 85 participants. An attempt was made to obtain a sample as presented in Table 1. However, the procedures yielded only an 78

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approximation of that intention. The actual sample is presented in Table 3. TABLE 3 Actual Gender. Age. and Race\Ethnicity Percentages for the Experimental and Control Groups Age Under 30 Over 30 Experimental Male 7 20 Female 2 20 Male 3 18 Control Female 4 11 Note: Only three Blacks, four Hispanic Americans, and two American Indians were involved in the study. 79 Four one-way analyses of variance (ANOVA) were performed as a preliminary analysis to determine whether there were significant differences among the six treatment groups. The means and standard deviations by variable and TABLE 4 Mean and Standard Deviations for the Experimental and Control Group El E2 E3 E4 E5 E6 All E Ctrl ALI M 155.5 174.0 165.0 159.9 129.2 178.0 158.5 130.3 SD 31.1 42.7 30.3 41.3 52.3 22.0 40.7 59.4 HSLI M 109.8 118.5 114.7 110.7 99.0 104.3 110.0 105.5 SD 23.3 19.6 15.1 21.9 20.2 32.1 21.4 27.4 JSDQ M 275.7 242.4 237.0 285.6 307.1 197.0 264.5 268.4 SD 123.2 86.9 66.2 103.4 173.4 90.9 114.7 101.2 HAT M 12.0 11.7 14.1 12.7 11. 6 13.5 12.4 11.4 SD 6.0 3.9 7.5 4.2 7.0 4.4 5.4 5.8

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80 group are shown in Table 4. No significant differences were found among the six treatment group means for any of the four dependent variables. Therefore, the data from the six treatment groups were combined into a single experimental group for all subsequent analyses. Multiple regression analyses, using the general linear model, were computed to evaluate all hypotheses. The .05 level of significance was used throughout. A standard, linear, weighted multiple regression approach was used. The demographic and substance-abuse related variables were added to the model in a stage-wise manner. In the first stage, only demographic variables were included. In the second stage, treatment was added to the model and interactions between treatment and the demographic variables were tested to determine whether the treatment had a differential impact on subjects with different demographic traits. In the third stage, substance-abuse history variables were used as the independent variables. In the fourth stage, treatment was added to the model and its interactions with substance-abuse history variables were examined. In the final stage, the original intent was to combine only variables shown to be significantly related to the dependent variables in the preceding models to determine their combined effects. These stages of analyses were to have been applied to all four dependent variables. However, because prior analyses

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did not yield sufficient variables to evaluate these hypotheses, no statistical analyses were conducted. Abstinence Likelihood Inventory Hypothesis 1 stated that there was no significant relationship between ALI scores and a weighted, linear combination of the demographic variables (i.e., gender, race, age, and education). The data analyses summary for evaluation of this hypothesis is shown in Table 5. There TABLE 5 Multiple Regression Results for the ALI and Demographic Variables source Model Gender Race DF sum of Squares Mean square 6 22698.8169 3783.1362 1 99.7387 99.7387 3 6258.0956 2086.0319 Age 1 Education 1 16376.8264 1507.5353 16376.8264 1507.5353 *P < .05 F Value Pr> F 0.14 0.1895 0.04 0.8429 0.83 0.4832 6.49 0.0128 0.60 0.4419 was not a significant relationship between the ALI and a weighted combination of the demographic variables. Therefore, hypothesis 1 was not rejected. However, there was a significant and positive relationship between ALI scores and age. 81 * Hypothesis 2 stated that there was no significant relationship between ALI scores and a weighted, linear combination of the demographic variables, treatment, and the interactions of treatment with these demographic variables.

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82 The data analysis summary for evaluation of this hypothesis is shown in Table 6. There was a significant difference by group, with the experimental group having the higher mean. There also was a relationship between the ALI scores and the demographic variable age. In addition, there was a TABLE 6 Multiple Regression Results for the ALI. Demographic Variables, and Treatment Interactions with the Demographic Variables Source OF Sum of squares Mean Square F Value Model 11 Gender 1 Race 3 Age 1 Education 1 Group 1 G*Group 1 R*Group 1 Age*Group 1 Ed*Group 1 *P < .05 59885.3344 0.8676 6203.2854 19741.5559 54.3569 20374.1557 1684.2818 21. 9130 893.9556 9796.6603 5444.1213 0.8676 2067.7618 19741. 5559 54.3569 20374.1557 1684.2818 21.9130 893.9556 9796.6603 2.49 0.00 0.95 9.03 0.02 9.32 0.77 0.01 0.41 4.48 Pr> F 0.0103 * 0.9842 0.4232 0.0036 * 0.8752 0.0032 * 0.3831 0.9205 0.5246 0.0377 * significant group-by-education level interaction. There were uneven distributions across grade levels of those in the experimental and control groups. Therefore, hypothesis 2 was rejected. Hypothesis 3 stated that there was no significant relationship between ALI scores and a weighted, linear combination of substance-abuse related variables (i.e., drug

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83 of choice, number of weekly meetings, and months of recovery). The data analysis summary for evaluation of this hypothesis is shown in Table 7. There was a significant relationship between the ALI and only length of time in recovery. Therefore, hypothesis 3 was rejected, but only length of recovery was related to ALI scores. TABLE 7 Multiple Rearession Results for the ALI and Substance-abuse Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 3 24835.2176 8278.4059 3.44 0.0205 * Drug of C 1 629.0992 629.0992 0.26 0.6103 Meetings 1 8121. 4021 8121. 4021 3.38 0.0697 Len of Rec 1 9999.7785 9999.7785 4.16 0.0446 * *P < .05 Hypothesis 4 stated that there was no significant relationship between ALI scores and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. The data analysis summary for evaluation of this hypothesis is shown in Table 8. There was a significant relationship between ALI scores and only length of time in recovery. Therefore, although hypothesis 4 was rejected, it yielded redundant information with hypothesis 3 in that only length of recovery was a significant predictor of ALI scores.

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84 TABLE 8 Multiple Regression Results for the ALI, Substance-abuse Variables, and Treatment Interactions with the Substance abuse Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 3 Drug of C 1 Meetings 1 Len of Rec 1 Group 1 DC*Group 1 Mtgs*Group 1 Len*Group 1 *P < .05 24835.2176 629.0992 8121. 4021 9999.7785 2216.7339 5872.2433 75.6972 2559.6044 8278.4059 629.0992 8121. 4021 9999.7785 2216.7339 5872.2433 75.6972 2559.6044 .44 0.26 3.38 4.16 0.98 2.60 0.03 1.13 0.0205 * 0.6103 0.0697 0.0446 * 0.3253 0.1113 0.8553 0.2908 Hypothesis 5 stated that there was no significant relationship between ALI scores and a weighted, linear combination of treatment, selected demographic variables, selected substance-abuse variables, and the interactions of treatment with the selected variables. Because prior analyses did not yield sufficient variables to evaluate this hypothesis, no statistical analysis was conducted for it. Therefore, hypothesis 5 was not tested. Help-Seeking Likelihood Inventory Hypothesis 6 stated that there was no significant relationship between HSLI scores and a weighted, linear combination of the demographic variables (i.e., gender, race, age, and education). The data analyses summary for

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evaluation of this hypothesis is shown in Table 9. There was not a significant relationship between the HSLI and a weighted combination of the demographic variables. Therefore, hypothesis 6 was not rejected. TABLE 9 Multiple Regression Results for the HSLI and Demographic Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 6 5029.7498 838.2916 1.50 0.1900 Gender 1 1136.8021 1136.8021 2.03 0.1581 Race 3 4102.3386 1367.4462 2.44 0.0704 Age 1 56.9640 56.9640 0.10 0.7506 Education 1 289.2033 289.2033 0.52 0.4744 85 Hypothesis 7 stated that there was no significant relationship between HSLI scores and a weighted, linear combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. The data analysis summary for evaluation of this hypothesis is shown in Table 10. There were no significant relationships, differences, or interactions. Therefore, hypothesis 7 was not rejected. Hypothesis 8 stated that there was no significant relationship between HSLI scores and a weighted, linear combination of substance-abuse variables (i.e., drug of choice, number of weekly meetings, and months of recovery).

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86 The data analysis summary for evaluation of this hypothesis is shown in Table 11. There was not a significant TABLE 10 Multiple Regression Results for the HSLI. Demographic Variables and Treatment Interactions with the Demographic Variables source OF Sum of Squares Mean Square F Value Pr> F Model 11 Gender 1 Race 3 Age 1 Education 1 Group 1 G*Group 1 R*Group 1 Age*Group 1 Ed*Group 1 TABLE 11 6468.3852 1608.2802 4070.4012 26.0763 402.8410 123.8208 311. 3700 225.4763 641. 9961 0.1300 588.0350 1608.2803. 1356.8004 26.0763 402.8410 123.8208 311. 3700 225.4763 641.9961 0.1300 1.02 0.4407 2.78 0.0997 2.35 0.0798 0.05 0.8324 0.70 0.4067 0.21 0.6450 0.54 0.4655 0.39 0.5343 1.11 0.2956 o.oo 0.9881 Multiple Regression Results for the HSLI and Substance-abuse Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 3 1461.1696 487.0565 0.84 0.478 Drug of C 1 424.3183 424.3183 0.73 0.3961 Meetings 1 0.6879 0.6879 0.00 0.9727 Len of Rec 1 1206.8233 1206.8233 2.07 0.1541

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87 relationship between the HSLI and a weighted combination of variables. Therefore, hypothesis 8 was not rejected. Hypothesis 9 stated that there was no significant relationship between HSLI scores and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. The data analysis summary for evaluation of this hypothesis is shown in Table 12. There were no significant relationships, differences, or interactions. Therefore, hypothesis 9 was not rejected. TABLE 12 Multiple Regression Results for the HSLI, Substance-abuse Variables, and Treatment Interactions with the Substance abuse Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 7 2953.7396 421.9628 0.71 0.6633 Drug of C 1 259.2825 259.2825 0.44 0.5108 Meetings 1 88.2745 88.2745 0.15 0.7009 Len of Rec 1 730.2304 730.2304 1.23 0.2710 Group 1 18.4745 18.4745 0.03 0.8605 DC*Group 1 454.0910 454.0910 0.76 0.3847 Mtgs*Group 1 178.5050 178.5050 0.30 0.5851 Len*Group 1 456.9829 456.9829 0.77 0.3831 Hypothesis 10 stated that there was no significant relationship between HSLI scores and a weighted, linear combination of treatment, selected demographic variables,

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88 selected substance abuse-variables, and the interactions of treatment with the selected variables. Because prior analyses did not yield sufficient variables to evaluate this hypothesis, no statistical analysis was conducted for it. Therefore, hypothesis 10 was not tested. Jourard Self-Disclosure Questionnaire Hypothesis 11 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of the demographic variables (i.e., gender, race, age, and education). The data analyses summary for evaluation of this hypothesis is shown in Table 13. There was not a significant relationship between the JSDQ scores and a weighted combination of the demographic variables. Therefore, hypothesis 11 was not rejected. TABLE 13 MultiQle Regr~ssion Results for JSDQ and DemograQhic Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 6 34177.1734 5696.1956 0.46 0.8325 Gender 1 0.2334 0.2334 0.00 0.9965 Race 3 26463.2649 8821.0883 0.72 0.5433 Age 1 10662.0471 10662.0471 0.87 0.3539 Education 1 2855.0173 2855.0173 0.23 0.6308 Hypothesis 12 stated that there was no significant relationship between JSDQ scores and a weighted, linear

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89 combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. The data analysis summary for evaluation of this hypothesis is shown in Table 14. There were few significant relationships, differences, or interactions. Hypothesis 12 was rejected, however, because there was a significant gender-by-group interaction. The experimental group had a mean of 280 for males and 246 for females. The control group had a mean of 288 for females and 249 for males. TABLE 14 Multiple Regression Results for the JSDO, Demographic Variables. and Treatment Interactions with the Demographic Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 11 128992.4560 11726.5869 0.99 0.4604 Gender 1 1007.7209 1007.7209 0.09 0.7709 Race 3 32514.7906 10838.2635 0.92 0.4363 Age 1 3794.6139 3794.6139 0.32 0.5724 Education 1 7349.9551 7349.9551 0.62 0.4326 Group 1 8747.3831 8747.3831 0.74 0.3921 G*Group 1 56562.5408 56562.5408 4.79 0.0318 * R*Group 1 3232.5934 3232.5934 0.27 0.6023 Age*Group 1 24710.9606 24710.9606 2.09 0.1522 Ed*Group 1 43166.2425 43166.2425 3.66 0.0697 *P < .05

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90 Hypothesis 13 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of substance-abuse variables (i.e., drug of choice, number of weekly meetings, and months of recovery). The data analysis summary for evaluation of this hypothesis is shown in Table 15. There was not a significant relationship between the JSDQ and a weighted combination of variables. Therefore, hypothesis 13 was not rejected. TABLE 15 Multiple Rearession Results for the JSDO and Substance-abuse Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 3 Drug of c 1 Meetings 1 Len of Rec 1 6055.2707 115.2378 5528.5037 0.8808 2018.4236 115.2378 5528.5037 0.8808 0.17 0.9189 0.01 0.9227 0.45 0.5019 o.oo 0.9932 Hypothesis 14 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. The data analysis summary for evaluation of this hypothesis is shown in Table 16. There were no significant relationships, differences, or interactions. Therefore, hypothesis 14 was not rejected.

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TABLE 16 Multiple Regression Results for the JSDO. Substance-abuse Variables. and Treatment Interactions with the Substance abuse Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 7 64029.2202 9147.0315 0.76 0.6221 Drug of C 1 47.6030 47.6030 0.00 0.9500 Meetings 1 25052.4009 25052 . 4009 2.08 0.1531 Len of Rec 1 6802.0190 6802.0190 0.57 0.4544 Group 1 3546.7267 3546.7267 0.29 0.5887 DC*Group 1 2722.1913 2722.1913 0.23 0.6357 Mtgs*Group 1 30781.3856 30781.3856 2.56 0.1138 Len*Group 1 46200.0447 46200.0447 3.84 0.0537 91 Hypothesis 15 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of treatment, selected demographic variables, selected substance-abuse variables, and the interactions of treatment with the selected variables. Because prior analyses did not yield sufficient variables to evaluate this hypothesis, no statistical analysis was conducted for it. Therefore, hypothesis 15 was not tested. Health Attribution Test Hypothesis 16 stated that there was no significant relationship between HAT scores and a weighted, linear combination of the demographic variables (i.e., gender, race, age, and education). The data analyses summary for

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evaluation of this hypothesis is shown in Table 17. There was not a significant relationship between the HAT and a weighted combination of the demographic variables. Therefore, hypothesis 16 was not rejected. TABLE 17 Multiple Regression Results for the HAT and Demographic Variables Source DF Sum of Squares Mean Square F Value Pr> F Model 6 143.0653 23.8442 0.74 0.6187 Gender 1 37.9919 37.9919 1.18 0.2807 Race 3 10.4615 3.4872 0.11 0.9550 Age 1 57.6978 57.6978 1. 79 0.1846 Education 1 20.5183 20.5183 0.64 0.4272 Hypothesis 17 stated that there was no significant relationship between HAT scores and a weighted, linear 92 combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. The data analysis summary for evaluation of this hypothesis is shown in Table 18. There were no significant relationships, differences, or interactions. Therefore, hypothesis 17 was not rejected. Hypothesis 18 stated that there was no significant relationship between HAT scores and a weighted, linear combination of substance-abuse variables (i.e., drug of choice, number of weekly meetings, and months of recovery).

