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Belief systems of alcoholics and problem drinkers Pallett, Joanne Hendrika 1982

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B E L I E F SYSTEMS OF A L C O H O L I C S AND P R O B L E M D R I N K E R S by JOANNE HENDRIKA P A L L E T T B . A . , Dalhousie U n i v e r s i t y , 1967 A THESIS SUBMITTED IN P A R T I A L F U L F I L L M E N T OF THE REQUIREMENTS FOR T H E D E G R E E OF MASTER OF A R T S in THE F A C U L T Y OF G R A D U A T E S T U D I E S (Department of Counselling Psychology) We accept this thesis as conforming to the r e q u i r e d standard  THE U N I V E R S I T Y OF B R I T I S H C O L U M B I A December 1982  © J . H . Pallett, 1982  In p r e s e n t i n g  this thesis  i n partial  f u l f i l m e n t of the  r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y of  British  it  freely available  agree that for  Columbia,  I agree that f o r reference  permission  the Library  shall  and study.  I further  f o rextensive copying o f t h i s  understood  that  copying o r p u b l i c a t i o n  f i n a n c i a l gain  of this  It is thesis  s h a l l n o t b e a l l o w e d w i t h o u t my  permission.  Joanne P a l l e t t  Department o f  Counselling  The U n i v e r s i t y o f B r i t i s h 1956 Main Mall V a n c o u v e r , Canada V6T 1Y3 Date  thesis  s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e h e a d o f my  d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . for  make  A  P  r  i  l  >  8  1  9  3  3  Psychology  Columbia  written  - i-  ABSTRACT A l c o h o l d e p e n d e n c e i s a complex c o n d i t i o n w h i c h may be as b o t h a d i s e a s e  and a behavioral  possibility that deviant  problem.  treatment A behavior  This s t u d y investigated the  d r i n k e r s t h e m s e l v e s choose one of t h e s e  that t h i s choice i s r e l a t e d to g e n e r a l specific and general  options,  b e l i e f s about c o n t r o l , a n d t h a t b o t h  beliefs change d u r i n g  a s t a y i n a f o u r week  residential  program.  questionnaire a n d disease  questionnaire centres.  was c o n s t r u c t e d  to m e a s u r e d i f f e r e n c e s b e t w e e n  o r i e n t e d b e l i e f s a b o u t alcohol d e p e n d e n c y .  This  was t e s t e d o n a g r o u p o f 104 c l i e n t s at two alcohol t r e a t m e n t  It was e s t a b l i s h e d that t h e i n s t r u m e n t f u l f i l l e d some o f t h e  criteria for psychometric soundness, notably,  an a c c e p t a b l e  internal consistency,  ability.  A  construed  volunteer  centres.  a n d some d i s c r i m i n a t o r y  sample of 59 men was t h e n t e s t e d at t h e s e same t r e a t m e n t  T h e y were d i v i d e d i n t o two g r o u p s :  alcoholics and problem  d r i n k e r s , d e p e n d i n g on which role label they p r e f e r r e d . r e c e i v e d a p r e test a n d a post  test.  On each occasion,  the B e l i e f s A b o u t A l c o h o l D e p e n d e n c e q u e s t i o n n a i r e , Control test, the Michigan Alcoholism information  l e v e l of  Screening  Everyone they  completed  t h e R o t t e r L o c u s of  test, and a demographic  questionnaire.  Results  indicate that there  b e t w e e n t h e two g r o u p s .  were some d i f f e r e n c e s i n b e l i e f  Self defined  a l c o h o l i c s h a d more d i s e a s e  b e l i e f s a n d a g r e a t e r t e n d e n c y to p e r c e i v e environment.  systems oriented  t h e m s e l v e s i n c o n t r o l of t h e i r  S e l f d e f i n e d p r o b l e m d r i n k e r s h a d more b e h a v i o r  oriented  - iib e l i e f s a n d a g r e a t e r t e n d e n c y to p e r c e i v e t h e m s e l v e s to b e c o n t r o l l e d b y v  their environment. d u r i n g treatment, The  While s p e c i f i c b e l i e f s a b o u t d e p e n d e n c e d i d n o t c h a n g e general beliefs about control o v e r the environment d i d .  i m p l i c a t i o n s of v i e w i n g  t h e a l c o h o l d e p e n d e n t p o p u l a t i o n as  v a r i a b l e w i t h r e s p e c t to b e l i e f s y s t e m s a r e d i s c u s s e d .  - iii T A B L E OF C O N T E N T S Page L i s t of T a b l e s  v  L i s t of F i g u r e s  vi  Acknowledgements  vii  I.  II.  Introduction  1  Background  1  The Problem  5  Rationale  7  Assumptions  10  Delimitations  10  Justifications  11  D e f i n i t i o n of T e r m s  12  Literature Review  15  Overview  15  Variability Among Alcoholics/ Problem D r i n k e r s  16  B e l i e f S y s t e m s of A l c o h o l i c s / Problem D r i n k e r s  20  A l c o h o l D e p e n d e n c y as a Cognitive Process  25  Control Orientation in Alcohol Dependence  31  Changes in Cognition during Alcohol Therapy  37  Summary  39  - iv Page III.  IV.  Methodology  V  40  Hypotheses  40  Design  40  Sample a n d P o p u l a t i o n s  41  Instruments  44  Procedure  49  Results  51  1. B e l i e f s A b o u t A l c o h o l D e p e n d e n c e Questionnaire  51  2. R e s u l t s o f M a i n S t u d y  V.  61  Hypothesis I  65  H y p o t h e s i s II  66  H y p o t h e s i s III  67  Hypothesis IV  . 7 0  Discussion  •  78  Differences Between Alcoholics and Problem Drinkers  78  T h e C o m p l e x i t y of C o n t r o l  79  Limitations  81  I m p l i c a t i o n s of a F u t u r e S t u d y  82  Summary  83  Bibliography  85  Appendices  90  - v LIST OF  TABLES  Table IV.  Page  1.  Items Selected  2.  Alcohol Beliefs Items Which D i s c r i m i n a t e d Between Alcoholics and Problem Drinkers  56  Mean Scores and S t a n d a r d Deviations Obtained b y Total Sample on Alcohol Beliefs Scale  57  Mean Scores and S t a n d a r d Deviations Obtained b y Alcoholics and Problem D r i n k e r s on Alcohol Beliefs Scale  59  Mean Scores of A l c o h o l i c s and Problem D r i n k e r s on the B e h a v i o r Subscale  63  Mean Scores of A l c o h o l i c s and Problem D r i n k e r s on the Disease Subscale  64  Means and S t a n d a r d Deviations of L o c u s of C o n t r o l Scores for Alcoholics and Problem Drinkers  68  C o r r e l a t i o n s B e t w e e n L o c u s of C o n t r o l Scores and Disease Beliefs, and Between L . O . C . and Behavior Beliefs  69  A N O V A R e s u l t s for L o c u s of C o n t r o l Scores (Pretest)  76  A N O V A R e s u l t s for L o c u s of C o n t r o l Scores (Posttest)  77  3.  4.  5.  6.  7.  8.  9.  10.  for A l c o h o l Beliefs Scale  54  - vi L I S T OF FIGURES  The Ba]anced Placebo Design Portion of Repertory G r i d Hypothesized Relationships Among Drinking Role, Beliefs About Alcohol, and Locus of Control Schematic Representation of Relationships Among Drinking Role, Beliefs About Alcohol, and Locus of Control Changes in Behavior Beliefs Changes in Disease Beliefs Changes in Locus of Control Scores  - vii -  ACKNOWLEDGMENTS  I w o u l d l i k e to e x p r e s s my a p p r e c i a t i o n to s e v e r a l p e o p l e , whose c o n t r i b u t i o n s t h i s work c o u l d n o t h a v e b e e n c o m p l e t e d :  without  to L a r r y C o c h r a n , whose p a t i e n c e a n d n e v e r - f a i l i n g e n t h u s i a s m p r o v i d e d most of the m o t i v a t i o n f o r c o m p l e t i n g the r e s e a r c h . I also t h a n k him f o r b e i n g a v a i l a b l e w h e n e v e r I needed help; to t h e s t a f f o f P a c i f i c a , who w i l l i n g l y a d a p t e d t h e i r b u s y s c h e d u l e to accommodate the data c o l l e c t i o n . I am e s p e c i a l l y g r a t e f u l to D r . Pauline G r e y , whose i n t e r e s t i n r e s e a r c h i m p r o v e d my own motivation; to t h e s t a f f of V i c t o r i a L i f e E n r i c h m e n t S o c i e t y , whose o f f e r to a s s i s t with t h e collection of data s t r e a m l i n e d t h e p r o c e s s , as well as m a k i n g it more economical. Their reliability and efficiency i n performing this task are g r e a t l y appreciated; to all t h e c l i e n t s at b o t h f a c i l i t i e s who v o l u n t e e r e d t h e i r time, a n d who o f t e n s t a y e d to d i s c u s s t h e q u e s t i o n n a i r e s with me; to D a n P a r s l o e , who gave f r e e l y of h i s own time to do t h e c o m p u t e r a n a l y s i s of the data, a n d who was a l w a y s a v a i l a b l e to c o n s u l t o n the i n t r i c a c i e s of s t a t i s t i c s , measurement-t h e o r y , a n d computer programs; to C a r o l R o b e r t s , who s p e n t many h o u r s t y p i n g , p r o o f r e a d i n g , and editing the manuscript. More t h a n t h a t , s h e p r o v i d e d m u c h n e e d e d i n c e n t i v e s to me to h u r r y u p a n d f i n i s h !  - 1-  CHAPTER I  SCOPE OF T H E  Background:  STUDY  Opposing Views of Alcohol Dependence  There are many theories about the etiology of the phenomenon labelled, by various writers, "alcoholism"^ "alcohol dependence", "deviant drinking", and "problem drinking" (Tarter and Sugerman, 1976; Drug Field, 1979).  Core Knowledge in the  However, it is the contention of this study that it is  worthwhile to construe this phenomenon as a learned behavior pattern.  in two ways:  as a disease entity and  The first approach construes what is then  termed "alcoholism" as a unitary phenomenon, explained through a paradigm much like the "mental illness" model (Sarbin and Mancuso, 1981).  The  second approach, the "problem drinking" model, describes a lifestyle problem best understood in terms of environmental variables. For many years the "disease concept of alcoholism" has been the most popular, indeed the only, paradigm, both scientifically and popularly. The Alcoholics Anonymous (AA) movement has, since the 1930's, advocated the conception of alcoholics as sick people rather than as moral degenerates, which was the prevailing paradigm before that time.  Alcoholism is thus a  disease, which the "alcoholic" is predisposed to develop, probably through the mechanism of an inherited metabolic deficiency.  Alcoholics are therefore  not responsible for contracting this condition and are powerless to control it, any more than diabetics can control their reaction to sugar.  Alcoholics  must therefore admit they have this irreversible condition and commit themselves to lifelong abstinence.  - 2The scientific body of knowledge with respect to the disease theory developed as an adjunct to these popular notions described above. initial (1946) work of E.M.  The  Jellinek, the most well-known researcher in  the field, was commissioned by AA.  Using retrospective data from  AA  members, Jellinek formulated his description of the "phases of alcoholism". This "ages and stages" description of a progressive deterioration is very compatible with a disease model. formulation of the disease model.  Jellinek went on to a more detailed He then (I960) suggested that there  were at least five "alcoholisms" and that not all fitted the disease model. However, Jellinek's caveats about the limitations of the disease model have largely been ignored;  the traditional view of alcoholism is that it  is a unitary condition which is best thought of as a disease (Goodwin, 1976 (a); Glatt, 1976) . The popular view of alcohol dependence is consistent with the disease model.  The alcoholic is depicted as a sick, helpless victim of a disease  process, whose only hope is acceptance of this and total abstinence, usually attained by commitment to the AA 1939) .  way  of life (Alcoholics Anonymous,  Scientific books written for popular consumption advocate this view  (Marty Mann, 1979; Vernon Johnson, 1973), as do novels (Joyce RebutaBurditt, 1977) and T V movies (You've Come a Long Way,  Katie).  In recent years a second approach to alcohol dependence has  developed.  According to the "problem drinking" model, alcohol dependence can best be described as a behavioral or lifestyle problem.  Thus, problem drinking is  - 3 a learned, adaptive behavior which conforms to the same scientific principles as other voluntary behaviors (Marlatt and Nathan, 1978).  Rather than  being a response to a popularized view, the problem drinking model developed as an alternative explanation when experimentally  was  obtained results  were found to be inconsistent with disease theory predictions.  For example,  a significant minority of those once diagnosed as "alcoholic" go back to non-problem drinking (Sobell and Sobell, 1979 ) . 1  expectations  Furthermore, an alcoholic's  or beliefs about alcohol have been shown to be more important  than the amount of alcohol consumed in influencing behavior (Marlatt and Rohsenov, 1980).  Some (Cahalan, 1970;  Pattison, Sobell and Sobell,  1977)  also argue that the problem drinking model is more justifiable than the disease model on conceptual grounds as well as empirically. The  " problem drinker" is thought to have violated social norms with  respect to alcohol, either by overdrinking to the point of repeated impairment, physical damage, or psychological or social problems. this behavior was  How  learned depends on the personality theory of the describer.  In any case, harmful drinking is construed as a problem behavior that is no more an irreversible condition of identity than is smoking. Some writers suggest that both "alcoholism" and  "problem d r i n k i n g "  models are correct, and that they apply to two different populations of deviant drinkers. the two 1  Goodwin (1976  (b)) used the following criteria to distinguish between  groups:  A recent evaluation by Pendery, Maltzman and West ( 1982) has challenged the validity of the Sobells' work on teaching controlled drinking to alcoholics.  - 4 -  Problem Drinker: for at least one year, has drunk daily, had six or more drinks two or three times a month, has had problems associated with this, but the problems are insufficient to meet the "alcoholic" criteria. Alcoholic: drinks the same or more than above, but in addition has problems in three of the four following categories, a) social or marital, b) job or police trouble, c) blackouts, seizures, withdrawal symptoms, d) loss of control, morning d r i n k i n g . Although these criteria imply a quantitative distinction between alcoholics and problem drinkers, Goodwin believes there is a qualitative distinction, while Miller and Caddy (1977) seem to argue for a quantitative distinction.  They  suggest the term "problem drinker" be used to describe all persons "experiencing  significant life problems related to alcohol".  The term "alcoholic"  should be reserved for a small subgroup of problem drinkers, and only those who  fit a v e r y specific set of diagnostic criteria. So far it has been argued that there are two models for explaining  alcohol dependence , and that, traditionally, the disease model paradigm has been more widely accepted both scientifically and popularly.  However,  there is some evidence that this traditional view is being challenged in scientific circles (Tournier, 1977)  as well as in more popularly read  magazines (Marlatt and Rohsenov, 1981) . Scientific theories, as well as having counterparts  on the popular  level, become translated into social policy (Paredes, 1976).  For example,  when alcoholics were thought of as morally weak and lacking in willpower, social policy dictated that they be dealt with within a religious framework or by criminal  justice systems.  Simply put, the alcoholic's choice  was  - 5 to be saved or punished.  The increasing acceptance of the disease N  over the last 30 years has changed social policy.  The  model  medical system is  now  charged with rehabilitating the alcoholic, and treatment is insured under Medicare.  Paid sick leave from work is usually authorized for the alcoholic  undergoing treatment.  It seems a wider acceptance of a behavioral model  would have important social implications as well.  Alcoholics now  often escape  sentencing for criminal offences, such as impaired d r i v i n g , by agreeing to receive treatment.  This notion of diminished responsibility might not apply  if there were a more popular acceptance for the problem drinking model. This would also result in a social policy that placed more emphasis on prevention than on treatment (Room, 1981).  The Problem:  Belief Systems of Deviant  Drinkers  If scientific or "objective" theories of alcohol dependence become popularized and translated into social policy, it seems reasonable to assume that deviant drinkers themselves also have this input available, and they may  develop their own  "subjective" theories.  Few  that  of the classical  theories of alcohol dependence imply that these subjective theories are important areas for investigation, perhaps with the exception of the  new  cognitive behavior models being developed by Marlatt and Rohsenov (1980) and others.  Yet their research clearly shows the importance of cognitive  factors in predicting alcoholics' behavior. describe how  Roman and Trice (1977) also  adopting the role of "alcoholic" may  person's implicit personality theory.  become part of the  The person who  adopts the label  - 6 -  may  come to think of him or her self as "a person who  and live up to those role expectations. "sick role" and may own  He/she may  drinks deviantly",  incorporate the implied  thereby be enabled to give up responsibility for his/her  cure. George Kelly (1955), in describing "personal construct theory", also  criticizes classical personality theorists for not taking into account the possibility that their subjects use the same logical processes they themselves use in describing, explaining, and predicting behavior. as his own way  Kelly describes  man  "personal scientist" and the "personal construct system" as the  he anticipates and replicates events.  A personal construct system is a  set of interrelated discriminations which allow a person to give meaning to his/her experience.  This system can be labelled one's "implicit personality  theory" since it is the process whereby one's behavior is channelled in a meaningful way.  Fransella (1972) has shown how  the incorporation of a  deviant role within one's construct system has important implications for both the maintenance of the deviant role and for rehabilitation. (Hoy,  1973;  Others  Heather, Edwards, and Hore, 1975) have shown that some of  the implications of personal construct theory apply to alcoholics as well. It was  the intention of this study to further examine the implicit  personality theories that deviant drinkers hold about themselves.  It was  suggested that once a person assumes a label pertaining to deviant drinking, he/she incorporates that role into the existing construct system.  Furthermore,  it seemed reasonable to assume that the person has a choice regarding label.  the  - 7If two  " o b j e c t i v e " b e l i e f s y s t e m s w i t h r e s p e c t to alcohol d e p e n d e n c e  a r e a v a i l a b l e , t h e n the d e v i a n t d r i n k e r c a n c h o o s e b e t w e e n them. s y s t e m is r e p r e s e n t e d  by  the "disease c o n c e p t of a l c o h o l i s m " a n d  a b o u t t h i s view c l o s e l y p a r a l l e l those about p h y s i c a l d i s e a s e s . s y s t e m i s r e f e r r e d to as a "problem d r i n k i n g " model a n d  One beliefs  The  other  uses a learned-  b e h a v i o r method of d e s c r i p t i o n .  R a t i o n a l e f o r the P r e s e n t S t u d y The  above section presents  d r i n k e r s h a v e two  the r a t i o n a l e f o r a s s u m i n g t h a t  choices i n i n c o r p o r a t i n g t h e i r d r i n k i n g r o l e i n t o t h e i r  existing personality theories.  T h o s e who  choose the d i s e a s e t h e o r y  b e c a u s e d e s c r i b i n g o n e s e l f as the v i c t i m of a d i s e a s e p r o c e s s , patient role, and advantageous.  deviant  r e l i n q u i s h i n g control and T h o s e who  do  adopting a sick,  r e s p o n s i b i l i t y are p s y c h o l o g i c a l l y  d e s c r i b e t h e m s e l v e s as p r o b l e m d r i n k e r s do  b e c a u s e a b e h a v i o r a l model is more m e a n i n g f u l to them t h a n a medical It was  so  so one.  t h e r e f o r e n e c e s s a r y to d e v e l o p an i n s t r u m e n t w h i c h d i s c r i m i n a t e s  b e t w e e n the two  belief systems.  G e o r g e K e l l y (1955) s u g g e s t e d t h a t a p e r s o n will c h o o s e t h o s e  constructs  w h i c h allow the g r e a t e s t e l a b o r a t i o n a n d  v a l i d a t i o n of the e x i s t i n g s y s t e m ,  i . e . , t h o s e w h i c h are most m e a n i n g f u l .  Therefore  between a "problem d r i n k e r " and by one  i t seems t h a t the  an " a l c o h o l i c " b e l i e f s y s t e m may  a more g e n e r a l i z e d v a r i a b l e , a n d  that the d e v i a n t d r i n k e r may  be  choice mediated  choose the  w h i c h allows the g r e a t e r e l a b o r a t i o n of the more g e n e r a l c o n s t r u c t .  A  c e n t r a l n o t i o n of the disease t h e o r y i s that i t a s s u m e s t h e i n d i v i d u a l ' s l a c k of c o n t r o l o v e r the c o n d i t i o n .  The  b e h a v i o r a l model, on the o t h e r  hand,  - 8 -  implies a degree of voluntary control.  The work of Rotter, ^Chance, and  Phares (1972), and of Phares (1975) suggests that individuals differ with respect to a generalized perception of internal versus external control of their behavior.  That is, some people believe that outcomes are, for the  most part, contingent upon their own  behavior; these people are said to  have an "internal" locus of control. Others believe that outcomes are the result of chance, luck, or other situational variables;  these people are said  to have an "external" locus of control. It seems reasonable to predict that the locus of control construct may  be one of the general variables underlying  the choice between construing oneself as an alcoholic or as a problem drinker. A scale that has some established validity in measuring locus of control is the Rotter Internal-External Locus of Control Scale (I-E) (Rotter et al, 1972). This scale has been widely used with alcoholic populations  (Cox,  1979;  Donovan and O'Leary, 1980). Changes in both specific beliefs about alcohol problems and in general perceptions of control could be expected from a therapy program.  The  direction of the change would depend on an interaction between the nature of the original beliefs and the type of therapy program.  Personal  construct  theory would predict that a person would be more likely to endorse a belief system that allowed the greater elaboration of his/her pre-existing beliefs. Thus, in a person who  believed that he/she was  a victim of circumstances,  that temperament was largely inherited, and personality a set of irreversible traits, an alcoholism treatment program which elaborated on the disease theory would find a willing adherent.  -  The  9  -  q u e s t i o n as to w h e t h e r a t r e a t m e n t p r o g r a m g e a r e d to a s p e c i f i c  b e l i e f s y s t e m c o u l d a f f e c t a g e n e r a l c o n s t r u c t s u c h as l o c u s of c o n t r o l seemed a worthwhile and D o n o v a n , 1976)  i n t e r e s t i n g one.  Several studies (O'Leary, Rohsenov,  h a v e r e l a t e d l o c u s of c o n t r o l to alcohol t r e a t m e n t , b u t  r e s u l t s are i n c o n c l u s i v e .  and  the  If b e l i e f s about alcohol d e p e n d e n c e are r e l a t e d to  b e l i e f s about r e s p o n s e - o u t c o m e c o n t i n g e n c i e s , it seems r e a s o n a b l e  that this  r e l a t i o n s h i p w o u l d i n t e r a c t with a t r e a t m e n t p r o g r a m , p a r t i c u l a r l y i f the n a t u r e of the p r o g r a m c o u l d be e s t a b l i s h e d as b e i n g c o n t i n u u m or the  at one  end  of t h e c o n t r o l  other.  Therefore,: f o u r h y p o t h e s e s were i n v e s t i g a t e d i n t h i s s t u d y : I  D e v i a n t d r i n k e r s who  p r e f e r the l a b e l "problem d r i n k e r " r a t h e r t h a n  " a l c o h o l i c " will show a s t r o n g e r p r e f e r e n c e  for implications associated  with a b e h a v i o r a l t h e o r y of alcohol d e p e n d e n c e implications a s s o c i a t e d with a d i s e a s e t h e o r y ,  as m e a s u r e d b y  Beliefs About Alcohol Dependence questionnaire. d e v i a n t d r i n k e r s who preference  t h a n f o r the: the  Conversely,  p r e f e r the l a b e l " a l c o h o l i c " will show a  stronger  f o r d i s e a s e t h e o r y i m p l i c a t i o n s as m e a s u r e d b y t h e same  questionnaire. II  S e l f - d e f i n e d a l c o h o l i c s a n d p r o b l e m d r i n k e r s will also d i f f e r o n  beliefs  about l o c u s of c o n t r o l , i n the d i r e c t i o n of g r e a t e r e x t e r n a l i t y f o r the a l c o h o l i c s , as m e a s u r e d b y III  the R o t t e r L o c u s of C o n t r o l  Scale.  A t r e a t m e n t p r o g r a m w h i c h e m p h a s i z e s a b e h a v i o r a l model of t r e a t m e n t will s e r v e to s t r e n g t h e n  b e h a v i o r a l l y oriented beliefs, and  weaken  - 10 -  d i s e a s e o r i e n t e d b e l i e f s , as m e a s u r e d b y t h e B e l i e f s A b o u t Dependence IV  Alcohol  questionnaire.  D u r i n g a stay i n a treatment p r o g r a m which emphasizes  personal  responsibility a n d self-control over d r i n k i n g , b o t h alcoholics a n d p r o b l e m d r i n k e r s will become more i n t e r n a l l y o r i e n t e d , as m e a s u r e d by  the Rotter  Scale.  Assumptions The  major a s s u m p t i o n made i n t h i s s t u d y was t h a t i t was j u s t i f i a b l e  to collapse all of t h e models o f alcohol d e p e n d e n c y i n t o two m u t u a l l y exclusive choices.  It was a s s u m e d t h a t t h e r e were two d i s t i n c t b e l i e f  s y s t e m s , a disease o r i e n t e d one a n d a b e h a v i o r a l one, a n d t h a t t h e y a r e negatively correlated.  T h i s does n o t p r e c l u d e  t h e e x i s t e n c e of o t h e r  r e l a t e d c o n s t r u c t s , b u t it was a s s u m e d t h a t t h e two b e l i e f s y s t e m s m e n t i o n e d w o u l d d i s c r i m i n a t e b e t w e e n two s u b g r o u p s of t h e alcohol d e p e n d e n t A s e c o n d a s s u m p t i o n was t h a t t h e q u e s t i o n n a i r e perform the operation described  would  a b o v e , i . e . , make t h e d i s c r i m i n a t i o n , a n d  do so i n a r e l i a b l e a n d v a l i d way. questionnaire  as c o n s t r u c t e d  population.  