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

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BELIEF SYSTEMS OF A L C O H O L I C S AND P R O B L E M DRINKERS by JOANNE HENDRIKA P A L L E T T B . A . , Dalhousie Un ive 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 THE DEGREE 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 STUDIES (Department of Counsell ing Psychology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF B R I T I S H COLUMBIA December 1982 © J . H . Pallett , 1982 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head of my department or by h i s or her r e p r e s e n t a t i v e s . I t i s understood t h a t copying o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n ot be allowed without my w r i t t e n p e r m i s s i o n . Joanne P a l l e t t Department of Counselling Psychology The U n i v e r s i t y o f B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date A P r i l 8> 1 9 3 3 - i -A B S T R A C T Alcohol dependence is a complex condition which may be construed as both a disease and a behavioral problem. This study investigated the possibility that deviant d r i n k e r s themselves choose one of these options, that this choice is related to general beliefs about control, and that both specific and general beliefs change du r i n g a stay in a four week residential treatment program. A questionnaire was constructed to measure differences between behavior and disease oriented beliefs about alcohol dependency. This questionnaire was tested on a group of 104 clients at two alcohol treatment centres. It was established that the instrument fulf i l l e d some of the criteria for psychometric soundness, notably, an acceptable level of internal consistency, and some discriminatory ability. A volunteer sample of 59 men was then tested at these same treatment centres. They were divided into two groups: alcoholics and problem drin k e r s , depending on which role label they p r e f e r r e d . Everyone received a pre test and a post test. On each occasion, they completed the Beliefs About Alcohol Dependence questionnaire, the Rotter Locus of Control test, the Michigan Alcoholism Screening test, and a demographic information questionnaire. Results indicate that there were some differences in belief systems between the two groups. S e l f defined alcoholics had more disease oriented beliefs and a greater tendency to perceive themselves i n control of their environment. Self defined problem d r i n k e r s had more behavior oriented - i i -beliefs and a greater tendency to p e r c e i v e themselves to be c o n t r o l l e d b y v t h e i r environment. While s p e c i f i c b e l i e f s about dependence d i d not change d u r i n g treatment, general b e l i e f s about control over the environment d i d . The implications of viewing the alcohol dependent population as v a r i a b l e w i t h respect to belief systems are d i s c u s s e d . - i i i -T A B L E O F 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 v i A c k n o w l e d g e m e n t s v i i I . I n t r o d u c t i o n 1 B a c k g r o u n d 1 T h e Prob lem 5 Ra t iona le 7 A s s u m p t i o n s 10 Del imi ta t ions 10 J u s t i f i c a t i o n s 11 D e f i n i t i o n of Terms 12 I I . L i t e r a t u r e Rev iew 15 O v e r v i e w 15 V a r i a b i l i t y Among A l c o h o l i c s / P rob lem D r i n k e r s 16 B e l i e f Sys tems of A l c o h o l i c s / P rob lem D r i n k e r s 20 A l c o h o l Dependency as a C o g n i t i v e P rocess 25 C o n t r o l Or i en t a t i on i n A l c o h o l Dependence 31 C h a n g e s i n C o g n i t i o n d u r i n g A l c o h o l T h e r a p y 37 Summary 39 - i v -Page I I I . Me thodo logy V 40 H y p o t h e s e s 40 D e s i g n 40 Sample and Popu la t ions 41 I n s t r u m e n t s 44 P r o c e d u r e 49 I V . R e s u l t s 51 1. B e l i e f s A b o u t A l c o h o l Dependence Q u e s t i o n n a i r e 51 2. R e s u l t s of Main S t u d y 61 H y p o t h e s i s 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 H y p o t h e s i s I V . 7 0 V . D i s c u s s i o n • 78 D i f f e r ences Be tween A l c o h o l i c s and P rob lem D r i n k e r s 78 T h e C o m p l e x i t y of C o n t r o l 79 L i m i t a t i o n s 81 Impl ica t ions of a F u t u r e S t u d y 82 Summary 83 B i b l i o g r a p h y 85 A p p e n d i c e s 90 - v -L I S T O F T A B L E S T a b l e P a g e I V . 1. I t e m s S e l e c t e d f o r A l c o h o l B e l i e f s S c a l e 54 2 . A l c o h o l B e l i e f s I t e m s 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 a n d P r o b l e m D r i n k e r s 56 3 . M e a n 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 o t a l S a m p l e o n A l c o h o l B e l i e f s S c a l e 57 4 . M e a n 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 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 A l c o h o l B e l i e f s S c a l e 59 5. M e a n S c o r e s o f 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 t h e B e h a v i o r S u b s c a l e 63 6. M e a n S c o r e s o f 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 t h e D i s e a s e S u b s c a l e 64 7. M e a n s a n d S t a n d a r d D e v i a t i o n s o f L o c u s o f C o n t r o l 