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93 The data analysis summary for evaluation of this hypothesis is shown in Table 19. There was not a significant TABLE 18 Multiple Regression Results for the HAT. Demographic Variables. and Treatment Interactions with the Demographic Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 11 282.7047 25.7004 0.79 0.6483 Gender 1 48.7070 48.7070 1.50 0.2248 Race 3 0.1400 0.0467 0.00 0.9999 Age 1 70.4791 70.4791 2.17 0.1451 Education 1 2.2460 2.2460 0.07 0.7934 Group 1 44.7739 44.7739 1.38 0.2443 G*Group 1 0.2356 0.2356 0.01 0.932 R*Group 1 33.0565 33.0565 1.02 0.3165 Age*Group 1 0.1223 0.1223 o.oo 0.9512 Ed*Group 1 57.7221 57.7221 1.78 0.1867 TABLE 19 Multiple Regression Results for the HAT and Substance-abuse Variables Source OF Sum of Squares Mean Square F Value Pr> F Model 3 220.2149 73.4050 2.44 0.0701 Drug of c 1 108.7270 108.7270 3.62 0.0607 Meetings 1 93.4405 93.4405 3.11 0.0816 Len of Rec 1 0.2338 0.2338 0.01 0.9299

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94 relationship between HAT scores and a weighted combination of variables. Therefore, hypothesis 18 was not rejected. Hypothesis 19 stated that there was no significant relationship between HAT scores and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these substance-abuse variables. The data analysis summary for evaluation of this hypothesis is shown in Table 20. There were no significant relationships or interactions. TABLE 20 Multiple Regression Results for HAT, Substance-abuse Variables, and Treatment Interactions with the Substance abuse Variables Source DF Sum of Squares Mean Square F Value Pr> F Model 7 317.7577 45.3940 1.50 0.1814 Drug of C 1 146.3236 146.3236 4.82 0.0311 * Meetings 1 53.3050 53.3050 1.76 0.1890 Len of Rec 1 1. 5041 1.5041 0.05 0.8244 Group 1 45.6061 45.6061 1.50 0.2240 DC*Group 1 6.2031 6.2031 0.20 0.6525 Mtgs*Group 1 0.005 0.005 o.oo 0.9899 Len*Group 1 36.4580 36.4580 1.20 0.2765 *P < .05 Therefore, hypothesis 19 was not rejected. However, there was a significant difference on the basis of drug of

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choice, with experimental group members having the higher mean. 95 Hypothesis 20 stated that there was no significant relationship between HAT scores and a weighted, linear combination of treatment, selected demographic variables, selected substance-abuse variables, and the interactions of treatment with the selected variables. Because prior analyses did not yield sufficient variables to evaluate this hypothesis, no statistical analysis was conducted for it. Therefore, hypothesis 20 was not tested. Treatment History Information The mental-imagery technique used in this study was an adjunct to various treatments which the participants had experienced at some time prior to this intervention. An other treatment history form (Appendix J) was given to the participants at the time that the other instruments were administered. Seventy-eight responded. Two participants did not respond to the first question, "Are you currently abstaining from alcohol and other drugs?" Seventy-six participants reported abstinence, 40 for the first time. Thirty-six answered no to the second question, "Is this your first time abstinent?" The mean number of relapses was eight, the total number being 145. Eleven persons also had been in treatment for other disorders. The average length of prior other treatment was 36 months, with a range from o264 months. Seventy-five of the respondents had attended

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96 12-step groups. Seventy-two attended AA group meetings. Six attended NA group meetings. Three attended both AA and NA. Thirty had attended outpatient group counseling and five outpatient individual counseling. Four had participated in family counseling, one in residential care, and three in other forms of treatment. The mean duration of prior other treatment was 3.5 months. The last other treatment consisted of 39 in twelve-step groups, 14 in outpatient groups, 11 in inpatient treatment, five in halfway houses, five in residential treatment, six in outpatient individual counseling, six in family therapy, and five in other forms of treatment. Followup A followup study was conducted approximately six weeks after each treatment group (Appendix I). Ten questions were asked of each of the experimental group participants. This was done via mail and followed by either a telephone or personal contact. The survey was intended to evaluate the participants' opinions of the treatment. The resultant means and standard deviations are reported in Table 21. The results of this survey suggest that most of the participants thought that the treatment was worthwhile. Also included in the followup survey were open-ended questions about most and least liked aspects of the workshop. There were 37 "positive" responses and 12 "negative" responses. Twenty-three respondents said they

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97 TABLE 21 Means and Standard Deviations for the Followup Study M SD Question 1 1.90 0.22 Question 2 7.41 1.99 Question 3 6.19 2.50 Question 4 6.19 2.20 Question 5 6.33 2.30 Question 6 6.19 2.40 Question 7 7.90 2.40 Question 8 7.70 2.50 Question 9 7.70 2.30 Question 10 7.80 2.30 highly valued the mental imagery. Seven stated that they enjoyed meeting others in recovery and four reported that they liked the "safe" atmosphere. Examples of positive statements included: (a) "It was an opportunity to meet others with issues in life they wish to clarify and resolve;" (b) I liked most the exercises and visualizations related to letting go of old feelings/behaviors;" (c) "The seminar helped me to slow down. Once I did, I was able to listen and learn more effectively;" (d) "I liked the assisted relaxation with other addicts/alcoholics and how being able to slowly become more real with feelings, as the workshop progressed;" (e) "The relaxation tapes were great.

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98 The visualization of actually throwing things away--my sponsees (persons in early recovery) think that'd be great too!!!;" (f) "I gained a greater understanding of myself ... how to live a more positive life by letting go of the negatives;" (g) "The workshop introduced me to meditation tapes. I now have one and listen to it often;" (h) "All in all, I did walk away with a gain which was important to me;" and (i) "The repitition of meditation and guided imagery was important and effective. I liked this." Although the results were mixed, respondents tended to report favorably on the workshop. The negative responses revealed that some respondents thought the workshop was too long. Two others thought that it was too brief. Most of the negative feedback was qualified with statements reporting satisfaction with some part of the workshop. Thus, participants' evaluations of the workshop were generally very favorable. It appeared they perceived more worth in the workshops than was reflected in their responses to the instruments.

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CHAPTER 5 DISCUSSION Research has shown a great need for relapse-prevention investigation, particularly in regard to chemical dependence. Research also has suggested that there is a strong need for empirical studies to investigate strategies for helping recovering addicts to maintain abstinence from mood-altering substances. Therefore, a number of researchers have examined the effects of brief and other interventions on the recovery of chemically-dependent persons. However, there have been few studies which have used mental imagery as the treatment modality, and even fewer that addressed the variables studied in this research. Improved treatment would help practitioners by providing more effective approaches to this problem. Limitations of the Study The treatment may not have worked with this group in particular because the sampling drew some participants who had obtained advanced, (i.e., long-term) recovery. That is, some participants had been abstinent for as long as about 10 years. Persons with a longer history of non-relapse are less likely to need assistance with it and probably have developed attitudes commensurate with non-relapse. Thus, 99

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100 some of the participants may not actually have had strong need for the intervention. The participants also may have been involved in self help treatment to the degree that many were not relapse prone. Most attended Alcoholics Anonymous and thus may be less representative of the population of persons who are in jeopardy of relapse. The participants also may have needed time after the treatment to practice the strategies taught before the full effects of the treatment took hold. That is, mental imagery may be more effective after there has been time to use the technique. Therefore, a different research design, one including a later post assessment, may have been more appropriate. The size of the groups (i.e., 7 to 10) may have been too large for one facilitator. However, the facilitators had many years of experience in managing large groups and have demonstrated ability to do so. Therefore, the format of the treatment was within accepted standards of service provision for this type of intervention. Generalizability may have been affected because the intended age, gender, and race variables were not fully represented. Results of this study are limited to those resulting from the sampling. In general, this would include Caucasians, those over 20 years of age and those who had at least a high school diploma.

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101 conclusions The first hypothesis was not rejected because there was not a significant relationship between ALI scores and a weighted, linear combination of gender, race, age, and education. ALI scores were significantly and positively correlated only to age. Older participants were more likely to abstain (i.e., not relapse). Hypothesis 2 stated that there was no significant relationship between ALI and a weighted, linear combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. There was a significant group difference. Persons in the experimental group had significantly higher ALI scores. Thus the treatment was effective in regard to abstinence likelihood. There was also a significant education-by-group interaction. There were uneven distributions across grade levels of those in the experimental and control groups in this interaction. Therefore, treatment effects were difficult to discern. The third hypothesis stated that there was no significant relationship between ALI scores and a weighted, linear combination of substance-abuse-related variables including drug of choice, number of weekly meetings, and months of recovery. The hypothesis was rejected but only because there was a significant, positive relationship between length of time in recovery and ALI scores. Similar

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102 to age, the longer the length of time in recovery, the greater the likelihood for abstinence. Hypothesis 4 stated that there was no significant relationship between ALI scores and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these demographic variables. This hypothesis was rejected but only because there was a significant relationship between ALI scores and length of time in recovery. The fifth hypothesis stated that there was no significant relationship between ALI scores and a weighted, linear combination of treatment, demographic variables, substance-abuse variables, and the interactions of treatment with the selected variables. This hypothesis also was not tested because a combination of these variables was not predictably associated with changes in abstinence likelihood. Hypothesis 6 stated that there was no significant relationship between HSLI scores and a weighted, linear combination of demographic variables. This hypothesis was not rejected, suggesting that collectively these variables were not associated with help-seeking behavior nor were there differences based on the independent variables. Hypothesis 7 stated that there was no significant relationship between HSLI scores and a weighted, linear combination of demographic variables, treatment, and the

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103 interactions of treatment with these demographic variables. This hypothesis also was not rejected. Therefore, the demographic variables were not associated with differences in help-seeking behavior. Hypothesis 8 stated that there was no significant relationship between HSLI scores and a weighted, linear combination of substance-abuse variables including drug of choice, number of weekly meetings, and months of recovery. This hypothesis was not rejected. Therefore, these variables were not associated with differences in help seeking behavior. The ninth hypothesis stated that there was no significant relationship between HSLI scores and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these demographic variables. This hypothesis also was not rejected, suggesting that collectively the variables were not associated with help-seeking behavior. Hypothesis 10 stated that there was no significant relationship between HSLI scores and a weighted, linear combination of treatment, demographic variables, substance abuse variables, and the interactions of treatment with the selected variables. This hypothesis also was not tested because a combination of these variables was not predictably associated with changes in help-seeking behavior.

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104 Hypothesis 11 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of demographic variables. This hypothesis was not rejected because the combined variables were not associated with help-seeking behavior changes. The twelth hypothesis stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. This hypothesis was rejected because there was a significant group-by-gender interaction. This suggested that males in the experimental group and females in the control group are more likely to practice self-disclosing behavior. Hypothesis 13 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of substance-abuse variables. This hypothesis was not rejected because the variables were not associated with differences in self disclosure. Hypothesis 14 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of substance-abuse variables, treatment, and the interactions of treatment with these demographic variables. This hypothesis was not rejected because the combination of the variables was not associated with increased self disclosure.

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105 Hypothesis 15 stated that there was no significant relationship between JSDQ scores and a weighted, linear combination of treatment, demographic variables, substance abuse variables, and the interactions of treatment with the selected variables. This hypothesis was not tested formally. The sixteenth hypothesis stated that there was no significant relationship between HAT scores and a weighted, linear combination of demographic variables. This hypothesis was not rejected because collectively the variables were not associated with positive lifestyle changes. Hypothesis 17 stated that there was no significant relationship between HAT scores and a weighted, linear combination of demographic variables, treatment, and the interactions of treatment with these demographic variables. This hypothesis was not rejected because a combinatioh of these variables was not predictably associated with lifestyle change. Hypothesis 18 stated that there was no significant relationship between HAT scores and a weighted, linear combination of substance-abuse variables. This hypothesis was not rejected because collectively the variables were not associated with lifestyle change. Hypothesis 19 stated that there was no significant relationship between HAT scores and a weighted, linear

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106 combination of substance-abuse variables, treatment, and the interactions of treatment with these demographic variables. This hypothesis was not rejected because a combination of the variables was not predictably associated with changes in lifestyle. The last hypothesis stated that there was no significant relationship between HAT scores and a weighted, linear combination of treatment, demographic variables, substance abuse variables, and the interactions of treatment with the selected variables. This hypothesis was not tested because the independent variables were not clearly associated with lifestyle behavior change. Discussion In general, data did not support the effectiveness of this particular intervention, a brief mental-imagery workshop for recovering chemically-dependent persons, except in very limited regard. Several possible explanations are evident. One possibility is that the treatment may have "worked," but the posttest administration was premature. That is, the treatment may have been found to be more effective if time to practice the strategies had been allowed before the posttest assessments. The followup responses suggest that the treatment was beneficial. For example, 37 of the experimental group respondents specifically stated that they valued the mental-imagery workshop techniques learned.

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107 Participants' ratings of treatment have been known to favor the treatment and the facilitator so this information may be biased. However, the feedback was consistently high and positive. Therefore, there apparently was a perception of benefit among the participants. Nonetheless, the treatment generally was not effective within the parameters of the study. Implications The results of this study have implications for both practitioners and researchers. It is apparent that the intervention was not effective in immediately fostering non relapse among chemically-dependent persons. Therefore, it may be that a brief mental-imagery intervention designed to raise these levels is not worth pursuing and practitioners should avoid such approaches. In general, the participants had an above average length of recovery, longer than was initially intended. Because this situation may have negated positive results, research should be conducted with chemically-dependent persons who have been in recovery less time. Conversely, this research should be replicated using a design in which the post assessments are conducted relatively long after the treatment has been given. Such research would evaluate whether a time interval is necessary for the effects to become evident.