Some p s y c h o m e t r i c e v a l u a t i o n of t h e  was done to e s t a b l i s h t h e s e c r i t e r i a .  Delimitations S e v e r a l p o i n t s about sample s e l e c t i o n limited t h e a p p l i c a b i l i t y of t h e s t u d y . T h e s u b j e c t s a n d t r e a t m e n t c e n t r e s were n o t s e l e c t e d i n a r a n d o m or r e p r e s e n t a t i v e f a s h i o n .  R a t h e r , t h e sample c o n s i s t e d o f almost all o f  - l i -  the p o p u l a t i o n period. and  a t t e n d i n g two r e s i d e n t i a l c e n t r e s d u r i n g  a t h r e e month  T h e c e n t r e s were s e l e c t e d o n the b a s i s that t h e y were a c c e s s i b l e  cooperative.  H o w e v e r , t h e f i n d i n g s may n o t g e n e r a l i z e , s i n c e c l i e n t s  are n o t r a n d o m l y a s s i g n e d The  to t r e a t m e n t  centres.  sample was d r a w n from an i n p a t i e n t r a t h e r t h a n a n o u t p a t i e n t  population  s i n c e it was f a r more e f f i c i e n t to o b t a i n a l a r g e sample from s u c h  a "captive" audience.  T h e r e may not b e a n y r e a s o n to assume a d i f f e r e n c e  b e t w e e n t h e s e two p o p u l a t i o n s , The  b u t t h i s p o i n t n e e d s to b e i n v e s t i g a t e d .  sample was r e s t r i c t e d to men o n l y , f o r two r e a s o n s . F i r s t , m a n y  researchers  feel that alcohol b e l i e f s y s t e m s of women may b e d i f f e r e n t from  t h o s e of men ( e . g . , M c L e l l a n d , D a v i s , R o h s e n o v , 1980).  K a l i n , a n d Wanner, 1972; M a r l a t t a n d  S e c o n d l y , women are u s u a l l y v a s t l y u n d e r r e p r e s e n t e d  i n a n y r e s i d e n t i a l p r o g r a m , so that it w o u l d not h a v e b e e n p o s s i b l e to g e t a sample l a r g e e n o u g h f o r a n a l y s i s w i t h i n the t h r e e m o n t h time frame. The  r e s u l t s of the s t u d y a p p l y o n l y to those whose t r o u b l e s w i t h  alcohol h a v e b e e n c o n s i d e r e d  s e r i o u s e n o u g h to h a v e w a r r a n t e d t r e a t m e n t  in a specialized facility.  Justification The extension  present  s t u d y seemed j u s t i f i e d o n the b a s i s t h a t i t allowed  of the c u r r e n t l y a c c e p t e d alcoholism p a r a d i g m to i n c l u d e a  p r o b l e m d r i n k i n g one,  a n d d i d t h i s b y i n v e s t i g a t i n g the i m p o r t a n c e o f t h e  b e l i e f s of d e v i a n t d r i n k e r s t h e m s e l v e s . Recently,  some ( e . g . , T o u r n i e r ,  1977, 1979; P a t t i s o n , S o b e l l ,  - 12 -  and Sobell, 1977) have called for an extension of the traditional, disease paradigm of alcoholism.  Tournier (1977) wrote that this approach has  become "counterproductive  [in that] it fetters innovation,  precludes  prevention, and ties us to a treatment strategy that it v e r y limited in its applicability" (p. 2) . As previously described, some writers have also called for an extension of the alcohol dependent population into at least two categories, but they have done so on the basis of external, objective criteria. Belief systems of alcoholics and problem drinkers have been investigated and found to be related to a number of variables: drinking patterns and consumption rates (Mello, Marlatt and Rohsenov, 1980);  1972;  treatment success (Dillavou, Vannicelli and Ryback, 1977); change during group therapy (Hoy,  1973);  relapse rate (Heather, Edwards, and Hore, 1975). However, no study thus far seems to have looked at the differences in belief systems within the alcohol dependent population and attempted to define some of the parameters of these differences. Definition of Terms ALCOHOLISM, A L C O H O L I C S  These terms are used to denote the  condition  of alcohol dependence or the alcohol dependent person when the disease or traditional model is being described.  These terms are also used when they  have been used by the author of a study under review.  Thus, if the  original article r e f e r r e d to "Fifty alcoholics at an alcoholism treatment centre"  - 13 t h o s e will b e t h e terms u s e d i n t h i s p a p e r w h e n r e f e r r i n g to t h e s t u d y . P R O B L E M DRINKING, PROBLEM DRINKER  T h e s e t e r m s a r e u s e d to  d e n o t e t h e c o n d i t i o n of alcohol d e p e n d e n c e o r t h e alcohol d e p e n d e n t i n d i v i d u a l w h e n t h e b e h a v i o r a l o r e n v i r o n m e n t a l model i s b e i n g d i s c u s s e d . T h e s e t e r m s a r e also u s e d when t h e y h a v e b e e n u s e d b y t h e a u t h o r o f a s t u d y u n d e r review. D E V I A N T DRINKING, DRINKER; A L C O H O L D E P E N D E N C E , A L C O H O L PROBLEMS, A L C O H O L DEPENDENT, or A D D I C T E D PERSON are used interchangeably and i n a generic fashion.  T h e s e terms  T h u s their use is  meant to i n d i c a t e alcohol d e p e n d e n c e i n g e n e r a l i s b e i n g d i s c u s s e d , without r e f e r e n c e to a s p e c i f i c model. ADDICTION, DEPENDENCY  T h e s e terms are u s e d i n t e r c h a n g e a b l y .  As  u s e d h e r e , t h e y r e f e r to t h e c o n d i t i o n o r p r o c e s s i n w h i c h a n i n d i v i d u a l ' s l i f e s t y l e i s a s s o c i a t e d i n a p r o b l e m a t i c way w i t h e x c e s s i v e u s e o f a l c o h o l . P H Y S I O L O G I C A L or P H Y S I C A L A D D I C T I O N / D E P E N D E N C Y  T h i s term  r e f e r s to t h e body's b e c o m i n g p h y s i c a l l y d e p e n d e n t o n a l c o h o l , as i s illustrated b y tolerance and withdrawal.  "Tolerance" o c c u r s when there  is a p h y s i o l o g i c a l o r metabolic a d a p t a t i o n to alcohol so t h a t t h e i n d i v i d u a l n e e d s i n c r e a s i n g amounts to get t h e same e f f e c t s .  "Withdrawal"  r e f e r s to  t h e o c c u r r e n c e of a d v e r s i v e o r u n p l e a s a n t p h y s i c a l s y m p t o m s u p o n a b r u p t c e s s a t i o n o f alcohol u s e . PSYCHOLOGICAL DEPENDENCE  T h i s c o n d i t i o n i s s a i d to b e p r e s e n t w h e n  an i n d i v i d u a l ' s l i f e s t y l e i s e x c e s s i v e l y c o n c e r n e d  w i t h alcohol use, a n d w h e n  t h e i n d i v i d u a l h a b i t u a l l y e x p r e s s e s a s t r o n g d e s i r e f o r alcohol a l t h o u g h  - 14 -  h e / s h e may n o t b e p h y s i c a l l y d e p e n d e n t . BELIEF SYSTEMS The  These  v  a r e c o g n i t i v e s t r u c t u r e s t h a t mediate  term i s u s e d i n a v e r y g e n e r a l s e n s e , i . e . , a " p e r s o n a l  behaviors.  construct  system'! i s a b e l i e f s y s t e m , a n d so a " g e n e r a l i z e d " e x p e c t a n c y f o r e x t e r n a l or interna] control. PERSONAL CONSTRUCT of a c o n c e p t u a l  A personal construct is a generalized  discrimination between events,  representations of those events.  or between the psychological  A c o n s t r u c t is more t h a n j u s t t h e v e r b a l  l a b e l a p p l i e d to i t , s i n c e i t i n c l u d e s p e r s o n a l e x p e r i e n c e verbal.  representation  T h u s t h e c o n s t r u c t "behaves r e s p o n s i b l y v e r s u s  w h i c h may b e n o n is irresponsible"  i n c l u d e s t h e p e r s o n ' s v e r b a l d e f i n i t i o n as well as h i s / h e r i d i o s y n c r a t i c experience  of t h a t c o n s t r u c t .  PERSONAL CONSTRUCT  Constructs  SYSTEM  are always b i - p o l a r .  T h i s term r e f e r s to a set o f i n t e r r e l a t e d  p e r s o n a l c o n s t r u c t s w h i c h a r e t h e core of e a c h p e r s o n ' s e x p e r i e n c e i . e . , t h e y allow d e c o d i n g a n d e n c o d i n g o f p e r s o n a l  of life,  behavior.  GENERALIZED E X P E C T A N C Y FOR EXTERNAL-INTERNAL CONTROL, ORIENTATION, L O C U S OF C O N T R O L and  T h e s e terms are u s e d  as d e s c r i b e d b y R o t t e r et al (1972) a n d b y P h a r e s (1975).  e x t e r n a l l y c o n t r o l l e d i n d i v i d u a l b e l i e v e s that h i s / h e r b e h a v i o r  CONTROL  interchangeably B r i e f l y , an a n d outcomes  are i n d e p e n d e n t , i . e . , that goals r e s u l t from good l u c k , f a t e , c h a n c e , o r i n t e r v e n t i o n of powerful others. has  control of reinforcements.  A n "internal" individual believes he/she  - 15 -  C H A P T E R II LITERATURE  REVIEW  Overview S e v e r a l a r e a s of p s y c h o l o g i c a l i n v e s t i g a t i o n h a v e b e e n r e v i e w e d i n o r d e r to p r o v i d e  a b a c k g r o u n d for this study.  It was  p r e d i c t e d that  there  are s u b g r o u p s among the alcohol d e p e n d e n t p o p u l a t i o n w h i c h h a v e d i f f e r e n t belief systems.  Therefore,  s t u d i e s were c i t e d w h i c h show s i g n i f i c a n t  variability in this population, dependence representing  e n o u g h to q u e s t i o n the c o n c e p t of alcohol  a single entity.  C o g n i t i v e p r o c e s s e s are  i m p o r t a n t v a r i a b l e i n d e s c r i b i n g alcohol r e l a t e d b e h a v i o r s . from a p e r s o n a l c o n s t r u c t t h e o r y  an  Studies r e s u l t i n g  framework showed that self definition i n  t e r m s of a d e v i a n t r o l e i m p l i e d an u n d e r l y i n g  cognitive structure which  had  p r e d i c t i v e value for behavior. The  s e c o n d h y p o t h e s i s a s s u m e d t h a t t h e r e is a r e l a t i o n s h i p b e t w e e n  alcoholics' a n d and  problem d r i n k e r s ' subjective theories about their condition  their expectations  about c o n t r o l o v e r t h e i r e n v i r o n m e n t .  L a c k of  c o n t r o l o v e r d r i n k i n g is an i m p o r t a n t c h a r a c t e r i s t i c of alcohol d e p e n d e n c y , b u t s t u d i e s r e v i e w e d show t h a t t h i s l a c k of c o n t r o l is m e d i a t e d c o g n i t i v e l y , not p h y s i o l o g i c a l l y . If c o n t r o l o v e r d r i n k i n g i s c o g n i t i v e l y mediated, seems to be a r a t i o n a l e f o r a s s u m i n g a r e l a t i o n s h i p to a more p e r s p e c t i v e on c o n t r o l .  Therefore,  there  general  s t u d i e s i n v e s t i g a t i n g the n a t u r e of  " l o c u s of c o n t r o l " i n t h i s p o p u l a t i o n were r e v i e w e d . The  t h i r d and  f o u r t h h y p o t h e s e s p r e d i c t e d that b e l i e f s y s t e m s c h a n g e  - 16 -  d u r i n g therapy, and studies which provide  s u p p o r t f o r t h i s p o s i t i o n were v  also r e v i e w e d .  Variability Among Alcoholics/Problem  Drinkers  J e l l i n e k (1946, 1960) was t h e f i r s t r e s e a r c h e r alcoholism was n o t a u n i t a r y p h e n o m e n o n . "alcoholisms"  to a c k n o w l e d g e t h a t  He wrote of " s p e c i e s " o f  a n d d e s c r i b e d t h e following f i v e , a l t h o u g h h e felt  there  might be more: 1)  A l p h a alcoholism, w h i c h i s c h a r a c t e r i z e d b y p s y c h o l o g i c a l dependence and psychosocial problems.  Physiological  d e p e n d e n c e i s not p r e s e n t . 2)  B e t a alcoholism, i n w h i c h t h e r e is h e a v y d r i n k i n g , r e s u l t i n g i n p h y s i c a l damage, b u t n e i t h e r p h y s i o l o g i c a l n o r p s y c h o l o g i c a l dependency.  One could describe the d r i n k i n g style i n F r a n c e  as b e i n g of t h i s 3)  type.  E p s i l o n alcoholism, w h i c h f e a t u r e s p e r i o d i c e p i s o d e s o f h e a v y d r i n k i n g , b u t without p h y s i c a l d e p e n d e n c e .  T h e d r i n k i n g style  e n c o u r a g e d b y Germany's b e e r f e s t s a n d t h a t o f t h e " b i n g e d r i n k e r " may be r e p r e s e n t a t i v e . 4)  Gamma alcoholism, w h i c h J e l l i n e k felt to b e t h e major t y p e prevalent i n North America.  It i n c l u d e s b o t h p h y s i c a l a n d  p s y c h o l o g i c a l d e p e n d e n c e , as well as a d v e r s e consequences. to t h i s t y p e ,  psychosocial  T h e t y p i c a l A A model of alcoholism  with "loss o f c o n t r o l " b e i n g  conforms  a chief characteristic.  5)  D e l t a alcoholism, w h i c h he also t h o u g h t is c h a r a c t e r i z e d b y  common on t h i s c o n t i n e n t ,  "an i n a b i l i t y to a b s t a i n " a l t h o u g h t h e amount  c o n s u m e d at a n y one time may  be c o n t r o l l e d .  Physical dependence  is also p r e s e n t , a l t h o u g h p e r s o n a l p r o b l e m s may Jellinek thought two  o r may  not  be.  the "disease c o n c e p t " s h o u l d a p p l y o n l y to t h e l a t t e r  t y p e s of alcoholism.  E v i d e n c e of p h y s i c a l a d d i c t i o n s h o u l d be  as i n d i c a t e d b y the o c c u r r e n c e of w i t h d r a w a l  present,  symptoms u p o n c e s s a t i o n of  alcohol u s e . J e l l i n e k ' s c o n c l u s i o n s are b a s e d c h i e f l y on c l i n i c a l o b s e r v a t i o n a n d survey study.  A q u e s t i o n n a i r e was  t h e i r n e w s l e t t e r , "The  Grapevine".  d i s t r i b u t e d to 1,600 Only  n u m b e r , w e r e u s e d i n the data a n a l y s i s .  AA  members  one  through  98, o r s i x p e r c e n t of the o r i g i n a l Nevertheless, Jellinek u s e d this  d a t a to f o r m u l a t e h i s c o n c e p t of the " p h a s e s of t h e d i s e a s e p r o c e s s of alcoholism He  a n a l y s e d t h e o c c u r r e n c e of 43 symptoms b y  d r i n k i n g h i s t o r y and  determined  age of o n s e t a n d  sequence in  t h a t t h e r e are t h r e e d i s t i n c t p h a s e s .  The  " p r o m o d a l p h a s e " i s c h a r a c t e r i z e d b y t h e o n s e t of b l a c k o u t s , the " c r u c i a l p h a s e ' b y t h e "loss of c o n t r o l " , a n d the " c h r o n i c p h a s e " b y p r o l o n g e d T h e s e p h a s e s a r e t h o u g h t of as s e q u e n t i a l a n d i n e v i t a b l e , a n d  intoxication. all t h e symptoms  a r e p a r t of t h e d i s e a s e p r o c e s s . The  a b o v e data c a n be c r i t i c i z e d on s e v e r a l g r o u n d s . T h e  items were "loaded"; a sample q u e s t i o n was: experience blackouts?"  The  sample was  to t h e genera] p o p u l a t i o n , o r to the A A c o n t r o l or comparison g r o u p s .  The  questionnaire  "At what age d i d y o u  first  not r e p r e s e n t a t i v e e i t h e r w i t h r e s p e c t membership.  T h e r e were no  adequate  data c o l l e c t e d were r e t r o s p e c t i v e i n n a t u r e ,  - 18 -  and  t h e r e f o r e s u b j e c t to contamination from memory l o s s , o r r e t r o a c t i v e v  inhibition.  In other words, respondents could have b e e n  "recalling"  what t h e y h a d b e e n t a u g h t at A A . J e l l i n e k was aware of all t h e s e l i m i t a t i o n s , a n d c a u t i o n e d wholesale a c c e p t a n c e o f h i s disease model.  Unfortunately,  against  t h i s is what  h a p p e n e d , a n d u n t i l t h e a d v e n t of t h e b e t t e r c o n t r o l l e d s t u d i e s , was c o n c e p t u a l i z e d and  as a u n i t a r y p h e n o m e n o n .  "alcoholism"  C l a r k a n d C a h a l a n (1976)  P a t t i s o n , S o b e l l , a n d Sobell (1977) r e v i e w a n u m b e r o f s u c h s t u d i e s .  T h e y c a n b e b r o k e n i n t o two c a t e g o r i e s : 1)  A t t e m p t s to r e p l i c a t e t h e J e l l i n e k f o r m u l a of q u e s t i o n i n g "admitted" alcoholics have not been s u c c e s s f u l .  There is  l i t t l e e v i d e n c e of d i s t i n c t p h a s e s c h a r a c t e r i z e d b y s p e c i f i c symptoms.  T h e r e does seem to b e a g e n e r a l  functional  d e t e r i o r a t i o n t h a t w o u l d b e e x p e c t e d from c h r o n i c  heavy  alcohol consumption. 2)  S t u d i e s o f r e p r e s e n t a t i v e c r o s s s e c t i o n s of t h e p o p u l a t i o n show t h e d e v e l o p m e n t o f " d r i n k i n g p r o b l e m s " to b e v a r i a b l e o v e r time.  These longitudinal studies generally use a version  of Cahalan's (1976) d e f i n i t i o n :  A "problem d r i n k e r " is o n e who  o b t a i n s a s c o r e of s e v e n o r more i n e l e v e n c a t e g o r i e s of p e r s o n a l o r social p r o b l e m s a s s o c i a t e d with d r i n k i n g .  Significant numbers  of p e o p l e move i n a n d o u t of t h e " p r o b l e m " c a t e g o r y o v e r a f o u r to 20 y e a r s p a n . The  C a h a l a n t y p e of s t u d y c a n b e c r i t i c i z e d o n t h e b a s i s t h a t it does  - 19 -  not s t u d y " t r u e a l c o h o l i c s " a n d does h o l d t r u e .  t h a t f o r t h i s select g r o u p a d i s e a s e  S t i l l , the e v i d e n c e p o i n t s to the p o s i t i o n t h a t most  d r i n k e r s do not c o n f o r m to a disease p r o c e s s , a n d of v a r i a b i l i t y i n t h i s p o p u l a t i o n .  deal  M a r k K e l l e r , i n c r i t i c i z i n g the s t u d i e s  that  " a l c o h o l i c s are d i f f e r e n t (from n o n - a l c o h o l i c s ) d i f f e r e n c e ! " (1977, p. 61).  i n t h i s way:  deviant  that there is a great  h a v e a t t e m p t e d to p i n p o i n t t r a i t s p e c u l i a r to an  no  process  " a l c o h o l i c p e r s o n a l i t y " wrote,  i n so m a n y w a y s t h a t i t makes  It seems that t h i s statement c o u l d be  rephrased  " a l c o h o l i c s are d i f f e r e n t from e a c h o t h e r i n more w a y s t h a n t h e y  are d i f f e r e n t from n o n - a l c o h o l i c s " . A r e c e n t s t u d y ( P a t t i s o n , Coe  and  D o e r r , 1977)  shows that i t is useful  to t h i n k of alcohol d e p e n d e n t i n d i v i d u a l s i n s e v e r a l d i s t i n c t s u b g r o u p i n g s . C l i e n t s at f o u r d i f f e r e n t alcohol treatment f a c i l i t i e s were c o m p a r e d :  an  a v e r s i o n c o n d i t i o n i n g h o s p i t a l ( A C H ) , an o u t p a t i e n t c l i n i c ( O P C ) , a h a l f w a y h o u s e (HWH), a n d were:  a police work rehabilitation centre  (PWC).  Measures taken  p e r s o n a l i t y p r o f i l e s (MMPI), d e m o g r a p h i c c h a r a c t e r i s t i c s , g e n e r a l  functioning  (health, vocational, i n t e r p e r s o n a l ) , and  o r i e n t a t i o n to t r e a t m e n t .  Data analysis yielded statistically significant differences between g r o u p s  on  several measures. P a t t i s o n et al s u g g e s t that t h e r e is e n o u g h v a r i a t i o n to s u g g e s t that four distinct populations discrimination can the A C H  population  were s u r v e y e d , a n d  be t h o u g h t of as a "social competence" f a c t o r . had  the h i g h e s t e d u c a t i o n a l l e v e l a n d  s t a t u s , the b e s t v o c a t i o n a l a n d conflict.  that the main b a s i s f o r For  example,  socioeconomic  interpersonal adjustment and  no  personality  T h i s h i g h social competence s c o r e allowed t h i s g r o u p to " e x t e r n a l i z e "  - 20 t h e i r alcohol d e p e n d e n c y , a n d to t h i n k of i t as a medical p r o b l e m heart t r o u b l e , or a b r o k e n l e g - something  such  t h e d o c t o r will " f i x " .  as  The  facility s u p p o r t s this interpretation b y treating only the d r i n k i n g behavior. The  o t h e r p o p u l a t i o n s e x p e r i e n c e d more p e r s o n a l c o n f l i c t  social d i s r u p t i o n , w i t h the O P C , t h i r d and f o u r t h respectively. p e r s o n a l adjustment viewed  HWH, The  a n d t h e PWC  OPC  and  groups ranking  second,  g r o u p e x p e r i e n c e d p r o b l e m s of  r a t h e r t h a n social d i s i n t e g r a t i o n , a n d t h u s t h e c l i e n t s  t h e i r alcohol d e p e n d e n c y as an e x p r e s s i o n of t h e i r i n t e r n a l c o n f l i c t s .  A g a i n , t h i s v i e w i s s u p p o r t e d b y the O P C psychotherapy.  F o r t h e r e m a i n i n g two  treatment approach,  groups,  HWH  a n d PWC,  which emphasized alcohol p r o b l e m s  w e r e a s s o c i a t e d with s i g n i f i c a n t social d e t e r i o r a t i o n a n d a l i e n a t i o n . s t e p to r e h a b i l i t a t i o n seemed to be a d h e r e n c e to t h e A A  The  key  model, a n d a total  lifestyle change. F o r p u r p o s e s of the p r e s e n t r e v i e w , the f o l l o w i n g i n t e r p r e t a t i o n s of P a t t i s o n et al s h o u l d be e m p h a s i z e d :  alcohol d e p e n d e n t i n d i v i d u a l s r e p r e s e n t  a w i d e l y d i v e r g e n t p o p u l a t i o n , i n d i v i d u a l s d i f f e r w i t h r e s p e c t to how define their alcohol d e p e n d e n c y , and these p e r c e p t i o n s determine,  they  to some  e x t e n t , t h e t y p e of t r e a t m e n t f a c i l i t y to w h i c h t h e y will b e a t t r a c t e d .  One  c o u l d p o i n t o u t that the i n t e r a c t i o n b e t w e e n i n d i v i d u a l a n d t y p e of t r e a t m e n t is determined  more b y socioeconomic f a c t o r s t h a n c o g n i t i v e o n e s .  definite test would relate  client p e r c e p t i o n s , treatment facility  A  more  and  s u c c e s s f u l outcomes.  B e l i e f S y s t e m s of A l c o h o l i c s / P r o b l e m D r i n k e r s R e c e n t y e a r s h a v e s e e n an i n c r e a s e d i n t e r e s t i n i n v e s t i g a t i n g t h e  - 21 -  relationship between cognitive variables and  alcohol d e p e n d e n c y .  i n t e r e s t r e s u l t s from the c o n t r o l l e d d r i n k i n g c o n t r o v e r s y R o u s e , 1975;  Miller a n d  C a d d y , 1977).  P a r t of t h i s  (e.g., Ewing  and  More i m p o r t a n t , h o w e v e r , i s the e v i d e n c e  t h a t c o g n i t i v e f a c t o r s a f f e c t alcohol c o n s u m p t i o n as well as r e l a t e d b e h a v i o r s (Marlatt and and  R o h s e n o v , 1980); p r e d i c t t r e a t m e n t c h o i c e  R y b a c k , 1977); a n d  (Dillavou, Vannicelli  are a s s o c i a t e d with r e l a p s e ( H e a t h e r , E d w a r d s  and  H o r e , 1975). A study by  Richard  and  Burley  (1978) s h o w e d t h a t a g r o u p s o f  20  alcoholic i n p a t i e n t s at a h o s p i t a l i d e n t i f i e d more c l o s e l y w i t h the r o l e of " c o n t r o l l e d d r i n k e r " t h a n that of "total a b s t a i n e r " . a s k e d to r a t e the c o n c e p t s , "myself" a n d of 13 b i p o l a r p e r s o n a l i t y d e s c r i p t i o n s . E a c h b i p o l a r item was three  the two  The  subjects  were  d r i n k i n g o n e s on a s e r i e s  (Examples,  "escapist-realist").  r a t e d on a s e v e n p o i n t s c a l e , a n d  s e p a r a t e l y f o r the  concepts. The  i m p l i c a t i o n of the a b o v e s t u d y is t h a t it i s e a s i e r f o r a p e r s o n to  a d o p t a r o l e w h i c h has Therefore,  more p s y c h o l o g i c a l m e a n i n g ( F r a n s e l l a , 1972).  it w o u l d be i m p o r t a n t at the b e g i n n i n g of t h e r a p y to a s s e s s the  d e g r e e of i d e n t i f i c a t i o n with c o n t r o l l e d d r i n k i n g o r a b s t a i n e r r o l e . t h e r a p i s t t h e n has two  choices:  c o n f o r m the t h e r a p e u t i c  The  goal to the client's  b e l i e f s y s t e m , o r e n c o u r a g e the client to c h a n g e h i s / h e r b e l i e f s to c o n f o r m to the a p p r o p r i a t e Marlatt and  goals. R o h s e n o v (1980) r e v i e w e d s e v e r a l e x p e r i m e n t a l s t u d i e s  u s i n g the " b a l a n c e d p l a c e b o " d e s i g n  ( F i g u r e 1).  This design provides  a  c o n t r o l c o n d i t i o n f o r c o g n i t i v e e f f e c t s as well as f o r the p h y s i o l o g i c a l o n e s ,  - 22 T h u s , from t h i s t y p e of d e s i g n , i t i s p o s s i b l e to a s s e s s t h e i m p o r t a n c e  of  v  f o u r c o n d i t i o n s , as i l l u s t r a t e d below: Figure 1 The  Balanced Placebo Design:  Marlatt and  Rohsenov  Receive Alcohol Yes "o 'o ~  both cognitive a> a n d p h y s i o l o g i c a l effects present  <J physiological Pu 3 e f f e c t s W only  No cognitive effect only neither effect present  In one s t u d y d e s c r i b e d b y M a r l a t t a n d R o h s e n o v a m a t c h e d g r o u p of n o n - a b s t i n e n t a l c o h o l i c s a n d social d r i n k e r s were a s k e d to p a r t i c i p a t e i n a "taste t e s t " .  S u b j e c t s i n the " e x p e c t a l c o h o l " c o n d i t i o n were l e d to b e l i e v e  t h e y were c o m p a r i n g t h r e e b r a n d s of v o d k a . r e c e i v e d tonic only.  H a l f of t h i s g r o u p a c t u a l l y  S u b j e c t s i n the "expect no a l c o h o l " c o n d i t i o n were t o l d  t h e y w o u l d b e c o m p a r i n g t h r e e b r a n d s of t o n i c water. t o n i c a n d v o d k a , the o t h e r s got t o n i c o n l y .  H a l f of t h e s e got  A l l s u b j e c t s were p r o v i d e d w i t h  a f u l l d e c a n t e r of b e v e r a g e a n d the amount c o n s u m e d was a l c o h o l i c s a n d social d r i n k e r s , the e x p e c t a n c y d r u n k , the a c t u a l p r e s e n c e of alcohol was The  measured.  of alcohol d e t e r m i n e d  For both the amount  not a s i g n i f i c a n t f a c t o r .  a b o v e d e s i g n has b e e n u s e d to s t u d y the e f f e c t s of alcohol on  experimental analogues  of emotional a n d s e x u a l b e h a v i o r s , as well as on motor  - 23 and  cognitive abilities.  of s h o c k s  1  In one  study, aggression  was  d e f i n e d as t h e n u m b e r  s u b j e c t s g a v e , when p r o v o k e d , to a n o t h e r s u b j e c t who  f a c t a c o n f e d e r a t e of the e x p e r i m e n t e r . p l a c e d i n one  Subjects  Subjects  who  s i g n i f i c a n t l y more a g g r e s s i v e  believed they had t h a n t h o s e who  in  were h e a v y d r i n k e r s ,  of f o u r t r e a t m e n t c o n d i t i o n s d e s c r i b e d i n F i g u r e  were c l e a r c u t .  was  1.  