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 68 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 o f C o n t r o l S c o r e s a n d D i s e a s e B e l i e f s , a n d B e t w e e n L . O . C . a n d B e h a v i o r B e l i e f s 69 9. A N O V A R e s u l t s f o r L o c u s o f C o n t r o l S c o r e s ( P r e t e s t ) 76 10. A N O V A R e s u l t s f o r L o c u s o f C o n t r o l S c o r e s ( P o s t t e s t ) 77 - vi -LIST OF FIGURES The Ba]anced Placebo Design Portion of Repertory Grid 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 - v i i -ACKNOWLEDGMENTS I would like to express my appreciation to several people, without whose contributions this work could not have been completed: to L a r r y Cochran, whose patience and nev e r - f a i l i n g enthusiasm provided most of the motivation for completing the research. I also thank him for being available whenever I needed help; to the staff of Pacifica, who willingly adapted their b u sy schedule to accommodate the data collection. I am especially grateful to Dr. Pauline Grey, whose interest i n research improved my own motivation; to the staff of Victoria Life Enrichment Society, whose offer to assist with the collection of data streamlined the process, as well as making it more economical. T h e i r r e l i a b i l i t y and efficiency in performing this task are greatly appreciated; to all the clients at both facilities who volunteered their time, and who often stayed to discuss the questionnaires with me; to Dan Parsloe, who gave freely of his own time to do the computer analysis of the data, and who was always available to consult on the intricacies of statistics, measurement--theory, and computer programs; to Carol Roberts, who spent many hours t y p i n g , proofreading, and editing the manuscript. More than that, she p r o v i d e d much needed incentives to me to h u r r y up and f i n i s h ! - 1 -CHAPTER I  SCOPE OF THE STUDY Background: 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; Core Knowledge in the Drug Field, 1979). However, it is the contention of this study that it is worthwhile to construe this phenomenon in two ways: as a disease entity and as a learned behavior pattern. 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. - 2 -The scientific body of knowledge with respect to the disease theory developed as an adjunct to these popular notions described above. The initial (1946) work of E.M. 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. Jellinek went on to a more detailed formulation of the disease model. 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 way of life (Alcoholics Anonymous, 1939) . Scientific books written for popular consumption advocate this view (Marty Mann, 1979; Vernon Johnson, 1973), as do novels (Joyce Rebuta-Burditt, 1977) and TV 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 was developed as an alternative explanation when experimentally 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. Furthermore, an alcoholic's expectations 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. How this behavior was 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 drinking" models are correct, and that they apply to two different populations of deviant drinkers. Goodwin (1976 (b)) used the following criteria to distinguish between the two groups: 1 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 drinking. 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 very 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 Ndisease model over the last 30 years has changed social policy. The 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 driving, 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 that they may develop their own "subjective" theories. Few 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. Roman and Trice (1977) also describe how adopting the role of "alcoholic" may become part of the person's implicit personality theory. The person who adopts the label - 6 -may come to think of him or her self as "a person who drinks deviantly", and live up to those role expectations. He/she may incorporate the implied "sick role" and may thereby be enabled to give up responsibility for his/her own 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. Kelly describes man as his own "personal scientist" and the "personal construct system" as the way 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. Others (Hoy, 1973; 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 the label. - 7 -If two "objective" belief systems with respect to alcohol dependence are available, then the deviant d r i n k e r can choose between them. One system is represented by the "disease concept of alcoholism" and beliefs about this view closely parallel those about physical diseases. The other system is r e f e r r e d to as a "problem d r i n k i n g " model and uses a learned-behavior method of description. Rationale for the Present Study The above section presents the rationale for assuming that deviant d r i n k e r s have two choices in incorporating their d r i n k i n g role into their existing personality theories. Those who choose the disease theory do so because describing oneself as the victim of a disease process, adopting a sick, patient