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108 Possibilities also exist that chemically-dependent persons are very difficult to treat, do not take instruction well or their personalities may not be conducive to an intervention of this type. Therefore, other formats and/or approaches should be investigated. Recommendations Practitioners attempting to use techniques such as the intervention in this study should proceed cautiously. This study did not produce evidence that the mental-imagery workshop had immediate positive effects in preventing relapse among chemically-dependent persons. Thus although workshops of this nature may be effective for other types of interventions, they probably should not be used when immediately evident results are desired. In view of the findings of the followup, the study may be worth replicating. The followup survey produced opinions that the treatment was effective in some (perceived) regards. Therefore, the study should be replicated with attention to effects other than those evaluated in this study. For example, attitudes toward relapse, counseling, or both might be investigated. The research should be simplified, for example, using only males, a younger population, and only persons in early recovery. These changes would simplify the design. The use of only males would eliminate the gender effect which, although important, may have made this study overly

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109 complicated. Using a younger population may eliminate the effect of having participants who had advanced recovery. This would make the groups more homogeneous and also simplify the procedures. Persons in early recovery are in more danger of relapse than those in advanced recovery. Inclusion of this variable would simplify the design as well as focus the study on those most in need of treatment. Results suggest that those whose length of recovery is greater have a better chance of abstaining from mood altering chemicals. Efforts to improve on this study might also include adding another treatment component so as to test for strength of treatment. Other approaches or a strengthened treatment could be employed. For example, a longer length of treatment could be used so as to add to the rigorousness of the treatment. Of significant concern in the counseling profession in regard to substance abuse counseling is whether different types of interventions work better at different points in the recovery process. Length of recovery by group interactions were not significant for any of the variables examined in this study. However, several approached statistical significance. Therefore, this study should be replicated with greater attention to this possibility. For example, a study utilizing clearly differentiated lengths of recovery criteria (e.g., less than six months and greater

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110 than 18 months) would facilitate understanding of whether treatments such as the one in this study are differentially effective based on length of recovery. Mental imagery has been supported in the literature yet may be effective only with non-addicts. Personality traits of addicts may preclude them from achieving the effects of imagery. For example, many chemically-dependent persons have formed habits and characteristics which are so engrained that they may not adapt to a treatment which is cognitively sophisticated. In conclusion, while the results of this study do not support the use of this approach with recovering persons, valuable information has been obtained. A well-planned, theoretically sound intervention couched in a commonly used treatment format did not yield the expected results. Therefore, researchers, practitioners and even theorists in the counseling profession should look to alternatives for successful relapse prevention among chemically-dependent persons.

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Author Alibrandi, T. (1978). Mcconaghy, N. , Armstrong, N., Blaszczynski, A., & Allcock, (1988). Caprio, F. & Berger, J. (1963). Clark, A. (1988). Clark, A. (1988). Clark, A. (1988). Donovan, D. M. & Marlatt, G. A. (1988). Rossi, E. L. & Ryan, M. 0. (1986). APPENDIX A Rationale for Interventions Findings Instrument This author stated that relaxation is ALI useful as a therapeutic tool with alcoholic inmates to decrease tension which leads to unmanageable states of being and, therefore, relapse (p. 105). Research results addicts strongly intervention not implications for (p. 371). using imagery with gambling suggested that this only is effective but has after-treatment effects These authors emphasized the subconscious nature of excessive drinking and used imagery to reduce cravings (p. 54). This author stressed the importance of counseling techniques to help addicts to change old habits and attitudes which lead to stress and conflict (p. 12). ALI HSLI JSDQ HAT ALI ALI HSLI JSDQ HAT This author stressed the importance of self JSDQ disclosure so as to restructure the addictive thinking. (p. 18) . This author stressed the importance of help-seeking behavior so as to restructure the addictive thinking (p. 18). These authors pointed out that situational factors in relapse involve high-risk times to include social pressure, thus signalling a need to address lifestyle change, e.g., avoidance of "using" friends (p. 9.). Erickson reported success with the use of relaxation and imagery in the treatment of alcoholism. His approaches involved the use of strong behavioral controls and changes in the environment, using hypnosis 111 HSLI HAT HSLI HAT

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Marlatt, G. A. & Gordon, J. R. (1985). Gorski, T. T. (1989). Gorski, T. T. & Miller, M. (1982). Gorski, T. T. & Miller, M. (1982). Kinney J. & Leaton, G. (1987). Knudson, w. (1987}. Marlatt, G. A. & Gordon, J. (1985). Marlatt, G. A. & Gordon, J. R. (1985}. 112 in a supporting role (p. 62). These authors reported on the use of relaxALI ation techniques with addictive problems as HAT a way to weaken or extinguish the anxiety response. This form of detachment can be used to cope with the unmanageability that triggers urges and craving experiences (p. 317). This author explained that a trigger event HAT is any internal or external occurrence that activates a craving and that the first step is activation of obsessive thinking about the drug. Cognitive restructuring leads to necessary decision making about life style (p. 44, 79). These authors suggested that relapse could be minimized by behavioral management of stress and seeking reassurance from others (p. 31). These authors suggested that relaxation exercises can be used as a tool for neurological retraining and stress reduction (p. 35). These authors stated that a recovering person is likely to face a multitude of problems, one being a high level of anxiety. Some positive strategies to combat this state are guided imagery along with relaxation (p. 273). ALI HSLI ALI HSLI JSDQ HAT ALI HSLI JSDQ HAT This author stated that many addicts succomb HAT to relapse because of a failure to develop a healthy lifestyle (p. 25). These authors emphasized the use of cognitive reframing to provide the client with alternative cognitions concerning the nature of habit-change process, to introduce coping imagery to deal with urges and early warning signals, and to reframe reactions to the initial lapse (p. 53}. These authors used relaxation and exercise to strengthen the addict's overall coping capacity and to reduce the frequency and intensity of urges and craving that are ALI HSLI JSDQ HAT HAT

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Marlatt, G. A. & Gordon, J. R. (1985). Mccrady, B. , Dean, L., Dubreuil, E., & Swanson, s. (1985). Millham, P. & Mason, B. (1987). Siegel, B. (1986). Vaillant, G. (1983). Witmer, J. & Young, M. (1985). Witmer, J. & Young, M. (1985). Witmer, J. & Young, M. (1985). often the product of an unbalenced lifestyle (p. 53). The authors stated that future research may reveal that imagery techniques are a helpful adjunct to treatment with addictive behavioral problems, particularly for motivational enhancement or creative problem solving (p. 323). These authors point toward the importance of cognitive restructuring with addicts in changing low expectations of self and thus preventing relapse (pp. 417-471). These authors supported the use of imagery by addicts to achieve goals such as staying abstinent (p. 43). This author stated that visualization can change attitudes because it reprograms at an unconscious level (p. 159). This author viewed addiction as an uncon scious conditioned behavior, thus establish ing a linkage to the use of mental imagery to change the conditioned habits and thought processes (p. 179). 113 ALI HSLI JSDQ HAT ALI HAT ALI ALI HSLI JSDQ HAT ALI HSLI JSDQ HAT These authors viewed images as mental repALI resentatives of thought that enables one HSLI to problem solve and influence behavior. JSDQ This is important for addicts because it is HAT necessary to reconstruct maladaptive thinking and lifestyle behaviors (unpublished handout). These authors stated that mental imagery ALI helps to create plans for the future, to HAT anticipate outcomes and consequences (unpub lished handout). These are behaviors which addicts need to learn in order to prevent relapse. These authors say that mental imagery helps HAT persons to be more sensitive to the moods and needs of others (unpublished handout). This is a necessary component of the recovering person, the ability to empathize (Johnson, 1980).

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Ya lorn, I. (1985). This author stated that successful alcoholics self disclose and seek help (p. 7). 114 HSLI JSDQ

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APPENDIX B BRIEF WORKSHOPS AND THEIR EFFECTIVENESS Author Brantlinger, E. (1983). Crowley, C. A. Reference An attitude scale on sexuality and the handicapped was developed and field tested on subjects in contact with mentally retarded persons. In addition, some if the subjects, including 50 institutions and 59 group home employees, were provided with one-day attempt to influence attitudes in a direction more consistent with principles of normalization and respect for the human rights of handicapped citizens in residential care. The results indicated that the scale was sensitive to differences in attitude in a direction more consistent with principles of normalization and respect for the human rights of handicapped citizens in residential care. The results indicated that the scale was sensitive to differences in attitudes within and between groups and the sexuality training was effective in producing attitude change. This study examined the effects of a self-coping cognitive treatment for test anxiety. The study, also, compared this treatment delivered in a massed format (single day, six-hour workshop) and a spaced format (two, one-hour sessions per week for three consecutive weeks) ... A multivariate analysis of covariance found an overall significance between group difference. Analysis of variance found significance between group differences on each dependent measure. The Scheffe test for differences between means found significant difference between the control group and each treatment condition on each dependent measure. 115

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Evans , L.A. , Acosta, F. X. , Yamamoto, J. & Skilbeck, W. M. (1984) Giddon, N. s. & Rollin, S. A. (1975). Gillis, H. L. 1986) Gonzalez, G. M. & Hanley, M. L. (1990). Lavecchia, F. (1981). 116 Results suggest that a brief seminar and correlated reading materials can modify therapist behavior toward poor and minority patients and thereby produce more favorable therapeutic outcomes and higher patient satisfaction. Describes a one-day workshop ondrug education program development that combined didactic features with innovative group techniques to generate a practical list of needs, resources, and program for use in public schools. Workshop leaders used psychodrama as a vehicle for cognitive exploration of possible resources and obstacles to proposed drug education programs. A 10week follow-up indicated that most participants were involved in establishing programs. This research compared and contrasted the metaphorical introduction of physical adventure activities (group initiatives and ropes courses activities) with traditional introductions to the same activities. Two groups received metaphorical presentations (n=20) and two received traditional presentations (n=13) while each participated in one a-hour, outdoor enrichment experience ... The metaphorical group means were consistently higher than the traditional group 6 weeks following the experience but on only one measure were significant differences found between groups. A personality characteristic, dominance, demonstrated a significant times measure, within group interaction. These authors stated that in general, campus-based alcohol and other drug education efforts have involved general awareness campaigns, institutional policy changes, and short-term interventions such as workshops, referral activities, counseling, and academic courses. "This study evaluated the effectiveness of an Alcohol Awareness Program consisting of a one-day workshop and follow-up seminars on the knowledge,

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Maybruck, I. L. (1985). Morrison, J. K., Cocozza, J. J., & Vanderrwyst, D. (1980) Pike, M. M. (1981) 117 attitudes, and behaviors about alcohol use and abuse of pre-service teacher education students enrolled in a Freshman Early Experiencing Program, as they relate to significant others, and the professional role of teacher •.. Conclusions drawn from the study included that the Program was effective in raising participants' level of awareness ... " The purpose of this study was to develop a research based business communication strategy workshop for the management of home health services The findings indicated that a business communication strategy workshop should be presented. The workshop's objectives should be to improve communication and management system should consist of a one day workshop at a comfortable facility with the appropriate brochures, marketing, speakers with experience and credibility, handouts, audio-visual aids and opportunities for role playing and discussion. During a seminar, 38 college students were presented with information that contradicted their somewhat negative constructs of mental patients., Data analysis indicated that the 2 hour demythologizing seminar was effective in significantly reducing some of the Subject's negative constructs, as measured by the semantic differential, and that this change was stable on a 5week follow-up. The Treatment Group attended a one-day workshop on death and dying and filled out Templer 's Death Anxiety Scale pre workshop, immediately post workshop, one month and three-months post workshops ... The findings showed there was a significant differences in the Treatment Group's level of death anxiety at one month and three months after educational intervention, and there was a significant difference in death anxiety levels three months after the intervention between the Treatment Group and the Control Group.

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Schutz, W. c. (1971) Sheikh, A. A. (1989). Shorkey, C. T. & Whiteman, v. L. {1977). Siegel, B. (1986). 118 I used to offer once-a-week groups, daily groups, individual sessions, and a wide variety of patterns anywhere from two days to three years in length. These experiences led me to the conclusion that the depth that could be reached in a concentrated workshop was so remarkable compared to the other approaches that I have virtually abandoned all other patterns. I now feel that an intensive workshop experience combined with the constant availability of workshops, such as at Esalen, is the most effective path to realizing the human potential. This approach requires that an individual plan his own growth experiences and therefore applies the principle of individual responsibility to selecting what one needs in order to grow. This author designed an imagery exercise to slow heart rate and raise body temperature psychological changes that signify a relaxed state. In workshops, patients using this imagery have discovered that many of their minor stress-related health problems have disappeared within a few weeks. These researchers developed a brief and efficient instrument (the Rational Behavior Inventory) for assessment, treatment planning, and evaluation of clients by counselors who use Rational Emotive Therapy (RET). Pre-and posttest scores were obtained for a 40-mental health professionals attending an all-day workshop on RET. Overall test scores were significantly different at the 0.025 level in the predicted direction. There was also a significant difference in the predicted direction between pretest scores of the professionals and the college students. This physician reported that, in the Fall of1979, the participated in a Life Death Transition workshop run by Elizabeth Kubler-Ross. He further stated that drawings which he made as part of the workshop helped him to reach a deeper understanding of the powerful

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relationship between one's unconscious and one's emotional life. 119

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APPENDIX C ABSTINENCE LIKELIHOOD INVENTORY (ALI) Instructions: Most of us have had "triggers" which led us to 11 use. 11 To what extent was each of the following a reason to have your drug of choice in the past? Use a scale ranging from o to 9: O = highly unlikely to engage in the behavior 9 = highly likely to engage in the behavior. when you were tired when you were hungry when you were with a "using" person to whom you were sexually attracted when you were with a person or persons who you admired when you had a lot of money in your pocket when you were in or near your favorite bar or neighborhood when you were at a social gathering after work during work before 5 p.m. after 5 p.m. during the week during the weekend when you were depressed when you were lonely when you thought that life was meaningless when you were feeling hopeless when you were feeling difficult emotions such as guilt, hurt, anger, fear, or happiness during holidays when you were hung over when you had job problems when you had family problems when you were bored at work when you were bored at any time when you were reminded of the "good times" when you denied reactivated when you lost contact with a Higher Power when you had relationship problems 120

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APPENDIX D ELEMENT (OR ITEM} REFERENCE SUPPORT FOR THE ALI Item #1. Tired Author (s) Daley, D. (1986). Gorski, T. T. & Miller, M., (1986). Monahan, B. (1985). Reference Relapse Prevention Workbook, p. 15. staying Sober: A Guide for Relapse Prevention, p. 37. Relapse: A Process recovery, p. 8. Rogers, R. L. & Don't Help, p. 235. #2. Hungry #3. McMillan, C. S. (1989). Gorski, T. T. & Miller, M. (1986). Gorski, T. T. & Miller, M., (1986). Jellinek, E. M. (1960). Rogers, R. L. & McMillan, C. S. (1989). With Cunningham, T. (1986). attractive Daley, D. (1989). drinker Gorski, T. T. (1989). Larsen, E. (1985). 121 Staying Sober: A Guide for Relapse Prevention, p. 37. Staying Sober: A Guide for Relapse Prevention, p. 37. The Disease Concept of Alcoholism, p.85. Don't Help, p. 236. King Baby, p. 15. Relapse Prevention Workbook, p. 4. Professional Counselor, p. 79. Stage 11 Recovery, p. 37.