The  and  results  r e c e i v e d alcohol were  d i d not b e l i e v e t h e y  had,  r e g a r d l e s s of a c t u a l alcohol c o n t e n t i n t h e i r d r i n k s . Marlatt and d r i n k i n g and  R o h s e n o v s u g g e s t the f o l l o w i n g r e l a t i o n s h i p b e t w e e n  aggression:  "produces" aggression  t h e r e is an e x i s t i n g c u l t u r a l b e l i e f t h a t alcohol  and  t h i s e x p e c t a n c y will be s t r o n g e s t i n h e a v y d r i n k e r s .  T h e s e i n d i v i d u a l s w o u l d be l i k e l y to i n d u l g e i n a g g r e s s i v e consuming alcohol, and  a t t r i b u t e r e s p o n s i b i l i t y f o r t h i s b e h a v i o r to the  alcohol r a t h e r t h a n to t h e m s e l v e s . sanctions against aggression, fail to a s s e r t t h e m s e l v e s a n d followed b y  aggression,  F u r t h e r m o r e , i n t h e face of h e a v y c u l t u r a l  some i n d i v i d u a l s , w h e n p r o v o k e d to a n g e r , consume a l c o h o l i n s t e a d .  Drinking  may  be  provocation.  a b o v e r e v i e w g i v e s s t r o n g e v i d e n c e f o r the i m p o r t a n c e of c o g n i t i o n  i n p r e d i c t i n g the b e h a v i o r of d e v i a n t d r i n k e r s .  The  c r u c i a l e f f e c t of c o g n i t i v e  e x p e c t a n c i e s has b e e n f o u n d i n alcohol t h e r a p y as w e l l .  D i l l a v o u et al  e x a m i n e d t h e r e l a t i o n s h i p b e t w e e n s c o r e s on t h e R o t t e r I-E Scale a n d  l  then  may  w h i c h i n t u r n c a n t h e n be a t t r i b u t e d to t h e alcohol,  r a t h e r t h a n to t h e e a r l i e r The  behavior after  acceptance  T h e c o n f e d e r a t e s u b j e c t s were not r e a l l y s h o c k e d , t h e y were h o o k e d to a m a c h i n e w h i c h made it seem as i f t h e y w e r e .  up  - 24 -  of t r e a t m e n t i n t e r v e n t i o n b y  45 a l c o h o l i c s at an i n p a t i e n t f a c i l i t y .  It  was  h y p o t h e s i z e d t h a t i n t e r n a l a l c o h o l i c s w o u l d be more a t t r a c t e d to i n s i g h t o r i e n t e d t h e r a p y , as m e a s u r e d b y  s t a f f r a t i n g s of i n v o l v e m e n t .  p r e d i c t e d t h a t e x t e r n a l a l c o h o l i c s w o u l d be more a c c e p t i n g t r e a t m e n t i n t e r v e n t i o n s u c h as AA,  Antabuse  f o u n d to be i n .the e x p e c t e d d i r e c t i o n :  score and  AA  T h e r e was  , and  t h e r e was  c o r r e l a t i o n b e t w e e n R o t t e r I-E s c o r e s a n d ( r = - .25 p « 0 6 ) .  1  of  It was  also  external  Aftercare.  Results  a significant negative  were 2  insight therapy involvement  a significant positive correlation between Rotter  a c c e p t a n c e ( r = .27 p<05) .  3  A l t h o u g h the a b o v e c o r r e l a t i o n s a r e s i g n i f i c a n t , o n l y a b o u t s e v e n p e r c e n t of the v a r i a n c e  i n t r e a t m e n t p r e f e r e n c e c a n be a c c o u n t e d f o r b y  I-E  scores.  R o t t e r (1975) w o u l d a r g u e t h a t t h i s is the d e g r e e of p r e d i c t i v e p o w e r to  be  e x p e c t e d w h e n a g e n e r a l f a c t o r i s u s e d to a c c o u n t f o r b e h a v i o r i n a s p e c i f i c situation.  T h u s the r e s u l t s of D i l l a v o u et al do i n d i c a t e t h a t the l o c u s  c o n t r o l d i m e n s i o n i s one  of the f a c t o r s t h a t i s a s s o c i a t e d  of  with differentia]  r e s p o n s e to t r e a t m e n t . It i s well e s t a b l i s h e d t h a t c o g n i t i o n s alcoholics' b e h a v i o r .  These cognitions  are i m p o r t a n t d e t e r m i n a n t s of  are i n v o l v e d e i t h e r t h r o u g h g e n e r a l  1  A d r u g w h i c h , w h e n t a k e n i n c o n j u n c t i o n with a l c o h o l , p r o d u c e s s e v e r e a n d u n c o m f o r t a b l e symptoms, s u c h as n a u s e a , h e a r t p a l p i t a t i o n s , a n d s w e a t i n g . It i s p r e s c r i b e d to e n c o u r a g e a b s t i n e n c e .  2  H i g h s c o r e s o n the R o t t e r Scale i n d i c a t e e x t e r n a l i t y ; low  3  O t h e r c o r r e l a t i o n s b e t w e e n I-E s c o r e s a n d significance.  scores, internality.  external treatment a p p r o a c h e d  - 25 -  f a c t o r s s u c h as p e r c e p t i o n o f c o n t r o l , o r t h r o u g h s p e c i f i c e x p e c t a n c i e s w i t h r e s p e c t to a l c o h o l .  It follows that t h e s t a t e , o r c o n d i t i o n , o f alcohol  d e p e n d e n c e c o u l d also b e s t u d i e d as a c o g n i t i v e p r o c e s s r a t h e r t h a n a physiological one.  A l c o h o l D e p e n d e n c e as a C o g n i t i v e  Process  One of t h e c e n t r a l h y p o t h e s e s u n d e r i n v e s t i g a t i o n i s t h a t two o b j e c t i v e t h e o r i e s of a l c o h o l d e p e n d e n c e c a n become t h e b a s i s f o r t h e s u b j e c t i v e theories of deviant d r i n k e r s . personal construct theory F r a n s e l l a , 1972).  A t h e o r e t i c a l b a s i s f o r t h i s p o s i t i o n comes f r o m  (e.g., K e l l y  According  1955; B a n n i s t e r  a n d F r a n s e l l a , 1971;  to t h i s model, t h e c r u c i a l d e t e r m i n a n t o f  b e h a v i o r i s a s y s t e m of c o g n i t i v e s t r u c t u r e s c a l l e d " p e r s o n a l  constructs".  A c o n s t r u c t i s a subjective r e p r e s e n t a t i o n of a generalized discrimination b e t w e e n two e v e n t s .  Constructs  w o u l d b e an example o f a p e r s o n a l  are thus bipolar.  "Warm, g i v i n g / s e l f i s h "  c o n s t r u c t , b u t it is i m p o r t a n t  that this is just a v e r b a l label given to a conceptual  process,  to r e m e m b e r  and the process  i n c l u d e s more t h a n j u s t a v e r b a l d i s c r i m i n a t i o n . S e v e r a l o t h e r c h a r a c t e r i s t i c s o f c o n s t r u c t s a r e i m p o r t a n t ; an i n d i v i d u a l ' s p e r s o n a l c o n s t r u c t s a r e i n t e r r e l a t e d , a n d some a r e s u b o r d i n a t e to o t h e r s .  T h e c o n s t r u c t s y s t e m h a s f u n c t i o n a l v a l u e i n t h a t it allows t h e  i n d i v i d u a l to d e r i v e m e a n i n g a n d make p r e d i c t i o n s .  F o r example, a 14 y e a r  o l d at h i s f i r s t c o - e d d a n c e h a s b e e n t o l d t h a t i f a g i r l smiles a n d n o d s at him, she will a g r e e to d a n c e , b u t i f s h e f r o w n s a n d l o o k s away, s h e will r e f u s e . The  n e r v o u s 14 y e a r o l d s p e n d s t h e f i r s t h o u r d i s c r i m i n a t i n g t h e s m i l i n g ,  - 26 -  n o d d i n g g i r l s from t h e f r o w n i n g , l o o k i n g - a w a y o n e s .  H e i s \ t r y i n g to  assimilate t h i s new c o n s t r u c t , make it m e a n i n g f u l b y r e l a t i n g it to t h e way i n w h i c h he a l r e a d y c o n s t r u e s .  So, he j u d g e s that t h e g i r l who s m i l e d a n d  n o d d e d at h i m i s t h e o n e he's n o t i c e d i n c l a s s as b e i n g and  outgoing and friendly,  h e p r e d i c t s t h a t s h e will p r o b a b l y d a n c e w i t h him.  warm a n d p l e a s a n t .  He f e e l s e x c i t e d ,  He l o o k s at t h e g i r l who f r o w n s a n d l o o k s away, r e m e m b e r s  h e r as t h e s h y o n e who l i v e s n e x t d o o r , a n d p r e d i c t s s h e will r e f u s e . feels c o l d , a f r a i d a n d n e r v o u s .  If h i s p r e d i c t i o n s a r e c o r r e c t , t h e c o n s t r u c t ,  "smiles, n o d s / f r o w n s , l o o k s away" may become a n i m p o r t a n t way. of events concerning An  He  construing  girls.  a p p r o a c h r e s u l t i n g from p e r s o n a l  construct theory  h a s b e e n u s e d to  show that p e o p l e h a v e a n e l a b o r a t e c o n s t r u c t s y s t e m a s s o c i a t e d w i t h a d e v i a n t role.  F r a n s e l l a (1972) u s e d t h e " I m p - G r i d " method to show t h a t a g r o u p o f 20  s t u t t e r e r s h a d s i g n i f i c a n t l y more p s y c h o l o g i c a l m e a n i n g a t t a c h e d " s t u t t e r e r " t h a n to b e i n g  a "fluent speaker".  t h r o u g h t h e r a p y , so t h a t b e i n g  T h i s r e l a t i o n s h i p was c h a n g e d  a " f l u e n t s p e a k e r " c a r r i e d a more e l a b o r a t e  c o n s t r u c t s y s t e m , a n d t h e r a t e of f l u e n t s p e e c h i m p r o v e d The  theory  to b e i n g a  dramatically.  s t a t e s t h a t a p e r s o n s t u t t e r s b e c a u s e i t i s from t h a t s t a n c e  t h a t t h e w o r l d i s more m e a n i n g f u l .  T h u s , t h e t e e n a g e r at t h e d a n c e , h a d  he b e e n a s t u t t e r e r , w o u l d h a v e c o n s t r u e d  t h e s i t u a t i o n i n t h i s way:  " T h a t g i r l i s s m i l i n g a n d n o d d i n g at me; e v e n t h o u g h s h e k n o w s I s t u t t e r , she'll p r o b a b l y d a n c e with me."  I n t h e F r a n s e l l a s t u d y , it was p r e d i c t e d  that the rate of f l u e n c y would improve only i f "being  a f l u e n t s p e a k e r " became  - 27 -  more m e a n i n g f u l t h a n " b e i n g a s t u t t e r e r " .  T h u s , d u r i n g ^ t h e r a p y , the clients  were r e q u i r e d to c o n s t r u e e v e r y e p i s o d e of f l u e n t s p e e c h t h e y and i n great detail.  R e s u l t s show t h a t t h e a v e r a g e  f o r a g r o u p of 20 s t u t t e r e r s , d e c r e a s e d from  experienced,  r a t e of d i s f l u e n t w o r d s ,  85 p e r t e s t o c c a s i o n to e i g h t .  T o show t h a t the u n d e r l y i n g c o n s t r u c t s y s t e m h a d  also c h a n g e d ,  F r a n s e l l a t e s t e d each client s e v e r a l times d u r i n g t h e c o u r s e of t h e r a p y , u s i n g t h e " I m p - G r i d " method.  The  a n d a c a r d o n w h i c h was  written, "The  w h e n I'm  stuttering".  One  c l i e n t was  s h o w n two p h o t o g r a p h s of p e o p l e , s o r t of p e r s o n p e o p l e see me  p h o t o g r a p h w o u l d e l i c i t one pole of c o n s t r u c t ,  t h e o t h e r p i c t u r e would p r o m p t the o p p o s i t e p o l e . see me  as "warm, g i v i n g " while "B"  demands".  T h i s p r o c e s s was  not s t u t t e r i n g " .  m i g h t see me  Thus, person  "A"  T h u s two  might  as " r e s e n t f u l of o t h e r s '  t h e n r e p e a t e d , t h i s time u s i n g the two  w i t h the s t i m u l u s c a r d r e a d i n g , "The w h e n I'm  as b e i n g  s o r t of p e r s o n p e o p l e see me  photographs  as b e i n g  g r i d s were c o n s t r u c t e d at e a c h s e s s i o n .  A t t h e b e g i n n i n g , the " s t u t t e r e r " c o n s t r u c t s y s t e m was  much  "richer",  i n t e r m s of t h e n u m b e r of, a n d i n t e r r e l a t i o n s h i p s among, c o n s t r u c t s t h a n t h e " f l u e n t s p e a k e r " one.  A t the e n d of t h e r a p y , t h e c o n s t r u c t s y s t e m  a s s o c i a t e d w i t h self as f l u e n t s p e a k e r was  the p s y c h o l o g i c a l l y r i c h e r  one.  A s t u d y b y C h r i s t i a n s e n , R e i c h , O b i t z a n d B a u m a n (1980) shows t h a t a l c o h o l i c s do c o n s t r u e o t h e r s d i f f e r e n t l y w h e n t h e o t h e r i s alcoholic t h a n w h e n he i s n ' t .  After watching  a v i d e o t a p e d r o l e - p l a y , male alcoholics  were t o l d e i t h e r t h a t a job c a n d i d a t e was student.  The  an a l c o h o l i c o r t h a t he was  a  alcoholic s u b j e c t s j u d g e d t h a t t h e " a l c o h o l i c ' s " b e h a v i o r i n the  job i n t e r v i e w was  i n f l u e n c e d b y s i t u a t i o n a l , o r e x t e r n a l , f a c t o r s , while the  - 28 "non-alcoholic's" b e h a v i o r was factors.  T h u s one  more i n f l u e n c e d b y  of the e x p e c t a t i o n s  t h a t a l c o h o l i c s seem to h a v e f o r t h e  " a l c o h o l i c " r o l e i s an e x t e r n a l l o c u s of c o n t r o l . alcoholic as b e i n g  controlled by  "attribution theory" Personal  If an a l c o h o l i c sees a n o t h e r  e x t e r n a l f a c t o r s , wouldn't he h a v e the same  about h i s own  construct theory  dispositional, or internal,  behavior?  w o u l d state t h a t a d e v i a n t d r i n k e r d e v e l o p s  a c o n s t r u c t s y s t e m about alcohol d e p e n d e n c y , a n d  that this i n t e r n a l  p s y c h o l o g i c a l p r o c e s s i s more i m p o r t a n t to i n v e s t i g a t e t h a n the p r o c e s s of physiological addiction.  F u r t h e r m o r e , i f the " o b j e c t i v e " o r e x t e r n a l models  of alcohol d e p e n d e n c y r e p r e s e n t  a p s y c h o l o g i c a l d i f f e r e n c e , t h e n the  i n d i v i d u a l will c h o o s e t h o s e that h a v e t h e most p s y c h o l o g i c a l m e a n i n g .  It  i s a p r e m i s e o f t h i s s t u d y t h a t the " d i s e a s e t h e o r y o f alcoholism" i s so p o p u l a r l y k n o w n t h a t the "alcoholic or p r o b l e m d r i n k e r " d i s t i n c t i o n does represent  a real choice.  P e r s o n s c h o o s i n g to c o n s t r u e t h e m s e l v e s as  " a l c o h o l i c s " k n o w what t h e y are b u y i n g i n t o . t h e m s e l v e s as "problem d r i n k e r s " may c h o s e n as what i s b e i n g One  c o u l d now  of the disease t h e o r y  not as m u c h k n o w what i s b e i n g  rejected.  ask the q u e s t i o n , and  "What are the d i f f e r i n g i m p l i c a t i o n s  the p r o b l e m d r i n k i n g one,  t r a n s l a t e d i n t o what the a l c o h o l i c / p r o b l e m Pattison, Sobell and the disease 1)  P e r s o n s c h o o s i n g to c o n s t r u e  and  how  might t h e s e  drinker believes?"  Sobell (1977) i d e n t i f y s i x p r e m i s e s i n h e r e n t i n  theory: Alcoholism  i s t h o u g h t of as a d i s t i n c t e n t i t y , a d i c h o t o m o u s  c h o i c e , i . e . , one  has it o r one  doesn't.  be  - 29 -  2)  The  condition progresses  t h r o u g h a s e r i e s of d i s t i n c t p h a s e s ,  and  i s fatal i f not a r r e s t e d .  D u r i n g e a c h p h a s e , the a l c o h o l i c  s u f f e r s from c h a r a c t e r i s t i c "symptoms", w h i c h a r e d e c r e m e n t s in p h y s i c a l and psychosocial f u n c t i o n i n g . 3)  A l c o h o l i c s are q u a l i t a t i v e l y d i f f e r e n t from n o n - a l c o h o l i c s . d i f f e r e n c e i s o f t e n t h o u g h t of as b i o l o g i c a l o r  This  metabolic,  but many believe there is a d i s t i n c t "alcoholic p e r s o n a l i t y " . 4)  A l c o h o l i c s s u f f e r from i r r e s i s t i b l e c r a v i n g s , o r c o m p u l s i o n s , to d r i n k alcohol.  5)  A l c o h o l i c s s u f f e r from a p h e n o m e n o n c a l l e d "loss of c o n t r o l " T h i s means t h a t , h a v i n g  t a k e n the f i r s t a l c o h o l i c d r i n k , t h e y are  p o w e r l e s s to r e s i s t the r e s t . 6)  Alcoholism is a permanent and  irreversible condition.  is s p o k e n of as " a r r e s t e d " o r " r e c o v e r i n g " , n e v e r as T h i s " r e m i s s i o n " r e q u i r e s total a n d  A n alcoholic "cured".  permanent abstinence  from  alcohol. Sobell a n d  S o b e l l (1978) a n d  P a t t i s o n et al p r o p o s e t h e f o l l o w i n g p r e m i s e s  to be c o n s i s t e n t with a l e a r n e d b e h a v i o r ,  o r e n v i r o n m e n t a l model of p r o b l e m  drinking: 1)  " A l c o h o l d e p e n d e n c e " i s a t e r m a p p l i e d to a v a r i e t y of patterns associated with problematic  2)  behavior  u s e of a l c o h o l .  T h e r e i s no d i c h o t o m y b e t w e e n p r o b l e m d r i n k e r s a n d  others,  it i s more u s e f u l to t h i n k of a c o n t i n u u m of alcohol use, from n o n - p r o b l e m to  problematic.  ranging  - 30 3)  The  d e v e l o p m e n t of p r o b l e m a t i c d r i n k i n g i s so v a r i a b l e as to  disallow the c o n c e p t of  "progression".  4)  A b s t i n e n c e b e a r s no n e c e s s a r y r e l a t i o n to r e h a b i l i t a t i o n .  5)  Psychological and  p h y s i c a l d e p e n d e n c e are e s t a b l i s h e d , b u t  related, phenomena.  An  i n d i v i d u a l may  not  experience a strong  need  to d r i n k i n some s i t u a t i o n s , b u t t h e r e is no e v i d e n c e f o r "loss of c o n t r o l " , "compulsions", or " p h y s i c a l 6)  The  problem d r i n k i n g population  cravings".  i s m u l t i v a r i a n t , w i t h more  differences than similarities. 7)  A l c o h o l p r o b l e m s are more s t r o n g l y r e l a t e d to e n v i r o n m e n t a l i n f l u e n c e s t h a n to b i o l o g i c a l p r e d i s p o s i t i o n s .  8)  A l c o h o l p r o b l e m s are u s u a l l y a s s o c i a t e d w i t h o t h e r l i f e p r o b l e m s .  F o r C a h a l a n (1976) a p r o b l e m d r i n k i n g model also implies d e s c r i p t i o n o n an e n v i r o n m e n t a l l e v e l , not a medical one.  Rather than a drug affecting  a biologically p r e d i s p o s e d i n d i v i d u a l , problem d r i n k i n g is conceptualized t h e r e s u l t of a complex i n t e r a c t i o n b e t w e e n an i n d i v i d u a l a n d It follows t h a t the d e v i a n t d e p e n d e n c y i n one may  of two  ways.  his/her  culture.  d r i n k e r s can also c o n s t r u e t h e i r a l c o h o l T h o s e who  p e r c e i v e t h e m s e l v e s as a l c o h o l i c s  b e l i e v e t h e y are the h e l p l e s s v i c t i m s of a d i s e a s e p r o c e s s .  e x p e c t to be t r e a t e d as p a t i e n t s , a n d profession.  as  by  They  may  d o c t o r s or members of the medical  T h e y w o u l d b e l i e v e t h e y c o u l d n e v e r l e a r n to c o n t r o l t h e i r u s e  of a l c o h o l , a n d  w o u l d e x p e c t to fail i f t h e y t r i e d .  T h e y might  characterize  t h e m s e l v e s as b e i n g " d i f f e r e n t " from o t h e r p e o p l e , b u t i d e n t i f y s t r o n g l y with other alcoholics.  T h e y might make statements s u c h as,  " A l l of us a l c o h o l i c s  - 31 a r e good m a n i p u l a t o r s " .  T h e y might not e x p e r i e n c e g u i l t o*ver a n t i s o c i a l  b e h a v i o r a s s o c i a t e d w i t h alcohol impairment.  T h e y w o u l d e x p e c t to b e  " a l c o h o l i c s " f o r t h e r e s t of t h e i r l i v e s . Problem  d r i n k e r s might also choose t h a t l a b e l b e c a u s e t h e c h a r a c t e r i s t i c s  of that model h o l d more a p p e a l f o r them t h a n do t h o s e o f t h e d i s e a s e model. T h e y w o u l d t h e n see t h e i r d r i n k i n g as an e x c e s s i v e , o r h a r m f u l b e h a v i o r which produces distressing consequences, lost c o n t r o l . problems,  a n d o v e r w h i c h t h e y seem to h a v e  T h e y p r o b a b l y see t h e i r d r i n k i n g p r o b l e m  as d u e to p e r s o n a l  a n d w o u l d want t h e r a p y to a d d r e s s t h o s e i s s u e s as well as the  d r i n k i n g p e r se.  T h e y may  experience distress and guilt over d r i n k i n g related  a n t i s o c i a l b e h a v i o r , s i n c e o u r c u l t u r e deems an i n d i v i d u a l to b e b l a m e w o r t h y if k n o w l e d g e a n d v o l i t i o n a r e p r e s e n t .  Control Orientation in Alcohol Dependence If a p e r s o n p e r c e i v e s a d i f f e r e n c e b e t w e e n the two models of a l c o h o l d e p e n d e n c e , a n d f i n d s one more m e a n i n g f u l t h a n t h e o t h e r , s h e / h e must  do  so b e c a u s e one i s more compatible w i t h h e r / h i s e x i s t i n g b e l i e f s .  the  Perhaps  c o m p a t i b i l i t y l i e s i n t h e r e l a t i o n s h i p b e t w e e n s p e c i f i c b e l i e f s about  control  o v e r one's d e p e n d e n c y a n d g e n e r a l i z e d e x p e c t a t i o n of c o n t r o l o v e r t h e environment. A c e n t r a l d i f f e r e n c e b e t w e e n t h e d i s e a s e model a n d t h e d r i n k i n g model i s the c o n c e p t of " c o n t r o l " .  problem  A c c o r d i n g to t h e f o r m e r model,  an alcoholic h a s no c o n t r o l o v e r h i s / h e r c o n d i t i o n .  It i s c a u s e d b y  an  e x t e r n a l a g e n t , t h e alcoholic i s s a i d to s u f f e r from a " c o m p u l s i o n " to d r i n k ,  - 32 -  and  "loss of c o n t r o l " i n s t o p p i n g .  e i t h e r ; r a t h e r one  must r e l y on  R e h a b i l i t a t i o n i s not u n d e r s e l f c o n t r o l ,  "powerful others".  model does i m p l y t h a t the d r i n k e r has so) o v e r i n i t i a t i o n a n d of l e a r n i n g a n d  The  problem  v o l u n t a r y c o n t r o l (at l e a s t p o t e n t i a l l y  m o d e r a t i o n of d r i n k i n g .  Rehabilitation is a p r o c e s s  r e i n f o r c i n g this control.  A l t h o u g h t r a d i t i o n a l l y "loss of c o n t r o l " o v e r alcohol was mediated b y  p h y s i o l o g i c a l v a r i a b l e s , the w o r k of M a r l a t t a n d  that c o g n i t i v e f a c t o r s are more i m p o r t a n t . b e l i e f that h e / s h e h a s cravings,  drinking  t h o u g h t to o t h e r s has  T h a t i s , it is the deviant  c o n s u m e d alcohol w h i c h i n i t i a t e s e x c e s s i v e  a g g r e s s i v e b e h a v i o r , a n x i e t y r e d u c t i o n .and,  d e c r e m e n t s i n motor and. c o g n i t i v e T h e r e f o r e , i t may  drinking,  e v e n at low  doses,  behaviors.  be that a p e r s o n i s a t t r a c t e d to t h e n o t i o n t h a t  b e i n g i n c o n t r o l of the e n v i r o n m e n t .  The  Rotter, Chance, and  not  c o n c e p t of " c o n t r o l o r i e n t a t i o n "  as b e i n g an i m p o r t a n t p e r s o n a l i t y t r a i t comes from s o c i a l l e a r n i n g by  shown  drinker's  alcohol p r o d u c e s " l o s s of c o n t r o l " b e c a u s e of a g e n e r a l p e r c e p t i o n of  as d e s c r i b e d  be  P h a r e s (1972), a n d  by  theory,  P h a r e s (1975).  In p r e d i c t i n g b e h a v i o r i n a g i v e n s i t u a t i o n , a s i g n i f i c a n t v a r i a b l e i s the p e r s o n ' s e x p e c t a t i o n that the b e h a v i o r will be the d e s i r e d outcome. this expectation. is somewhere on an  An  s u c c e s s f u l , i . e . , will p r o d u c e  " C o n t r o l o r i e n t a t i o n " i s one  of the f a c t o r s t h a t mediate  i n d i v i d u a l ' s c o n t r o l o r i e n t a t i o n , o r "locus of c o n t r o l " ,  a c o n t i n u u m from " i n t e r n a l " to " e x t e r n a l " .  " i n t e r n a l l o c u s of c o n t r o l " has  Someone w i t h  a h i g h e x p e c t a n c y of c o n t r o l o v e r  environment, i . e . , they believe in response-outcome dependence. p e r s o n will a t t r i b u t e s u c c e s s to h i s / h e r own  efforts or e n d u r i n g  the An  internal  personality  - 33 -  characteristics.  T h i s i n d i v i d u a l w o u l d a g r e e w i t h s t a t e m e n t s s u c h as,  is p r e t t y m u c h what y o u l o c u s of c o n t r o l " has behavior and  In c o n t r a s t , the p e r s o n with an  "external  a g e n e r a l i z e d b e l i e f t h a t outcomes a r e i n d e p e n d e n t of  m a i n l y the r e s u l t of l u c k , c h a n c e , o r the i n t e r v e n t i o n of  powerful others. little g u y  make of i t . "  "Life  T h i s p e r s o n w o u l d a g r e e with s t a t e m e n t s s u c h as,  "The  c a n h a v e no s a y i n p o l i t i c s t h e s e d a y s . "  B e c a u s e of the o b v i o u s s i m i l a r i t y b e t w e e n Rotter's concept and  " l o c u s of c o n t r o l "  t h e n o t i o n of "loss of c o n t r o l " i n a l c o h o l d e p e n d e n c e ,  the  d i m e n s i o n of I n t e r n a l i t y - E x t e r n a l i t y has b e e n i n v e s t i g a t e d e x t e n s i v e l y i n this population.  The  main i n s t r u m e n t u s e d has b e e n the R o t t e r I n t e r n a l -  E x t e r n a l L o c u s of C o n t r o l Scale ( I - E Scale) as d e s c r i b e d b y (1972, C h a p . 4 - 6 )  and  P h a r e s (1975, C h a p . 4 ) .  The  R o t t e r et al  s c a l e c o n s i s t s of 29  f o r c e d c h o i c e items; s c o r i n g is i n the e x t e r n a l d i r e c t i o n (see A p p e n d i x S t u d i e s c o m p a r i n g l o c u s of c o n t r o l of v a r i o u s g r o u p s of  B).  deviant  d r i n k e r s w i t h t h a t of c o m p a r i s o n g r o u p s h a v e y i e l d e d e q u i v o c a l r e s u l t s . reviewers (Rohsenov and  O'Leary, 1978;  Cox,  1979)  agree that the problem  w i t h e a r l i e r s t u d i e s l a y i n the i n a d e q u a c y of the c o m p a r i s o n g r o u p s . g r o u p s h a v e b e e n c o m p a r e d f o r e x t e r n a l i t y to c o l l e g e s t u d e n t s , and  ex-alcoholic counsellors, and  cases.  Two  Alcoholic  c h u r c h members,  h a v e b e e n f o u n d to b e more i n t e r n a l i n all  H o w e v e r , f a c t o r s o t h e r t h a n alcohol c a n a c c o u n t f o r the u n e x p e c t e d  d i r e c t i o n of the I-E d i f f e r e n c e s , s i n c e a l l of t h e s e c o m p a r i s o n g r o u p s h a v e c h a r a c t e r i s t i c s w h i c h c o u l d be a s s o c i a t e d w i t h an e x t e r n a l l o c u s of c o n t r o l . Butts and  Chotlos  w i t h a g r o u p of 68 men  (1973) c o m p a r e d a g r o u p of 74 a l c o h o l i c s i n t r e a t m e n t of c o m p a r a b l e age,  education,  and  socioeconomic c l a s s .  - 34 -  The  alcoholic g r o u p was f o u n d to b e s i g n i f i c a n t l y more e x t e r n a l o n t h e R o t t e r  I-E S c a l e . (1975).  T h i s i s at v a r i a n c e with r e s u l t s r e p o r t e d b y D o n o v a n a n d O ' L e a r y  T h e y m a t c h e d a g r o u p o f 23 alcoholic p a t i e n t s w i t h o t h e r  patients and staff.  (medical)  No s i g n i f i c a n t d i f f e r e n c e o n t h e I-E Scale was f o u n d .  S t i l l , t h e two r e v i e w a r t i c l e s ( R o h s e n o v et a l ; C o x ) c o n c l u d e t h a t , i n cases of m a t c h e d c o m p a r i s o n g r o u p s , a l c o h o l i c s do t e n d to b e more e x t e r n a l l y focused than non-alcoholics. A n o t h e r explanation for the inconsistent r e s u l t s d e s c r i b e d above could lie i n t h e c h a r a c t e r i s t i c s of t h e alcohol d e p e n d e n t p o p u l a t i o n i t s e l f .  