role, and relinquishing control and responsibility are psychologically advantageous. Those who describe themselves as problem d r i n k e r s do so because a behavioral model is more meaningful to them than a medical one. It was therefore necessary to develop an instrument which discriminates between the two belief systems. George Kelly (1955) suggested that a person will choose those constructs which allow the greatest elaboration and validation of the existing system, i. e . , those which are most meaningful. Therefore it seems that the choice between a "problem dr i n k e r " and an "alcoholic" belief system may be mediated by a more generalized variable, and that the deviant d r i n k e r may choose the one which allows the greater elaboration of the more general construct. A central notion of the disease theory is that it assumes the individual's lack of control over the condition. The behavioral model, on the other 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. - 9 -The question as to whether a treatment program geared to a specific belief system could affect a general construct such as locus of control seemed a worthwhile and interesting one. Several studies (O'Leary, Rohsenov, and Donovan, 1976) have related locus of control to alcohol treatment, but the results are inconclusive. If beliefs about alcohol dependence are related to beliefs about response-outcome contingencies, it seems reasonable that this relationship would interact with a treatment program, p a r t i c u l a r l y if the nature of the program could be established as being at one end of the control continuum or the other. Therefore,: four hypotheses were investigated in this study: I Deviant drinkers who prefer the label "problem d r i n k e r " rather than "alcoholic" will show a stronger preference for implications associated with a behavioral theory of alcohol dependence than for the: implications associated with a disease theory, as measured b y the Beliefs About Alcohol Dependence questionnaire. Conversely, deviant drinkers who prefer the label "alcoholic" will show a stronger preference for disease theory implications as measured by the same questionnaire. II Self-defined alcoholics and problem drinkers will also differ on beliefs about locus of control, in the direction of greater externality for the alcoholics, as measured by the Rotter Locus of Control Scale. III A treatment program which emphasizes a behavioral model of treatment will serve to strengthen behaviorally oriented beliefs, and weaken - 10 -disease oriented beliefs, as measured by the Beliefs About Alcohol Dependence questionnaire. IV During a stay i n a treatment program which emphasizes personal responsibility and self-control over d r i n k i n g , both alcoholics and problem drinkers will become more internally oriented, as measured by the Rotter Scale. Assumptions The major assumption made in this study was that it was justifiable to collapse all of the models of alcohol dependency into two mutually exclusive choices. It was assumed that there were two distinct belief systems, a disease oriented one and a behavioral one, and that they are negatively correlated. This does not preclude the existence of other related constructs, but it was assumed that the two belief systems mentioned would discriminate between two subgroups of the alcohol dependent population. A second assumption was that the questionnaire as constructed would perform the operation described above, i.e. , make the discrimination, and do so in a reliable and valid way. Some psychometric evaluation of the questionnaire was done to establish these c r i t e r i a . Delimitations Several points about sample selection limited the applicability of the study . The subjects and treatment centres were not selected in a random or representative fashion. Rather, the sample consisted of almost all of - l i -the population attending two residential centres during a three month period. The centres were selected on the basis that they were accessible and cooperative. However, the findings may not generalize, since clients are not randomly assigned to treatment centres. The sample was drawn from an inpatient rather than an outpatient population since it was far more efficient to obtain a large sample from such a "captive" audience. There may not be any reason to assume a difference between these two populations, but this point needs to be investigated. The sample was re s t r i c t e d to men only, for two reasons. F i r s t , many researchers feel that alcohol belief systems of women may be different from those of men (e.g., McLelland, Davis, Kalin, and Wanner, 1972; Marlatt and Rohsenov, 1980). Secondly, women are usually vastly underrepresented in any residential program, so that it would not have been possible to get a sample large enough for analysis within the three month time frame. The results of the study apply only to those whose troubles with alcohol have been considered serious enough to have warranted treatment in a specialized facil i t y . Justification The present study seemed justified on the basis that it allowed extension of the c u r r e n t l y accepted alcoholism paradigm to include a problem d r i n k i n g one, and did this by investigating