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122 #4. Admired Daley, D. (1986). Relapse Prevention Workbook, p. 5. #5. Money p.79. #6. In a bar #7. Social Daley, D. (1986). Tamminen, A. W., Smaby, M. H., Powless, R. E., & Gun, M. F. (1980}. Gorski, T. T. (1989). Nuckols, c. c. (1987). Nuckols, c. c. (1987). Daley, D. (1986). Daley, D. (1986). Monahan, B. ( 1985) . Relapse Prevention Workbook, p. 10. Counselor Education and supervision, p. 315. Professional Counselor, Cocaine, p. 79. Cocaine, p. 93. Relapse Prevention Workbook, p. 2. Relapse Prevention Workbook, p. 4. Relapse: A process recovery, p. 8. Rogers, R. L. & Don't Help, p. 228. McMillan, C. S. (1989). Trubo, R. (1989). Medical World News, p. 62. Boylan, J. c., Malley, Practicum and Internship P. B. & Scott, J. (1988) Textbook for Counseling and Psychotherapy, pp. 269-270. Daley, D. (1986). Gorski, T. T. & Miller, M. (1986). Rogers, R. L. & McMillan, C. S. (1989). Trubo, R. (1989). Relapse Prevention Workbook, p. 5. Staying Sober: A Guide for Relapse Prevention, p. 37. Don't Help, p. 228. Medical World News, p. 62.

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#8. "Lift" before work #9. "Lift" during work #10. 123 Boylan, J.C., Malley, Practicum and InternshipP.B. & Scott, J. (1988). Textbook for Counseling and Psychotherapy, p. 270. Alcoholics Anonymous World Services (1988). Hancock, D. c. (1982). Jellinek, E. M. (1960). Boylan, J.C., Malley, P. B. & Scott, J. (1988). Hamel, R. A. (1985). Hamel, R. A. (1985). Heilman, R. D. (1973). Hoban, P. (1989). AA A Message to Teenagers, p. 4. I Can't be an Alcoholic Because, p. 5. The Disease Concept of Alcoholism, p. 85. Pracaticum and InternshipTextbook for Counseling and Psychotherapy, p. 274. A Good First Step, p. 3. A Good First Step, p. 36. Early Recognition of Alcoholism and Other Drug Dependence, p. 11. Getting Clean A New Generation Fights Addiction, p. 44. "Lift" Daley, D. (1986). after Relapse Prevention Workbook, p. 7. work Hancock, D. c. (1982). Heilman, R. O. (1973). #11. I Can't be an Alcoholic Because, p. 5. Early Recognition of Alcoholism and Other Drug Dependence, p. 11. "Lift" Boylan, J.C., Malley, Practicum and Internship on P.B. & Scott, J. (1988). Textbook for Counseling and weekends Psychotherapy, pp. 269-271. Caprio, F. s. & Berger, J. R. , ( 1963) . Helping Yourself with Self Hypnosis, p. 85.

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Daley, D. (1986). Hancock, D. C. (1982). #12. Depress-Brody, J. (1989). ed Daley, D. (1986). Da 1 ey , D . ( 19 8 6 ) . Hancock, D. C. ( 1982) . Relapse Prevention Workbook, p. 7. I Can't be an Alcoholic Because, p. 7. AA Grapevine, p. 41. Relapse Prevention Workbook, p. 2. Relapse Prevention Workbook, p. 4. I Can't be an Alcoholic Because, p. 9. 124 Rogers, R.L. & McMillan, Don't Help, p. 229. c. s. (1989). #13. Lonely Daley, o. (1986). #14. Hancock, D. C. (1982). Gorski, T. T. & Miller, M. (1986). Gorski, T. T. & Miller, M. (1986). MeanDaley, D. (1986). inglessness Gorski, T. T. & Miller, M. (1986). Hamel, R. A. (1985). Wright, D. M. (1989). Relapse Prevention Workbook, p. 9. I can't be an Alcoholic Because, p. 9. Staying Sober: A Guide for Relapse Prevention, pp. 5859. Staying Sober: A Guide for Relapse Prevention, pp. 64. Relapse Prevention Workbook, p. 9. Staying Sober: A Guide for Relapse Prevention Workbook, pp. 58-59. A Good First Step, p. 36. p. 9. Personally Speaking: Behind the Label "Alcoholic," pp. 482-483.

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#15. Hope less #16. Feel ings #17. Holi days #18. Hang over Daley, D. (1986). Gorski, T. T. & Miller, M. (1986). Gorski, T. & Miller, M. ( 1986) . Jellinek, E. M. (1960). Daley, D. (1986). Gorski, T. T. & Miller, M. (1986). Hancock, D. c. (1982). Monahan, B. (1985). Boylan, J. C., Mallery, P.B. & Scott, J. (1988). Daley, D. (1986). Donovan, D. M. & Marlatt, G. A. (1988). Goodwin, D. W. (1988). Chamberlain, c. A. (1984). Relapse Prevention Workbook, p. 4. 125 Staying Sober: A Guide for Relapse Prevention, p. 50. Staying Sober: A Guide to Relapse Prevention, p. 59. The Disease Concept of Alcoholism, p. 85. Relapse Prevention Workbook, p. 2. Staying Sober: A Guide for Relapse Prevention, p. 59. I Can't be an Alcoholic Because, p. 9. Relapses: A Process recovery, p. 8. Practicum and Internship Textbook for Counseling and Psychotherapy, pp. 269-271. Relapse Prevention Workbook, p. 2. Assessment of Addictive Behaviors, pp.460-461 Is Alcoholism Hereditary? p.59. A New Pair of Glasses, p. xii Jellinek, E. M. (1960). The Disease Concept of Alcoholism, p. 85. Milam, J. R. & Ketcham, Under the Influence, p. 66. K. (1988).

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#19. Job #20. Family #21. Work #22. Bored Springborn, w. (1983). Boylan, J. c., Malley, P.B. & Scott, J. (1988). STEP One: The foundation of Recovery, p. 3. 126 Practicum and Internship Textbook for Counseling and Psychotherapy, pp. 269271. Jellinek, E. M. (1960). The Disease Concept of Alcoholism, p. 85. Monahan, B. (1985). Springborn, W. (1983). Relapse: A Process recovery, p. 8. STEP One: The Foundation of Recovery, p. 3. Boylan, J. c., Mallery, Practicum and Internship P.B. & Scott, J. (1988). Textbook for Counseling and Psychotherapy, p. 270. Goodwin, D. w. (1988). Is Alcoholism Hereditary? p. 59. Hamel, R. A. (1985). A Good First Step. p. 36. Jellinek, E. M. (1960). The Disease Concept of Alcoholism, p. 85. Springborn, w. (1983). STEP One: The Foundation of Recovery, p. 3. Goodwin, D. w. (1988). Daley, D. (1986). Daley, D. (1986). Daley, D. (1986). Gorski, T. T. (1989). Hancock, D. c. (1982). Is Alcoholism Hereditary? p. 193. Relapse Prevention Workbook, p. 7. Relapse Prevention Workbook, p. 2. Relapse Prevention Workbook, p. 4. Passages Through Recovery, p. 100. I Can't be an Alcoholic Because, p. 10.

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127 #23. EuphorJohnson, Vernon (1980). I'll Quit Tomorrow, p. 43. ic recall #24. Denial #25. No H.P. #26. Rela tion ships Kinney, J. & Leaton, G. (1987). Knudson, W. A. (1987). Loosening the Grip, p. 156. Relapse: The Myth Behind the Stigma, p. 26. Boylan, J.C., Malley, Practicum and Interniship P.B. & Scott, J. (1988). Textbook for counseling and Psychotherapy, p. 272. Gorski, T. T. (1989). Passages Through Recovery, p. 21. Johnson, Vernon (1980). I'll Quit Tomorrow, p. 112. Chamberlain, c. A. (1984). Donovan, D. M. & Marlatt, G. A. (1988). Larsen, E. (1985). Selby, S. (1985). A New Pair of Glasses, p. xii Assessment of Addictive Behaviors, pp. 460-461. Stage Two Recovery Life Beyond Addiction, p. 73. A Look at Cross-Addiction, p. 12. Boylan, J. c., Malley, Practicum and Internship P.B. & Scott, J. (1988). Textbook for Counseling and Psychotherapy, p. 272. Daley, D. (1987). Hamel, R. A. (1985). Jellinek, E. M. (1960). Trubo, R. (1989). Relapse Prevention Workbook, p. 2. A Good First step, p. 36. p. 67. The Disease Concept of Alcoholism, p. 85. Drying Out is Just a Start Alcoholism, p. 62.

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APPENDIX E HELP-SEEKING LIKELIHOOD INVENTORY (HSLI) Instructions: Most of us need help from time to time with our recovery program. Please respond to each of the activities listed below to indicate your likelihood to engage in each of the Behaviors listed. Use a scale ranging from Oto 9: o = highly unlikely to engage in the behavior. 9 = highly likely to engage in the behavior. Seek help from: ------a friend in recovery ------anyone else ------your best friend ------your sponsor ------a parent ------some type of reading ------another family member ------the same sex frien ------the opposite sex frien ------a family physician ------a Higher Power ------a mental health worker ------a psychiatrist or psychologist ------a member of the clergy ------a relative ------myself (work it out on my own) ------an employer ------an AA &/or an NA meeting a spouse other (please specify) 128

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Item #1. Friend #2. Anyone else #3. Best friend APPENDIX F ELEMENT (OR ITEM) REFERENCE SUPPORT FOR THE HSLI Author(s) Crewe, c. W. ( 19 8 6) . Da 1 ey, D . ( 19 8 7 ) Dunn , R. ( 19 8 6 ) Sheeren, M. (1985). Trubo, R. (1989). Beattie, M. (1986). Daley, D. (1987). Reference A Look at Relapse, p. 7. Relapse: A Guide to successful Recovery, p. 17. Relapse and the Addict pp. 2 & 3. The Relationship between Relapse and Involvement in Alcoholics Anonymous, p. 106. Medical World News, p. 56. Denial, p. 19. Relapse: A Guide for Relapse Precovery, p. 6. Gorski, T. T. & Miller, Staying Sober: A Guide M. (1986). for Relapse Prevention, p. 122. Kinney, J. & Leaton, G. Loosening the Grip, (1987). p. 156. Daley, D. (1987). Relapse: A Guide to Successfull Recovery, p. 6. Gorski, T. T. & Miller, Staying Sober: A Guide (1986). for Relapse Prevention, p. 12 2. 129

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#4. Sponsor #5. Parent #6. Reading Gorski, T. T. (1989). Passages through Recovery, p. 96. 130 Alcoholics Anonymous Living Sober, p. 24. World Services (1979). Alcoholics Anonymous Living Sober, p. 26. World Services (1979). Hoban, P. (1989). Getting Clean A New Generation Fights Addiction, p. 43. Larsen, E. (1985). Stage Two Recovery Life Beyond Addiction, p. 70. Sheeren, M. (1985). The Relationship between Relapse and Involvement in Alcoholics Anonymous, p.105. Dunn, R. (1986). Relapse and the Addict, p. 10. Gorski, T.T., & Miller, Staying Sober: A Guide M. (1986). for Relapse Prevention, p. 122. Milam, J. R., & Ketcham, K. (1988). Alcoholics Anonymous World services (1976). Daley, D. (1987). Hoolihan, P. (1984). Sheeren, M (1985). Under the Influence, p. 125. Alcoholics Anonymous, p. 87. Relapse: A Guide to Successful Recovery, p. 17. Stress and Recovery, p. 13. The Relationship between Relapse and Involvement in Alcoholics Anonymous, pp. 104-105.

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#1. Family Member #8. Same Gender Friend #9. Opposite Gender Friend #10. Physician Daley, D. (1987). Dunn , R . ( 19 8 6 ) . Relapse: A Guide to Successful Recovery, p. 32. 131 Relapse and the Addict, pp. 2 & 3. Gorski, T.T., & Miller, Staying Sober: A Guide M. (1986). for Relapse Prevention, p. 122. Milam, J.R., & Ketcham, Under the Influence, K. (1988). p. 125. Alcoholics Anonymous World Services (1976). Daley, D. (1987). Dunn, R. (1986). Gorski, T. T. (1989). Johnson, v. (1980). Kinney, J., & Leaton, G. (1987). Kinney, J. & Leaton, G. (1987). Milam, J. R. & Ketcham, I<. (1988). Sisson, R W., & Ayzin, N. H. (1989). Wilson, w. (1958). Alcoholics Anonymous, pp. 147-148. Relapse: A Guide to Successful Recovery, p. 31. Relapse and the Addict p. 6. Passages through Recovery, p. 96. I'll Quit Tomorrow, p. 125. Loosening the Grip, p. 210. Loosening the Grip, p. 337. Under the Influence, p. 128. In Handbook of Alcohol Treatment Approaches, p. 243. Three Talks to Medical Societies, p. 6.