Perhaps  t h e w i t h i n g r o u p v a r i a b i l i t y o n c o n t r o l o r i e n t a t i o n i s so l a r g e as to o b s c u r e differences from other g r o u p s .  T h e review b y Rohsenov a n d O'Leary  r e p o r t e d mean I-E s c o r e s f o r 12 s t u d i e s c o m p a r i n g a l c o h o l i c s w i t h control groups. and  various  T h e means r a n g e from 4.7 to 8.28 f o r t h e alcoholic g r o u p s ,  from 2.3 to 9.5 f o r t h e c o m p a r i s o n g r o u p s .  T h u s there is considerable  r a n g e a n d o v e r l a p , s u p p o r t i n g the i n t e r p r e t a t i o n of i n t r a g r o u p  variance.  T h e r e f o r e , i t m i g h t b e a more u s e f u l t a s k to i n v e s t i g a t e t h e n a t u r e of l o c u s of c o n t r o l w i t h i n t h e alcohol d e p e n d e n t p o p u l a t i o n a n d to a s k , "What a r e t h e differences between internal and external alcoholics/problem d r i n k e r s ? " In t h i s v e i n , t h e s t u d y b y D i l l a v o u et al d e s c r i b e d e a r l i e r i l l u s t r a t e s t h a t i t i s u s e f u l to d i v i d e d e v i a n t d r i n k e r s i n t o " i n t e r n a l s " a n d " e x t e r n a l s " at l e a s t o n t h e b a s i s o f d i f f e r e n t i a l r e s p o n s e to t r e a t m e n t . h e r e i s that p r e t r e a t m e n t  T h e implication  a s s e s s m e n t o f l o c u s o f c o n t r o l s h o u l d be one of  t h e d e t e r m i n a n t s of t y p e of t r e a t m e n t .  F u r t h e r investigation is needed  of t h e i n t e r a c t i o n b e t w e e n d e g r e e of i n t e r n a l i t y t y p e a n d s u c c e s s o f t h e r a p y .  - 35 -  A s t u d y b y B o w e n a n d T w e n l o w (1978) f o u n d t h a t I - E s c o r e s w e r e n o t v  r e l a t e d to d r o p o u t from t r e a t m e n t .  N i n e t y alcoholic p a t i e n t s at a r e s i d e n t i a l  f a c i l i t y o f f e r i n g b i o f e e d b a c k t r a i n i n g completed the R o t t e r I-E S c a l e , b u t it was  not p o s s i b l e to p r e d i c t t h o s e who  s i x - w e e k p e r i o d from t h e i r s c o r e s .  left t r e a t m e n t b e f o r e the e n d of the  T h i s i s not p a r t i c u l a r l y  surprising.  A s the a u t h o r s admit, i n t e r n a l l y o r i e n t e d i n d i v i d u a l s a n d e x t e r n a l l y o r i e n t e d ones may  both leave treatment, b u t f o r different reasons.  The  former  may  leave because they believe they can control d r i n k i n g without t h e r a p e u t i c intervention.  T h e l a t t e r may  leave because  t h e y feel c o m p e l l e d b y  some  pressure. T h e a b o v e s t u d y , as well as s e v e r a l o t h e r s , f o u n d t h a t d e g r e e of internality i n c r e a s e d d u r i n g treatment.  However, O'Leary, Rohsenov,  D o n o v a n (1976) f o u n d t h a t i n c r e a s e d i n t e r n a l i t y d u r i n g t r e a t m e n t a s s o c i a t e d with g r e a t e r d r o p o u t f r o m t h e a f t e r c a r e p r o g r a m .  and  was  Still, the  u s e of the I-E d i m e n s i o n to p r e d i c t t r e a t m e n t d r o p o u t r e p r e s e n t s m i s u s e of the c o n s t r u c t . T h e q u e s t i o n to b e a s k e d i s , "What l e d to t h e g r e a t e r d r o p o u t r a t e from a f t e r c a r e f o r t h o s e who I-E s c o r e s d u r i n g t r e a t m e n t ? "  It may  showed the greatest decrease i n  be t h a t the a f t e r c a r e p r o g r a m  had  f e a t u r e s i n c o n s i s t e n t w i t h a p e r c e p t i o n of i n t e r n a l c o n t r o l , a n d t h e i n t e r n a l clients found these features unacceptable and p e r h a p s t h r e a t e n i n g .  Phares  (1975) r e v i e w s e v i d e n c e to show t h a t i n t e r n a l i n d i v i d u a l s o f t e n r e j e c t i n f o r m a t i o n t h e y c o n s i d e r to b e " p r o p a g a n d a " . often heavily AA  A f t e r c a r e programs are  oriented, and clients are i n u n d a t e d with information about  - 36 -  the d i s e a s e model, w h i c h t h e y are t o l d to a c c e p t a n d not q u e s t i o n .  It seems  c o n s i s t e n t w i t h P h a r e s ' f i n d i n g s to p r e d i c t t h a t i n t e r n a l c l i e n t s w o u l d f i n d t h i s t y p e of p r o g r a m  untenable.  R o t t e r (1975) c a u t i o n s a g a i n s t the use of a g e n e r a l c o n s t r u c t , s u c h as c o n t r o l o r i e n t a t i o n , to p r e d i c t b e h a v i o r i n s p e c i f i c , h i g h l y familiar s i t u a t i o n s . I n t h e s e c a s e s , b e h a v i o r i s more p r e d i c t a b l e from s i t u a t i o n a l v a r i a b l e s , s u c h as r e i n f o r c e m e n t  h i s t o r y f o r that s p e c i f i c b e h a v i o r , a n d  from m o t i v a t i o n .  T h i s line of r e a s o n i n g h a s p r o m p t e d the d e v e l o p m e n t of a l o c u s of c o n t r o l scale s p e c i f i c a l l y f o r d r i n k i n g .  The  " D r i n k i n g R e l a t e d L o c u s of C o n t r o l Scale"  ( D R I E ) m e a s u r e s an i n d i v i d u a l ' s p e r c e p t i o n of c o n t r o l o v e r a l c o h o l .  The  test  format is t h e same as that of the R o t t e r I-E Scale, with 25 f o r c e d c h o i c e items. One  choice r e f l e c t s a b e l i e f that i t is p o s s i b l e to h a v e s e l f c o n t r o l o v e r d r i n k i n g ,  while the o t h e r c h o i c e r e f l e c t s a b e l i e f that d r i n k i n g i s u n d e r the c o n t r o l of e x t e r n a l f a c t o r s ( D o n o v a n a n d O'Leary, 1978; A detailed investigation b y  Donovan and  Oziel, Obitz and  K e y s o n , 1972).  O'Leary does i n d i c a t e that the  D R I E has v a l i d i t y f o r use with alcohol d e p e n d e n t p o p u l a t i o n s .  Alcoholics  t e s t e d on t h e D R I E o b t a i n e d s i g n i f i c a n t l y h i g h e r , i . e . , more e x t e r n a l s c o r e s than a matched comparison group. t h a t the v a r i a n c e was  t h e r e s u l t of t h r e e f a c t o r s .  p e r s o n a l c o n t r o l , e.g., c o n t r o l , e.g., f i r s t two  F a c t o r a n a l y s i s of t h e s c o r e s i n d i c a t e d T h e s e were l a b e l l e d i n t r a -  c o n t r o l o v e r a d v e r s e emotional s t a t e s ; i n t e r p e r s o n a l  c o n t r o l o v e r p e e r p r e s s u r e to d r i n k ; g e n e r a l c o n t r o l .  f a c t o r s were f o u n d to be the most  powerful.  The  - 37 -  Changes in Cognitions During Alcohol T h e r a p y  -  x  It has b e e n s h o w n that t h e r a p y f o r alcohol d e p e n d e n c e was  associated  with c h a n g e s i n the u n d e r l y i n g c o g n i t i v e s t r u c t u r e s , a l t h o u g h the r e l a t i o n s h i p to outcome was  unclear.  Heather, Edwards, and  H o r e (1975) s h o w e d that  a l c o h o l i c s c h a n g e d t h e i r c o n s t r u c t s y s t e m r e l a t e d to a l c o h o l d e p e n d e n c y d u r i n g a 10 to 12 week i n p a t i e n t t r e a t m e n t p r o g r a m . u s e d was (1971).  a form of t h e r e p e r t o r y g r i d d e s c r i b e d b y The  elements p r e s e n t e d  to s e l f p e r c e p t i o n a n d  drinking.  s u b j e c t s to d e s c r i b e how  two  The  measuring instrument  Bannister and Fransella  to the s u b j e c t s c o n s i s t e d of 10 r o l e s r e l a t i n g Ten  b i p o l a r c o n s t r u c t s were elicited b y  r o l e s were s i m i l a r a n d  asking  also d i f f e r e n t from a t h i r d .  S u b j e c t s were t h e n a s k e d to r a t e e a c h r o l e o n e a c h c o n s t r u c t , a c c o r d i n g to a seven point scale.  A  10 x 10 g r i d was  i l l u s t r a t e d i n F i g u r e 2. i n the s t u d y ; one followed u p The  Two  g r i d s were c o m p l e t e d w i t h e a c h of the 40  at admission, the o t h e r at d i s c h a r g e .  Subjects  subjects  were  s i x months l a t e r . important measure considered  between any  two  r o l e s , i . e . , how  changed d u r i n g therapy, and The  t h u s g e n e r a t e d , a p o r t i o n of w h i c h i s  was  the "psychological distance"  s i m i l a r l y t h e y were c o n s t r u e d ,  w h e t h e r t h i s c h a n g e was  how  this  r e l a t e d to outcome.  most s i g n i f i c a n t c h a n g e s i n c o n s t r u i n g d u r i n g t h e r a p y o c c u r r e d i n  r e l a t i o n to s e l f - p e r c e p t i o n s , i n that s u b j e c t s m o v e d to c l o s e r i d e n t i f i c a t i o n with s o c i a l l y a p p r o v e d d r i n k i n g r o l e s a n d approved roles.  An  o v e r a l l c h a n g e f a c t o r , w h i c h was  with " d e v i a n c e o v e r r e s p e c t a b i l i t y " was and  f u r t h e r away f r o m s o c i a l l y d i s i n t e r p r e t e d as c o n c e r n  r e l a t e d to r e l a p s e .  B o t h maximal  minimal c h a n g e ( t o w a r d r e s p e c t a b i l i t y ) were p r e d i c t i v e of r e l a p s e .  - 38 -  F i g u r e 2 - Portion of R e p e r t o r y G r i d \  Roles  Constructs Gay/pompous L i v e s life/misses out Relaxed/anxious  (elements)  - 39 -  The  relapse  r a t e of the "minimal" c h a n g e g r o u p was  r e l a t e d to t h e i r p e r c e i v e d  social d e v i a n c y .  not s u r p r i s i n g , s i n c e i t was  T h a t the g r o u p w h i c h e x p e r i e n c e d  the g r e a t e s t c h a n g e i n self c o n s t r u c t i o n also h a d  a p o o r p r o g n o s i s was  by  h e n c e a d e s i r e to be  t h e i r " o v e r i d e n t i f i c a t i o n " with n o r m a l c y , a n d  explained social  drinkers. Two  p o i n t s a b o u t the a b o v e s t u d y are w o r t h e m p h a s i z i n g :  i n self c o n s t r u c t i o n o b s e r v e d to o c c u r d u r i n g t h e r a p y c a n n o t be r e s u l t of t h e r a p y , s i n c e t h e r e was  1) the  change  s a i d to be  the  no c o n t r o l g r o u p ; 2) the c h a n g e s i n c o n s t r u c t i o n  of d r i n k i n g r e l a t e d r o l e s were minimal, i . e . , s u b j e c t s a p p a r e n t l y t h e i r d i s c r i m i n a t i o n s among c o n s t r u c t s r e l a t e d to d r i n k i n g .  d i d not  elaborate  T h e y a p p e a r to h a v e  m o v e d from a l i g n i n g t h e m s e l v e s with d e v i a n t r o l e s to i d e n t i f y i n g w i t h s o c i a l l y approved roles.  T h i s adaptation  c o u l d be the r e s u l t of t h e p a r t i c u l a r t h e r a p y  p r o g r a m , w h i c h a p p e a r s to h a v e b e e n q u i t e t r a d i t i o n a l a n d  AA  oriented.  Summary It seems w o r t h w h i l e a n d  j u s t i f i e d , on the b a s i s of p r e v i o u s  research,  to  i n v e s t i g a t e alcohol d e p e n d e n c e as a c o g n i t i v e as well as a p h y s i o l o g i c a l p r o c e s s . Alcoholics and  p r o b l e m d r i n k e r s are i n f l u e n c e d b y  alcohol as well as b y  their self perceptions.  their expectations  T h e r e is a l a r g e amount of e v i d e n c e  to i n d i c a t e t h a t d e v i a n t d r i n k e r s do not c o n s t i t u t e an h o m o g e n e o u s One  about  population.  i n t e r e s t i n g s p e c u l a t i o n i s that a s u b g r o u p i n g c o u l d be made on t h e b a s i s  of the n a t u r e of t h e i r implicit t h e o r y  about t h e i r alcohol d e p e n d e n c y .  It has  b e e n s h o w n t h a t c o g n i t i v e f a c t o r s are a s s o c i a t e d w i t h d i f f e r e n t i a l r e s p o n s e to therapy, and  t h i s c o u l d also be the case f o r alcohol d e p e n d e n c y b e l i e f s .  -49  -  \  b)  eliminate females from t h e a n a l y s i s  c)  p r o v i d e b a s i c d e m o g r a p h i c data f o r c o m p a r i s o n p u r p o s e s  d)  e s t a b l i s h d r i n k i n g role  preference  T w o v e r s i o n s o f t h i s q u e s t i o n n a i r e were u s e d ; a 10 item one o n t h e p r e t e s t and  a s i x item one o n t h e p o s t t e s t .  Procedure A l l s u b j e c t s were t e s t e d i n g r o u p s of v a r y i n g s i z e s , r a n g i n g 12 to 30. A t f a c i l i t y B, t h e i n v e s t i g a t o r c o l l e c t e d all o f t h e d a t a .  from about A t facility A  t h e i n v e s t i g a t o r c o l l e c t e d data from one g r o u p , a n d t h e s t a f f o f t h e f a c i l i t y c o m p l e t e d d a t a c o l l e c t i o n o n two o t h e r g r o u p s .  T h e nature of the study  was  e x p l a i n e d i n g e n e r a l t e r m s , a n d i t was s t r e s s e d t h a t p a r t i c i p a t i o n was v o l u n t a r y and  confidential.  T h e i n s t r u c t i o n s as d e s c r i b e d i n A p p e n d i x B w e r e t h e n g i v e n .  S u b j e c t s g e n e r a l l y completed t h e q u e s t i o n n a i r e s i n 15 m i n u t e s ; no o n e took l o n g e r than half an hour. The orders:  q u e s t i o n n a i r e s were p r e s e n t e d ,  s t a p l e d t o g e t h e r , i n one o f two  1) A l c o h o l B e l i e f s , L o c u s of C o n t r o l "Scale, M A S T , d e m o g r a p h i c  questions.  2) L o c u s o f C o n t r o l S c a l e , A l c o h o l B e l i e f s , M A S T , d e m o g r a p h i c q u e s t i o n s .  These  o r d e r s w e r e g i v e n o u t r a n d o m l y , so t h a t about h a l f t h e s u b j e c t s c o m p l e t e d t h e A l c o h o l B e l i e f s q u e s t i o n n a i r e a n d about h a l f d i d t h e L o c u s o f C o n t r o l scale f i r s t . A p i l o t s t u d y was c o n d u c t e d to a s s e s s t h e p s y c h o m e t r i c s o u n d n e s s of t h e A l c o h o l B e l i e f s q u e s t i o n n a i r e , while t h e main s t u d y was p e r f o r m e d t o test t h e four hypotheses. 1.  Pilot G r o u p :  D a t a were c o l l e c t e d f o r t h e s e two s t u d i e s i n t h e f o l l o w i n g way: T h e r e was a total of 104 men a n d women i n t h i s g r o u p .  T h i r t y - f i v e o f them were t e s t e d d u r i n g t h e l a s t week of t h e i r p r o g r a m .  Eleven  - 50 w e r e t e s t e d i n the middle.  T h e s e 46 s u b j e c t s r e c e i v e d o n l y one t e s t .  male s u b j e c t s were t e s t e d twice, once at t h e b e g i n n i n g , of t h e i r p r o g r a m .  Main s t u d y :  a n d once at the  end  O n l y the s c o r e s from the f i r s t s e s s i o n were u s e d i n the  a n a l y s e s f o r the pilot 2.  Fifty-nine  study.  T h i s s t u d y was  the subjects d e s c r i b e d above.  done u s i n g t h e p r e a n d  p o s t t e s t data from  - 51 -  C H A P T E R IV.  x  RESULTS  The  r e s u l t s are p r e s e n t e d i n two  psychometric  sections:  1) T h e  r e s u l t s of t h e  o p e r a t i o n s p e r f o r m e d on t h e " B e l i e f s A b o u t A l c o h o l D e p e n d e n c e "  q u e s t i o n n a i r e , a n d the r e s u l t i n g d e c i s i o n s made.  2)  The  p e r t a i n i n g to t h e f o u r h y p o t h e s e s u n d e r i n v e s t i g a t i o n .  r e s u l t s of t h e  A l l statistical  study  analyses  were done b y c o m p u t e r , u s i n g t h e " S t a t i s t i c a l P r o g r a m s f o r the S o c i a l S c i e n c e s " package (SPSS).  A l l c a l c u l a t i o n s w e r e r o u n d e d o f f to two  decimal p o i n t s ;  p e r c e n t a g e f i g u r e s were r o u n d e d o f f to t h e n e a r e s t whole n u m b e r .  1.  Beliefs About Alcohol Dependence  Questionnaire  T h e s e r e s u l t s were b a s e d on a sample of 104 p e o p l e , men,  from the two  treatment  p o i n t s i n t h e i r treatment middle, how  and  facilities.  s i x women a n d  T h e s e s u b j e c t s were t e s t e d at v a r i o u s  p r o g r a m ; 59 c o m p l e t e d at t h e b e g i n n i n g ,  34 i n t h e f i n a l week.  98  Appendix C  the sample a n s w e r e d t h e M A S T a n d  11 i n the  (1) c o n t a i n s a d e s c r i p t i o n of  the d e m o g r a p h i c q u e s t i o n s .  The  average  c l i e n t can be d e s c r i b e d as male, 37 y e a r s o l d , with an income of a b o u t $25,000 a year. and AA  He  c o n s i d e r s h i s d r i n k i n g to h a v e b e e n a p r o b l e m f o r a b o u t 11 y e a r s ,  s c o r e s i n the e x p e c t e d  r a n g e for alcoholics i n the M A S T .  attender and p r e f e r s the label "alcoholic" r a t h e r than  He  i s not a r e g u l a r  " p r o b l e m d r i n k e r " to  describe his d r i n k i n g role. The criteria.  " B e l i e f s " q u e s t i o n n a i r e was  a s s e s s e d on r e l i a b i l i t y and  validity  - 52 Nunnally for a new  (1978) writes that the most c r i t i c a l m e a s u r e of r e l i a b i l i t y  test is its internal consistency, which can be r e p r e s e n t e d  m e a s u r i n g how  well t h e items c o r r e l a t e w i t h e a c h o t h e r .  by  A h i g h l e v e l of  i n t e r n a l c o n s i s t e n c y i n d i c a t e s that the t e s t items come f r o m t h e same population and  t h a t r e s p o n d e n t s are a n s w e r i n g on a s i m i l a r b a s i s , i . e . , a  h i g h l e v e l i n t e r n a l c o n s i s t e n c y t h u s means low l e v e l s of i n t e r n a l e x t e r n a l s o u r c e s of measurement e r r o r . u s e d i n t h i s s t u d y was  t h e K-R  The  and  m e a s u r e of i n t e r n a l c o n s i s t e n c y  20 v e r s i o n o f c o e f f i c i e n t a l p h a , as c o m p u t e d  b y the S P S S v e r s i o n 8 p r o g r a m , " R e l i a b i l i t y " ( K - R  i s t h e model f o r p o i n t -  biserial data) . The  40 item B e l i e f A b o u t A l c o h o l D e p e n d e n c e q u e s t i o n n a i r e  s c o r e d as two "Behavior"  s e p a r a t e s u b s c a l e s , a 20 item " D i s e a s e " s c a l e a n d  scale.  The  Nunnally,  a 20 item  initial r u n on the computer p r o g r a m p r o d u c e d  a l p h a s of a=.58 f o r t h e D i s e a s e , a n d respectively.  was  a=.47 f o r t h e B e h a v i o r s c a l e s ,  T h e s e s c o r e s are below a c c e p t a b l e l e v e l s , a c c o r d i n g to  s i n c e he a d v i s e s that o t h e r r e l i a b i l i t y c o e f f i c i e n t s are u s u a l l y  lower. T h e r e f o r e , a n u m b e r o f m e a s u r e s were c o n s i d e r e d as c r i t e r i a f o r r e t a i n i n g r e l i a b l e t e s t items.  E a c h i n d i v i d u a l item was  c o n s i d e r e d i n terms  of i t s mean s c o r e , s t a n d a r d d e v i a t i o n , d i s t r i b u t i o n , a n d T h e s e data are p r e s e n t e d in A p p e n d i x D ( l ) , and  item-total correlation.  a r e more a c c u r a t e l y d e s c r i b e d  below: Mean Score: " T r u e " r e s p o n s e s were e n c o d e d "1". "False" responses were e n c o d e d "0". T h e p o s s i b l e r a n g e of mean s c o r e s i s 0 - 1. Standard  Deviations:  Range  Frequency Distribution: to as t r u e o r f a l s e .  The  0-1. p e r c e n t a g e of time an item was  responded  - 53 -  Item-total C o r r e l a t i o n : E x p r e s s e d as a p o i n t b i s e r i a l c o e f f i c i e n t , t h e p r o b a b l e l e v e l of e a c h coefficient's c h a n c e o c c u r r e n c e was also d e t e r m i n e d ( G l a s s a n d S t a n l e y , 1970). The a response  item-total c o r r e l a t i o n i s a m e a s u r e of c o n s i s t e n c y b e t w e e n on a p a r t i c u l a r item a n d t h e total s c o r e .  i m p o r t a n t c r i t e r i o n f o r item s e l e c t i o n .  Nunnally  As  s u c h , i t i s an  s t a t e s t h a t an i t e m - t o t a l  c o r r e l a t i o n w h i c h has a 10% o r l e s s p r o b a b i l i t y of o c c u r r i n g b y c h a n c e i s a c c e p t a b l e i n an e x p l o r a t o r y s t u d y . and  F o r t h i s sample s i z e , a c c o r d i n g to G l a s s  S t a n l e y , an item-total c o r r e l a t i o n of r =.16  F i f t e e n d i s e a s e items a n d  11 b e h a v i o r items met  26 items, f i v e h a d l e s s t h a n optimal f r e q u e n c y deviations.  i s s i g n i f i c a n t at p  =.10.  this criterion.  these  d i s t r i b u t i o n s and  Of  standard  T h e s e f i v e were a n s w e r e d as e i t h e r t r u e o r false more t h a n  80% of t h e time, a n d h a d  Sd's below .40, w h i c h w o u l d l e a d to t h e s e  h a v i n g poor discriminating power.  items  A l l 26 items are c o n t a i n e d i n T a b l e  1.  S e v e r a l tests of v a l i d i t y were a p p l i e d to t h e B e l i e f s q u e s t i o n n a i r e . A c c o r d i n g to the r a t i o n a l e u p o n w h i c h i t was  constructed.,- t h i s scale c o n s i s t s  of two d i f f e r e n t s u b t e s t s w h i c h s h o u l d b e n e g a t i v e l y c o r r e l a t e d . T h a t i s , p e o p l e who  a d h e r e to d i s e a s e b e l i e f s s h o u l d t e n d to d i s a v o w b e h a v i o r b e l i e f s .  T a b l e 3 c o n t a i n s the mean s c o r e s a n d total sample on each s u b s c a l e .  A  standard deviations obtained by  the  " t " t e s t f o r c o r r e l a t e d samples i n d i c a t e d a  s i g n i f i c a n t d i f f e r e n c e b e t w e e n the means (t=8. 20,p<. 01). B e h a v i o r a l l y o r i e n t e d b e l i e f s w e r e f a r more p o p u l a r t h a n d i s e a s e o n e s . A s p r e d i c t e d , t h e r e was s i g n i f i c a n t n e g a t i v e c o r r e l a t i o n b e t w e e n t h e two  subscales (Pearson  r=-.31, p<.01). T h u s , the s t r o n g e r t h e e x p r e s s e d  a  product-moment  a d h e r e n c e to b e h a v i o r a l  - 54 -  TABLE 1  x  " A l c o h o l B e l i e f s " Items w h i c h Met Item-total C r i t e r i o n D i s e a s e Items D--1  A p e r s o n l i k e me c a n n e v e r l e a r n to d r i n k  D--3  I feel I am d i f f e r e n t from  D--4  I c a n n o t feel good u n l e s s I am  D--6  The  D--7  Maintaining  D-•8  My d r i n k i n g p r o b l e m c a n b e s t b e d e s c r i b e d  D-•9  O n l y a n o t h e r alcoholic c a n r e a l l y u n d e r s t a n d what I am g o i n g t h r o u g h .  D-•10  We a l c o h o l i c s metabolize alcohol d i f f e r e n t l y t h a n o t h e r s do.  D-•12  Staying  D- 13  I feel p o w e r l e s s to c o n t r o l my  D- 15  I am sometimes f o r c e d i n t o d r i n k i n g b y c i r c u m s t a n c e s b e y o n d my c o n t r o l .  D- 16  A l c o h o l i c s l i k e me a r e b o r n , n o t made.  D- 17  B e i n g an alcoholic i s j u s t s o m e t h i n g I'll h a v e to l i v e with t h e r e s t of my  D- 18  We a l c o h o l i c s a r e s i c k p e o p l e a n d s h o u l d b e t r e a t e d as s u c h .  D- 19  I b e l i e v e I was b o r n with a n a d d i c t i o n - p r o n e  saying,  socially.  non-alcoholics. drinking.  "One d r i n k , one d r u n k " a p p l i e s to me t o t a l l y . s o b r i e t y i s my c h i e f g b a l i n l i f e . as a d i s e a s e .  s o b e r i s l a r g e l y a matter o f l u c k a n d g e t t i n g t h e r i g h t b r e a k s . drinking.  personality.  B e h a v i o r items  B-2  With t h e p r o p e r h e l p , I c o u l d l e a r n to d r i n k  socially.  B-3  T h e r e a r e j u s t as many d i f f e r e n c e s b e t w e e n me a n d t h e n e x t a l c o h o l i c as t h e r e a r e b e t w e e n me a n d t h e n e x t n o n - a l c o h o l i c .  B-4  T h e r e i s n o s u c h t h i n g as a n o v e r p o w e r i n g d e s i r e f o r a l c o h o l , I k n o w I j u s t choose to g i v e i n .  life  - 55 B-6  My alcohol a d d i c t i o n i s n o t t h e r e s u l t o f a p h y s i c a l d i f f e r e n c e .  B-9  I don't t h i n k I h a v e to be a n a l c o h o l i c f o r t h e r e s t of ^ny l i f e .  B-ll  I t h i n k a p r o g r a m of l e a r n i n g c o n t r o l l e d d r i n k i n g w o u l d b e more e f f e c t i v e f o r me t h a n t a k i n g a n t a b u s e .  B-12  I o f t e n blame myself f o r n o t l e a r n i n g b e t t e r s e l f c o n t r o l w h e n i t comes to d r i n k i n g .  B-13  A l c o h o l i c s l i k e me a r e made, n o t b o r n .  B-14  It's no g o o d s a y i n g o t h e r people f o r c e y o u to d r i n k , I k n o w o n l y I c a n d e c i d e w h e n a n d how m u c h to d r i n k .  B-16  Sometimes I feel v e r y g u i l t y o v e r my l a c k of s e l f c o n t r o l o v e r a l c o h o l .  B-18  I n t h i s d a y a n d age a n y o n e c o u l d become a n a l c o h o l i c l i k e I d i d .  - 56 -  TABLE  2  " A l c o h o l B e l i e f s " Items w h i c h D i s c r i m i n a t e d Alcoholics and  Problem  Between  Drinkers  D i s e a s e Items  D-l  A p e r s o n l i k e me  D-6  The  D-7  Maintaining  D-8  My  D-ll  Often, other people d r i v e you  to d r i n k .  D-13  I feel p o w e r l e s s to c o n t r o l my  drinking.  D-17  B e i n g an alcoholic i s j u s t s o m e t h i n g I'll h a v e to l i v e w i t h the r e s t of my l i f e .  saying,  "One  c a n n e v e r l e a r n to d r i n k s o c i a l l y . d r i n k , one  s o b r i e t y is my  d r u n k " a p p l i e s to me  totally.  c h i e f goal i n l i f e .  d r i n k i n g p r o b l e m c a n b e s t be d e s c r i b e d as a d i s e a s e .  B e h a v i o r Items  B-2  With the p r o p e r h e l p , I c o u l d l e a r n to d r i n k s o c i a l l y .  B-5  My d r i n k i n g p r o b l e m i s due upbringing.  B-9  I don't t h i n k I h a v e to be an a l c o h o l i c f o r the r e s t of my  B-ll  I t h i n k a p r o g r a m of l e a r n i n g c o n t r o l l e d d r i n k i n g w o u l d be e f f e c t i v e f o r me t h a n t a k i n g A n t a b u s e .  B-19  T h e r a p y f o r my o t h e r p e r s o n a l p r o b l e m s i s p r o b a b l y as l e a r n i n g to c o n t r o l my d r i n k i n g .  to a s o c i a l c a u s e , s u c h as family  life. more  j u s t as i m p o r t a n t  - 57 TABLE 3 Mean S c o r e a n d S t a n d a r d D e v i a t i o n s O b t a i n e d b y  TotaKSample  on A l c o h o l B e l i e f s Scale  D i s e a s e Items n 104  * 1  x 9.19  B e h a v i o r Items Sd  x  Sd  2.88  12.75  2.59  p<-01 A l l " t " t e s t s were t w o - t a i l e d  "t"  1  8.20*  r -.31*  - 58 -  b e l i e f s , t h e w e a k e r t h e a d h e r e n c e to d i s e a s e b e l i e f s . items a c c o u n t e d The  Scores on the behavior  f o r 9.61% of t h e v a r i a n c e i n d i s e a s e s c o r e s .  " A l c o h o l B e l i e f s " q u e s t i o n n a i r e s h o u l d also d i s c r i m i n a t e b e t w e e n  s e l f - d e f i n e d alcoholics and self-defined problem d r i n k e r s .  Therefore, the  sample of 104 was d i v i d e d into two g r o u p s o n t h e b a s i s o f t h e i r s t a t e d p r e f e r e n c e in d r i n k i n g role.  T h i s y i e l d e d 72 " a l c o h o l i c s " a n d 32 " p r o b l e m d r i n k e r s " .  T a b l e 4 c o n t a i n s t h e mean s u b test s c o r e s a n d s t a n d a r d d e v i a t i o n s o b t a i n e d b y t h e s e two g r o u p s o n t h e " A l c o h o l B e l i e f s " t e s t . "T" t e s t s f o r i n d e p e n d e n t samples i n d i c a t e d t h a t t h e alcoholics' mean d i s e a s e s c o r e was s i g n i f i c a n t l y h i g h e r t h a n t h a t o f t h e p r o b l e m d r i n k e r s (t = 2.67;  p <.01) .  T h e " t " test also s h o w e d t h a t t h e p r o b l e m d r i n k e r s s c o r e d  s i g n i f i c a n t l y a b o v e t h e alcoholics o n b e h a v i o r a l items (t = 2.81; p <.01). I n t e r m s o f t o t a l s u b scale s c o r e s , t h e r e f o r e , t h e  Beliefs About Alcohol Dependence  test d i s c r i m i n a t e d between self-defined alcoholics a n d problem d r i n k e r s . I n d i v i d u a l test items s h o u l d also b e v a l i d , i . e . , t h e y s h o u l d d i s c r i m i n a t e between alcoholics and problem d r i n k e r s .  T h u s , t h e mean s c o r e s f o r b o t h  g r o u p s o n e a c h i n d i v i d u a l item were c o m p u t e d .  Mean s c o r e s a n d s t a n d a r d  d e v i a t i o n s f o r e a c h test' item i n b o t h t h e b e h a v i o r a l a n d t h e d i s e a s e s u b s c a l e s a r e p r e s e n t e d s e p a r a t e l y f o r each g r o u p i n A p p e n d i x E .  Mean s c o r e s f o r  a l c o h o l i c s a n d p r o b l e m d r i n k e r s o n e a c h t e s t item w e r e c o m p a r e d u s i n g a " t " t e s t f o r i n d e p e n d e n t samples.  A c r i t e r i o n l e v e l o f p = .10 was a g a i n u s e d i n  d e t e r m i n i n g w h i c h means were s i g n i f i c a n t l y d i f f e r e n t .  A c c o r d i n g to t h i s  c r i t e r i o n s e v e n d i s e a s e items a n d f i v e b e h a v i o r a l ones d i s c r i m i n a t e d b e t w e e n  - 59 -  ..TABLE 4  \.  Mean S c o r e s a n d S t a n d a r d D e v i a t i o n s O b t a i n e d b y Alcoholics a n d Problem  Group  D r i n k e r s o n A l c o h o l B e l i e f s Scale  Disease  Behavior  x  n  X  Sd  Alcoholics  72  9.69  2.72  12 .26  2.37  Problem  32  8.06  2.90  13 .84  2.76  Drinkers  1  * p 1  t = 2..67*  <01 A l l " t " t e s t s were t w o - t a i l e d  t := 2. 81*  Sd  - 60 -  alcoholics a n d p r o b l e m By  drinkers.  T h e s e 12 items a r e d e s c r i b e d i n T a b l e 4.  c h a n c e , one w o u l d e x p e c t two d i s c r i m i n a n t items o u t of 20 at t h e 10% l e v e l .  T h e r e f o r e , o b t a i n i n g s e v e n out of 20 f o r t h e d i s e a s e s c a l e a n d f i v e o u t of 20 f o r the b e h a v i o r scale e x c e e d s the c h a n c e e x p e c t a t i o n . It was  d e c i d e d to u s e the "item-total c o r r e l a t i o n " as t h e s i n g l e c r i t e r i o n  f o r item s e l e c t i o n i n t h e " A l c o h o l B e l i e f s " q u e s t i o n n a i r e . Item-total c o r r e l a t i o n s s i g n i f i c a n t at t h e 10% l e v e l a r e d e s c r i b e d b y N u n n a l l y as s u f f i c i e n t i n an i n i t i a l , e x p l o r a t o r y s t u d y f o r s e l e c t i n g t e s t items.  This procedure  yielded  26 items f o r a n a l y s i s , a 15 item d i s e a s e s c a l e , a n d an 11 item b e h a v i o r s c a l e . F i v e items o f t h e 26 s e l e c t e d d i d not h a v e optimum s t a n d a r d d e v i a t i o n s a n d frequency distribution.  H o w e v e r , t h i s may  d i s c r e p a n c y i n t h e s i z e o f t h e two a l c o h o l i c s as p r o b l e m  h a v e r e s u l t e d i n p a r t from  the  g r o u p s , i . e . , t h e r e w e r e twice as many  d r i n k e r s . n If t h e s e n u m b e r s were e q u a l i z e d , p e r h a p s  r e s p o n s e s to t h e s e items w o u l d be more e q u a l l y d i s t r i b u t e d . T h e r e a r e t h r e e t e s t items w h i c h d i s c r i m i n a t e d b e t w e e n a l c o h o l i c s problem  d r i n k e r s , b u t d i d not meet t h e i t e m - t o t a l c o r r e l a t i o n c r i t e r i o n ,  t h e y were t h u s e x c l u d e d .  d r i n k e r s than the alcoholics.  T h u s , while p r o b l e m  and  O f t h e s e , item D - l l i n f a c t c o u l d b e r e g a r d e d as a  b e h a v i o r a l item, s i n c e i t was  item-total c o r r e l a t i o n was  and  a g r e e d to s i g n i f i c a n t l y more o f t e n b y t h e Item B-5  was  problem  e x c l u d e d b e c a u s e the o b t a i n e d  n e g a t i v e , a l t h o u g h s i g n i f i c a n t ( r = - .18, p = .10).  d r i n k e r s a g r e e d w i t h t h i s statement a n d a l c o h o l i c s d i s a g r e e d ,  t h e y d i d so a c c o r d i n g to a d i f f e r e n t b a s i s from w h i c h t h e y a n s w e r e d the r e s t of t h e t e s t . approached  The  t h i r d item, D-19,  o b t a i n e d an i t e m - t o t a l c o r r e l a t i o n w h i c h  s i g n i f i c a n c e ( r = .11; w h e r e r = .16, p = .10).  - 61 -  The  S P S S ( v e r s i o n 8) p r o g r a m " R e l i a b i l i t y " was  a g a i n u s e d to compute  t h e i n t e r n a l c o n s i s t e n c y o f t h e 26 item A l c o h o l B e l i e f s t e s t . was  The analysis  done s e p a r a t e l y f o r the 15 item d i s e a s e s c a l e a n d t h e 11 item b e h a v i o r  Appendix D  (2) p r e s e n t s the i t e m - t o t a l c o r r e l a t i o n o f e a c h item, t h e o v e r a l l  subscale alpha and, deleted.  As  scale.  f o r e a c h item, t h e total s u b s c a l e a l p h a i f t h a t item were  c a n be seen, t h e o v e r a l l i n t e r n a l c o n s i s t e n c y i s i m p r o v e d  c o n s i d e r a b l y o v e r the 40 item t e s t , p a r t i c u l a r l y f o r t h e b e h a v i o r scale (26 item behavior  a=.62, d i s e a s e ct=.60).  N u n n a l l y i n d i c a t e s t h a t , d e p e n d i n g on t e s t  u s a g e , a l p h a s of .70 o r .80 are d e s i r a b l e , b u t i t was  felt the o b t a i n e d s c o r e s  made t h e i n s t r u m e n t a c c e p t a b l e f o r u s e i n an e x p l o r a t o r y s t u d y . A c c o r d i n g to the r e v i s e d " R e l i a b i l i t y " p r o g r a m , t h r e e of t h e 26 items d i d not meet the e s t a b l i s h e d item-total c r i t e r i a , i . e . , t h e y were below r p =.10.  A s c a n be s e e n from t h e t a b l e i n A p p e n d i x D  t h e s e items w o u l d not r e s u l t i n a n y i n t e r n a l c o n s i s t e n c y of the t e s t .  =.16,  ( 2 ) , the d e l e t i o n of  discernible improvement in the overall  Two  items, i f d e l e t e d , w o u l d not a f f e c t t h e  a l p h a at a l l , while the d e l e t i o n of the t h i r d w o u l d i m p r o v e the i n t e r n a l consistency by  2.  a=.01.  T h e s e items w e r e t h e r e f o r e r e t a i n e d .  R e s u l t s of t h e Main S t u d y T h e s e r e s u l t s were b a s e d on a sample of 59 men  who  f o u r week treatment p r o g r a m a n d were g i v e n a p r e t e s t a n d  completed t h e i r a posttest.  D e m o g r a p h i c c h a r a c t e r i s t i c s of t h i s sample a r e d e s c r i b e d i n A p p e n d i x C ( 2 ) . The  samples f o r the two treatment  centres are d e s c r i b e d separately.  On all  - 62 -  b u t one of t h e v a r i a b l e s t h e r e was no n o t i c e a b l e d i f f e r e n c e b e t w e e n t h e s e two g r o u p s .  T h i s sample does n o t a p p e a r d i f f e r e n t from t h e sample of 104  s u b j e c t s u s e d i n t h e pilot s t u d y , a n d t h e d e s c r i p t i o n a p p l i e d to t h o s e s u b j e c t s a p p e a r s v a l i d f o r t h e smaller as w e l l . T h e r e was a d i f f e r e n c e b e t w e e n f a c i l i t i e s A a n d B i n s t a t e d role preference.  drinking  S u b j e c t s from t h e f o r m e r g r o u p b y f a r p r e f e r r e d t h e  " a l c o h o l i c " l a b e l ( 6 9 % o f t h e time) to t h e " p r o b l e m d r i n k e r " l a b e l ( 3 1 % ) . Subjects from the latter g r o u p chose b o t h labels equally often.  T h e reasons  f o r t h i s d i f f e r e n c e were n o t i n v e s t i g a t e d , b u t t h e d i s c r e p a n c y may h a v e i n f l u e n c e d some of t h e r e s u l t s , as will b e d i s c u s s e d  later.  T h e sample was f u r t h e r c o m p a r e d b y d i v i d i n g s u b j e c t s i n t o s e l f - d e f i n e d alcoholics a n d p r o b l e m d r i n k e r s . on the demographic  Appendix  C ( 3 ) c o m p a r e s t h e s e two g r o u p s  v a r i a b l e s , age, income, p r o b l e m h i s t o r y , M A S T  and A A involvement.  scores,  "T" t e s t s f o r i n d e p e n d e n t samples w e r e p e r f o r m e d to  compare t h e mean s c o r e s f o r t h e two g r o u p s o n all o f t h e s e v a r i a b l e s .  Two  " t " v a l u e s a p p r o a c h e d s i g n i f i c a n c e , i n d i c a t i n g t h a t o n two i n d e p e n d e n t v a r i a b l e s t h e two g r o u p s may h a v e come from d i f f e r e n t p o p u l a t i o n s . d r i n k e r s t e n d e d to b e y o u n g e r  ( t = 1.93; p = .06) a n d r e p o r t e d  p r o b l e m h i s t o r y ( t = 1.92; p = .06) t h a n t h e a l c o h o l i c s .  Problem  a shorter  T h e two v a r i a b l e s  c o u l d b e r e l a t e d , s i n c e y o u n g e r p e o p l e may h a v e b e e n d r i n k i n g f o r a s h o r t e r p e r i o d o f time.  It i s i n t e r e s t i n g to n o t e , h o w e v e r , t h a t t h e s e v e r i t y o f alcohol  p r o b l e m s , as m e a s u r e d b y t h e M A S T  v  was n o t d i f f e r e n t f o r t h e two g r o u p s .  - 63 -  TABLE  5  V  Mean S c o r e s of A l c o h o l i c s a n d P r o b l e m on the Behavior Sub  Pretest  Group  n  Alcoholics Problem D r i n k e r s  p <. 10  **  p<.05  1  Scale  Posttest  x  Sd  37  7.54  1.77  7.14  1.64  1.59  32  8.59  2.11  8.18  1.50  .96  1  *  Drinkers  A l l " t " t e s t s were  t .1.96*  two-tailed  x  Sd  2.50**  11  1"  - 64 -  TABLE 6  \  Mean S c o r e s of A l c o h o l i c s a n d P r o b l e m on the Disease Sub  Pretest  Drinkers  Scale  Posttest  Group  n  Alcoholics  37  9.05  2.54  7.43  1.97  1.87*  Problem D r i n k e r s  22  5.96  2.65  5.77  2.72  .34  i *  p<.10  **  p <.05  ***  p <.01  1  t  x  Sd  2.99***  A l l " t " t e s t s were two-tailed  x  Sd  2.50**  "t"  - 65 -  H y p o t h e s i s I: S e l f - d e f i n e d p r o b l e m d r i n k e r s will s c o r e h i g h e r t h a n s e l f - d e f i n e d a l c o h o l i c s o n t h e b e h a v i o r a l items o f t h e B e l i e f s A b o u t A l c o h o l Dependence questionnaire. A l c o h o l i c s will s c o r e h i g h e r o n t h e d i s e a s e items o f t h i s q u e s t i o n n a i r e . The  mean s c o r e s  a n d standard deviations obtained b y both alcoholics a n d  p r o b l e m d r i n k e r s o n t h e b e h a v i o r a l items o f t h e " A l c o h o l B e l i e f s " t e s t a r e described  i n T a b l e 5.  Both pretest and posttest scores are given.  "T" tests  for i n d e p e n d e n t sample were done to compare mean s c o r e s , p r e a n d p o s t : f o r both groups.  O n t h e p r e t e s t , t h e d i f f e r e n c e b e t w e e n t h e a l c o h o l i c s ' mean  s c o r e a n d t h a t o f t h e p r o b l e m d r i n k e r s a p p r o a c h e d s i g n i f i c a n c e (t = 1.96; p = .06).  O n t h e posttest. t h e d i f f e r e n c e b e t w e e n t h e two g r o u p s was s i g n i f i c a n t  (t = -2.50; p = .02).  I n t e r m s of a b s o l u t e  differences, the alcoholics  scored  an a v e r a g e o f o n e t e s t item below t h e p r o b l e m d r i n k e r s o n b o t h p r e t e s t a n d posttest.  H o w e v e r , t h e b e h a v i o r s u b scale c o n t a i n e d  only  11 items, a n d t h e  mean d i f f e r e n c e b e t w e e n t h e two g r o u p s was c o n s i s t e n t e n o u g h to r e a c h statistical s i g n i f i c a n c e . Scores obtained b y alcoholics a n d problem d r i n k e r s on the p r e t e s t a n d p o s t t e s t o f t h e d i s e a s e items a r e r e p o r t e d contained  i n T a b l e 6.  T h e d i s e a s e s u b scale  15 items, a n d t h e d i f f e r e n c e s b e t w e e n g r o u p s a r e l a r g e r t h a n t h o s e  obtained on the behavior sub scale.  O n t h e p r e t e s t , t h e mean d i f f e r e n c e b e t w e e n  the two g r o u p s w o u l d h a v e o c c u r r e d  b y c h a n c e l e s s t h a n o n e i n 100 times  (t = 2.99; p = .005).  Alcoholics scored,  o n t h e a v e r a g e , a b o u t t h r e e items  above t h e p r o b l e m d r i n k e r s o n t h e p r e t e s t , a n d almost two items h i g h e r o n t h e p o s t t e s t (t = 2.50; p = .02). T h e r e w o u l d a p p e a r to b e a c l e a r e r d i s t i n c t i o n b e t w e e n a l c o h o l i c s a n d  - 66 -  p r o b l e m d r i n k e r s o n t h e d i s e a s e items t h a n t h e r e i s o n t h e b e h a v i o r Hypothesis  items.  I I : S e l f - d e f i n e d p r o b l e m d r i n k e r s will s c o r e s i g n i f i c a n t l y below s e l f - d e f i n e d alcoholics o n t h e R o t t e r L o c u s o f C o n t r o l S c a l e , indicating a greater degree of i n t e r n a l i t y f o r problem d r i n k e r s .  Mean s c o r e s o n p r e t e s t a n d p o s t t e s t o f t h e R o t t e r S c a l e f o r a l c o h o l i c s a n d p r o b l e m d r i n k e r s a r e r e p o r t e d in> T a b l e 7.  "T" tests for independent  samples w e r e p e r f o r m e d to compare t h e two g r o u p s o n b o t h t h e p r e t e s t a n d the posttest.  O n t h e p r e t e s t , a l c o h o l i c s s c o r e d s i g n i f i c a n t l y below t h e p r o b l e m  d r i n k e r s (t = 2.23; p = .03).  O n t h e p o s t t e s t t h e d i f f e r e n c e b e t w e e n t h e means  was also s i g n i f i c a n t (t = 2.80; p = .01).  T h u s , i n f a c t , t h e r e s u l t s were  o p p o s i t e to t h o s e p r e d i c t e d , i . e . , a l c o h o l i c s s h o w e d a m u c h g r e a t e r d e g r e e o f internality than d i d problem d r i n k e r s . Part of the rationale for i n v e s t i g a t i n g locus of c o n t r o l scores f o r d e v i a n t d r i n k e r s was t h a t i t was a s s u m e d t h a t t h e r e was a r e l a t i o n s h i p b e t w e e n s p e c i f i c b e l i e f s about alcohol d e p e n d e n c e a n d g e n e r a l b e l i e f s about control over response-outcome contingencies.  T h u s , there should be  c o r r e l a t i o n s among t h e t h r e e i n d e p e n d e n t v a r i a b l e s , d r i n k i n g r o l e p r e f e r e n c e , alcohol b e l i e f s , a n d l o c u s o f c o n t r o l . i l l u s t r a t e d b y T a b l e 8..  T h i s p r o v e d n o t t o b e t h e c a s e , as i s  L o c u s of control scores d i d not correlate significantly  w i t h e i t h e r d i s e a s e b e l i e f items o r b e h a v i o r b e l i e f items o n t h e B e l i e f s A b o u t Alcohol Dependence questionnaire.  T e s t s of correlation were p e r f o r m e d  b e t w e e n total l o c u s o f c o n t r o l s c o r e s a n d total b e l i e f s c o r e s , f o r p r e t e s t a n d p o s t t e s t d a t a , a n d s e p a r a t e l y f o r each f a c i l i t y .  T h e same o p e r a t i o n s were  p e r f o r m e d to c o r r e l a t e l o c u s of c o n t r o l s c o r e s a n d b e h a v i o r a l s c o r e s .  The  - 67 -  Pearson product-moment correlation test f o r continuous all i n s t a n c e s .  data"- was  used in  None of the c h a n c e p r o b a b i l i t i e s a s s o c i a t e d with a n y  correlations in Table 8 reached  s i g n i f i c a n c e at t h e 10% l e v e l .  r e l a t i o n s h i p d i a g r a m m e d i n F i g u r e 1, b y Figure 1 in this chapter.  of t h e  T h u s the  C h a p t e r III, i s more c o r r e c t l y  While d r i n k i n g r o l e p r e f e r e n c e was  a l c o h o l b e l i e f s a n d l o c u s of c o n t r o l , t h e l a t t e r two  represented  r e l a t e d to  v a r i a b l e s were not r e l a t e d  to e a c h o t h e r . Hypothesis  III. B o t h alcoholics and p r o b l e m d r i n k e r s will show s i g n i f i c a n t i n c r e a s e s i n b e h a v i o r b e l i e f s d u r i n g t h e treatment p r o g r a m , as m e a s u r e d b y the B e l i e f s A b o u t A l c o h o l D e p e n d e n c e q u e s t i o n n a i r e . T h e r e will b e minimal o r n e g a t i v e c h a n g e i n the d i s e a s e b e l i e f s as m e a s u r e d b y t h e same q u e s t i o n n a i r e .  P r e t e s t a n d p o s t t e s t s c o r e s f o r b o t h g r o u p s were c o m p a r e d u s i n g a " t " t e s t f o r c o r r e l a t e d samples. b e l i e f items.  Table 5 d e s c r i b e s the r e s u l t s for the  N e i t h e r alcoholics n o r p r o b l e m d r i n k e r s s h o w e d a n y  c h a n g e from p r e to p o s t t e s t i n g ( a l c o h o l i c s , t = 1.59;  behavior  significant  p r o b l e m d r i n k e r s , t = .96).  T a b l e 6 d e s c r i b e s the r e s u l t s of " t " t e s t s p e r f o r m e d on p r e t e s t a n d p o s t t e s t means f o r t h e d i s e a s e b e l i e f items. s i g n i f i c a n t c h a n g e (t = .34).  The  The  problem d r i n k e r s showed  no  d i f f e r e n c e i n mean s c o r e s f o r t h e a l c o h o l i c s '  g r o u p a p p r o a c h e d s i g n i f i c a n c e (t = 1.87;  p = .07).  T h u s , the alcoholics  t e n d e d to d e c r e a s e t h e i r p r e f e r e n c e f o r d i s e a s e o r i e n t e d b e l i e f s a b o u t a l c o h o l dependence d u r i n g treatment.  The  changes i n behavior beliefs d u r i n g  treatment  a r e i l l u s t r a t e d g r a p h i c a l l y i n F i g u r e 2, while F i g u r e 3 i l l u s t r a t e s c h a n g e s i n disease beliefs. In summary, v e r y l i t t l e s u p p o r t was  found  for the t h i r d  hypothesis.  - 68 -  TABLE 7 Means a n d S t a n d a r d D e v i a t i o n s of L o c u s o f C o n t r o l S c o r e s for Alcoholics and Problem  Group  n  Alcoholics  36  Problem D r i n k e r s  22  1  Pretest  Posttest  x  Sd  x  Sd  5.89  3.77  3.25  3.03  8.41  4.39  t = 2.23*  *pS.05 ** p 6 .01 Note: 1  Drinkers  A l l " t " t e s t s were t w o - t a i l e d  S c o r e s f o r one s u b j e c t were n o t u s a b l e .  6.09  4.11  t = 2.80**  t 4.89** 4.46**  - 69 -  TABLE 8 C o r r e l a t i o n s B e t w e e n L o c u s of C o n t r o l S c o r e s \ and Disease Belief Scores, a n d Between L o c u s of C o n t r o l S c o r e s a n d B e h a v i o r B e l i e f s S c o r e s  Disease Beliefs  Facility A  Pretest r = .05  Posttest r = .03  Behavior Beliefs  Pretest r = .20  Posttest r = .12  - 70 -  FIGURE 1 Schematic Representation  of R e l a t i o n s h i p Among-  D r i n k i n g Role, B e l i e f s A b o u t A l c o h o l , and  L o c u s of C o n t r o l  1.  D r i n k i n g Role  Preference  2.  Beliefs About Alcohol Dependence  3.  L o c u s of C o n t r o l  g  Commonality  - 71 -  FIGURE 2 C h a n g e s i n Behavior Belief D u r i n g  Treatment  10 .»  Problem D r i n k e r s  8  Alcoholics  6 IX O o  4 2 0  x  x  Pre  Post  FIGURE 3 C h a n g e s i n Disease Beliefs D u r i n g  Treatment  10  Alcoholics  ix o  Problem D r i n k e r s  o  2 0  x Pre  x Post  - 72 -  B e h a v i o r a l b e l i e f s d i d not c h a n g e f o r e i t h e r g r o u p . minimally  T h e r e was  a  s i g n i f i c a n t d e c r e a s e i n disease b e l i e f s f o r the s e l f - d e f i n e d  a l c o h o l i c s , b u t t h i s was  not the case f o r the p r o b l e m d r i n k e r s .  f o r t h e s e r e s u l t s will be d i s c u s s e d i n C h a p t e r  Reasons  V.  H y p o t h e s i s I V . B o t h a l c o h o l i c s and p r o b l e m d r i n k e r s will show s i g n i f i c a n t i n c r e a s e s i n i n t e r n a l i t y d u r i n g t r e a t m e n t , as m e a s u r e d b y the R o t t e r L o c u s of C o n t r o l S c a l e . The  f o u r t h h y p o t h e s i s was  supported:  more i n t e r n a l l y o r i e n t e d d u r i n g t r e a t m e n t . and  standard  d e v i a t i o n s on p r e t e s t a n d  b o t h alcoholics and and  b o t h g r o u p s became s i g n i f i c a n t l y T a b l e 7 d e s c r i b e s the mean  p o s t t e s t l o c u s of c o n t r o l s c o r e s , f o r  problem d r i n k e r s .  The  c h a n g e s i n mean s c o r e s on  p o s t t e s t s a r e i l l u s t r a t e d g r a p h i c a l l y i n F i g u r e 4.  (Note that on  p e r f o r m e d to compare p r e t e s t a n d d i f f e r e n c e s i n p r e t e s t and a l c o h o l i c s (t = 4.89, The  p  "T"  pretests  the  R o t t e r t e s t , lower s c o r e s i n d i c a t e an i n t e r n a l l o c u s of c o n t r o l , h i g h e r a r e i n d i c a t i v e of an e x t e r n a l l o c u s . )  scores  scores  t e s t s f o r c o r r e l a t e d samples were  p o s t t e s t means f o r b o t h g r o u p s .  The  p o s t t e s t s c o r e s were h i g h l y s i g n i f i c a n t f o r b o t h  <.001) a n d  problem d r i n k e r s  mean l o c u s of c o n t r o l s c o r e s o b t a i n e d  (t = 4.46,  p  < .001).  b y b o t h g r o u p s on the p r e t e s t  a r e s i m i l a r to s c o r e s r e p o r t e d f o r d e v i a n t d r i n k e r s e l s e w h e r e ( R o h s e n o v O ' L e a r y , 1978) .  The  mean s c o r e of the p r o b l e m d r i n k e r s on the p o s t t e s t  i s also w i t h i n t h a t r a n g e (8.28 posttest score  (x = 3.25)  - 4.70).  However, the  seems u n u s u a l l y  a l c o h o l i c s ' mean  low.  T o i n v e s t i g a t e f u r t h e r the r e l a t i v e e f f e c t s of d r i n k i n g r o l e and  t r e a t m e n t l o c a t i o n on l o c u s of c o n t r o l s c o r e s , two  w e r e p e r f o r m e d , one  and  on the p r e t e s t d a t a , a n d  one  analyses  preference  of  on the p o s t t e s t .  variance Tables  - 73 -  9 and  10 p r e s e n t t h e r e s u l t s of t h e s e a n a l y s e s . T h e A N O V A o n t h e p r e t e s t s c o r e s i n d i c a t e d a s i g n i f i c a n t main e f f e c t  for d r i n k i n g r o l e p r e f e r e n c e .  A l c o h o l i c s as a g r o u p w e r e s i g n i f i c a n t l y more  i n t e r n a l t h a n p r o b l e m d r i n k e r s , r e g a r d l e s s of w h i c h t r e a t m e n t c e n t r e t h e y came from.  T h e d i f f e r e n c e s b e t w e e n t h e two d r i n k e r g r o u p s was  at the 4% l e v e l , w h i c h was T a b l e 7.  T h e r e was  significant  consistent with the " t " test r e s u l t s d e s c r i b e d i n  no e f f e c t f o r t r e a t m e n t c e n t r e , a n d no i n t e r a c t i v e e f f e c t .  T h u s , on d a y one a l c o h o l i c s at f a c i l i t i e s A a n d B h a d s i g n i f i c a n t l y l o w e r s c o r e s (n  = 26, x = 5.73,  A and B  a n d n = 10, x = 6.0) t h a n p r o b l e m d r i n k e r s at f a c i l i t i e s  ( n = 12, x = 7.75,  On  a n d n = 12, x = 9.2  respectively).  t h e p o s t t e s t A N O V A , b o t h main e f f e c t s were s i g n i f i c a n t at t h e 1% l e v e l .  C l i e n t s from f a c i l i t y A s c o r e d s i g n i f i c a n t l y below c l i e n t s from f a c i l i t y i n d i c a t i n g t h e f o r m e r g r o u p s w e r e more i n t e r n a l .  B,  A l c o h o l i c s were s i g n i f i c a n t l y  more i n t e r n a l t h a n p r o b l e m d r i n k e r s , as h a d b e e n t h e c a s e o n t h e p r e t e s t . was no i n t e r a c t i v e e f f e c t b e t w e e n t h e two v a r i a b l e s . g r o u p were t h e a l c o h o l i c s at f a c i l i t y A  s c o r e of t h e p r o b l e m d r i n k e r s at f a c i l i t y A was alcoholics at f a c i l i t y B  T h u s , t h e most i n t e r n a l  ( n = 26, *x = 2..58) .  g r o u p were t h e p r o b l e m d r i n k e r s : at f a c i l i t y B  ( n = 12, "x = 4.58,  There  T h e most e x t e r n a l  ( n = 10, x = 7.9).  The  mean  almost t h e same as t h a t of t h e  a n d n = 10, x = 5.00  respectively).  It i s o f i n t e r e s t to note t h e d i f f e r e n c e s b e t w e e n t h e e x p l a i n e d amounts of v a r i a n c e o n t h e two A N O V A s .  O n t h e p r e t e s t A N O V A , t h e amount of  v a r i a n c e e x p l a i n e d b y t h e two i n d e p e n d e n t v a r i a b l e s was c o m p a r e d to t h e amount of e r r o r v a r i a n c e . the  not significant when  However, on the posttest scores  two i n d e p e n d e n t v a r i a b l e s do a c c o u n t f o r a s i g n i f i c a n t amount of t h e v a r i a n c e  in scores.  It c o u l d b e c o n c l u d e d t h a t , a f t e r t r e a t m e n t , c l i e n t s become a more  - 74 h o m o g e n e o u s g r o u p w i t h r e s p e c t t o how t h e y s c o r e d o n t h e l o c u s o f c o n t r o l . test.  • T h e c h a n g e i n I-E s c o r e s d u r i n g t r e a t m e n t  a specific treatment general health.  V  '  does i n p a r t seem to b e  e f f e c t r a t h e r t h a n d u e t o n o n s p e c i f i c f a c t o r s , s u c h as  T h i s c o n c l u s i o n was r e a c h e d b y e x a m i n i n g t h e d i f f e r e n c e s  between treatment  centres.  While t h e r e was no d i f f e r e n c e i n I-E s c o r e s  b e t w e e n f a c i l i t y A a n d f a c i l i t y B o n t h e p r e t e s t , t h e r e was s u c h a d i f f e r e n c e on the posttest.  T h u s , t h e d i f f e r e n c e b e t w e e n t h e t w o c e n t r e s , i n f a v o u r of  g r e a t e r i n t e r n a l i t y f o r f a c i l i t y A c l i e n t s o n t h e p o s t t e s t , c a n b e s a i d to r e s u l t from a treatment  effect.  - 75 -  FIGURE 4 C h a n g e s i n L o c u s of C o n t r o l S c o r e , By  Treatment Location and D r i n k i n g Role P r e f e r e n c e  Legend:  Facility B -#  Facility B problem d r i n k e r s Facility A  _^  alcoholics  alcoholics  Facility A problem d r i n k e r s  - 76 -  TABLE  9  v  A N O V A R e s u l t s f o r L o c u s of C o n t r o l S c o r e s ( P r e t e s t )  Sum o f S q u a r e s  Source of V a r i a t i o n  Main e f f e c t Treatment Drinking  Cen. Role  DF  Mean  Square  F  98.13  2  49.06  2.98  11.70  1  11.40  .69  73.12  1  73.12  4.44  2.41  1  2.41  .15 2.03  Interaction T-centre x drinker Explained  100.54  3  33.51  Residual  889.059  54  16.46  989.597  57  17.36  Total  p = < . 10 p = < .05  :  - 77 -  TABLE ANOVA  10  Results for Locus of C o n t r o l Scores (Posttest)  Source of V a r i a t i o n  Sum of S q u a r e s  DF  Mean  Square  210.13  2  105.07  9.85*  Treatment Cen.  99.92  1  99.92  .9.37*  D r i n k i n g Role  72.62  1  72.62  6.81*  2.48  1  2.48  .23  Explained  212.61  3  70.87  6.64*  Residual  576.16  54  10.67  788.77  57  13.83  Main e f f e c t  Interaction T-centre  x drinker  Total  * p  <.01  - 78 -  CHAPTER  V  DISCUSSION T h i s s t u d y was  u n d e r t a k e n to i n v e s t i g a t e w h e t h e r d i f f e r e n t b e l i e f s  a b o u t alcohol d e p e n d e n c y e x i s t w i t h i n an a d d i c t e d p o p u l a t i o n , a n d some of t h e p a r a m e t e r s of t h o s e d i f f e r e n c e s may r e s u l t s were f o u n d ,  their interpretation and  p e c u l i a r to t h i s s t u d y .  be.  what  While some s i g n i f i c a n t  significance is limited b y  factors  In t h i s s e c t i o n , t h e m e a n i n g o f t h e r e s u l t s , as well  as t h e i r l i m i t a t i o n s , are d i s c u s s e d . Differences Between Alcoholics and Problem  Drinkers  T w e l v e items on t h e B e l i e f s A b o u t A l c o h o l D e p e n d e n c e q u e s t i o n n a i r e c l e a r l y d i s c r i m i n a t e d s e l f - c o n f e s s e d a l c o h o l i c s from p r o b l e m d r i n k e r s . A l c o h o l i c s i n d i c a t e d t h a t t h e y b e l i e v e d t h e y h a v e an i r r e v e r s i b l e d i s e a s e , t h a t t h e y h a v e no c o n t r o l o v e r t h e i r d r i n k i n g , a n d t h a t t h e i r o n l y c h o i c e i s abstinence.  T a k e n t o g e t h e r , t h e s e statements  t h e o r y i m p l i c a t i o n s , p a r t i c u l a r l y as r e g a r d s process.  "loss of c o n t r o l " a n d a d i s e a s e  In c o m p a r i s o n , p r o b l e m d r i n k e r s h a d  their dependency.  seem to fit with t h e d i s e a s e  a l e s s i r r e v e r s i b l e view of  T h e y b e l i e v e d t h e i r d r i n k i n g p r o b l e m s were l e a r n e d b e h a v i o r s ,  r e l a t e d to o t h e r p e r s o n a l p r o b l e m s , a n d  saw  social d r i n k i n g as an  alternative.  P e r h a p s t h e t e n d e n c y to " b e h a v i o r a l v e r s u s d i s e a s e o r i e n t e d " v i e w s of t h e i r p r o b l e m s i s i l l u s t r a t e d b y t h e p a t t e r n of r e s p o n d i n g  on item D - l l .  c o n s t r u c t e d as a d i s e a s e item, p r o b l e m d r i n k e r s more o f t e n a g r e e d statement,  " O f t e n , o t h e r p e o p l e d r i v e y o u to d r i n k . "  Although with the  Since alcoholics believe  t h a t i t i s t h e d i s e a s e t h a t " c a u s e s " t h e i r d r i n k i n g , t h e y w o u l d not blame other people.  The  h i g h e r e n d o r s e m e n t of t h i s item b y t h e p r o b l e m d r i n k e r s  - 79 -  is c o n s i s t e n t w i t h an e n v i r o n m e n t a l view of alcohol d e p e n d e n c y . T h e r e w e r e f i f t e e n t e s t items t h a t d i d not d i s c r i m i n a t e b e t w e e n t h e two  groups.  Alcoholics and  p r o b l e m d r i n k e r s a g r e e d t h a t the i n i t i a t i o n  o f d r i n k i n g i s l a r g e l y a m a t t e r of p e r s o n a l  choice a n d  responsibility.  Both  g r o u p s indicated that they experience guilt over poor self control, but  they  also felt a l c o h o l d e p e n d e n c y c o u l d h a p p e n to a n y o n e , a n d  an  inherited condition. perceived  On  that i t i s not  o t h e r items, b o t h g r o u p s w e r e c o n c e r n e d w i t h  d i f f e r e n c e s from  non-alcoholics.  A l c o h o l i c s a c h i e v e d h i g h e r total d i s e a s e b e l i e f s c o r e s t h a n d i d p r o b l e m drinkers.  The  latter obtained higher behavioral  although statistically s i g n i f i c a n t and magnitude.  scores.  i n the p r e d i c t e d d i r e c t i o n , were of small  It a p p e a r s t h a t , while t h e r e are d i f f e r e n c e s among  d r i n k e r s , the b e l i e f s y s t e m s i n v o l v e d are complex a n d p e r h a p s t h e p r e f e r r e d r o l e l a b e l i s o n l y one The  C o m p l e x i t y of The  deviant  multivariant,  factor i n these differences.  c o n c l u s i o n t h a t the b e l i e f s y s t e m s of alcohol d e p e n d e n t p e r s o n s a d i s c u s s i o n of the c o n c e p t of  C o n t r o l , b o t h i n the s e n s e of s p e c i f i c b e l i e f s a b o u t c o n t r o l o v e r  d r i n k i n g behavior, and  i n the s e n s e of g e n e r a l b e l i e f s about c o n t r o l o v e r  the e n v i r o n m e n t , i s a complex i s s u e .  A l c o h o l i c s , i . e . , t h o s e who  t h e y h a v e a d i s e a s e w i t h a s s o c i a t e d l o s s of c o n t r o l o v e r d r i n k i n g , perceived  and  Control  multivariant is p e r h a p s best illustrated by "control".  These differences,  t h e m s e l v e s to be i n c o n t r o l of o t h e r  believe also  s p h e r e s of t h e i r l i v e s .  comparison with problem d r i n k e r s , alcoholics scored  In  s i g n i f i c a n t l y more  t o w a r d the i n t e r n a l e x t r e m e of the R o t t e r L o c u s of C o n t r o l t e s t .  In f a c t ,  are  - 80 -  t h e i r s c o r e s seemed e x t r e m e w h e n c o m p a r e d w i t h o t h e r r e f e r e n c e g r o u p s as well.  It may b e that t h e a l c o h o l i c s a r e o v e r c o m p e n s a t i n g f o r t h e i r  difficulties with alcohol.  Construing  perceived  all t h e u n m a n a g e a b l e p a r t s o f t h e i r l i v e s  as p a r t of a d i s e a s e p r o c e s s l e a v e s them f r e e to e x p e c t t h a t t h e y a r e i n c o n t r o l of e v e r y t h i n g  else.  It is as i f t h e y s a y to t h e m s e l v e s , "Once t h i s  is c u r e d , t h e r e s t of my! life will b e u n d e r my own c o n t r o l . "  alcoholism  It seems that t h i s  c o n s t r u c t i o n of t h e meaning of c o n t r o l w o u l d h a v e f u n c t i o n a l v a l u e t o t h e i n d i v i d u a l , b e c a u s e i t allows t h e m a i n t e n a n c e o f s e l f esteem, some r e d u c t i o n i n g u i l t , a n d t h e p o s s i b i l i t y f o r c h a n g e to a l e s s t r o u b l e s o m e l i f e . The  compensatory explanation  could account for the apparent  discrepancy  between the alcoholics' belief that they c o n t r o l the initiation of d r i n k i n g , b u t t h a t t h e y h a v e no c o n t r o l o v e r t h e amount d r u n k .  T h u s , the disease  "takes  o v e r " a f t e r d r i n k i n g h a s b e g u n , b u t t h e p e r s o n i s s t i l l i n c h a r g e u p to t h a t point.  T h i s l i n e of r e a s o n i n g  is c o n g r u e n t w i t h t h e A A f o l k l o r e , w h i c h t e a c h e s  t h a t t h e a l c o h o l i c c h o o s e s t h e f i r s t d r i n k , b u t s u f f e r s f r o m "loss o f c o n t r o l " after that.  It i s also a n i m p o r t a n t r a t i o n a l e f o r t h e b e l i e f t h a t a b s t i n e n c e i s  necessary.  T h u s , t h i s s t u d y i n d i c a t e s t h a t some d e v i a n t d r i n k e r s do i n d e e d  h a v e a h i g h l y p o l a r i z e d c o n s t r u c t with r e s p e c t to e x p e c t a t i o n s  about c o n t r o l  o v e r alcohol. T h e r e i s s t i l l a s i z e a b l e g r o u p o f d e v i a n t d r i n k e r s f o r whom t h e c o n t r o l c o n s t r u c t i s n o t as c l e a r l y c r y s t a l l i z e d .  I n t h i s s t u d y t h e y were t h o s e c l i e n t s  who p r e f e r r e d t h e r o l e l a b e l "problem d r i n k e r " to d e s c r i b e t h e i r d e p e n d e n c y . T h e y were n o t as c l e a r about what p a r t o f t h e d r i n k i n g p r o c e s s was u n d e r their control, a n d their general expectation  a b o u t t h e i r a b i l i t y to c o n t r o l t h e i r  - 81 -  l i v e s r a n g e d f r o m low t o a v e r a g e .  I t i s i n t e r e s t i n g to note that t h e average  age a n d l e n g t h of p r o b l e m h i s t o r y r e p o r t e d b y t h i s g r o u p , was l o w e r t h a n that r e p o r t e d b y the alcoholics, a l t h o u g h the s e v e r i t y of alcohol involvement was t h e same.  T h i s may l e a d o n e t o s u s p e c t t h a t i t i s l e n g t h o f e x p o s u r e  t o t h e d i s e a s e model w h i c h p r o d u c e s t h e a d h e r e n c e t o i t s v i e w s . Changes D u r i n g Treatment Specific beliefs about alcohol d e p e n d e n c y d i d not change d u r i n g t h e t r e a t m e n t p r o g r a m , w h i l e g e n e r a l b e l i e f s a b o u t c o n t r o l d i d . T w o f a c t o r s may have c o n t r i b u t e d to this f i n d i n g :  the limitations of the "Alcohol B e l i e f s "  test, and the nature of the treatment programs themselves.  Based on the  i n v e s t i g a t o r ' s p e r s o n a l e x p e r i e n c e , as w e l l as o n e x a m i n a t i o n o f t h e l i t e r a t u r e p r o v i d e d , i t seems t h a t t h e p r o g r a m s may o f f e r more e d u c a t i o n i n s e l f c o n t r o l t h a n i n models o f a l c o h o l d e p e n d e n c e .  T h i s seems p a r t i c u l a r l y t r u e o f t h e  p r o g r a m at F a c i l i t y A, w h i c h also h a d t h e h i g h e s t i n c r e a s e i n i n t e r n a l i t y . T h e p r o g r a m at t h i s t r e a t m e n t c e n t r e a p p e a r s t o p l a c e a major e m p h a s i s o n t h e i n d i v i d u a l ' s a b i l i t y t o make c h o i c e s a n d t o a c c e p t r e s p o n s i b i l i t y f o r t h o s e choices. Limitations Generalizations about t h e r e s u l t s of this s t u d y are limited b y t h e n a t u r e of t h e sample u s e d a n d b y t h e p s y c h o m e t r i c s o u n d n e s s o f t h e " A l c o h o l B e l i e f s " questionnaire.  A l c o h o l treatment c e n t r e s t e n d to v a r y w i d e l y i n t h e n a t u r e  of t h e p r o g r a m s t h e y o f f e r , a n d w i t h r e s p e c t t o t h e t y p e o f c l i e n t s t h e y admit. T h e r e f o r e , b o t h t h e p r e a n d p o s t t r e a t m e n t d i f f e r e n c e s o b s e r v e d may n o t h a v e o c c u r r e d w i t h a d i f f e r e n t sample of t r e a t m e n t c e n t r e s .  The s t u d y d i d not  - 82 -  c o n s i d e r women s u b j e c t s , o r d r o p o u t s from t r e a t m e n t , e x c e p t o n t h e p i l o t study.  L a s t l y , t h e majority of c l i e n t s i n t h e sample w e r e i n t h e m o d e r a t e to  s e v e r e r a n g e o f alcohol d e p e n d e n c e , a n d t h e r e s u l t s may h a v e b e e n d i f f e r e n t had  a more m i l d l y i n v o l v e d p o p u l a t i o n b e e n t e s t e d .  F o r example, i t w o u l d be  i n t e r e s t i n g to a s s e s s t h e alcohol d e p e n d e n c e b e l i e f s o f a sample o f c l i e n t s at a n outpatient facility o f f e r i n g a controlled d r i n k i n g program. A l t h o u g h some attempts were made to e s t a b l i s h v a l i d i t y a n d r e l i a b i l i t y for the Beliefs A b o u t Alcohol Dependence questionnaire, this test c a n only be considered  a n e x p l o r a t o r y one at t h i s s t a g e .  T h i s limitation could have  c o n t r i b u t e d to t h e small m a g n i t u d e of t h e d i f f e r e n c e s f o u n d , b o t h b e t w e e n t h e a l c o h o l i c s a n d p r o b l e m d r i n k e r s g r o u p s , as well as to t h e l a c k o f s i g n i f i c a n t pre/post  treatment d i f f e r e n c e s .  Therefore,  a l t h o u g h t h i s q u e s t i o n n a i r e p o i n t s to  t h e p o s s i b i l i t y t h a t some i n t e r e s t i n g d i f f e r e n c e s e x i s t , i t n e e d s f u r t h e r d e v e l o p ment b e f o r e i t w o u l d b e u s e f u l i n e i t h e r r e s e a r c h o r c l i n i c a l s e t t i n g s . Implications f o r F u t u r e  Study  T h e r e s u l t s of the present  s t u d y a d d to t h e e m p i r i c a l k n o w l e d g e b a s e  a b o u t t h e b e l i e f s y s t e m s i n v o l v e d i n alcohol d e p e n d e n c e , b u t t h e c l i n i c a l i m p l i c a t i o n s n e e d to b e i n v e s t i g a t e d e x p e r i m e n t a l l y . w o u l d b e a two s t a g e p r o c e s s , instrument,  This future  research  consisting of refinement of the measuring  and hypothesis investigation.  T o d e v e l o p a q u e s t i o n n a i r e that i s v a l i d i n a s s e s s i n g self  perceptions  r e l a t e d to alcohol d e p e n d e n c e , a r i g o r o u s p s y c h o m e t r i c p r o c e s s  n e e d s to b e  followed.  A l a r g e pool o f test items n e e d s to b e d e v e l o p e d , a n d p i l o t e d o n  a l a r g e sample o f alcohol d e p e n d e n t p o p u l a t i o n s .  A wide r a n g e of r e l i a b i l i t y  - 83 and  v a l i d i t y c r i t e r i a n e e d s to be a p p l i e d to t h e items, • a n d  items s e l e c t e d f o r the f i n a l s c a l e . T h i s s c a l e w o u l d t h e n be a sample p o p u l a t i o n , w o u l d also be  appropriate  test  further tested  to d e t e r m i n e n o r m a t i v e s c o r i n g p a t t e r n s .  The  on  results  f a c t o r a n a l y z e d to d e t e r m i n e w h e t h e r t h e r e i s a s t a t i s t i c a l b a s i s  f o r g r o u p i n g c l u s t e r s , o f items.  T h e s e g r o u p s of items a n d  the r e s u l t i n g  " f a c t o r s " w o u l d t h e n d e s c r i b e the main c o n s t r u c t s of the b e l i e f s y s t e m s t h a t deviant  d r i n k e r s h a v e about t h e i r alcohol d e p e n d e n c y .  The behaviors.  s e c o n d stage w o u l d i n v o l v e e x p e r i m e n t a l m a n i p u l a t i o n of c l i n i c a l The  t e s t w o u l d be u s e d to d i v i d e an a p p r o p r i a t e l y  alcohol d e p e n d e n t sample i n t o two view of t h e i r d e p e n d e n c y and  g r o u p s , t h o s e who  t h o s e who  selected  h a v e a disease  oriented  have a b e h a v i o r a l l y oriented view.  H a l f o f e a c h g r o u p w o u l d be r a n d o m l y a s s i g n e d to a t h e r a p e u t i c p r o g r a m c o n g r u e n t w i t h t h e i r b e l i e f s , while h a l f w o u l d be a s s i g n e d to an i n c o n g r u e n t p r o g r a m . O u t c o m e s f o r all f o u r g r o u p s w o u l d be c o m p a r e d to d e t e r m i n e w h e t h e r b e l i e f s y s t e m s are an i m p o r t a n t d e t e r m i n a n t of t r e a t m e n t e f f e c t i v e n e s s .  A  m e a s u r e w o u l d also i n c l u d e p o s s i b l e c h a n g e s i n b e l i e f s y s t e m s , a n d  post treatment a possible  treatment/belief interaction. Summary T h i s s t u d y s u g g e s t s that the alcohol d e p e n d e n t p o p u l a t i o n with r e s p e c t to what t h e y b e l i e v e about t h e i r a d d i c t i o n .  Further  n e e d e d to i n v e s t i g a t e the c l i n i c a l u s e f u l l n e s s of t h i s f i n d i n g . i n the a d d i c t i o n s f i e l d seems to be i n c r e a s i n g l y f o c u s s e d between clients' beliefs and 1982;  treatment fit (e.g.,  L y o n s , Welte, B r o w n , Sokolow, a n d  is heterogeneous research is  Current  on the r e l a t i o n s h i p  Gossop, E i s e r , and  H y n e s , 1982).  research  Ward,  H o p e f u l l y , all  - 84 -  t h e s e i n v e s t i g a t i o n s will c o n t r i b u t e to t h e d e v e l o p m e n t of i m p r o v e d t e c h n i q u e s f o r c l i e n t s w i t h alcohol a n d d r u g p r o b l e m s .  assessment  - 85 -  BIBLIOGRAPHY  Alcoholics Anonymous.  New  York:  v.  Works P u b l i s h i n g ,  1939.  A l d e n , L y n n . P r e v e n t i o n s t r a t e g i e s i n alcohol a b u s e , IN D a v i d s o n , P.O., a n d D a v i d s o n , S. 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Sokolow, L . , a n d H y n e s , G. Variation i n t r e a t m e n t outcome: d i f f e r e n t i a l impact u p o n s p e c i f i c s u b p o p u l a t i o n s , A l c o h o l i s m C l i n i c a l a n d E x p e r i m e n t a l R e s e a r c h , 1982, 6^.333 - 343. M a c A n d r e w s , C. A r e t r o s p e c t i v e s t u d y of d r u n k e n n e s s - a s s o c i a t e d c h a n g e s i n t h e s e l f - d e p i c t i o n s o f a l a r g e sample o f male o u t - p a t i e n t a l c o h o l i c s , A d d i c t i v e B e h a v i o r s , 1979, 4^_ 373, 381. McClelland, D . C , New Y o r k :  D a v i s , W.N., K a l i n , R., F r e e P r e s s , 1972.  a n d Wanner, E .  The Drinking  M a l t b y , K. C h a l l e n g e to S o b e l l w o r k will h a v e b r o a d impact, T h e T o r o n t o : A . R . F . , A u g u s t , 1982. Mann, M. Marty Mann answers y o u r Questions on Alcoholism. H o l t , R i n e h a r t a n d Winston, 1979.  New  Man.  Journal,  York:  M a r l a t t , G.A. a n d N a t h a n , P.E. B e h a v i o r a l A p p r o a c h e s to A l c o h o l i s m . New B r u n s w i c k , N . J . : R u t g e r s C e n t e r o n A l c o h o l S t u d i e s , 1978. M a r l a t t , G.A. a n d R o h s e n o v , D . J . C o g n i t i v e p r o c e s s e s i n a l c o h o l u s e : e x p e c t a n c y a n d t h e b a l a n c e d p l a c e b o d e s i g n , IN N. Mello ( e d . ) , Advances i n Substance Abuse, v . l . . Greenwich, Conn.: JAI Press, M a r l a t t , G.A. a n d R o h s e n o v , D . J . D e c e m b e r , 1981.  1980.  The think-drink effect, Psychology Today,  Mello, N.K. B e h a v i o r a l s t u d i e s of alcoholism, IN K i s s i n , B . a n d B e g l e i t e r , H. ( e d s . ) , B i o l o g y of A l c o h o l i s m , v . 11. New Y o r k : P l e n u m P r e s s , 1972. M e n d e l s o n , J . H . a n d Mello, N.K. ( e d s . ) , T h e D i a g n o s i s a n d T r e a t m e n t of A l c o h o l i s m . New Y o r k : M c G r a w - H i l l , 1979. M i l l e r , W.R. a n d C a d d y , G.R. A b s t i n e n c e and controlled d r i n k i n g i n the t r e a t m e n t of p r o b l e m d r i n k e r s , J o u r n a l of S t u d i e s o n A l c o h o l , 1977, 38, ( 5 ) , 986 - 998.  - 88 -  N a t h a n , P. Ideal mental h e a l t h s e r v i c e s f o r a l c o h o l i c s a n d p r o b l e m d r i n k e r s , IN Davidson and Davidson, (eds.) , Behavioral Medicine: C h a n g i n g Health L i f e s t y l e s . New Y o r k : B r u n n e r / M a z e l , 1980. x  National C o u n c i l on Alcoholism, C r i t e r i a for d i a g n o s i n g of alcoholism, American J o u r n a l o f P s y c h i a t r y . 1972, 129(2), 127 - 135. Nunnally, J . Psychometric Theory.  New  York:  M c G r a w - H i l l , 1978.  O g b o r n e , A . C . a n d B o r n e t , A . A b s t i n e n c e a n d a b u s i v e d r i n k i n g among affiliates of A A : A r e these the o n l y alternatives? A d d i c t i v e B e h a v i o r s , 1982, 7 ( 2 ) , 199 - 202. O z i e l , L . J . , O b i t z , F.W., a n d K e y s o n , M. G e n e r a l a n d s p e c i f i c p e r c e i v e d l o c u s of c o n t r o l i n a l c o h o l i c s , P s y c h o l o g i c a l R e p o r t s , 1972, 30, 957 - 958. P a c i f i c a , a r e s i d e n t i a l t r e a t m e n t f a c i l i t y , b r o c h u r e a v a i l a b l e from 811 R o y a l A v e n u e , New Westminster, B . C . P a r e d e s , A . T h e h i s t o r y a n d c o n c e p t of a l c o h o l i s m , IN T a r t e r a n d S u g e r m a n ( e d s . ) , Alcoholism: I n t e r d i s c i p l i n a r y A p p r o a c h e s to an E n d u r i n g Problem. Reading, Mass.: A d d i s o n - W e s l e y , 1976. P a r e d e s , A., G r e g o r y , D., a n d R u n d e l l , O.H. E m p i r i c a l a n a l y s i s o f alcoholism s e r v i c e s d e l i v e r y s y s t e m s , I N Y. I s r a e l et al ( e d s ) , R e s e a r c h A d v a n c e s i n A l c o h o l a n d D r u g P r o b l e m s , v.6... New Y o r k : P l e n u m P r e s s , 1981. P a t t i s o n , E.M., S o b e l l , M. a n d S o b e l l , L . E m e r g i n g D e p e n d e n c e . New Y o r k : S p r i n g e r , 1977.  C o n c e p t s of A l c o h o l  Pendery,. M., M a l t z m a n n , I . , a n d West, J . C o n t r o l l e d d r i n k i n g b y a l c o h o l i c s ? S c i e n c e , J u l y / 1982. P h a r e s , E . J . L o c u s of Control i n Personality. L e a r n i n g P r e s s , 1975.  Morristown, N.J.: General  P o k o r n y , A.D., M i l l e r , B . A . a n d K a p l a n , M.B. T h e brief MAST: a shortened v e r s i o n of the Michigan Alcoholism S c r e e n i n g T e s t , American J o u r n a l of P s y c h i a t r y , 1972, 129, 118 - 121. P o m e r l e a u , O., P e r t s h u k , M., a n d S t i n n e t t , J . A c r i t i c a l e x a m i n a t i o n o f some c u r r e n t a s s u m p t i o n s i n t h e t r e a t m e n t o f a l c o h o l i s m , J o u r n a l of S t u d i e s o n A l c o h o l i s m , 1976, 37^ 849 - 867. R e b u t a - B u r d i t t , J . T h e C r a c k e r F a c t o r y , New Y o r k :  B a n t a m B o o k s , 1977.  - 89 -  R i c h a r d , P. a n d B u r l e y , P. A l c o h o l i c s ' b e l i e f s a b o u t a n d a t t i t u d e s to c o n t r o l l e d d r i n k i n g a n d total a b s t i n e n c e , J o u r n a l o f S o c i a l a n d C l i n i c a l P s y c h o l o g y , 1978, 17, 159 - 163. R o h s e n o v , D . J . a n d O'Leary, M.R. L o c u s o f c o n t r o l r e s e a r c h o n alcoholic p o p u l a t i o n s : a r e v i e w , I n t e r n a t i o n a l J o u r n a l o f t h e A d d i c t i o n s , 1978, 13, ( 1 ) , 55 - 78. Roman, P.M. a n d T r i c e , H.M. T h e sick role, labelling theory, a n d the deviant* d r i n k e r , I N P a t t i s o n , E.M., S o b e l l , M., a n d S o b e l l , L . E m e r g i n g C o n c e p t s o f A l c o h o l D e p e n d e n c e . New Y o r k : S p r i n g e r , 1977. Room, R. A f a r e w e l l to alcoholism? A c o m m e n t a r y o n t h e WHO 1980 e x p e r t r e p o r t , B r i t i s h J o u r n a l o f A d d i c t i o n , 1981, 76, 115 - 123.  committee  Rotter, J . B . Generalized expectancies for internal v e r s u s external control of r e i n f o r c e m e n t , IN R o t t e r , C h a n c e a n d P h a r e s ( e d s . ) , A p p l i c a t i o n s of a S o c i a l L e a r n i n g T h e o r y . New Y o r k : Holt R i n e h a r t , 1972. S k i n n e r , H.A. A s s e s s m e n t of alcohol p r o b l e m s , IN Y. I s r a e l et al ( e d s . ) , R e s e a r c h A d v a n c e s i n A l c o h o l a n d D r u g P r o b l e m s , v . 6. New Y o r k : Plenum P r e s s . T a r t e r , R . E . a n d S c h n e i d e r , D.U. Models a n d t h e o r i e s o f alcoholism, IN T a r t e r and S u g e r m a n ( e d s . ) , A l c o h o l i s m : I n t e r d i s c i p l i n a r y A p p r o a c h e s to a n E n d u r i n g Problem... R e a d i n g , Mass. : A d d i s o n - W e s l e y , 1976. T o l o r , A., a n d T a m e r i n , J . S . T h e a t t i t u d e t o w a r d alcoholism i n s t r u m e n t , a measure of attitudes toward alcoholics a n d the nature a n d causes of alcoholism, B r i t i s h J o u r n a l of A d d i c t i o n , 1975, 70, 223 - 231. T o u r n i e r , R.E. Alcoholics Anonymous a n d the t y r a n n y of treatment: paper p r e s e n t e d at t h e S o c i e t y f o r t h e S t u d y of P r o b l e m s , a n n u a l m e e t i n g , C h i c a g o , S e p t e m b e r , 1977. T r i c e , H. a n d Roman, P. D e l a b e l i n g , r e l a b e l i n g a n d a l c o h o l i c s a n o n y m o u s , Social P r o b l e m s , 1972, 20^ 539 - 547. V i c t o r i a L i f e E n r i c h m e n t S o c i e t y . " R e s i d e n t i a l P r o g r a m s , 1982", b r o c h u r e a v a i l a b l e , 101 I s l a n d H i g h w a y , V i c t o r i a , B . C . You've Come a L o n g Way, K a t i e , C a n a d i a n B r o a d c a s t i n g T o r o n t o , 1978.  Corporation.,  - 90 APPENDIX Literature provided by  the Two  A Treatment  Centres  - 91 VICTORIA LIFE ENRICHMENT SOCIETY 211 - 101 Island Highway  Victoria, B.C. V9B 1E8  RESIDENTIAL PROGRAMMES 1982  The Victoria Life Enrichment Society i s a non-profit society. The goals of the Society, as stated i n i t s constitution, are as follows: (a)  To promote programmes for change for people who are dissatisfied and unhappy and/or who become i l l because of .the way they l i v e .  (b)  To promote programmes for change for people who must modify their l i f e styles due to i l l n e s s dr. natural process.  (c)  To train professionals and others i n methods of helping people to change..  The programmes presented are designed with emphasis on the relationship between l i f e style and health.  We believe that the  individual's attitudes and approach to l i f e i s as important to health as i s the presence or absence of any specific i l l n e s s .  The Society  defines health, not i n relation to illness or disease, but i n relation to personal fulfillment.  In the individual, this means that "health"  i s always something more than the absence of a diagnosible illness and likewise "family health" i s always something more than the absence of sickness i n one or more of i t s members. From the V.L.E.S. point of view, people and families could be considered healthy when they are doing "the best they can with what they have got". The Victoria Life Enrichment Society i s currently offering  residential programmes t o c h e m i c a l l y d e p e n d e n t p e o p l e a n d t o t h o s e w i t h marital problems.  In addition, the Society conducts workshops on  chemical dependence, counselling, stress management and a 10-week course on counselling the chemically dependent•  - 92 -  The following i s a detailed description of the four-week residential programme for people who have developed a damaging dependency on alcohol and/or other drugs.  PROGRAMME PHILOSOPHY A  Definitions 1.  Chemical dependency - The use o f a chemical as a means of altering one's experience o f s e l f and the world.  2. Harmful chemical dependency - dependency that interferes with effective funtioning and/or causes damage to the user or to those around him. 3.  