the importance of the beliefs of deviant drinkers themselves. Recently, some (e.g., Tournier, 1977, 1979; Pattison, Sobell, - 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 very 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, 1972; Marlatt and Rohsenov, 1980); 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, ALCOHOLICS 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 referred to "Fifty alcoholics at an alcoholism treatment centre" - 13 -those will be the terms used in this paper when r e f e r r i n g to the study. PROBLEM DRINKING, PROBLEM DRINKER These terms are used to denote the condition of alcohol dependence or the alcohol dependent indi v i d u a l when the behavioral or environmental model is being discussed. These terms are also used when they have been used b y the author of a study under review. D E V I A N T DRINKING, DRINKER; A L C O H O L DEPENDENCE, 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 These terms are used interchangeably and in a generic fashion. Thus their use is meant to indicate alcohol dependence in general is being discussed, without reference to a specific model. ADDICTION, DEPENDENCY These terms are used interchangeably. As used here, they refer to the condition or process i n which an individual's lifestyle is associated in a problematic way with excessive use of alcohol. P H YSIOLOGICAL or PHYSICAL ADDICTION/DEPENDENCY This term r e f e r s to the body's becoming physically dependent on alcohol, as is illu s t r a t e d b y tolerance and withdrawal. "Tolerance" occurs when there is a physiological or metabolic adaptation to alcohol so that the individual needs increasing amounts to get the same effects. "Withdrawal" ref e r s to the occurrence of adversive or unpleasant physical symptoms upon abrupt cessation of alcohol use. P S Y C H O L O G I C A L DEPENDENCE This condition is said to be present when an individual's lifestyle is excessively concerned with alcohol use, and when the individual habitually expresses a strong desire for alcohol although - 14 -he/she may not be physically dependent. v B E L I E F SYSTEMS These are cognitive structures that mediate behaviors. The term is used in a v e r y general sense, i.e . , a "personal construct system'! is a belief system, and so a "generalized" expectancy for external or interna] control. PERSONAL C O N S T R U C T A personal construct is a generalized representation of a conceptual discrimination between events, or between the psychological representations of those events. A construct is more than just the verbal label applied to i t , since it includes personal experience which may be non-verb a l . Thus the construct "behaves responsibly versus is irresponsible" includes the person's verbal definition as well as his/her i d i o s y n c r a t i c experience of that construct. Constructs are always b i - p o l a r . P ERSONAL C O N S T R U C T SYSTEM This term ref e r s to a set of interrelated personal constructs which are the core of each person's experience of l i f e , i . e . , they allow decoding and encoding of personal behavior. GENERALIZED E X P E C T A N C Y FOR E X T E R N A L - I N T E R N A L CONTROL, CONTROL ORIENTATION, L O C U S OF CONTROL These terms are used interchangeably and as described b y Rotter et al (1972) and by Phares (1975). B r i e f l y , an externally controlled individual believes that his/her behavior and outcomes are independent, i.e . , that goals result from good luck, fate, chance, or intervention of powerful others. An "internal" individual believes he/she has control of reinforcements. - 15 -C H A P T E R II  L I T E R A T U R E REVIEW Overview Several areas of psychological investigation have been reviewed in order to provide a background for this study. It was predicted that there are subgroups among the alcohol dependent population which have different belief systems. Therefore, studies were cited which show significant vari a b i l i t y in this population, enough to question the concept of alcohol dependence representing a single entity. Cognitive processes are an important variable in describing alcohol related behaviors. Studies r e s u l t i n g from a personal construct theory framework showed that self definition in terms of a deviant role implied an u n d e r l y i n g cognitive structure which had predictive value for behavior. The second hypothesis assumed that there is a relationship between alcoholics' and problem drinkers' subjective theories about their condition and their expectations about control over their environment. Lack of control over d r i n k i n g is an important characteristic of alcohol dependency, but studies reviewed show that this lack of control is mediated cognitively, not physiologically. If control over d r i n k i n g is cognitively mediated, there seems to be a rationale for assuming a relationship to a more general perspective on control. Therefore, studies investigating the nature of "locus of control" in this population were reviewed. The t h i r d and fourth hypotheses predicted that belief systems change - 16 -duri n g therapy, and studies which provide support for this v position were also reviewed. Vari a b i l i t y Among Alcoholics/Problem Drinkers Jellinek (1946, 1960) was the f i r s t researcher to acknowledge that alcoholism was not a unita r y phenomenon. He wrote of "species" of "alcoholisms" and described the following five, although he felt there might be more: 1) Alpha alcoholism, which is characterized b y psychological dependence and psychosocial problems. Physiological dependence is not present. 