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#11. Higher Power #12. Health Worker #13. Psychol ogist #14. Clergy #15. Relative Daley, D. Dunn, R. Vaillant, Clark, A. Hoolihan, (1987). (1986). G. (1983). (1988). P. (1984). Relapse: A Guide to Successful Recovery, p. 34. 132 Relapse and the Addict, pp. 2-3. The Natural History of Alcoholism, p. 194. Surrender to Win, p. 12. Stress and Recovery, p. 13. Milam, J. R. & Ketcham, Under the Influence, K. (1988). p. 151. Small, J. ( 1982) Alcoholics Anonymous World Services (1976). Hoolihan, P. (1984). Becoming Naturally Therapeutic, p. 97. Alcoholics Anonymous, p. 18. Stress and Recovery, p. 13. Milam, J. R. & Ketcham, Under the Influence, K. (1988). p. 125. Wilson, w. (1958). Alcoholics Anonymous World Services (1976). Kinney, J., & Leaton, G. (1987). Kinney, J., & Leaton, G. (1987). Daley, D. (1987). Gorski, T. T. (1989). Three Talks to Medical Societies, p. 6. Alcoholics Anonymous, p. 87. Loosening the Grip, p. 265. Loosening the Grip, p. 267. Relapse: A Guide to successful Recovery, p.34. Passages through Recovery, p. 100.

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#16. Self #17. Employer #18. AA/NA 133 Gorski, T.T., & Miller, Counseling for Relapse M. (1986). Prevention, p. 77. Hoolihan, P. (1984). Stress and Recovery, p. 12. Alcoholics Anonymous Living Sober, p. 50 World Services (1975). Hoolihan, P. (1984). Johnson, V. (1980). Kinney, J., & Leaton, G. (1987). Stress and Recovery, p. 13. I'll Quit Tomorrow, p. 112. Loosening the Grip, p. 212. Milam, J.R., & Ketcham, Under the Influence, K. (1988}. p. 151. Alcoholics Anonymous World Services (1976). Alcoholics Anonymous, pp. 144-145. Gorski, T.T., & Miller, Counseling for Relapse M. (1986). Prevention, p. 122. Milam, J.R., & Ketcham, Under the Influence, K. (1988}. p. 126. Alcoholics Anonymous Services (1984). Crewe, c. w. (1974). Hoban, P. (1989). Monahan, B. (1985). The AA Member Med ications and other Drugs, p. 4. A Look at Relapse, p. 10. Getting Clean A New Generation Fights Addiction, p. 42 Relapse: A Process Recovery, p. 8.

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#19. Spouse Sheeren, M. (1985). Alcoholics Anonymous World Services (1976). Daley, D. (1987). Daley, D. (1987). Johnson, V. (1980). The Relationship between Relapse and Involvement in Alcoholics Anonymous, pp. 104-105. Alcoholics Anonymous, p. 111. Relapse: A Guide to Successful Recovery, p. 16. Relapse: A Guide to Successful Recovery, p.18. I'll Quit Tomorrow, p. 125. 134

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8:30 9 APPENDIX G DESCRIPTION OF TREATMENT The facilitator (f) will meet this writer and review any last A.M. minute A.M. details. The f will become acquainted with the facility and ask any last minute questions. At 8:45, the f will go to the reception area and greet the participants with a smile by saying, "Good morning, I'm and I'd like to welcome you to the workshop-.-We'll begin at 9 o'clock. Please make yourself comfortable." He then asks one of the early arrivers to go downstairs and directs the others to the workshop area upstairs. He then goes on to greet other participants as they enter. At 9 o'clock, the f makes an announcement, "Please join me in the group room," and waves his hand for all to follow. Orientation. As people enter the group room, the facilitator (f) will say, "Please take a chair or sit on the floor or on a pillow it you brought one. Make yourself comfortable." After everyone is seated the f says, "Welcome to the Day of Abstinence Workshop. we will be enjoying this group until five p.m.today. I would now like to cover some 'administrivia.' The bathrooms are in the reception area. Peel free to leave when the need arises but keep in that the exercises that we will do work batter if you can be here for their entirety. This is very important. Every one of us will need to help achieve this goal. Therefore, please be present from the start of any exercise to the finish. There is no smoking in the building but you can smoke outside. There'• also a refrigerator in the reception area. Also, please be aware that this group is confidential. Please do not mention anyone else's name outside ot this room. Next, be aware that time is important and that some of the exercises will be timed. Please follow my direction regarding time but feel free to share your thoughts. Lastly, I want you to feel safe and comfortable and plan to take the to create this atmosphere. we want your experience of this workshop today to be casual. Take your shoes oft if you want, relax, and enjoy the day." At this point, the f smiles and, as he hands out the name tags, says, "Here are your name tags. Please write your names on them, and put them on your shirts or tops where they are visible. Here are some magic markers." The f pauses for two minutes while name tags are written. 135

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9:05 9:10 9:00 9:05 9:10 9:15 9:30 136 Questions are now solicited. "We have about five minutes to ask questions or give comments? Are there any?" If no one responds or after comments are made, the f tells a joke, "Here's a joke for you. Why do Al-Anons and Nar-Anons make love with their eyes closed? {Pause for two seconds) Because they can't stand the sight of their spouse having a good time." and encourages ones from the participants (p) by asking, "Does anyone have a joke?" The f takes a maximum of five minutes for this. If questions about the agenda are asked, the f answers in the best way he knows. If questions about the content of the day are asked, the f states that "These will be addressed throughout the day and it is important that we move on to the activities. Many of your question• will be answered as the day progresses. Thank you for your patience." The agenda is explained by the f. He says, "Now I'd like to explain the agenda for the day. It's like the soup of the day which reminds me of a story. I was in a restaurant the other day and asked the waiter what the soup de jour was. Be said it was the soup of the day. (Pause for laughter) At any rate, the purpose of this workshop is to enhance the quality of your recovery programs so as to prevent relapse. In general, the day will look much like this: In just a few minutes we will begin an exercise during which we'll meet the other group aembera. Following this, I'll talk about relaxation and do a brief exercise. After a question and answer period we'll do a mental imagery exercise followed by a debriefing period. At noon we'll have lunch and then a short walk. In the afternoon we'll have four mental imagery exercises, each followed by a debriefing. There will be on 10 minute break in the morning and one in the afternoon. At 4:30 sharp we will fill out the paperwork. This will be a full day and I want to keep my commitment to be finished by S:OO." The f then reads the agenda verbatim saying, "In closing, I'll now read the agenda word for word. We've written it out and it goes like this:" {The f reads the following) (APPENDIX H) Agenda orientation and name tags Question and comment period Review of agenda Milling exercise Introductions

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10:15 10:20 10:30 10:40 11:00 11:15 11:30 11:35 11:50 11:58 Noon 1:00 1:20 1:22 1:30 1:45 2:05 2:25 2:45 3:00 3:20 4:00 4:05 4:10 4:20 5:00 9:15 9:30 137 Lecture and brief demonstration of relaxation exercise Question and answer time Break Relaxation exercise Process relaxation exercise Lecture on the benefits of relaxation Lecture on mental imagery (M.I.) Mental imagery exercise -(four dependent variables) Process mental imagery (on the four variables) Lunch and walk instruction for variables Lunch Walk Greeting and review of last mental imagery and relapse prevention Discussion -mutual goal setting M.I. exercise on help-seeking behavior (hsb) (cassette tape) Process M.I. (hsb) M.I. exercise on self disclosure (sd) (cassette tape) Process M.I. (sd) Break Discussion and M.I. exercise on unmanageability/powerlessness (pwls) (cassette tape) Process M.I. (pwls) Exercise M.I. exercise on Lifestyle Change (ls) (cassette tape) Process M.I. (ls) Posttest End of workshop -dismissal The f then says, "Now I'd like to move on to the next activity." Milling exercise. The f then says, "Now I would like for you to take two or three minutes and mingle with your fellow group members. Just walk around and 'touch base' with people. Say hello or shake hands with at least 10 others. In addition, choose someone from the group who you want to know better and think you could talk with about yourself. I'll ask you to spend time with this parson later. say hello and remember the person's name and face. I'll let you know when the time is up." The group begins to mingle. After two minutes the f says, "Time." Introductions. The f says: "I'd now like you to introduce yourselves briefly by giving your name and the name that you prefer to be called. Then I'd like you to tell us why you decided to attend this workshop and what you hope to accomplish today for your recovery. Please begin whenever you are ready."

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138 The f waits for 30 seconds until a participant speaks up and decides to volunteer and, if no one does so, he calls on people. He asks for a name if the person fails to state their name and waits until they give a reason for being present at the workshop and a goal. Should either of the latter two not be given, the f asks the person to tell him why she or he has come to workshop and what they expect from the day. When the person is finished speaking or when two minutes have passed the f then asks if she or he is satisfied with their response and solicits the next person by saying the word 'Next.' Should participants fail to respond correctly an example will be given: "For example, my name is Kika, and I'm here to learn more about recovery and how to stop isolating so much." No feedback is given at this point but, should the participant choose not to respond the f says, "That's fine. Be here for yourself and the others. Thanks." IYalom (1985) claimed that the initial stage of a group orientation, was vital to the life of the group and that this stage could be facilitated by the members' introductions. Marlatt (1985) thought that autonomy was an important characteristic for change to occur. I 10:15 Lecture on relaxation exercise. The f will define and describe relaxation as follows: "Relaxation has been widely accepted as beneficial to recovering parsons. The concept has been around for many years and is easy and effortless to learn. The idea is that it is difficult to be thoughtless and tense at the same time. Therefore, we shall attempt to relax by listening to a cassette tape narration. The relaxation exercise consists of breathing directions and imagining a stressless visit to a atreasless place." 10:16 Demonstration of relaxation exercise. The f will say, "Now I'm going to play a relaxation tape for you. This has been prerecorded. The tape will have specific instructions. Please follow these to the best of your ability. Relax and enjoy the tape." The f begins the tape and stays in the room. The tape begins, "Bello, I'm going to take you through a relaxation experience. Simply follow my voice and enjoy yourself. Thank you for being a part of this experience. Begin to unwind by telling yourself that you're now going to slow down. Relax and take a deep breath. Great! Lat yourself release all of your tension by breathing in and out -in and out. Breathe in fresh air and breathe out

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139 tension. Good! Do this tvo or three times nov" (Pause for five seconds) After five seconds say, "Good, nov pay attention only to your breathing. Breathe normally and pay attention only to your breathing. In and out. Good: Next, in your mind, go to a safe place that you either have been to or might want to visit. This could be the beach or the woods or any place of your choice. Look around and enjoy the peacefulness. Nov come back to the room as I count to five and realize that it will be a little lighter in the room as you come back. 1, 2, 3, 4, 5. Good." The f turns off the tape and waits until all have opened their eyes. 10:20 Questions and comments are solicited. The f will say, "I'd now like you to pair up with someone and share your experience. Choose anyone in the room besides me and sit together. Tell what it was like for two minutes and I'll say at the end of tvo minutes. Then switch and listen to the other person for tvo minutes. I'll say atop at the end of another tvo minutes. Now begin." At the end of two minutes, the f says, "Stop. Now switch." At the end of another two minutes, the f says, "Stop. Nov I'd like for us to go around the room and talk about the exercise. Take a couple of minutes and describe your partner's experience. First, ask him or her if that is alright to do. If not, share YQY1: experience. Now let's start on this side of the room (f points to the person on his left) "Would you start?" If the person says no or indicates that he or she would rather wait or pass, the f asks the next person to share. The f asks people until someone he chooses begins to share or someone else volunteers to share by raising his or her hand or begins to speak. Probing questions are: "Was your (or your) experience pleasant or unpleasant?" "Would you share your partner's (or your) experience?" "Could they (or you) relate to the imagery?" After two minutes the f says, "Thank you for sharing. Nov hear from the next person." He then turns to the next person and asks him or her to share using the same probes. "If the first person agrees to talk, he follows the same procedure. After one-half hour he stops the exercise and thank the members. :Gazda (1982) suggested the use of "probes" to motivate group members in sharing their experiences.I 10:30 Break. The f will say, "Now let's break for 10 minutes. I'll call you back in." After 10 minutes, the f goes outside and says, "Come back in please."

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140 10:40 The f says, "Welcome back. Nov I'd like to have a discussion group and a brief lecture. I'll talk to you for a while about letting go of negative thoughts, then I want you to participate. To begin, I'd like you to relax while I talk for a while. Keep in mind that this is a safe atmosphere and that ve are all in this together. Nov agree to do aoaething special. I'd like you to make a commitment to yourself. It goes like this. When I aay to begin, I want you to take every negative thought that you're ever had and mentally make a note of th-. It doesn't matter whether you know all of these negative thoughts. Simply begin to access them and be aure to focus on the negative thoughts that you've had about yourself. some examples are, 'I'm not good enough.' never be able to stay clean.' 'It is impossible for me to do so.' 'I'm a loser.' Now go ahead, write these down." The f hands out note pads and pens and says, "Ok, now begin." (Pause for one minute) After one minute, the f says, "Ok atop. If you're not done, take about 10 aeconds and write a aentence that represents all of your negative thought• about yourself, something like, 'This sentence represent• all my self-negativity."' The f pauses for 10 seconds, then says, "Nov say these things to yourself after me. I'll pause after each sentence. 'I've learned to put myself down sometimes.' 'I have to be right all of the time.' 'I'm not very smart."' (Pause for five seconds) "'I learned this as a child.'" (Pause for five seconds) "'I learned these things from others who probably didn't like a part of themselves and passed it on to me.'" (Pauses for five seconds) '"I forgive them.' 'I forgive ae.'" '(Pause for five seconds) "'I promise never to put myself down again."' (Pause for five seconds) '"Putting myself down doesn't help me.' Nov I'd like you to take your list of negative things and tear it up, crumple it, destroy it in any way you want, and let it go. These negative things are harmful to recovery and, now that you've accessed them, are easily released. Please destroy them now. I'll pause for a few moments. The wastepaper basket is in the corner." (Pause for 30 seconds) "Ok. Please return to your seats. Thanks." 11:00 Relaxation exercise. The f will say: "Let'• again by doing another relaxation. This will involve another tape. Again, the tape will have specific instructions. Please let this guide you through the exercise. Relax; enjoy the tape. Please take a deep breath and begin to relax. Breathe in through your nose and out through your mouth. Remember that