Problem drinking - i s any use of alcohol that results i n damage to the drinker and/or others and/or interferes with effective functioning.  /..  Health or well being - doing the best you can with what you have got.  B  Basic Assumptions i About Human Nature Our bias about people i s that they are at their best when they experience themselves as being i n control of their l i v e s . We believe i t i s good f o r people to experience themselves as being free or s e l f directing.  We take the position that for the  most part people choose t o do the things they do and that i t i s reasonable that they should be accountable f o r the f a i r and l o g i c a l consequences o f t h e i r d e c i s i o n s .  At V.L.E.S. we believe  that people need t o recognize that they are responsible to one  another and responsible f o r themselves.  Being responsible to  others we c a l l S o c i a l Responsibility and being responsible for ourselves we designate Personal Responsibility.  The programme  - 93 -  places i t s greatest emphasis on Personal R e s p o n s i b i l i t y which i s - "the awareness t h a t what I am and w i l l become i s mostly up t o me".  [Another assumption about people t h a t i s  j j n f l u e n t i a l i n t h i s programme i s the b e l i e f t h a t when a person i s c l e a r l y and a c c u r a t e l y aware of her/his motives and  the  a v a i l a b l e a l t e r n a t i v e s , she/he w i l l be more i n c l i n e d t o make d e c i s i o n s t h a t are p e r s o n a l l y c o n s t r u c t i v e and u s u a l l y able to others*]  accept-  1  i i Nature of the Problem The programme i s based on the b e l i e f t h a t the most u s e f u l way of c o n c e p t u a l i z i n g chemical dependency i s as a l i f e s t y l e problem.  The abuse of a l c o h o l o r other chemicals may be  the  most dramatic and i d e n t i f y i n g feature of t h i s way of l i f e  but  i t i s o n l y one and not the most important.  Tn our view, the  most d i f f i c u l t problem faced by people who  pursue a chemicall.y  dependent approach t o l i f e i s t h e i r c a p a c i t y f o r s e l f  deception.  The most common problem i s d e n i a l of t h e i r power t o choose t h e i r behaviour and/or a r e f u s a l t o be responsible f o r the choices they make.  Viewing chemical abuse as a l i f e s t y l e problem i m p l i e s  t h a t s t a b l e recovery requires much more than a simple from the chemical.  separation  In most instances i t r e q u i r e s a fundamental  change i n the person's approach t o l i f e .  Consistent w i t h the  above, we b e l i e v e t h a t while chemically dependent people do not choose t o become chemical abusers or problem d r i n k e r s , they do choose, t o behave i n a manner which maintains t h e i r problem, and t h a t they have the capacity to make d i f f e r e n t choices. Drugs do not maintain dependency - people do.  i i i Nature of Treatment Most, i f not a l l , treatment or change programmes are based on the assumption t h a t change i s p o s s i b l e .  This means b e l i e v i n g  t h a t given the r i g h t set of circumstances an i n d i v i d u a l can  and  - 94 -  w i l l make different choices.  The change programme i s i n fact  a systematic attempt to influence the individual to recognize the need for change and then to start making a different set of choices. In addition to the above, the V.L.E.S. programme makes the further assumption that accurate awareness of self and the world around self i s the key to constructive change. The change programme, therefore, must create opportunities for the development of accurate awareness. The programme does not do the changing - i t creates the opportunity for change to occur. Programme Goals 1.  To promote awareness of the fact that how one lives deterrnines one's state of health.  2.  To work with those residents who are willing to commit . themselves to the discovery and practice of a health promoting way of l i f e .  (Health means doing the best you  can with what you have got.)  C  The V.L.E.S. Approach i  Conduct i n the V.L.E.S. Community The a b i l i t y of people to relate to one another i n an effective manner depends on, among other things, a willingness to adhere to a common set of values.  The values or standards  which are used as a guide for conduct i n the V.L.E.S. community are: (a)  acceptance of the idea of personal responsibility as defined earlier  .(b)  regard for self and others  (c)  honesty with self' and others  (d)  a commitment to the programme goals There i s no l i s t of rules and regulations to be found at  V.L.E.S. just the governing principles outlined above.  - 95 No attempt i s made t o l e g i s l a t e problems  out o f  existence o r t o c o n t r o l behaviour through a s e t o f r u l e s . The programme t r i e s t o d e a l w i t h p r o b l e m b e h a v i o u r as i t o c c u r s u s i n g i t as an o p p o r t u n i t y f o r l e a r n i n g . whose b e h a v i o u r p e r s i s t e n t l y v i o l a t e s t h e b a s i c  Any p e r s o n principles  o f t h e community w i l l have t h e o p p o r t u n i t y o f e x p l a i n i n g h e r / his  conduct t o h i s p e e r s and f a c i n g t h e i r judgement. When i t becomes a p p a r e n t t h a t a r e s i d e n t has no i n -  t e n t i o n o f l i v i n g b y t h e v a l u e s o f t h e community and/or has no i n t e n t i o n o f t r y i n g t o change h i s / h e r a p p r o a c h t o l i f e t h e n he/she w i l l be g i v e n t h e o p p o r t u n i t y o f e x p l a i n i n g t o the  ii  group why he/she s h o u l d remain i n t h e community.  The R o l e o f S t a f f and S i g n i f i c a n t A c h e m i c a l dependent  Others  approach t o l i f e  a vacuum o r o c c u r o v e r n i g h t .  does n o t d e v e l o p i n  I t evolved through  with others over a l o n g p e r i o d o f time.  interaction  Change, t h e r e f o r e ,  a l s o t a k e time and r e q u i r e i n t e r a c t i o n w i t h o t h e r s . difficult  will  It i s  f o r any i n d i v i d u a l t o b r i n g about a s i g n i f i c a n t  change  i n h e r / h i s l i f e w i t h o u t u n d e r s t a n d i n g and s u p p o r t from o t h e r s . The V.L.E.S. programme c r e a t e s o p p o r t u n i t i e s f o r t h e i n v o l v e ment o f t h e p a r e n t s , spouse, employers  children,  (where a p p r o p r i a t e )  and any o t h e r s i g n i f i c a n t p e o p l e i n t h e p e r s o n ' s  We c o n s i d e r i t a g r e a t v a l u e t o t h e p r o c e s s o f r e c o v e r y if  (change)  a l l t h e s i g n i f i c a n t people w i l l respond o r r e l a t e t o t h e  recovering person i n a c o n s i s t e n t  iii  life.  R e l a t i n g to the Problem  fashion.  Person  At V i L . E . S . we believe i t i s helpful t o approach the troubled person i n such a manner as to constantly frustrate any attempts on h i s / h e r part to pursue a dependent and irresponsible approach t o l i f e .  This can best be accomplished when t h e staff  o f the programme and a l l other significant people i n the person's l i f e take the following approach:  - 96 -  1)  S t a f f and o t h e r s s h o u l d r e f u s e t o do a n y t h i n g f o r t h e individual that self.  2)  (Small favours r e f l e c t i n g g o o d w i l l excepted)  terms o f him b e i n g s i c k o r h e l p l e s s .  S t a f f and o t h e r s s h o u l d r e f u s e t o p r o v i d e o r condone mood modifying sleeping  4)  o f d o i n g f o r him/her  S t a f f and o t h e r s s h o u l d r e f u s e t o r e l a t e t o t h e i n d i v i d u a l in  3)  he/she i s capable  chemicals, pills,  ( i . e . stimulants, t r a n q u i l i z e r s ,  alcohol, etc.)  S t a f f and o t h e r s s h o u l d r e f u s e t o a c c e p t o r appear t o a c c e p t any r a t i o n a l i z a t i o n f o r something l e s s t h a n a t o t a l commitment o f t h e i n d i v i d u a l t o h e r / h i s programme o f recovery.  5)  Apart  from q u e s t i o n s p e r t a i n i n g  t o the provision  of informa-  tion,  s t a f f s h o u l d r e f u s e t o answer a l l q u e s t i o n s , p a r t i -  c u l a r l y , "should I ? " questions. 6)  S t a f f s h o u l d c o n s t a n t l y emphasize t h e i n d i v i d u a l ' s  power  and r i g h t t o choose. 7)  S t a f f and o t h e r s s h o u l d ensure t h a t opportunity of facing,  t h e i n d i v i d u a l has t h e  i m m e d i a t e l y , t h e f a i r and l o g i c a l  consequences o f h i s c h o i c e . 8)  S t a f f and o t h e r s s h o u l d r e s p e c t t h e i n d i v i d u a l ' s  right to  choose t o r e j e c t t h e v a l u e s o f t h e programme, namely r e s p o n s i b i l i t y , honesty, r e s p e c t f o r s e l f and o t h e r s and • h i s / h e r r i g h t t o choose a drunken l i f e  style.  and l o g i c a l consequences o f such a d e c i s i o n  (The f a i r  would be t o  ask t h e i n d i v i d u a l t o l e a v e t h e programme.) 9)  S t a f f should c o n s i s t e n t l y  f r u s t r a t e the i n d i v i d u a l ' s  attempt t o p r e t e n d he has no c h o i c e o r t o make c h o i c e s and evade t h e i r consequences. The be  attitude  o f the s t a f f w i l l r e f l e c t t h e i r w i l l i n g n e s s  to  r e s p o n s i b l e t o t h e c l i e n t as opposed t o b e i n g r e s p o n s i b l e f o r  - 97 -  him/her.  They w i l l  recovery.  assume no r e s p o n s i b i l i t y f o r t h e c l i e n t ' s  They s h o u l d , however, be w i l l i n g t o share  themselves,  t h e i r knowledge, e x p e r i e n c e and o p i n i o n s w i t h him/her.  i v The S t a f f The  s t a f f i s composed o f seven i n d i v i d u a l s who a r e d e e p l y  committed t o t h e p r i n c i p l e s on which t h e programme i s b a s e d and h i g h l y e x p e r i e n c e d i n t h e f i e l d o f c h e m i c a l  dependency.  P r o f e s s i o n a l l y , they consist o f 3 p s y c h o l o g i s t s , 2 part-time p h y s i c i a n s , and two t r a i n e d l a y c o u n s e l l o r s and one s e c r e t a r y receptionist.  v Programme S t r u c t u r e E v e r y e f f o r t i s made w i t h i n t h e c o n s t r a i n t s o f t h e f a c i l i t y to  c r e a t e a t h e r a p e u t i c community b a s e d  mentioned.  A l l behaviours  a r e j u d g e d and d e a l t w i t h i n r e l a t i o n -  s h i p t o s t a t e d programme v a l u e s . is holistic  twelve  The approach t o t h e i n d i v i d u a l  so t h a t a l l h i s b e h a v i o u r w i l l be c o n s i d e r e d l e g i t i -  mate d a t a t o be d e a l t The  on t h e v a l u e s p r e v i o u s l y  with.  i n i t i a l r e c o v e r y p r o c e s s has a d u r a t i o n o f a p p r o x i m a t e l y  months, c o n s i s t i n g o f f o u r major phases o r emphasis.  i n - r e s i d e n c y p e r i o d w i l l be f o r f o u r weeks and w i l l  The  normally  c o v e r t h e f i r s t t h r e e phases, w h i c h a r e : a)  R e c o g n i t i o n and acceptance  - The emphasis d u r i n g t h i s  phase i s t o h e l p t h e i n d i v i d u a l t o r e c o g n i z e and t h e n accept his c u r r e n t s t y l e o r approach t o l i f e .  The work  d u r i n g t h i s phase i s aimed at i n c r e a s i n g awareness of t h e c u r r e n t s i t u a t i o n b y i d e n t i f y i n g damaging d e f e n c e s and d e s t r o y i n g the.system o f r a t i o n a l i z a t i o n .  This i s c o n s i d e r e d  a c r u c i a l phase as the beginning of change s t a r t s w i t h the r e c o g n i t i o n and acceptance  o f "what i s " .  I n most i n s t a n c e s ,  t h i s phase has s t a r t e d b e f o r e t h e i n d i v i d u a l e n t e r s t h e  programme•  - 98 b)  Exploration and discovery - The emphasis during this phase i s to encourage the individual to explore his potential for being different and to discover the effect of a different approach to people within the safe* environment of the programme setting.  c)  Taking charge - During this phase, the emphasis i s on encouraging the individual to assess and mobilize his resources, to consolidate what he has discovered, to plan for continued growth, and to experience his power to participate i n what he w i l l become.  d)  The reconstruction - This i s the post-residential phase, during which time the individual i s faced with the real l i f e experience of developing, consolidating, and expanding his new approach to l i f e .  It i s hoped that he w i l l be supported  during this phase through attendance at community based resources and self-help groups such as A. A. (The phases as outlined are rarely clear and distinct, nor does every client proceed through them i n a sequential fashion.  They are presented as a convenience i n communicating  the major emphasis to be covered i n the programme.)  v i Follow-up The V.L.E.S. programme offers continued support beyond the residential phase i n the form of a newsletter and by making available "renewal experiences" i n the year following discharge. The "renewal experience" takes the form of an intensive one, two or three day in-residence experience aimed at' the problems encountered i n becoming re-established.  A l l residents are re-  ferred back to their original referral source and/or are made aware of the resources available to them for on-going support i n their own community.  - 99 D  Programme Methods Within the general t h e r a p e u t i c m i l i e u , the methods are 1)  following specific  employed:  Thorough p h y s i c a l and p s y c h o - s o c i a l assessment, f o l l o w e d  by  s p e c i f i c recommendations r e g a r d i n g d i e t , e x e r c i s e programme, e t c . 2)  Group t h e r a p y - one for  f o u r weeks.  three-hour  s e s s i o n p e r day,  Monday t o F r i d a y ,  These a r e i n t e n s i v e s m a l l g r o u p p s y c h o - t h e r a p y  s e s s i o n s conducted by s t a f f members. 3)  Lecture - d i s c u s s i o n . i d e a s on a l c o h o l and  I n c l u d e s i n f o r m a t i o n and i n t e r c h a n g e  drug dependency, p e r s o n a l and  of  social  r e s p o n s i b i l i t y , i n t e r - p e r s o n a l communication, s e x u a l i t y , v a l u e s and new  d i r e c t i o n s f o r coping with  4)  Yoga e x e r c i s e and  5)  E v e n i n g programme (4 n i g h t s a week, 7 p.m.  relaxation t r a i n i n g (stress reduction)  r e l e v a n t f i l m s , self-awareness 6)  Personal  z i n g a case conference  t o 9 p.m.)  of "free-time",  s p e c i f i c plans  f o r the  A.  keeping  future, organi-  d u r i n g t h e t h i r d week o f t h e  7)  I n d i v i d u a l and m a r i t a l c o u n s e l l i n g .  8)  S p e c i a l one week spouse programme (Week #4  9)  S i x t e e n A. A. meetings are made a v a i l a b l e d u r i n g t h e the  includes  e x e r c i s e s , i n t r o d u c t i o n t o A.  r e s p o n s i b i l i t y - p l a n n i n g use  d a i l y j o u r n a l , developing  E  life.  programme.  f o r married  clients)  course  of  programme•  Admission The  programme i s d e s i g n e d t o provide h e l p t o i n d i v i d u a l s  have d e v e l o p e d a  who  harmful dependency on what we have c a l l e d t h e  s o c i a l l y acceptable or l e g i t i m a t e drugs, namely a l c o h o l , t r a n q u i l i z e r s and  sleeping p i l l s . ' .  -100. -  Factors favouring  suitability:  1)  A reasonably  s t a b l e work r e c o r d  2)  An i n t a c t home, i f m a r r i e d ,  o r the p o s s i b i l i t y o f achieving v  one 3)  A r e c o g n i t i o n b y t h e a p p l i c a n t o f t h e n e e d f o r change.  4)  Absence o f any i l l n e s s l i k e l y t o i n t e r f e r e w i t h  full  parti-  c i p a t i o n i n t h e programme 5)  A w i l l i n g n e s s t o l i v e without  mood m o d i f y i n g  f o r t h e d u r a t i o n o f t h e programme.  chemicals,  at least  R e f u s a l t o make o r keep t h i s  commitment w i l l be s u f f i c i e n t r e a s o n  t o deny a d m i s s i o n  orf o r  expulsion. 6)  Drug f r e e and n o t i n w i t h d r a w a l .  ( A p p l i c a n t s who a r r i v e i n -  t o x i c a t e d o r i n w i t h d r a w a l w i l l n o t be a d m i t t e d . ) 7)  P h y s i c a l l y and m e n t a l l y  capable  and w i l l i n g t o l o o k a f t e r  self  and b e i n g r e s p o n s i b l e f o r s e l f .  What t h e Programme i s Not The V.L.E.S. programme does n o t o f f e r c u s t o d i a l o r m e d i c a l care.  No one who i s u n a b l e oi- u n w i l l i n g t o l o o k a f t e r  himself/  h e r s e l f o r who r e q u i r e s any k i n d o f s u p e r v i s i o n s h o u l d be r e f e r r e d . The programme does n o t b e l i e v e t h e p r o b l e m p e r s o n i s a v i c t i m o f powers beyond h i s / h e r c o n t r o l and, t h e r e f o r e , does n o t p r o v i d e a f a c i l i t y appropriate dependent  t o t h e needs o f t h e h e l p l e s s and g r o s s l y  person.  Physical F a c i l i t i e s The programme i s housed i n the C r a i g f l o w e r Motel, l o c a t e d on the Gorge Waterway, a t t h e i n t e r s e c t i o n o f C r a i g f l o w e r and Road i n V i c t o r i a .  Admirals  A RESIDENTIAL T R E A T M E N T  CENTRE  Administered By: The Fraser Valley Alcoholism Society "An agency supported by the Ministry of Health, Alcohol & Drug Commission" 811 - ROYAL AVENUE, NEW WESTMINSTER, B.C. V3M  1K1  PRC3?J.M_ D E S C R I P T I O N '  i r  /  P a c i f i c a o f f e r s a f c u r week r e s i d e n t i a l t r e a t m e n t program to both men and women who a r e c h e m i c a l l y dependent. The program i s s u i t e d t o t h o s e a d d i c t e d i n d i v i d u a l s whose l i f e s t y l e shows a degree o f s o c i a l s t a b i l i t y , u s u a l l y i n d i c a t e d by c u r r e n t o r r e c e n t fmployinert.  I.  THERAPEUTIC MODEL: The program i s p s y c h o s o c i a l i n i t s c o n c e p t u a l framework. Treatment i s based upon the b e l i e f t h a t b e h a v i o r i s leerr.ed end t h a t i n d i v i d u a l s have the a b i l i t y t o change t h e i r b e h a v i o r .  tic. a. b. c. d. e.  II.  The f a c t o r s c o n t r i b u t i n g to chr.nrs e r e numerous and Seme w h i c h v;o h o l d as r.cst in,--.-tent e r e :  sometimes  idiosyncra-  an awareness of c n e s e l f , a c c e p t a n c e o f r e s p c r . n i h i l i t y f o r ones' a c t i o n s , a r e s p e c t and e x p e c t a t i o n on the t h e r a p i s t s p a r t f o r the c l i e n t s ' a b i l i t y t o make changes, a t r a n s l a t i o n o f v a l u e s ar.d f e e l i n g s i n t o b & h a v i o r s and a c t i o n s , and a c o o p e r a t i v e e f f o r t between c l i e n t and t h e r a p i s t towards t r e a t m e n t g o a l s .  GOALS OF TR3ATM.~:iT: The g o a l o f tre^tmr-mt a t P o . c i f i c a i s t h ~ development o f a s a t i s f y i n g l i f e s t y l e f r e e o f c h . n i c a l uzo ( a l c o h o l c r o t h e r d r u g s ) . We b e l i e v e t h a t a b s t i n e n c e from c h a r ice.io i s beet ;=ccor.pl i shed as p a r t o f a l i f e s t y l e chance, r a t h e r then a r i n 7 l e !:^hav\cral r ^ i f i c a t i o n . V?hile we b e l i e v e t h a t a d d i t i o n a l l i f e s t y l e che.^rz are s u p p e r t i v a o f a b s t i n e n c e , we do n o t h o l d t h a t t r e a t r . e n t s h o u l d " i r n c r o " th.3 a d d i c t i o n by f o c u s i n g e x c l u s i v e l y on o t h e r l i f e s t y l e i c r u e s . Thus crr.siderrhl-> t i n e i s s p e n t e x a m i n i n g the a d d i c t i v e b e h a v i o r , p o . r t i c u l r . r l y the consequences o f s u c h b e h a v i o r . Problems of d e n i a l a r e ?ddr^scecl, a l o n e w i t h c o n f r o n t a t i o n o f the consequences ( p e r s o n a l , m e d i c a l , s o c i a l , c.r.pIc^-T^r.t) o f c h e r . i c a l dependency. Given t h e t i m e l i r . i t s c f the procram, an i d e a l outcome o f t r e a t m e n t i s a c l i e n t who h r s a s t r o n g ce-'.iitr-T.t t o a b s t i n e n c e , i s more aware not o n l y i n terms of h i s dependency, bv.t c f h i r . c e l f as a p e r s o n , and has i n the l a t t e r s t a g e s o f treatr.ent begun t o impler.ent some l i f e s t y l e changes d i r e c t e d towards b u i l d i n g a s a t i s f y i n g s o b r i e t y .  - 102 III.  THERAPY FORMAT: Therapy i s c o n d u c t e d on a group b a s i s . D u r i n g the f i r s t f o u r t o f i v e days a l l o f the i n d i v i d u a l s admitted on t h a t p a r t i c u l a r a d m i s s i o n remain t o g e t h e r f o r the i n i t i a l phase of the program. T h i s phase i n c l u d e s o r i e n t a t i o n , assessment, e d u c a t i o n r e g a r d i n g dependency problems, and an i n t r o d u c t i o n t o group t h e r a p y . The l a r g e a d m i s s i o n group (15 t o 19 p e r s o n s ) i s then d i v i d e d i n t o two s m a l l e r groups (average s i z e 8 c l i e n t s ) f o r the remainder o f the program. C l i e n t s are i n group each morning from 9:00 t o 12:00, and each a f t e r n o o n from 2:00 to 4:30. Some e v e n i n g s e s s i o n s are a l s o h e l d two o r t h r e e times a week. I n d i v i d u a l t h e r a p y i s not o f f e r e d d u r i n g the program l e s t i t undermine the group p r o c e s s . However, should a c l i e n t e x p e r i e n c e e x t r a o r d i n a r y d i f f i c u l t y i n the program, o r be seen t o be making no p r o g r e s s , he would be seen on an i n d i v i d u a l b a s i s t o d i s c u s s the i s s u e w i t h h i s c o u n s e l l o r . If the c l i e n t i s an E.A.P. r e f e r r a l , i t i s o f t e n most h e l p f u l on such o c c a s i o n s i f the r e f e r r i n g agent i s a b l e t o a t t e n d a meeting w i t h the c o u n s e l l o r and the c l i e n t . Should the c l i e n t o r the r e f e r r a l s o u r c e w i s h a "Going home c o n f e r e n c e " , such a three-way meeting between the c o u n s e l l o r , c l i e n t , and r e f e r r a l s o u r c e may be a r r a n g e d by c o n t a c t i n g the c l i e n t ' s c o u n s e l l o r i n the second week of t r e a t m e n t .  IV.  COMPONENTS OF A.  TREATMENT:  Therapeutic  Techniques  As noted e a r l i e r , the p r i m a r y mode of t h e r a p y a t P a c i f i c a i s based upon the group p r o c e s s . Depending upon the p a r t i c u l a r group and the n a t u r e of c l i e n t d i f f i c u l t i e s , d i f f e r e n t t h e r a p e u t i c approaches a r e p u r sued. Some s e s s i o n s are h i g h l y s t r u c t u r e d , i n v o l v i n g s p e c i f i c e x e r c i s e s to h e l p i n c r e a s e c l i e n t s ' awareness o r s k i l l l e v e l s . In o t h e r i n s t a n c e s c l i e n t c e n t e r e d , g e s t a l t , o r b e h a v i o r a l approaches a r e p u r s u e d . No one t h e r a p e u t i c t e c h n i q u e i s adhered t o , to the e x c l u s i o n o f a l l o t h e r s . The r e a s o n f o r t h i s i s t h r o e - f o l d : (1 ) (2) (3)  we b e l i e v e t h a t n o t e . l l problems and c o n c e r n s a r e b e s t d e a l t w i t h i n the samo way c o u n s e l l o r s p o s s e s s a v a r i e t y of s k i l l s and techniques c l i e n t s r e s p o n d d i f f e r e n t i a l l y t o v a r i o u s t e c h n i q u e s and approaches  O f t e n i t c a n n o t be p r e d i c t e d which p a r t i c u l a r t e c h n i q u e s o r e x p e r i ences w i l l have the g r e a t e s t impact i n an i n d i v i d u a l c a s e . Thus, w i t h out becoming e c l e c t i c to the p o i n t of b e i n g c o n t r a d i c t o r y o r s e l f - d e f e a t i n g , we do c o n s c i o u s l y o f f e r a v a r i e t y of t h e r a p e u t i c a c t i v i t i e s i n our e f f o r t s to a s s i s t c l i e n t s i n t h e i r recovery. B.  Family  Involvement  I n c l u s i o n of f a m i l y members, o r o t h e r s p e r s o n a l l y i n v o l v e d i n the c l i e n t ' s l i f e i s an i m p o r t a n t a s p e c t o f the program. Such p e o p l e a r e  - 103 -  encouraged to p a r t i c i p a t e i n the program on a t l e a s t two s p e c i f i c o c c a s i o n s ( c u r r e n t l y the second Tuesday and t h i r d F r i d a y o f t r e a t m e n t ) . Our aim i n t h i s a r e a i s not to p r o v i d e f a m i l y o r m a r i t a l c o u n s e l l i n g per se, but t o : t h r o u g h i n f o r m a t i o n i n c r e a s e the f a m i l y ' s u n d e r s t a n d i n g o f the p r o b lem , and the p r o c e s s o f r e c o v e r y p r o v i d e c o u n s e l l o r s w i t h a c l e a r , and perhaps more a c c u r a t e p i c t u r e of the c l i e n t and h i s c i r c u m s t a n c e s gain material for confrontation i f t h i s i s appropriate by e n c o u r a g i n g c o n s t r u c t i v e f e e d b a c k from f a m i l i e s r e g a r d i n g the impact o f the c l i e n t ' s b e h a v i o r , a s s i s t the c l i e n t i n over-coming denial In t h o s e i n s t a n c e s when i t i s i m p o s s i b l e f o r f a m i l y members t o a t tend on the s p e c i f i c f a m i l y d a y s , i n d i v i d u a l c o n s u l t a t i o n s can be a r ranged . C.  A l c o h o l i c s Anonymous A l l c l i e n t s are i n t r o d u c e d t o A . A . w h i l e a t P a c i f i c a . F o l l o w i n g an o r i e n t a t i o n t o the A . A . program i n t h e f i r s t week o f t r e a t m e n t , c l i e n t s are encouraged t o a t t e n d A . A . m e e t i n g s i n the community w h i l e they are c o m p l e t i n g t h e i r r e s i d e n t i a l program.  D.  N u t r i t i o n and  Exercise  Good n u t r i t i o n a l h a b i t s and r e g u l a r e x e r c i s e a r e b a s i c a s p e c t s of a healthy l i f e s t y l e . Meals a t P a c i f i c a a r e p r e p a r e d w i t h r e f e r e n c e to a w e l l balanced d i e t . N u t r i t i o u s snack f o o d s ( f r u i t , y o g u r t , c h e e s e ) a r e a v a i l a b l e between meals a l o n g w i t h j u i c e s , m i l k , and d e c a f f e i n a t e d c o f f e e . E x e r c i s e i s not a mandatory p a r t o f treatment, b u t equipment i s a v a i l a b l e f o r c l i e n t s ' use. C l i e n t s a r e a l s o encouraged t o use commun i t y f a c i l i t i e s f o r swimming e t c . Some c l i e n t s i n c o r p o r a t e the c l a s s e s i n yoga, i n which a l l c l i e n t s are r e q u i r e d t o p a r t i c i p a t e , as p a r t o f t h e i r own i n d i v i d u a l e x e r c i s e program. Our p r i m a r y purpose i n o f f e r i n g yoga i s t o p r o v i d e c l i e n t s w i t h a n o n - c h e m i c a l form of s t r e s s management. I n s t r u c t i o n s e s s i o n s are t w i c e weekly. Both the l e v e l of c o m p l e x i t y and p h y s i c a l demand a r e t a i l o r e d t o the i n d i v i d u a l c l i e n t . E.  