2) Beta alcoholism, in which there is heavy d r i n k i n g , r e s u l t i n g i n p hysical damage, but neither physiological nor psychological dependency. One could describe the d r i n k i n g style in France as being of this type. 3) Epsilon alcoholism, which features periodic episodes of heavy d r i n k i n g , but without physical dependence. The d r i n k i n g style encouraged by Germany's beer fests and that of the "binge d r i n k e r " may be representative. 4) Gamma alcoholism, which Jellinek felt to be the major type prevalent i n North America. It includes both physical and psychological dependence, as well as adverse psychosocial consequences. The typical AA model of alcoholism conforms to this type, with "loss of control" being a chief characteristic. 5) Delta alcoholism, which he also thought common on this continent, is characterized by "an inability to abstain" although the amount consumed at any one time may be controlled. Physical dependence is also present, although personal problems may or may not be. Jellinek thought the "disease concept" should apply only to the latter two types of alcoholism. Evidence of physical addiction should be present, as indicated b y the occurrence of withdrawal symptoms upon cessation of alcohol use. Jellinek's conclusions are based chiefly on clinical observation and one s u r v e y study. A questionnaire was d i s t r i b u t e d to 1,600 AA members through their newsletter, "The Grapevine". Only 98, or six percent of the original number, were used in the data analysis. Nevertheless, Jellinek used this data to formulate his concept of the "phases of the disease process of alcoholism He analysed the occurrence of 43 symptoms by age of onset and sequence in d r i n k i n g h i s t o r y and determined that there are three distinct phases. The "promodal phase" is characterized by the onset of blackouts, the "crucial phase' b y the "loss of control", and the "chronic phase" by prolonged intoxication. These phases are thought of as sequential and inevitable, and all the symptoms are part of the disease process. The above data can be criticized on several grounds . The questionnaire items were "loaded"; a sample question was: "At what age did you f i r s t experience blackouts?" The sample was not representative either with respect to the genera] population, or to the AA membership. There were no adequate control or comparison groups. The data collected were retrospective in nature, - 18 -and therefore subject to contamination from memory loss, o r v r e t r o a c t i v e inhibition. In other words, respondents could have been "recalling" what they had been taught at AA. Jellinek was aware of all these limitations, and cautioned against wholesale acceptance of his disease model. Unfortunately, this is what happened, and unt i l the advent of the better controlled studies, "alcoholism" was conceptualized as a unitary phenomenon. Clark and Cahalan (1976) and Pattison, Sobell, and Sobell (1977) review a number of such studies. They can be broken into two categories: 1) Attempts to replicate the Jellinek formula of questioning "admitted" alcoholics have not been successful. There is little evidence of distinct phases characterized b y specific symptoms. There does seem to be a general functional deterioration that would be expected from chronic heavy alcohol consumption. 2) Studies of representative cross sections of the population show the development of "drinking problems" to be variable over time. These longitudinal studies generally use a version of Cahalan's (1976) definition: A "problem d r i n k e r " is one who obtains a score of seven or more in eleven categories of personal or social problems associated with d r i n k i n g . Significant numbers of people move in and out of the "problem" category over a four to 20 year span. The Cahalan type of study can be criticiz e d on the basis that it does - 19 -not study "true alcoholics" and that for this select group a disease process does hold true. S t i l l , the evidence points to the position that most deviant d r i n k e r s do not conform to a disease process, and that there is a great deal of vari a b i l i t y i n this population. Mark Keller, in c r i t i c i z i n g the studies that have attempted to pinpoint traits peculiar to an "alcoholic personality" wrote, "alcoholics are different (from non-alcoholics) in so many ways that it makes no difference!" (1977, p. 61). It seems that this statement could be rephrased in this way: "alcoholics are different from each other in more ways than they are different from non-alcoholics" . A recent study (Pattison, Coe and Doerr, 1977) shows that it is useful to think of alcohol dependent individuals in several distinct subgroupings. Clients at four different alcohol treatment facilities were compared: an aversion conditioning hospital (ACH), an outpatient clinic (OPC), a halfway house (HWH), and a police work rehabilitation centre (PWC). Measures taken were: personality profiles (MMPI), demographic characteristics, general functioning (health, vocational, interpersonal), and orientation to treatment. Data analysis yielded statistically significant differences between groups on several measures. Pattison et al suggest that there is enough variation to suggest that four distinct populations were surveyed, and that the main basis for discrimination can be thought of as a "social competence" factor. For example, the A C H population had the highest educational level and socioeconomic status, the best vocational and interpersonal adjustment and no personality conflict. T h i s high social competence score allowed this group to "externalize" - 20 -their alcohol dependency, and to think of it as a medical problem such as heart trouble, or a broken leg - something the doctor will " f i x " . The facility supports this interpretation b y treating only the d r i n k i n g behavior. The other populations experienced more personal conflict and social disruption, with the OPC, HWH, and the PWC groups ranking second, t h i r d and fo u r t h respectively. The OPC group experienced problems of personal adjustment rather than social disintegration, and thus the clients viewed their alcohol dependency as an expression of their internal conflicts. Again, this view is supported by the OPC treatment approach, which emphasized psychotherapy. For the remaining two groups, HWH and PWC, alcohol problems were associated with significant social deterioration and alienation. The key step to rehabilitation seemed to be adherence to the A A model, and a total li f e s t y l e change. For purposes of the present review, the following interpretations of Pattison et al should be emphasized: alcohol dependent individuals represent a widely divergent population, individuals d i f f e r with respect to how they define their alcohol dependency, and these perceptions determine, to some extent, the type of treatment facility to which they will be attracted. One could point out that the interaction between individual and type of treatment is determined more by socioeconomic factors than cognitive ones. A more definite test would relate client perceptions, treatment facility and successful outcomes. Belief Systems of Alcoholics/Problem Drinkers Recent years have seen an increased interest i n investigating the - 21 -relationship between cognitive variables and alcohol dependency. Part of this interest results from the controlled d r i n k i n g controversy (e.g., Ewing and Rouse, 1975; Miller and Caddy, 1977). More important, however, is the evidence that cognitive factors affect alcohol consumption as well as related behaviors (Marlatt and Rohsenov, 1980); predict treatment choice (Dillavou, Vannicelli and Ryback, 1977); and are associated with relapse (Heather, Edwards and Hore, 1975). A study b y Richard and Burley (1978) showed that a groups of 20 alcoholic inpatients at a hospital identified more closely with the role of "controlled d r i n k e r " than that of "total abstainer". The subjects were asked to rate the concepts, "myself" and the two d r i n k i n g ones on a series of 13 bipolar personality descriptions. (Examples, " e s c a p i s t - r e a l i s t " ) . Each bipolar item was rated on a seven point scale, and separately for the three concepts. The implication of the above study is that it is easier for a person to adopt a role which has more psychological meaning (Fransella, 1972). Therefore, it would be important at the beginning of therapy to assess the degree of identification with controlled d r i n k i n g or abstainer role. The therapist then has two choices: conform the therapeutic goal to the client's belief system, or encourage the client to change his/her beliefs to conform to the appropriate goals. Marlatt and Rohsenov (1980) reviewed several experimental studies using the "balanced placebo" design (Figure 1). This design provides a control condition for cognitive effects as well as for the physiological ones, - 22 -Thus, from this type of design, it is possible to assess the importance of v four conditions , as illustrated below: Figure 1 The Balanced Placebo Design: Marlatt and Rohsenov Receive Alcohol Yes No "o both cognitive cognitive 'o a> and physiological effect ~ effects present only <J physiological neither Pu 3 effects effect W only present In one study described b y Marlatt and Rohsenov a matched group of non-abstinent alcoholics and social d r i n k e r s were asked to participate in a "taste test". Subjects in the "expect alcohol" condition were led to believe they were comparing three brands of vodka. Half of this group actually received tonic only. Subjects in the "expect no alcohol" condition were told they would be comparing three brands of tonic water. Half of these got tonic and vodka, the others got tonic only. All subjects were provided with a full decanter of beverage and the amount consumed was measured. For both alcoholics and social d r i n k e r s , the expectancy of alcohol determined the amount drunk, the actual presence of alcohol was not a significant factor. The above design has been used to study the effects of alcohol on experimental