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141 there is no right way to do this and that you can take your time. we don't have to do this perfectly. Now take a couple more breaths and relax." (Pause for three seconds.) "Next, choose a word that you can associate with your relaxation. It can be any word, just so long as it's yours. I want you to use this word when ve do more exercises today. It will serve as a way to enter a relaxed state because you can associate this word with a cal.JR state. Use this word throughout your relaxation experience. Bow slowly go deeper into a relaxed state, deeper and deeper. Nov let go of any tension in your body as you become and more relaxed. Go to a place where you feel safe." (Pause for two seconds) "Look around and see the beauty, feel the warm air, hear the beautiful sounds. Nov think of a special word. If you don't have one yet, use your name or the word love or peace or a name or an object that you think is special, maybe your favorite person, or animal, or lake. Say the word as you feel more and more relaxed. Nov spend about a minute doing whatever you want in your special place. I'm going to stop talking and let you relax. I'll say 'stop' in one minute and then I'll count from five to one and then I'd like you to come back to the room on one and open your eyes." Pause for one minute. After one minute, the f says, "Stop. s, 4, 3, it'll be lighter in the room, 2, 1. Open your eyes. Good." The f turns the tape off and then waits until all of the participants have opened his or her eyes and then says, "Good!" jBandler and Grinder (1979) suggest the use of anchors to facilitate learning. !Jacobson (1929) advocated the use of relaxation which included muscle relaxation.: 11:05 Process relaxation exercise. The f will ask the group to take 10 minutes to talk about this exercise. If the group volunteers, the f will listen and not give feedback but will say, "Thank you" after each participant has shared. Should the group have difficulty the following questions will be asked: (a) "Could you notice a difference in your state of relaxation?" (b) "Was this pleasant or unpleasant?" (c) "What was the value of this exercise for you?" 11:15 Lecture on the benefits of relaxation exercises. The f explains the benefits of relaxation in combination with imaging and thought reconstruction in relation to relapse prevention. The f says, "We all have the power to create our reality. This within reach. The technique of relaxation along with imaging or picturing images in our minds and

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142 positive thinking can greatly enhance our ability to stay sober and clean and lead us to better living. By using imagery we can be guided through an experience as if it were actually happening. I plan to guide you through experiences in which you can positively create favorable endings. Your imagination will be used to create new and different ways of finding peace of mind, confidence, aecurity, and whatever other qualities you want to enhance. The imagery will be personalized. Be aware that your experience may vary from the experience of others. This is fine. simply know that you are growing and learning more effective of living, whether it be a change in your daily routine, attitudes, peace of mind in recovery in general, or relationships. we are using relaxation along with imagery because it is important for the mind to be relaxed in order for the imagery to be useful. We are reaching the unconscious mind where your most powerful learning can be instilled. The mind must be relaxed to do this. However, let the ezperience be unpressured. You can simply let it happen without much effort. Even if you lose track of what we are doing, it's ok. The process will happen anyway." jSheikh (1989) has used this explanation of mental imagery. Richardson (1969) has used a similar explanation of their relaxation and imagery training. j 11:30 Lecture on mental imagery. The f says, "Mental imagery is a form of vivid picturing in your conscious mind and holding that image until it sinks into your unconscious. When this concept i• applied, it can help you to solve problems, strengthen your personality, improve your health, and greatly enhance your chances for success in any endeavor. are using the relaxation technique along with mental imagery to produce a powerful relapse prevention experience." 11:35 Mental imagery. The f conducts (via cassette recording) a mental imagery exercise aimed at helping the subjects access their thoughts and feelings when they consider (a)asking for help in recovery, (b) verbalizing about personal problems, (c) evaluating their ability to overcome relapse triggers, and (d) evaluate their willingness to practice a healthy lifestyle. The f says, "We are now going to have another relaxation exercise which also involves seeing yourself being able to confidently turn down your drug of choice. Again the tape will have specific instructions to follow." Now I would like

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143 you to again relax. Think of your special word that you said when you were very relaxed in the last relaxation exercise. Relax. Breathe in through your nose and out through your mouth two or three times. Good! Now, as you begin to relax more and more, imagine that you are on an escalator slowly going down and, as I count from 10 to 1, I want you to recognize your body relaxing more and more. How relax. Good! (Pause for five seconds) 10, ,, a, 7, 6, good, 5, relax 4, 3, good, 2, 1. That'• great! I want you to realize that, although you're probably very relaxed already, you are still very auch in control. You are now more alert than you usually are. How imagine the word that you use to relax. Now feel yourself sinking into the rug or pillow. Feel the rug supporting you. Let yourself go to this relaxed state. Good! Remember that there'• no right way to do this. Your way is excellent. Nov I'd like you to imagine what it's like for you to ask for help. sea yourself asking someone to 'be there for you' when you're feeling concerned about something. Do you do this freely or is it difficult? Look again. Bow does it feel? Ia it pleasant or unpleasant? Maka it a pleasant experience. Now let's move on. Relax. Sea yourself overcoming soma of the old triggers. Saa yourself being able to avoid using or drinking in these situations? These situations are different for us all. Yours are private and may be different from the of others. Bow do you feel as these present themselves? Remember that whatever you are feeling is fine. Your feelings are yours. Bow do you feel as these triggers present themselves? I would like you to imagine that you are a powerful animal who possesses tremendous strength. Maka this experience a positive one. You are that powerful." (Pause for three seconds) "Next, imagine yourself talking about yourself with a friend or at a meeting. Sae yourself telling your story to a group. Bow does this feel? What are your thoughts? Ara they positive or negative? Imagine that you have a herd of Buffalo inside of you instead of butterflies. Use this confidence and commitment to refuse to use. Feel the confidence." (Pause for three seconds) "Next, imagine yourself practicing a healthy lifestyle. This includes good nutrition, exercise, attendance and participation at AA/NA meetings, good relationships, career satisfaction. Do you feel like you want to do these things? What are your feelings and thoughts as you imagine doing these things? Are there barriers? What is it that you say to yourself about these things? create a positive experience by gently

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144 thinking and acting in a manner which helpful to your sobriety/clean time. If your were unpleasant, do not acknowledge thea. Simply aove on to create a situation which is in your best interests. Imagine that you are an athelete. Imagine that you are someone whom you think wonderful. This can be yourself or a mentor or a coach, sponsor, or parent. Relax. You're doing fine." (Pause for three seconds) "Nov I will count to five and at five I want you to come back to the room very slowly. Remember that it will be a little brighter in the room. You will feel refreshed and ready to continue working. 5, 4, 3, 2, 1. Ok, now open your eyes." When everyone has opened his or her eyes, the f says, "Good!" 11:50 Process. The f will explain that, "Th• negative thoughts represent lack of confidence, fear of success/failure, or simply habits that were learned. These are ways to refuse to act in our best interests and are your personal relapse triggers. Simply put, if you refuse to do these things, you have a higher chance of relapse. Conversely, if you do things, you have a good chance of staying clean and sober. You can easily alter the negative experiences." The f will then ask the following questions and call for volunteers. If time is limited, the f will ask three people to share and say, "Thank you" after each has shared. If none volunteer, he will call on the first person to his left and proceed in the direction until all have had an opportunity to speak. If asked, he states that, "It is alright to pass." If anyone has difficulty speaking, he encourages them by asking, the experience pleasant or unpleasant?" Further probes are: "Is it difficult to talk?" "Should I come back to you?" "Are you shy?" (a) "Were your thoughts positive or negative in the 4 areas?" (b) "Which ones?" (c) "Would you like to change your negative thoughts?" 11:58 The f says, "Ok. Now please take one hour for lunch and eat with the special person who you would like to get to know better. Please talk about the imagery exercise and share your experience with the other person. In addition, choose a meal or at least one food that is good for you, one that you may not ordinarily eat but that is good for you. Take a minute as you order to acknowledge yourself for treating your body and mind well. I would like to meet at 1:00 outside of the building near the front door and take a brief walk before resuming this

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NOON 1:00 1:20 1:22 145 afternoon. Therefore, we'll all meet outside of the building at 1:00. There are places to eat that are nearby, especially on semoran Boulevard. Zf you brought a lunch you can eat it here. (The f is enthusiastic) You are all doing great! See ya at one." :Gorski (1989} emphasized the importance of the use of community in effecting change. Schutz (1971) stressed the concept of telling our negative thoughts to another in order to let go of them.: LUNCH The group meets outside of the building. The f says, "I hope that you had a good lunch. We're nov going to take a brief walk. If you go to the end of the driveway, turn left, and cross the street, you can go around the block. This should take about 10 minutes. Please choose a walking partner with whom you're comfortable. You can use your lunch partner if you so choose and walk with him or her. I'd like you to tell that person exactly what got you into recovery. Talk about 'what it was like.' Tate about five minutes and then switch. By that time you'll be back to the building. Walk right in and we'll regroup." :Milam and Ketcham (1988) pointed out the importance of exercise in recovery. Small (1982) claimed that telling another about the problems while "using" was important in order to remain abstinent. Back in the group room the f emphasizes the goals for the day, lowers his voice, speaks slowly and methodically and says, "Good afternoon. Welcome back. I hope that your lunch was good. As a very brief review, the areas that we explored this morning are areas that are some of the major concerns in recovery. so, if we can learn to talk about our disease, reach out for help when distressed, change our lifestyles, and admit that we were powerless over our drug, we have a good chance of maintaining sobriety/clean time and of doing this somewhat comfortably." Discussion. The f says, "What do you think about this as the direction of today's workshop? Please give me your opinions, your thoughts, or your comments on this. Let's take about two to three minutes for this." The f listens to the input without any comments except to say, "Thank you" after each person. After the last person shares, the f moves on to the next exercise by saying, "Thant you. Let's move on."

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1:30 146 Negative thought discussion. The f says, "How imagine yourself in a situation or go back to when you now have finally realized that alcohol and/or drugs are taking over your life or certain areas of your life. Your choices are being partially or wholly decided by your use of drugs and/or alcohol. You have much strength and willpower in other areas but you are being controlled by a drug. You are strong enough to admit this and accept it because you see it as true. Ara these thoughts unpleasant? Are they unpleasant because they are untrue or are they unpleasant because they are offensive, signalling you that you are weak or immoral? Check this out honestly. Your disease is not immoral or founded on weak will. It is a problea like cancer, diabetes, or asthma. It requires treatment. The people who manage to succeed and become successful in recovery without having to return to this progressive downfall are ones who accept the reality that we become powerless over the substance. This powerlessness manifests itself in several different ways. Try to think of how this powerlessness looked in your life. sometimes we are powerless after the first 'hit' or drink. We continue even after we've said we will only drink one or take one bit or pill. We then dismiss it as 'no big deal' when actually we're not in control. This is our way of justifying being out of control. sometimes we miss an appointment or date or promise to be home for dinner or lunch or breakfast after we have made the commitment. we rationalize our thinking again with some excuse such as 'it was more important to talk with Jim or be at the bar,' or some such rationalization. We may have difficulty in keeping our promise to ourselves not to indulge on any given day or night. When we do so anyway, many times we reason that it was ok because we didn't have anything special to do that day or we say, 'it could wait.' we learn how to think in this manner. It justifies our using and is used to justify much of our behavior. It assists the disease as it justifies our destructive drinking and drugging behavior. It adds to our powerlessness. Next, I'd like you to access your thoughts about your disease. Are they negative or positive. Let's take a minute to let go of the negative thoughts. Later, we're going to replace these with positive ones. It's important to 'clean the slate' of the negative thoughts or else, when we attempt to replace them with positive thoughts, they simply cover up the existing negative thoughts. We're going to do this very quickly. Now, do you identify with the

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1:30 147 following? 'I'm a real jerk because I hurt wife, or my kids, or my girlfriend or boyfriend, or boss or my relatives, or my friends.' These are very norm.al thoughts to have after you've entered recovery. Don't judge them, simply admit and accept them. we all have these thoughts. They come from past experiences when ve harmed ourselves and others. We don't have to feel badly when ve have these thoughts. It is important to free ourselves from these thoughts. They hinder our recovery because they affect our self-esteem and keep us from asking for help, talking about our problems, admitting unmanageability, and changing our lifestyle. sometimes do not take care of ourselves in recovery because ve still think in negative ways. Choose to release these thoughts even if you haven't accessed them yet. This will still work. Take about 10 minutes and write them down and then tell them to someone in the room with whom you have connected. Feel free to pass and not do this exercise. However, if you do pass, you are agreeing to bang onto much worry, fear, anger, and guilt. Please agree to let these go." The f hands out paper and pens to all and says, "I'll time you while you talk to your partner. Take 10 minutes in all." After five minutes, the f says, "Time. I'll say time after five ainutaa and you can then pair up. Please pair up with your partner now and share your list. Remember that you both have a list so make sure to take turns. After five minutes, I'll say time and we'll be done. Nov begin." lLund {1990) has developed the above activity for use with recovering persons.: After five minutes, the f says, "Let's process this ' past exercise. We'll take about 10 minutes so please be brief. Who would like to go first?" If no one volunteers, the f will ask the person to his immediate left to begin and continue around the room until someone volunteers. After five minutes, he says, "Nov I would like you all to decide to lat go of any negative judgments about yourself whether you are aware of them or not. so, I want to do this one more time to make sure we've got it. Tell your partner that you now let go of any negative judgements that you have about yourself, especially those relating to your "using." Take one minute to do this. Now begin." After one minute, the f says, "Great! Thanks for doing that. You all are doing really good!" Mental imagery relating to help-seeking behavior. The f will say, "Next, we're going to do another exercise which is directed toward asking for help, an area

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148 which is very difficult for most of us. Again, I'd like you to close your eyes and relax and sink into the rug or chair or couch which you. Keep in mind that you can do this exercise at home or anywhere. However, avoid doing this while driving or while your attention is needed elsewhere. First breath two or three times in through your nose and out through your mouth. Goodl How relax and breathe out any tension you may feel. Sometime• we tension in the neck or chest or legs. Go to these spots and tighten them up as you inhale. Exhale and release the tension -release the tension; let it leave your body. Goodl Just let it happen. How, feel yourself, see yourself going down on an escalator as I count from 10 to 1. 10, 9, a, 7, you're doing great! s, 4, relax, 2, 1. How relax and think of the word which helps to relax you. Good! say this word a couple of times and lat it calm you down." (Pause for five seconds) "Hext, I want you to conquer some of your triggers. Triggers are events or people which make you want to use. I want you to practice saying no to your drug of choice. Imagine yourself in a situation when you could easily drink and/or drug. Take a couple of minutes to do this. Close your eyes and go to a place where there may be drugs or alcohol. Practice refusing your former drug of choice. Be sure to feel your recovery strength and support from others and visualize the place with its sounds, smells, tastes. When asked to use, simply say, 'no, I've bad enough.' Feel free to use your own situation if you choose. Now begin." Pause for two minutes. After two minutes, say, "Now, the logical course of action is to seek help from someone who is more adept at sobriety. This could be your sponsor or God or an AA group or NA group or a parent, friend, anyone. The important thing is to become aware of your powerlessness and the need to ask for help. Now remember to whom you turned and visualize the experience. To whom did you go when you wanted to get clean/sober? Was it a priest, friend, did you call AA? Visualize this for a few minutes. Nov begin." Pause for three minutes. After three minutes, say the following with inspiration, "Nov, I want you to take the judgment out of asking for help if you judged it. If you didn't, just go along with the exercise in your own way and redo it with more acceptance. If you judged the experience remember that it's wise to ask for help with an addiction that renders its victims powerless. Reassure yourself that asking for help is smart and a sign of strength. Be strong enough to value your willingness to live.