Medical  Care  M e d i c a l c o v e r a g e i s p r o v i d e d t o a l l c l i e n t s by the program's c o n s u l t ing p h y s i c i a n . Each c l i e n t c o m p l e t e s a m e d i c a l h i s t o r y and i s examined by the p h y s i c i a n s h o r t l y a f t e r a d m i s s i o n . In some i n s t a n c e s where t h e r e i s c o n c e r n r e g a r d i n g the i n d i v i d u a l ' s m e d i c a l c o n d i t i o n , a c o n s u l t a t i o n w i t h the p h y s i c i a n may b a a r r a n g e d p r i o r t o a d m i s s i o n . Should any medi c a l emergency a r i s e d u r i n g an i n d i v i d u a l ' s s t a y a t P a c i f i c a , i t would be h a n d l e d by the p h y s i c i a n and/or by r e f e r r a l t o the emergency d e p a r t ment o f the Royal Columbian H o s p i t a l . M e d i c a t i o n i s r a r e l y p r e s c r i b e d .  - 104 -  APPENDIX  B  Questionnaires and Tests Completed b y  Respondents  a)  Beliefs About Alcohol  Dependence  b)  Rotter I n t e r n a l - E x t e r n a l L o c u s of C o n t r o l T e s t  c)  Michigan Alcoholism S c r e e n i n g  d)  Demographic  e)  Instructions read  Information aloud  Test  ( M A S T ) ( s h o r t form)  Questionnaire  Questionnaire A, pg. ]  - 105 -  Instructions: The following statements are some beliefs that people may have about their alcohol problems. Please circle "T" i f you agree that the statement is what'you believe to be true about yourself. Circle "F"-if you don't agree that.the statement is true about yourself. 1.  A person like me can never learn to drink socially.  T  F  2.  There is no such thing as the "alcoholic personality," at least as. far as I'm.concerned.  T  F  3.  With the proper help I could learn to drink socially.  T  F  4.  There are just as many differences between me and the next alcoholic as there are between me and the next non-alcoholic. My drinking problem is due to a physical cause, such as an  T  F  allergy to alcohol.  T  F  6.  I feel that I am different from non-alcoholics.  T  F  7.  There is no such thing as an overpowering desire for alcohol, I know I just choose to give in. My drinking problem is due to a social cause, such as family upbringing.  T  F  T  F  5.  8. 9.  My alcohol addiction is not the result of a physical difference. T  F  10.  I cannot feel good unless I am drinking.  T  F  11.  Denial is one. of the main personality characteristics of us alcoholics.  T  F  12.  The saying, "One drink, one drunk," applies to me, totally.  T  F  13.  Maintaining sobriety is my chief goal in l i f e .  T  F  14.  One should not be forced into alcohol treatment against his or her will. If a person chooses to drink, that's his own business.T  F  15.  My drinking problem can best be described as a disease.  T  F  16.  I'm not really different from other people who have problems in living, even i f they're not alcoholics. I don't think I have to be an alcoholic for the rest of my life.  T T  F F  T  F  17. 18.  Only another alcoholic can really understand what I'm going through.  pg.  -106 -  19.  We alcoholics metabolize alcohol differently than others do. •  T  F  20.  Often, other people drive you to drink.  T  F  21.  It is always possible to resist temptations to drink.  T  F  22.  I think a program of learning controlled drinking would be more effective for me than taking Antabuse. .T  F  23.  Staying sober is largely a matter of luck and getting the right breaks.  T  F  24.  I feel powerless to control my drinking.  T.  F  25.  I often blame myself for not learning better self control when it comes to drinking.  T  F  26.  Alcoholics like me are made, not born.  T  F  27.  Alcoholics like me are such good manipulators that they usually need to be coerced into treatment. It's no good saying that other people force you to.drink; I know that only I can decide when and how much to drink.  T  F  T  F  T  F  T  F  28. 29.  I am sometimes forced into drinking by circumstances beyond my control.  30.. Alcoholics like me are born, not made. 31.  Being an alcoholic is just something I ' l l have to live with for the rest of my l i f e . A counsellor or a therapist, not a medical doctor, should deal with alcohol problems.  T  F  T  F  Sometimes I feel very guilty over my lack of self control over alcohol.  T  F  34.  We alcoholics are sick people and should be treated as such.  T  F  35.  I believe my addiction to alcohol is the result of poor learning habits.  T  F  36.  I believe-I was born with an addiction-prone personality.  T  F  37.  It's not my fault that I have a drinking'problem, so there's no point in feeling guilty about i t .  T  F  In this day and age, anyone could become an alcoholic like I did.  T  F  Therapy for my other personal problems is probably more important than learning to control my drinking.  T  F  I know that alcohol is just an excuse for my irresponsible behavior.  T  F  32. 33.  38. 39. 40.  2  QUESTIONNAIRE B , pg.' 1  - 107 -  Instructions: T h i s i s a q u e s t i o n n a i r e t o f i n d o u t t h e way i n w h i c h c e r t a i n i m p o r t a n t e v e n t s i n o u r s o c i e t y a f f e c t p e o p l e . Each i t e m c o n s i s t s o f a p a i r o f a l t e r n a t i v e s , l e t t e r e d a o r b . P l e a s e s e l e c t t h e a l t e r n a t i v e y o u b e l i e v e t o be more t r u e a s f a r as y o u are c o n c e r n e d , a n d c i r c l e " a " o r "b". T h i s i s a t e s t o f p e r s o n a l b e l i e f s ; t h e r e are no r i g h t o r wrong answers. 1.. a b  C h i l d r e n g e t i n t o t r o u b l e because t h e i r p a r e n t s p u n i s h them t o o much, The t r o u b l e w i t h most c h i l d r e n now-adays i s t h a t t h e i r p a r e n t s a r e t o o e a s y w i t h them.  2.  * b  Many o f t h e unhappy t h i n g s i n p e o p l e ' s l i v e s a r e p a r t l y due t o b a d l u c k , P e o p l e ' s m i s f o r t u n e s r e s u l t from t h e m i s t a k e s t h e y make.  3.  a  One o f t h e major r e a s o n s we have wars i s b e c a u s e p e o p l e d o n ' t t a k e enough interest i n politics, There w i l l a l w a y s be w a r s , no m a t t e r how h a r d p e o p l e t r y t o p r e v e n t them.  b 4.  a b  I n t h e l o n g r u n , p e o p l e g e t the r e s p e c t t h e y d e s e r v e i n t h i s w o r l d . U n f o r t u n a t e l y , an i n d i v i d u a l ' s w o r t h o f t e n p a s s e s u n r e c o g n i z e d , no m a t t e r how h a r d he t r i e s .  5.  a b  The i d e a t h a t t e a c h e r s a r e u n f a i r t o s t u d e n t s i s nonsense. Most s t u d e n t s d o n ' t r e a l i z e t h e e x t e n t t o w h i c h t h e i r g r a d e s a r e i n f l u e n c e d by a c c i d e n t a l h a p p e n i n g s .  6.  a b  W i t h o u t t h e r i g h t b r e a k s one c a n n o t be an e f f e c t i v e l e a d e r . C a p a b l e p e o p l e who f a i l t o become l e a d e r s have n o t t a k e n advantage o f t h e i r opportunities.  7.  P> No m a t t e r how h a r d y o u t r y , some p e o p l e j u s t d o n ' t l i k e y o u . b P e o p l e who c a n " t get o t h e r s t o l i k e them d o n ' t u n d e r s t a n d how t o g e t a l o n g with others.  8.  a b  H e r e d i t y p l a y s t h e major r o l e i n d e t e r m i n i n g one's p e r s o n a l i t y . I t i s one's e x p e r i e n c e s i n l i f e w h i c h d e t e r m i n e s what t h e y ' r e l i k e .  9.  a b  I have o f t e n found t h a t what i s g o i n g t o happen w i l l happen. T r u s t i n g t o f a t e h a s n e v e r worked o u t a s w e l l f o r me a s making a d e c i s i o n to take a d e f i n i t e course o f a c t i o n .  10.  a  I n t h e c a s e o f t h e w e l l p r e p a r e d s t u d e n t t h e r e i s r a r e l y i f e v e r such a t h i n g as an u n f a i r t e s t , Many t i m e s exam q u e s t i o n s t e n d t o be s o u n r e l a t e d t o t h e c o u r s e work t h a t studying i s r e a l l y useless.  b  - 108 a b  Becoming a s u c c e s s i s a matter o f h a r d work, l u c k h a s l i t t l e o r n o t h i n g to do w i t h i t . G e t t i n g a good j o b depends m a i n l y on b e i n g i n t h e r i g h t p l a c e a t t h e r i g h t time.  a b  The average c i t i z e n can have an i n f l u e n c e i n government d e c i s i o n s , T h i s w o r l d i s r u n by t h e few p e o p l e i n power, and t h e r e i s n o t much t h e l i t t l e guy c a n do about i t .  a b  When I make p l a n s , I am a l m o s t c e r t a i n t h a t I c a n make them work, I t i s n o t a l w a y s wise t o p l a n t o o f a r ahead, because many t h i n g s t u r n o u t ^ t o be a m a t t e r o f good o r bad f o r t u n e anyhow. There a r e c e r t a i n p e o p l e who a r e j u s t no good. There i s some good i n everybody.  15.  a b  I n my c a s e , g e t t i n g what I want has l i t t l e o r n o t h i n g t o do w i t h l u c k , Many t i m e s we might j u s t as w e l l d e c i d e what t o do by f l i p p i n g a c o i n .  16.  a  Who g e t s t o be t h e b o s s o f t e n depends on who was l u c k y enough t o be i n t h e right place f i r s t . G e t t i n g p e o p l e t o do t h e r i g h t t h i n g depends on a b i l i t y ; l u c k h a s l i t t l e o r n o t h i n g t o do w i t h i t .  b  17.  a b  18.  a  As f a r a s w o r l d a f f a i r s a r e c o n c e r n e d , most o f u s a r e t h e v i c t i m s o f f o r c e s we can n e i t h e r u n d e r s t a n d , n o r c o n t r o l , By t a k i n g an a c t i v e p a r t i n p o l i t i c a l and s o c i a l a f f a i r s t h e p e o p l e c a n c o n t r o l world a f f a i r s .  b  Most p e o p l e d o n ' t r e a l i z e t h e e x t e n t t o which t h e i r by a c c i d e n t a l h a p p e n i n g s , There i s r e a l l y no such t h i n g a s "bad l u c k . "  l i v e s are controlled  19.  .a b  One s h o u l d always be w i l l i n g t o admit one's m i s t a k e s , I t i s u s u a l l y b e s t t o c o v e r up one's m i s t a k e s .  20.  a . b  21.  a  I n t h e l o n g r u n t h e bad t h i n g s t h a t happen t o us a r e b a l a n c e d by t h e good  b  Most m i s f o r t u n e s a r e t h e r e s u l t o f l a c k o f a b i l i t y ,  I t i s h a r d t o know whether o r n o r a p e r s o n l i k e s y o u . How many f r i e n d s you have depends on how n i c e a p e r s o n you a r e .  ones. all 22.  ignorance, l a z i n e s s , o r  three.  a  With enough e f f o r t  b  It i sdifficult  we c a n wipe o u t p o l i t i c a l  corruption.  f o r p e o p l e t o have much c o n t r o l o v e r t h e t h i n g s p o l i t i c i a n s  do i n o f f i c e . 23.  a b  Sometimes I c a n ' t u n d e r s t a n d how t e a c h e r s a r r i v e a t t h e g r a d e s t h e y g i v e . There i s a d i r e c t c o n n e c t i o n between how h a r d I s t u d y and t h e g r a d e s I g e t .  - 109 -  pg. 3  24.  a b  A good l e a d e r e x p e c t s p e o p l e t o d e c i d e f o r t h e m s e l v e s what t h e y s h o u l d do. A good l e a d e r makes i t c l e a r t o everybody what t h e i r j o b s a r e .  25.  a  Many t i m e s I f e e l  t h a t I have l i t t l e  i n f l u e n c e over the t h i n g s that  happen t o me. b  I t i s i m p o s s i b l e f o r me t o t h i n k t h a t l u c k o r chance p l a y s an i m p o r t a n t r o l e i n my  26.  a  P e o p l e a r e l o n e l y because  b  T h e r e ' s n o t much u s e i n t r y i n g t o o h a r d t o p l e a s e p e o p l e , i f t h e y you,  27...a b 28.  they d o n ' t  t r y t o be f r i e n d l y . like  they l i k e you.  T h e r e i s t o o much emphasis on a t h l e t i c s i n h i g h s c h o o l , Team s p o r t s a r e an e x c e l l e n t way t o b u i l d c h a r a c t e r .  a "What happens t o me i s my own d o i n g . b  Sometimes life  29.  life.  a  I f e e l t h a t I don't have enough c o n t r o l o v e r t h e d i r e c t i o n my  i s taking.  Most o f t h e t i m e I c a n ' t u n d e r s t a n d why p o l i t i c i a n s behave t h e way t h e y do.  b  In t h e l o n g r u n t h e p e o p l e a r e r e s p o n s i b l e f o r bad government on a n a t i o n a l as w e l l as on a l o c a l  level.  - 110 -  Please circle the correct answer: 1.  Do you feel you are a normal drinker?  yes  no  2.  Do friends or relatives think you are a normal drinker? \  yes  no  3.  Have you ever attended a meeting of Alcoholics anonymous (AA)?  yes  no  4.  Have you ever lost friends or girlfriends/boyfriends because of your drinking?  yes  no  Have you ever gotten into trouble at work because of drinking?  yes  no  6. Have you ever neglected your obligations, your family, or your work, for more than tv/o days because of drinking?  yes  no  5.  7.  Have you ever had delerium tremens (DTs), severe shaking, heard voices, or seen things that weren't there after heavy drinking?  yes  no  8.  Have you ever gone to anyone for help about your drinking?  yes  no  yes  no  yes  no  9. Have you ever been in a hospital because of drinking? 10.  Have you ever been arrested for drunk driving or driving after drinking?  guebi lunnaire L) - Ill -  Please answer the following questions; the information will not be used to identify you in any way. 1.  Today's date  2.  Name of facility you are attending  3.  Date you entered this facility  4.  Your birthdate  5.  Sex: Male Female  v  6. Your average yearly income, or that of your family 7.  How long, in years, has your drinking been a problem?  8.  Do you attend AA regularly?  Yes No  9. Do you think of yourself as: an alcoholic (i .e. a" person who suffers from a disease.) a problem drinker (i.e. a person who has a behavioral problem.) neither 10. Print the first two letters of your last name  - 112 -  GENERAL  INTRODUCTION  Y o u a r e b e i n g a s k e d to p a r t i c i p a t e i n a s t u d y o f alcohol p r o b l e m s . T h i s s t u d y i s p a r t o f an M.A. t h e s i s b e i n g c o n d u c t e d b y J o a n n e P a l l e t t through U.B.C. \ T h e p u r p o s e of t h e s t u d y , i n g e n e r a l t e r m s , i s t h a t i t i s a n i n v e s t i g a t i o n o f what people i n t r e a t m e n t c e n t r e s b e l i e v e about v a r i o u s c u r r e n t i s s u e s , i n c l u d i n g alcohol p r o b l e m s . It i s h o p e d t h a t t h e r e s u l t s will h e l p i n p r o v i d i n g b e t t e r a s s e s s m e n t p r o c e d u r e s f o r t h e r a p i s t s . Y o u r p a r t i n t h e s t u d y w o u l d i n v o l v e two, 30 m i n u t e , p e r i o d s o f y o u r time, one now, a n d one t o w a r d t h e e n d of y o u r s t a y h e r e . Y o u w o u l d b e a s k e d to complete a f o u r p a r t q u e s t i o n n a i r e . T h e questionnaires are filled out anonymously, i n a group. Your name does n o t go o n them, a n d no attempt will b e made to i d e n t i f y y o u . A n y q u e s t i o n s ? (If people h a v e s p e c i f i c q u e s t i o n s about t h e n a t u r e of t h e s t u d y , e x p l a i n that t h i s w o u l d b i a s t h e i r a n s w e r s , a n d t h a t s u c h questions c a n be answered after the second session.) A t t h i s p o i n t , those who may w i s h to do so, may l e a v e . A l s o , t h o s e who a r e t h e r e f o r t h e treatment of a d e p e n d e n c y p r o b l e m o t h e r t h a n alcohol, may also l e a v e .  SPECIAL INSTRUCTIONS [Before distributing the questionnaires.] T h e s e a r e all q u e s t i o n s of p e r s o n a l o p i n i o n s o r b e l i e f s . no r i g h t o r w r o n g a n s w e r s .  T h e r e are  A l l t h e q u e s t i o n s a r e of t h e t y p e t h a t a s k y o u t o p i c k "A" o r "B"; " T r u e " o r " F a l s e " . Sometimes i t i s h a r d to make a c h o i c e , s i n c e b o t h a l t e r n a t i v e s may b e t r u e . H o w e v e r , t r y to p i c k t h e one t h a t i s what y o u b e l i e v e most of t h e time. T r y to a n s w e r e v e r y q u e s t i o n . T h e q u e s t i o n n a i r e s a r e n o t all i n t h e same o r d e r ; y o u a r e a l l g e t t i n g t h e same q u e s t i o n s , j u s t i n d i f f e r e n t o r d e r s . P l e a s e d o them i n t h e o r d e r i n w h i c h t h e y a r e p r e s e n t e d . T h a t i s , do p a g e 1 f i r s t , t h e n go o n to p a g e 2, a n d so f o r t h . P l e a s e w o r k at y o u r own p a c e , a n d h a n d y o u r q u e s t i o n n a i r e i n when r e a d y . Thank you.  - 113 -  APPENDIX Tables pertaining  C  to d e s c r i p t i o n  used in study  of sample  - 114 -  Table  1.  D e s c r i p t i o n of Sample of 104 S u b j e c t s U s e d by  Facility  Age  and  Number Male Female  n  Study,  Income *  Age Total  i n Pilot  Income  x  Sd  n  x  Sd  A  59  2  61  60  40.28  9.54  59  3.12  1.31  B  39  4  43  42  38.64  11.57  37  2.57  1.02  98  6  104  102  39.60  12.69  96  2.92  1.23  Total  T a b l e 2.  D e s c r i p t i o n of Sample of 104 S u b j e c t s U s e d  b y L e n g t h of A l c o h o l P r o b l e m ,  MAST, AA  i n Pilot  Study,  Involvement,  a n d D r i n k i n g Role P r e f e r e n c e *  Facility  L e n g t h of A l c o h o l Problem n  Sd  X  MAST S h o r t form n  X  AA Involvement Sd  No  %No  D r i n k i n g Role Preference Yes  %Yes  n Ale.  **  n  P.D.  0 0  **  A  60  11.20  8.04  61  19..74  6.25  41  68  19  32  43  75  14  25  B  91  10.98  6.11  43  20.,47  5.48  36  84  7  16  24  57  18  43  101  11.11  7.25  104  20. 04  5.76  77  45  26  25  67  68  32  32  Total  *  o 0  T h e total n u m b e r of s u b j e c t s i n each c a t e g o r y d i d not always r e a c h 104, s i n c e some s u b j e c t s d i d not a n s w e r some of t h e q u e s t i o n s on t h e d e m o g r a p h i c q u e s t i o n n a i r e .  ** A l e . = A l c o h o l i c , P.D.  = Problem  Drinker  - 115 -  Table  3.  Age  B  AA  Sd 41.10  20 3 9 . 9 5  involvement  L e n g t h of Dependency  Income  n 39  D e s c r i p t i o n of 5 9 S u b j e c t s U s e d i n M a i n  n  Sd  x  n  Sd  x  * D r i n k i n g Role A A I n v o l v e . A l e . P.D . **  MAST n  x  Study  Sd  n  x  Sd  n  -8  n  9 . 9 7 3 9 2 . 9 5 1 . 2 3 3 9 1 1 . 5 4 8 . 8 3 3 9 1 8 . 7 2 6 . 5 5 3 9 . 2 6 . 4 4 2 7 6 9 12 3 1 1 1 . 4 6 2 0 2 . 4 5 1 . 1 9 20 1 1 . 2 5 7 . 1 9 20 2 0 . 4 0  was e n c o d e d  0 = "no", 1 = " y e s " .  :  A l e . = A l c o h o l i c , P.D. = P r o b l e m  Table 4 .  5 . 3 6 2 0 . 1 0 . 3 1 10 5 0 1 0 5 0  Drinker.  D e s c r i p t i o n of A l c o h o l i c s a n d P r o b l e m  Age x  L g t h . of Depen'cy  Income  MAST  Sd  x  9.58  3.02 1.13 12.92 8.64 20.49  D r i n k i n g Role  n  Alcoholics  37  42.75  Problem D r i n k e r s  20  37.27 11.06  * A A involvement  was e n c o d e d :  Sd  x  Drinkers  2 . 5 0 1.26  SD  x  A A Involve. * Sd  x  Sd  5.83 .24 .44  8 . 9 5 7.05 17.73 6 . 5 7 .14 .35  0 = "no", 1 = " y e s " .  - 116 The  following i s a more d e t a i l e d d e s c r i p t i o n o f t h e d e m o g r a p h i c  variables  i n T a b l e s 1 , 2, 3 a n d 4. Age  T h i s was e n c o d e d  as t h e s u b j e c t ' s age i n y e a r s o n t h e f i r s t d a y o f t h e  month of t h e test. Income  F o r c o n v e n i e n c e ' s s a k e , y e a r l y income was e n c o d e d  i n the following  way: Y e a r l y income  -  Code  < $10,000  -  1  > $10,000  < S20,000  -  2  > $20,000  < $30,000  -  3  > $30,000  < $40,000  4  > $40,000  -  L e n g t h of Alcohol Problems  T h i s was e n c o d e d  indicated their d r i n k i n g h a d been a MAST  ( s h o r t form)  problems.  Pokorny,  5 as t h e n u m b e r  Miller a n d K a p l a n  as a n i n d e x o f s e v e r i t y o f alcohol (1972) r e p o r t e d t h a t 55% o f t h e  a l c o h o l i c s t h e y t e s t e d s c o r e d i n t h e 18 - 25 p o i n t r a n g e .  AA  Involvement  respondents  "problem".  T h i s test was u s e d  60 s u b j e c t s s c o r e d below t h a t  of years  Only  11 o f t h e i r  range.  S u b j e c t s were a s k e d w h e t h e r t h e y c o n s i d e r e d t h e m s e l v e s  r e g u l a r A A a t t e n d e r s , to a s c e r t a i n d e g r e e o f commitment to i t .  to b e  While t h e  v a s t majority ( 7 7 % of t h e total sample) s a i d t h e y were n o t r e g u l a r A A  members,  v i r t u a l l y a l l o f t h e sample i n d i c a t e d t h e y h a d b e e n t o at least o n e A A  meeting  ( t h i s i s o n e of t h e M A S T simply encoded AA  questions).  I n T a b l e 1, A A i n v o l v e m e n t i s  as p e r c e n t a g e s o f " y e s " a n d "no" a n s w e r s .  i n v o l v e m e n t was e n c o d e d  numerically - zero indicated  I n T a b l e s 2 a n d 3, "no" a n d one, " y e s " .  - 117 -  Drinking or  Role  "neither".  Appendix B ) .  Subjects h a d three choices:  "alcoholic",  T h e f i r s t two l a b e l s were e l a b o r a t e d b y d e f i n i t i o n s T h e majority chose the "alcoholic" l a b e l .  was a r e m a r k a b l y stable  choice.  ( Q u e s t i o n n a i r e D,  ^Furthermore, this  role p r e f e r e n c e after three  T h e s e s u b j e c t s were l a b e l l e d as " a l c o h o l i c s "  since that  Of'the" 59 "subjects who h a s a p r e t e s t  d i d n o t make a c h o i c e o n t h e p r e t e s t . label o n t h e p o s t t e s t ,  drinker",  F o r t h o s e who c o m p l e t e d two t e s t s , o n l y two  s u b j e c t s o u t o f 59 c h a n g e d t h e i r d r i n k i n g  pretest.  "problem  weeks.  was t h e i r c h o i c e at t h e  and a posttest,  a further  three  T w o of t h e s e c h o s e t h e " a l c o h o l i c "  while one made no c h o i c e o n e i t h e r  s u b j e c t s were all e n c o d e d b y t h e c o m p u t e r as a l c o h o l i c s .  test.  These  three  .v.'-'  - 118 -  APPENDIX R e l i a b i l i t y Estimates  D  for "Beliefs About Alcohol Dependence"  Scale  - 119 T a b l e D (1) R e l i a b i l i t y E s t i m a t e s f o r 40 Item  "Alcohol Beliefs"  c o m p u t e d i n d a t a o b t a i n e d from  Disease S u b  Scale  Scale,  104 s u b j e c t s  B e h a v i o r Sub  F r e q u e n c y Item - *• %:F T Total Correlation  Scale  3  Mean  Sd  1  2  Item  Mean  Sd  % :F  T  ItemTotal Correlation  Item  1  .72  .45  28  72  _ 25***  1  .31  46  69  31  .00  2  .15  .36  85  15  .13  2  .22  42  78  22  .21**  3  .64  .48  36  63  . 24**  3  .69  .46  31  69  . 23**  4  .20  .40  80  20  .26***  4  .54  50  46  54  . 27**  5  .80  .40  20  80  .07  5  .27  45  73  27  6  .74  44  26  74  . 21**  -.18*  6  .51  .50  49  51  _ 25***  7  .78  .42  22  78  . 19**  7  .82  39  18  82  .01  8  .78  42  22  78  -.07  8  .78  .42  23  78  25***  9  .62  .49  38  61  . 19**  9  .60  49  40  60  .26***  _ 34***  10  .56  50  43  57  . 14  11  .39  49  61  38  t  .21**  12  .87  34  13  86  41***  10  .53  .50  47  53  11  .30  .46  69  31 -.01  12  .05  .22  95  5  13  .45  .50  55  45  _ 32***  13  .79  41  21  79  .26***  14  .64  .48  36  63  .11  14  .92  27  8  92  .21**  15  .18  .39  82  18  .18*  15  .84  37  16  84  .08  16  .16  .37  84  16  .17*  16  .91  17  3  97  . 21**  17  .68  .47  32  68  . 18*  17  .38  49  62  37  .06  18  .66  .48  34  66  . 17*  18  .77  42  23  77  .17*  19  .26  .44  74  26  .29*  19  .57  50  43  57  . 11  20  .19  .30  90  10 -.04  20  .76  43  24  76  .07  K-R  K-R  20 = .58 a  Standardized  a  =  20 a = .47  S t a n d a r d i z e d a = .50  .57  Mean - T h e arithmetic mean f o r e a c h item r a n g e s from 0 to 1. were encode*d "0", " T r u e " r e s p o n s e s were e n c o d e d "1" Standard deviation - range 0 figures rounded  to t h e n e a r e s t whole n u m b e r .  * p<.10; ** pg.05; *** pS.01  "False" responses  1.  F r e q u e n c y - T h e p e r c e n t of time a n item was a n s w e r e d AH  3^***  "True" and "False"  - 120 -  T A B L E D(2) R e l i a b i l i t y E s t i m a t e s o n 26 S e l e c t e d Items f o r " A l c o h o l B e l i e f s " Scale , c o m p u t e d on d a t a o b t a i n e d from 104 S u b j e c t s \  Disease Item  Scale  Behavior a i f item deleted  Item-total correlation 1  Item  Scale  Item-total correlation  a i f item deleted  1  .24**  .58  2  _ 30***  .59  3  .20**  .59  3  .22**  .61 .58  4  2 7 * * *  .58  4  _  6  .28***  .57  6  . 23**  .61  7  .24**  .58  9  ^^***  .56  8  .28***  .59  11  9  . 21**  .58  12  _ 41***  .58  10  _  .57  13  .22**  .61  12  .22**  .59  14  .21**  .61  13  _ 3 3 * * *  .57  16  .13  .62  15  .12  .60  18  .11  .63  16  .18*  .59  17  .21**  .59  18  .16*  .60  19  .26***  .58  2 9 * * *  K-R  3 5 * * *  4 5 * * *  20a=. 62  S t a n d a r d i z e d a =.62  K-R  2 0 a =.60  Standardized 1  a =.60  *p<.10;  **pS.05;  ***p<.01  .56  - 121 -  APPENDIX  E  I n d i v i d u a l Item S c o r e s O b t a i n e d b y and Problem on  "Beliefs About  Alcoholics  Drinkers  Alcohol  Dependence"  a n d P r o b l e m D r i n k e r s on B e l i e f s Scale  Scale  Alcoholics  Problem D r i n k e r s  "t"  3  \  l  Disease i 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20  Sd  Sd -  2  .88 .15 .65 .21 .82 .63 .85 .85 .63 .56 .19 .03 .51 .65 .15 .15 .73 .71 .26 . 10  .33 .36. .48 .40 .39 .49 .36 .36 .48 .50 .40 .16 .50 .48 .36 .36 .44 .46 .44 .30  .38 .16 .59 .19 .75 .25 .63 .63 .59 .47 .56 .09 .31 .59 .25 .19 .56 .56 .25 .09  .49 .37 .50 .40 .44 .44 .49 .49 .50 .51 .50 .30 .47 .50 .44 .40 .50 .50 .44 .30  .28 .09 .65 .50 .21 .71 .83 .82 .51 .58 .29 .85 .79 .94 .86 .99 .33 .76 .51 .76  .45 .30 .48 .50 .40 .46 .38 .38 .50 .50 .46 .36 .41 .23 .35 .12 .48 .43 .50 .43  .38 .50 .78 .63 .41 .81 .78 .69 .78 .53 .59 .91 .78 .88 .78 .94 .47 .78 .69 .75  .49 .51 .42 .49 .50 .40 .42 .47 .42 .51 .50 .30 .42 .34 .42 .25 .51 .42 .47 .44  5.24** -.04 .56 .24 .77 3.88*** 2.29** 2.29** .30 .81 -3.65*** -1.18 ]_ Q7** >  ! 56 -1.10 -.42 1.68* 1.40 . 15 .06  Behavior.; 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1  Mean  s c o r e s - r a n g e 0 ( F a l s e ) to 1  Standard 3  d e v i a t i o n , r a n g e 0 to 1  * pS.10; ** p^.05; *** pS ,'01  (True)  -.95 -4.18*** -1.38 -1.19 -1  97**  -1.18 .60 1.39 -2,81*** .49 -2.92*** -.87 .12 1.06 .94 1.07 -1.28 -.19 -1. 70* .15  

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