analogues of emotional and sexual behaviors, as well as on motor - 23 -and cognitive abilities. In one study, aggression was defined as the number of shocks 1 subjects gave, when provoked, to another subject who was in fact a confederate of the experimenter. Subjects were heavy d r i n k e r s , and placed in one of four treatment conditions described in F i g u r e 1. The results were clearcut. Subjects who believed they had received alcohol were significantly more aggressive than those who d i d not believe they had, regardless of actual alcohol content in their d r i n k s . Marlatt and Rohsenov suggest the following relationship between d r i n k i n g and aggression: there is an existing cultural belief that alcohol "produces" aggression and this expectancy will be strongest in heavy dri n k e r s . These individuals would be likely to indulge in aggressive behavior after consuming alcohol, and attribute responsibility for this behavior to the alcohol rather than to themselves. Furthermore, in the face of heavy cultural sanctions against aggression, some indi v i d u a l s , when provoked to anger, may fail to assert themselves and consume alcohol instead. D r i n k i n g may then be followed b y aggression, which in t u r n can then be a t t r i b u t e d to the alcohol, rather than to the earlier provocation. The above review gives strong evidence for the importance of cognition in predicting the behavior of deviant d r i n k e r s . The cr u c i a l effect of cognitive expectancies has been found in alcohol therapy as well. Dillavou et al examined the relationship between scores on the Rotter I-E Scale and acceptance l The confederate subjects were not really shocked, they were hooked up to a machine which made it seem as if they were. - 24 -of treatment intervention b y 45 alcoholics at an inpatient f a c i l i t y . It was hypothesized that internal alcoholics would be more attracted to i n s i g h t oriented therapy, as measured by staff ratings of involvement. It was also predicted that external alcoholics would be more accepting of external treatment intervention such as AA, A n t a b u s e 1 , and A f t e r c a r e . Results were found to be in .the expected direction: there was a significant negative 2 correlation between Rotter I-E scores and insight therapy involvement (r = - .25 p«06). There was a significant positive correlation between Rotter score and AA acceptance (r = .27 p<05) .3 Although the above correlations are significant, only about seven percent of the variance in treatment preference can be accounted for b y I-E scores. Rotter (1975) would argue that this is the degree of predictive power to be expected when a general factor is used to account for behavior in a specific situation. T hus the results of Dillavou et al do indicate that the locus of control dimension is one of the factors that is associated with differentia] response to treatment. It is well established that cognitions are important determinants of alcoholics' behavior. These cognitions are involved either through general 1 A d r u g which, when taken in conjunction with alcohol, produces severe and uncomfortable symptoms, such as nausea, heart palpitations, and sweating. It is p r e s c r i b e d to encourage abstinence. 2 High scores on the Rotter Scale indicate externality; low scores, internality. 3 Other correlations between I-E scores and external treatment approached significance. - 25 -factors such as perception of control, or through specific expectancies with respect to alcohol. It follows that the state, or condition, of alcohol dependence could also be studied as a cognitive process rather than a physiological one. Alcohol Dependence as a Cognitive Process One of the central hypotheses under investigation is that two objective theories of alcohol dependence can become the basis for the subjective theories of deviant d r i n k e r s . A theoretical basis for this position comes from personal construct theory (e.g., Kelly 1955; Bannister and Fransella, 1971; Fransella, 1972). According to this model, the crucial determinant of behavior is a system of cognitive s t r u c t u r e s called "personal constructs". A construct is a subjective representation of a generalized discrimination between two events. Constructs are thus bipolar. "Warm, gi v i n g / s e l f i s h " would be an example of a personal construct, but it is important to remember that this is just a verbal label given to a conceptual process, and the process includes more than just a verbal discrimination. Several other characteristics of constructs are important; an individual's personal constructs are interrelated, and some are subordinate to others. The construct system has functional value i n that it allows the individual to derive meaning and make predictions. For example, a 14 year old at his f i r s t co-ed dance has been told that if a g i r l smiles and nods at him, she will agree to dance, but if she frowns and looks away, she will refuse. The nervous 14 year old spends the f i r s t hour discriminating the smiling, - 26 -nodding girls from the frowning, looking-away ones. He i s \ t r y i n g to assimilate this new construct, make it meaningful by relating it to the way in which he already