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1:45 2:05 149 Next, picture yourself asking for help in other circumstances. After we become abstinent, we no longer turn to our drug for comfort. must reach out for people instead of drugs and alcohol. Now go back to the same scene and redo it without judging yourself. See yourself asking for help from others. Picture this event. Condone it. Give yourself loving permission to do so. Try this for two to three minutes. Picture the person, what they have on, what their voices sound like. 'What is the place?' 'Are there smells which you recognize?' Notice all of these as you think about visuali•ing the scene. Now begin." Pause for three minutes. After three minutes, say, "Good! Now relax and when I count from 1 to 5 come back to the room slowly feeling refreshed and well. Keep in mind that the room will be a little bit brighter. You're doing great. 1,2, 3, 4, 5." The f waits until everyone opens his or her eyes and then says, "Great!" Process Mental imagery. The f will say, "Now let's go around the room and talk about the exercise. Take a couple of minutes and describe your experience. Now let's start here (f points to the person on his left). "Would you start?" If the person says no or indicates that he or she would rather wait or pass, the f asks the next person to share. The f asks people until someone he chooses begins to share or someone else volunteers to share by raising his or her hand or begins to speak. Probing questions are: "Was this experience pleasant or unpleasant?" "Would you share your experience?" "Could you relate to the imagery?" After two minutes the f says, "Thank you for sharing. Now let's hear from the next person." The f turns to the next person and asks him or her to share using the same probes. If this person agrees to talk, he follows the same procedure. After one-half hour he stops the exercise and thanks the members. Mental imagery relating to self disclosure. The f will say, "Now, I want you to again relax and begin to think about an area with which we're not very accustomed. It's called self disclosure or talking about yourself. This is important in recovery because, even though it's necessary to 'get out of ourselves' at times, it's equally important to be able to talk about our problems when they surface, and they do surface! Now close your eyes and breath in through your nose and out through the mouth. Tense the areas which are already tight and, while exhaling, release the tension. Good! Go to the key word that triggers your relaxed state. Great! sink

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150 into the rug and let it support you. Goodl I'll count down while you go down on the escalator. 10, 9, a, 7, ,, s, 4, doing fine, 2, 1. Relazl I'd like for you to imagine yourself having a problem which you can't really put your finger on but you know you can handle because you can talk it out with someone. Your first thought is that right now it's important to talk this thing out; this anxiety, this feeling of being depressed or just 'down.' Nov imagine that you're in your house, in your bedroom. You can see your bed and what you have on the walls. The smell of your home is apparent and you can hear the sounds that are peculiar to your house and to your room. Maybe you have a fish tank or a birdhouse outside or a dog or cat. Bear these sounds. Now be aware of the negative state. You could be angry or sad or fearful or guilty feeling or just upset. You become aware that you're not very happy on this particular day. Check your thoughts." (Pause for 10 seconds) After 10 seconds the f says, '"Are they pleasant or unpleasant?' 'Are you judging this process?' If not, that's greatl If so, that's ok too, but soma changes need to be made in order to strengthen your 'program.' Again, if you experienced a negative feeling when you began to sea yourself in an unpleasant state, accept this and work on it. Step number one is identifying the thought. What was the negative thought? Did you think, 'I'm a jerk for feeling down?' or 'I'm not supposed to be down.' or 'I'm supposed to be strong.' 'I'm supposed to be grateful?' Drop the 'supposed to' and 'should.' You just simply have a feeling state. This is ok. You're human. Replace the thought with 'It's ok to expect perfection or to have high standards, but I'm human. Everyone has a bad day. It's human to feel bad. It's up to me to take action.' say this to yourself or use your own words if that works batter. Take a minute and substitute gentle and loving thoughts instead of criticism. Pause for one minute. After one minute say, "Now I'd like you to imagine yourself picking up the phone, going to an AA or NA meeting, visiting a friend or confidant or your sponsor, parents, clergy, or anyone you want and telling them that you want to talk. You can say that you want to talk. You can say that you need to talk, that you're feeling "antsy" or whatever you want. Just give yourself permission to do this. You're important! You have much to do now that you're clean and sober. You need your power. Thia ia how you can get it. Take five minutes and share your concerns with someone. Then reverse the situation and become

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2:25 2:45 3:00 151 concerned about them. Get out of yourself totally. Enjoy this experience as much as you can. Each time that you confide in someone, it gets easier and more enjoyable. Practice this!" Pause for five minutes. After five minutes, say, "Ok, good! Now as I count from 1 to 5 I'd like you to come back to the room refreshed and energized. You're doing great. 1, 2, 3, 4, 5. Good!" The f waits until all open their eyes and says, "Good!" Process Mental imagery. The f will say, "Now let's go around the room and talk about the exercise. Take a couple of minutes and describe your experience. Now let's start here." (f points to the person on his left) "Would you start?" If the person says no or indicates that he or she would rather wait or pass, the f asks the next person to share. The f asks people until someone he chooses begins sharing or someone else volunteers to share by raising his or her hand or begins to speak. Probing questions are: "Was this experience pleasant or unpleasant?" "Would you share your experience?" "Could you relate to the imagery?" After two minutes, the f says: "Thank you for sharing. Now let's bear from the next person. The f asks him or her to share using the same procedure. After one half hour he stops the exercise and thanks the members. Break: The f will say, "Now we'll break for 15 minutes." The f says, "I hope that you bad a good break. It's important to take breaks in life. Let's move ahead and have another discussion group. I'll take a few minutes to explain the purpose of this time and then give examples. I'll start by talking a little about 'what it was like.' At this point I'd like for you to go back to the time when you were 'using' and bad hit your bottom (bad problems) because of your using. When we speak of drinking or drugging we'll say using. If this is difficult, then just think of your term, e.g., drinking, when we say using. I know that for most of you this is a very personal experience but let's walk through it together. The purpose is to let go of the negative thoughts that we have of ourselves. This is similar to the other discussion that we bad earlier. Now, let's begin with some of the common problems. They bad to do with spending too much money, procrastinating, losing friends, lying, stealing, not being reliable, and being out too late. Other problems had to do with with our health. For example, problems included diarrhea,

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152 indigestion, hangovers, bruises, or even broken bones from accidents or fights. Other problems have been more subtle. These included being leas productive at work, losing your job, or being expelled from school because of a hangover, staying home to drink to avoid driving, losing your tamper, isolating in your house, leaving work early, or padding the expense account. Many problems stemmed from simply being "foggy" and detached froa life. In a way, many of us lost our meaning of life and were spiritually dead. Emotionally, we became bitter or apathetic, sometimes thinking only of the next "high." Many of us wallowed in sadness or guilt because of our past behavior. we neglected our hygiene. Others became paranoid and/or suicidal, delusional, or hallucinated. Soma overdosed. our fears usually surfaced daily and were masked under much anger. Eventually, we were living an unmanageable life. The degree of this unmanageability was different for each of us, but it l[ll unmanageability. Eventually the negativity and shame shaped our thoughts about ourselves and the people around us. Today we are letting go of these self-defeating things. we see the benefits in valuing ourselves enough to ask for help. It may be difficult to see these problems. Maybe you had very few of these or you think you had few of these. However, take time to acknowledge the problems that you did have. Relax and imagine yourself in a problem situation when drinking/using or post drinking/using caused problems. This could be anytime before or after using. See yourself in a situation when you experienced problems. Now begin. I'll pause for about two minutes to give you time to play this out." Pause for about two minutes. At the end of two minutes say, "Now I'd like you to monitor your thought process. Where is your mind taking you? Relax and become aware of what you are thinking. Is it pleasant or unpleasant? It may take a minute to access this information so I'll give you a minute to relax and become aware." Pause for one minute. After one minute say, "If your thoughts were loving and accepting of your using, then that's great. Just leave it and continue to accept your past without regret. If you experienced negative thoughts, that's ok too. However, we want you to accept this and change the thoughts to positive ones. What if this is only a decision! The experiences have happened and, try as we might, we can't change them. However, we can change the way that we think about them. This is important. You may have thought, 'God, that was

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3:25 3:30 153 awful,' or 'what a jerk I was,' or 'man, did I ever blow it,' or 'what a stupid idiot I am.' Accept this as old thinking. B• gentle with yourself and simply begin to sea these experiences as part of your history of using, your disease history. Next, take a pad and pen (the f hands out pads and pen) and write down these negative thoughts about yourself or anyone else. If you had only positive thoughts, write, 'I now release any negative thoughts or judgments that I have toward myself. I now any negative thoughts or judgements that I have toward anyone or anything. Take a minute or two to do this." The f pauses for two minutes and then says, "Now I'd like you to pair up again with your partner and share your negative thoughts. Take two minutes to do this. First choose who will go first and then begin to read your list. After one minute, switch and let your partner talk. Now begin." After two minutes, the f says, "Stop. In case you didn't switch or finish, take one more minute to finish. Remember that you can be very brief. Thanks. Ok, begin." After one minute, the f says, "Stop. Thanks." The f conducts a debriefing session similar to the prior ones. Mental imagery relating to unmanageability. The f will say, "Now we'll begin another exhilarating visualization exercise. Keep in mind that this is like the others. There is no right way to do it. Just relax and listen. The exercise is very safe and is aimed at strengthening your recovery program. First, I'd like you to close your eyes, relax and make yourself comfortable. Get in a comfortable position and loosen any tight clothing you may be wearing. Now breathe in through your nose, out through your mouth three or four times. As you do this become aware of any tension or tightness in your body. Breathe into the tightness and let it go out of your body. Breathe into the tightness and let it go out of your body and exhale through your mouth. Good! Now relax more and more. You're doing final Now take a couple of more breaths and relax. Great! (Pause for 10 seconds) Good! Now I'd like you to sink into the rug or whatever is supporting you at this time. Let the floor support your back, your legs, your neck, and your head. Relax! Imagine yourself going down on an elevator or escalator. There's no one around and you're going down slowly. As I count from 10 to 1, go down further and further. 10,9, you're doing very well, just great, a, 7,

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154 you're doing great, s, 4, relax, 2, 1. Good! How once again I'd like you to remember the word that you used to get relaxed earlier today. say that word a few times and allow yourself to become even more relaxed. Now go to a safe place where you can be comfortable. Look around at the beautiful sights and wonderful melodious sounds. Notice that your body is very much at ease and that you're feeling safe and sound. see yourself in recovery and enjoying your life. see your body healed and in shape. Peel proud of yourself for your changes and know that you deserve them. You deserve all things good. The past is gone and you have left the negative behind. How imagine that you have your list of negative thought• and actions that left you feeling bad. How switch your attitude. You can do this. Decide to accept your humanness and stop judging these thoughts this 'laundry list' of put downs. Now I'm going to ask you to do something totally ridiculous. (pause for two seconds) Smile when you've let go of th• negative. I'm going to wait until everyone smiles. come on now! Give it up; a great big smile! (The f waits until everyone has smiled or two minutes, whichever is shorter) Great! It's good to have tun with these issues. It takes the 'charge' out of it. Change your thinking more. Right now be aware that today you don't do these things and that you've changed. See the experience again and say, 'Isn't this interesting,' with a somewhat casual attitude. Judge the experience positively just as you would accept these mistakes in someone about whom you cared deeply and wanted to comfort. Take a few minutes to do this. Relax and be loving to yourself. Nov begin." Pause for three minutes. After three minutes, the f says, "Ok. Stop. Nov continue with your transformation. Get rid of the garbage. Burn it, tear it up, crumple it and throw it in the wastepaper basket. Let it go. Release these negatives so that you can become free of their influences. Remember that you deserve and can handle the positive thoughts that are entering into your life. When you decided to come to this workshop your intentions were to accept all things good into your life. Take a few seconds and mentally destroy the list. (Pause for 30 seconds) The negatives are now gone. You have released them and are ready to fill up with life's positive thoughts and things. The old negative actions can no longer influence you. Those days are over. You are changed! Nov see yourself today after some clean time/sober time. see yourself being able to handle life's situations without using.

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3:50 155 Imagine now that your are in a when you would have probably used, such as your favorite bar or a friend's house. In this be aura and see the people you used with and the place where you would have used. Notice the decor and particulars of this place. Ara there special smells or tastes? Experience this fully. Imagine that you have a temptation to use or are feeling badly and are in a feeling mode in which you would usually use. Saa yourself being able to acknowledge being tempted but are not willing to use. Visualize saying no or refusing the drug or drink. Again, you accept the fact that it could get unmanageable again and turn down the opportunity to indulge. Kake sure that you acknowledge yourself for turning it down. Give yourself a pat on the back. You did great! Now take about two minutes to do this. Relax and be confident. Think of new and creative ways to refuse the substance. Now begin." Pause for two minutes. After two minutes say, "Now relax and know that you never have to use again. Never! However, it's important to remember how bad it got. This is ok to remember. It's useful to know and is a key ingredient in keeping abstinent. Bowever,you are a different person than the one who was using. You have changed incredibily. Congratulationsl Now, when I count to five I want you to coma back to the room feeling refreshed and good. I'll be a little bit lighter in the room and you'll be slowed down so come back slowly and relax. 1, 2, 3, 4, S." The f waits until all have opened their eyes. Process Mental imagery. The f will say, "Now let's go around the room and talk about the exercise. Take a couple of minutes and describe your experience. Now let's start hara." The f points to the person on his left. "Would you start?" If the person says no or indicates that he or she would rather wait or pass, the f asks the next person to share. The f asks people until someone chooses to share or someone else volunteers to share by raising his or her hand or beginning to speaks. Probing questions are: "Was this experience pleasant or unpleasant?" "Would you share your experience?" "Could you relate to the imagery?" After two minutes the f says, "Thank you for sharing. Now let's hear from the next person." The f asks him or her to share using the same probes. If the first person agrees to talk, he follows the same procedure. After one-half hour the f stops the exercise and thanks the members.

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4:00 4:05 156 Exercise: The f says, "Everyone find a partner and say what you think about the exercises. Take five minutes." After five minutes the f says, "Stop." Mental imagery relating to lifestyle change. The f will say, "At this time I'd like to do another exercise. You're probably getting used to relaxing on command by nov so I'd like you to do so. Say your word and enter into a relaxed state. I'll give you a minute to practice this. (Pause for one minute) Nov be aware that you can instantly decrease any 'down' feeling by going into this state. Say your vord and you'll relax. Nov I vant you to go down on the escalator and relax deeper as I count from 10 to 1. Again, sink into the rug and allow it to support you. 10, 9, relax,,, s, good, 3, 2, 1. Next, vere going to vork on lifestyle change. The quality of your recovery is important in order to stay sober and clean. This includes a support group, aom• kind of exercise, diet, spirituality, friends, vork, hobbies and so forth. As I mention these things monitor your thoughts. Are they pleasant or unpleasant? If unpleasant, change them to positive ones. I vant you to go to your favorite place in the world to do this. Enter into a world where you are safe and confident. A place where you feel special. Enter into a place where you feel respected by others, respected by yourself. Do this nov. 11 (Pause for five seconds) "See the magnificent surroundings and take the time to look at them. You see statuesque and billowy clouds, multicolored birds and bright red rosebushes in full bloom. Perhaps you are indoors and see paintings or people, whatever you want. See the splendor of your private place. See the splendor!'' (Pause for five seconds) "Nov smell the beautiful flowers around you. There are the rich smells of the roses and the pungent odors of gardenias. Enjoy these fragrances. Stop to smell the roses." (Pause for five seconds) "Next, touch some of the things around you that are appealing. The surface is safe and nourishing. Imagine the feel of a cool marble table, a velvet rose, some tree bark vith callouses, a bubbling brook, or a cushion of hay or new mown grass that is soft as cotton." (Pause for five seconds) "Listen to the melodious sounds in your special spot. You hear your favorite song played on the finest instruments as though you vere in the finest concert hall ever. Let these sounds bring a smile to your face." (Pause for five seconds) "Now taste something. Perhaps a delicious food that is a favorite food of yours. Something tells me that you like chocolate. Just enjoy this mouth-watering food

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157 -savor the taste. (Pause for five seconds) How repeat the following statements to yourself with conviction and sincerity. I'll now begin a aeries of positive statements. The first one is, 'I can handle any and all rewards and success which results from my loving me more.' (Pause for five seconds) 'I vow to treat myself well.' (Pause for five seconds) 'I deserve sobriety."' (Pause for five seconds) "Good. How take the list of negative thoughts and put it in your hand. Imagine a roaring fire in front of you. You can feel its warmth and hear th• sparks of the cinders as they pop; take the negative writings and throw them in the fire as you forcefully say, 'Thia is over! I let go of all negative thought• about myself. I will be loving to myself. I will take care of me. I deserve this.' Relax and be confident. You have done a major service for yourself and others. This decision will help you all the days of your life. You are moving on to a new dimension which will get progressively batter. Let's now take some time to use this new found self-love. Watch the negative thoughts as they burn. You get a warm feeling in your heart as you watch this release. As you see them turn to ashes say good-bye to the old negativity and welcome your positive lifestyle with joy and happiness. It's been a long time in coming and you will wear it well. Let yourself feel confident and safe with this 'new you.' Experience and celebrate a positive outlook. Give yourself permission to do this. How imagine a day in your life which will be an example of self-love. Visualize yourself getting up in the morning and drinking cool, fresh water. Take five seconds and do this." (Pause for five seconds) "You're collllittad to your health. Next, you pray and ask for another clean and sober day. Take five seconds and do this." After five seconds the f says, "You are spiritually committed to a Higher Power, whatever that means to you. Next, you meditate to maintain a conscious contact and think positive thoughts. The time given to meditate is your decision. Everything is your decision. Take five seconds and do this." After five seconds the f says, "You then use the bathroom and brush your teeth. You do all things today at 100%, whatever that means to you. You respect your life and your self. You are important. How you eat breakfast; you eat only good food using little sugar and white flour. Take five seconds and do this." After five seconds, the f says, "You respect your body. You eat moderately. If you find yourself over indulging, you call your sponsor to see if you are 'holding' any guilt or resentment or other feelings

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158 and take care of this as soon as possible. Take five seconds and do this." (Pause for five seconds) "When you are thirsty you drink healthy things, remembering to drink eight glasses of water per day. Take five seconds and do this." After five seconds, the f says, "If you drink coffee or anything with caffeine, you use this drug moderately. Eventually, you will not use it. You will atop using unhealthy chemicals. You find that you have a new outlook on smoking also. If you use cigarettes you will progressively b• beaded in a direction of abstinence. All of things may not happen at once but you see them happening now anyway -to you. Do not worry about the enormity of it all. It will happen. You don't have to work hard at it. Your attitude baa changed. Now, as you begin to dress, you are aware that you want to look good. You choose clothes that are very nice and that represent you. Take five seconds and do this." After five seconds, the f says, "You now become excited about the day. You look forward to a good day at work or play or school. You have chosen a creative, interesting way to spend your tilll• and make money doing it. This is your job. You choose to do what you enjoy. This is your dream. You know that 'money follows excellence' and that you can perform well if you are living your dream. Take five seconds and do this." After five seconds, the f says, "You have good relationships at work. You are able to nurture relationships with those around you. Take five seconds and do this." After five seconds, the f says, "After work, you attend a 12step meeting and share your thoughts and feelings. Feel free to attend any other meeting or activity you choose that helps your recovery, that helps you stay positive and inspired. Your recovery is your choice, yours only. You also practice service work by greeting a newcomer or chairing a meeting, cleaning up after the meeting or saying something important to someone who needs it. Take five seconds and do this. (Pause for five seconds) After the meeting, you eat with family and/or friends and have an enjoyable meal. The food is healthy. You avoid fatty foods with high cholesterol such as meats and cheese, milk and so on. Your diet is largely vegetables, fruits, water, poultry, juices, grains, and whatever else you decide is good for you. You decide this. You are concerned with your health, not what others think of you." (Pause for five seconds) "Next, you spend 5-10 minutes alone in meditation or quiet time. This may be walking or meditating or reading or simply sitting. You relax! This may be time to have a conscious contact with a

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4:10 4:20 159 Higher Power. A Higher Power watches over and guides you. Take five seconds and do this." After five seconds, the f says, "Hext, you decide to exercise. You make a decision to be healthy and take care of your body in yet another way. See yourself doing an exercise that appeals to you and also which is practical, one which you can do and will do. It may be walking, jogging, running, bicycling, swimming, playing tennis or any activity you choose. It works well if you choose some activity that you enjoy. Take a minute to visualize yourself doing this exercise and thus strengthen your cardiovascular system. It's important to keep your heart strong. Bow see yourself doing this. Take five seconds and do this." After five seconds, the f says, "Good! You've done great. We're now going to wind this down. Please remember that you can do any of these positive things whenever you choose. You don't have to do it perfectly and you deserve to live well. Relax and when I count to five come back to the room slowly feeling refreshed and renewed. 1, 2, 3, 4, s. 11 The f waits until all have opened their eyes and says, "Good." Process Mental imagery. The f says, "Bow let's go around the room and talk about the exercise. Take a couple of minutes and describe your experience. Nov, let's start here." (the f points to the person on his left) "Would you start?" If the person says no or indicates that he or she would rather wait or pass, the f asks the next person to share his or her thoughts and feelings about the exercise. The f asks people until someone he chooses or someone else volunteers by raising his or her hand or by speaking. Probing questions are: "Was this experience pleasant or unpleasant?" "Would you share your experience?" "Could you relate to the imagery?" After two minutes the f says, "Thank you for sharing. Nov let's hear from the next person." The f turns to the next person and asks him or her to share using the same probes. If the first person agrees to talk, the f follows the same procedure. After one-half hour the f stops the exercise and thanks the members, saying, "We are now finished with this part of the exercise." Upon completion of the workshop, the f says, "It is now time to complete forms. Thank you for your your cooperation. I wish you all the greatest success. Business cards are in the waiting room; take one if you wish. In six weeks I'll ask you to fill out followup forms. This next part takes about one-half hour and involves completing four instruments

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160 necessary, important, and integral to the atudy. Please complete thconscientiously. The results will be coded and kept confidential. Please write the last four digits of your social security number, age, and Mor P for male or female in the upper right corner of these instruments. Also, write today'• date as soon as I say to begin. complete one form at a time, respond to every item in order, and don't skip items. Instructions are written on each form. Read thasa carefully, relax, and respond to all items as honesty as you can. Raise your hand when you finish all four forms. It should take you about 20 minutes but you are not being timed. Begin now." The facilitator will then give each participant a pencil and the four forms. He will stay in the room, answer questions, and distribute more forms and/or pencils if needed. As participants finish, he will check the forms for social security digits and gender information. He also will check for completion of all items. Forms will be placed in a box marked E (1-5).

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9:00 AM 9:05 9:10 9:15 9:30 10:15 10:20 10:30 10:40 11:00 11:15 11:30 11:35 11:50 11:58 Noon 1:00 1:20 1:22 1:30 1: 45 2:05 2:25 2:45 3:00 3:20 4:00 4:05 4:10 4:20 5:00 APPENDIX H AGENDA Orientation and name tags Question and comment period Review of agenda Greeting exercise Introductions Lecture and brief demonstration of relaxation exercise Questions and answer time Break Relaxation exercise Process relaxation exercise Lecture on the benefits of relaxation Lecture on mental imagery (M.I.) Mental imagery exercise -(four dependent variables) Process mental imagery exercise (on the four variables) Lunch and walk instructions for variables Lunch Walk Greeting and review of last mental imagery and relapse prevention Discussion -mutual goal setting Mental imagery exercise on help-seeking behavior (hsb) (cassette tape) Process M.I. (hsb) M. I. exercise on self disclosure (sd) (cassette tape) Process M.I. (sd) Break Discussion and M.I. exercise on unmanageability/powerlessness (pwls) (cassette tape) Process M.I. (pwls) Exercise M.I. exercise on lifestyle change (ls) (cassette tape) Process M.I. (ls) Posttest End of workshop -dismissal 161

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Name: APPENDIX I FOLLOWUP FORM Last 4 digits of SS# --Gender ---Age ____ _ Have you relapsed since participation in the workshop? Yes No Please use a scale of 1 to 10, where 1 = low to 10 = high, to evaluate each of the following statements: I benefitted from participating in the workshop. My personal (abstinence) "program" has improved as a result of participation in the workshop. My lifestyle has improved as a result of participation in the workshop. My help-seeking behavior has improved as a result of participation in the workshop. My self disclosure has improved as a result of participation in the workshop. I would recommend this workshop to other persons trying to maintain abstinence. The workshop would be beneficial to recovering people who had been in: 162

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163 inpatient treatment programs, outpatient treatment programs, residential treatment programs. On the backside of this page please indicate what you liked most and what you liked least about the workshop.

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APPENDIX J TREATMENT HISTORY FORM Last 4 digits of SS# Gender Age Are you currently abstaining from alcohol and other drugs? Yes No Is this your first time sober and/or clean since stopping? Yes No --If no, how many times have you tried? 1 3 5 7 10 15-20 Are you currently in treatment for any other mental health or behavioral disorder such as an eating disorder, depression, post-traumatic stress disorder, etc. Yes No --How long have you been in treatment currently for chemical dependence? ___ months Is your current treatment for chemical dependence: Check as many as apply) a) inpatient b) outpatient group c) A.A. d) N.A. e) halfway house f) residential treatment 164

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165 g) one-to-one outpatient counseling h) family therapy i) other Have you been in chemical dependence treatment before? Yes No ----If yes how many times? How long were you in treatment the last time? months ---What did your last treatment for chemical dependence consist of: (check as many as apply) a) inpatient 1 week 2 weeks every 28 days other b) outpatient group c) A.A. d) N.A. e) halfway house f) residential treatment g) one-to-one outpatient counseling h) family therapy i) other

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183 Turk, D., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine. New York: Guilford Press. United States Department of Education. (1986). What works: Schools without drugs. Washington, DC: Author. Vaillant, G. E. (1983). The natural history of alcoholism. Cambridge, MA: Harvard University Press. Washton, A. M. (1989). Cocaine addiction: Treatment. recovery. and relapse prevention. New York: W. w. Norton & Company. Watkins, G. T. (1989). In-house: Window of opportunity. EAP Digest, ~(6), 6. Wegscheider-cruse, s. (1987). Learning to love yourself. Pompano Beach, FL: Health Communications. Weil, A. (1972). The natural mind: A new way of looking at drugs and the hiaher consciousness. Boston, MA: Houghton Mifflin. Weisman, M. N., & Robe, L.B. (1983). Relapse/slips: Abstinent alcoholics who return to drinking. Minneapolis, MN: Johnson Institute. Wilson, B. (1958). Three talks to medical societies. York: Alcoholics Anonymous World Services, Inc. New Witmer, J.M., & Young, M. E. (1985). The silent partner. Journal of Counseling and Development, 64, 187-190. Wright, D. M. (1989). Personally speaking: Behind the label "alcoholic." Journal of Counseling and Development, 65, 482-483. Yalom, I. D. (1985). The theory and practice of group psychotherapy. New York: Basic Books, Inc., Publishers.

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BIOGRAPHICAL SKETCH Peter A. Butkins was born in Syracuse, New York, in 1945. He received his elementary and secondary education there. In 1967, he was awarded a B.S. in English from Niagara University. Upon graduation, he taught high school English and was employed as a guidance counselor. At the time, he also was attending Niagara University pursuing a master's degree. He earned an M.S. in guidance and counseling in June of 1969. Peter was employed at this position until 1970 when he elected to continue his counseling career at the Niagara Falls Community Mental Health Center. After one and one half years, he was recruited to supervise the suicide prevention component of the Niagara Falls Drug and Alcohol agency. In 1975, he accepted a position in Syracuse, New York, working for a Federal Narcotics and Drug Research Grant. His work there involved developing and funding crisis centers for communities at risk in New York. In 1979, Peter relocated to Orlando, Florida, where he worked for one year as a guidance counselor and teacher. In 1981, he began Quest Counseling Centre, his private practice. Licensed in marriage and family counseling and chemical dependence counseling, he has successfully 184

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185 practiced in both these areas since then. Freedom Quest is his non-profit agency which provides free drug and alcohol abuse counseling interventions to families and individuals. He also conducts training workshops and other forms of consultation for a variety of agencies and businesses.

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degr of Doctor of ,hilosyrhy. {P~ Larry . Loesc, Chair Prof ssor of Counselor Education I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, ins pe and quality, as a dissertation for the d jree of Doctor o Philosophy. Profess I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. /~t.d-
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