construes. So, he judges that the g i r l who smiled and nodded at him is the one he's noticed in class as being outgoing and friendly, and he predicts that she will probably dance with him. He feels excited, warm and pleasant. He looks at the girl who frowns and looks away, remembers her as the shy one who lives next door, and predicts she will refuse. He feels cold, afraid and nervous. If his predictions are correct, the construct, "smiles, nods/frowns, looks away" may become an important way. of construing events concerning g i r l s . A n approach resu l t i n g from personal construct theory has been used to show that people have an elaborate construct system associated with a deviant role. Fransella (1972) used the "Imp-Grid" method to show that a group of 20 stutterers had significantly more psychological meaning attached to being a "stutterer" than to being a "fluent speaker". Th i s relationship was changed through therapy, so that being a "fluent speaker" c a r r i e d a more elaborate construct system, and the rate of fluent speech improved dramatically. The theory states that a person stutters because it is from that stance that the world is more meaningful. Thus, the teenager at the dance,had he been a stutterer, would have construed the situation i n this way: "That girl is smiling and nodding at me; even though she knows I stutter, she'll probably dance with me." In the Fransella study, it was pre d i c t e d that the rate of fluency would improve only if "being a fluent speaker" became - 27 -more meaningful than "being a stutterer". T hus, during^ therapy, the clients were r e q u i r e d to construe every episode of fluent speech they experienced, and in great detail. Results show that the average rate of disfluent words, for a group of 20 stutterers, decreased from 85 per test occasion to eight. To show that the underlying construct system had also changed, Fransella tested each client several times d u r i n g the course of therapy, using the "Imp-Grid" method. The client was shown two photographs of people, and a card on which was written, "The sort of person people see me as being when I'm s t u t t e r i n g " . One photograph would elicit one pole of construct, the other picture would prompt the opposite pole. Thus, person "A" might see me as "warm, giving" while "B" might see me as "resentful of others' demands". Thi s process was then repeated, this time u s i n g the two photographs with the stimulus card reading, "The sort of person people see me as being when I'm not stuttering". T hus two grids were constructed at each session. At the beginning, the "stutterer" construct system was much "r i c h e r " , in terms of the number of, and interrelationships among, constructs than the "fluent speaker" one. At the end of therapy, the construct system associated with self as fluent speaker was the psychologically r i c h e r one. A study b y Christiansen, Reich, Obitz and Bauman (1980) shows that alcoholics do construe others di f f e r e n t l y when the other is alcoholic than when he isn't. After watching a videotaped role-play, male alcoholics were told either that a job candidate was an alcoholic or that he was a student. The alcoholic subjects judged that the "alcoholic's" behavior in the job interview was influenced b y situational, or external, factors, while the - 28 -"non-alcoholic's" behavior was more influenced b y dispositional, or internal, factors. T hus one of the expectations that alcoholics seem to have for the "alcoholic" role is an external locus of control. If an alcoholic sees another alcoholic as being controlled by external factors, wouldn't he have the same "attribution theory" about his own behavior? Personal construct theory would state that a deviant drinker develops a construct system about alcohol dependency, and that this internal psychological process is more important to investigate than the process of physiological addiction. Furthermore, if the "objective" or external models of alcohol dependency represent a psychological difference, then the individual will choose those that have the most psychological meaning. It is a premise of this study that the "disease theory of alcoholism" is so popularly known that the "alcoholic or problem d r i n k e r " distinction does represent a real choice. Persons choosing to construe themselves as "alcoholics" know what they are b u y i n g into. Persons choosing to construe themselves as "problem d r i n k e r s " may not as much know what is being chosen as what is being rejected. One could now ask the question, "What are the d i f f e r i n g implications of the disease theory and the problem d r i n k i n g one, and how might these be translated into what the alcoholic/problem d r i n k e r believes?" Pattison, Sobell and Sobell (1977) identify six premises inherent in the disease theory: 1) Alcoholism is thought of as a distinct entity, a dichotomous choice, i . e . , one has it or one doesn't. - 29 -2) The condition progresses through a series of distinct phases, and is fatal if not arrested. D u r i n g each phase, the alcoholic su f f e r s from characteristic "symptoms", which are decrements in physical and psychosocial functioning. 3) Alcoholics are qualitatively different from non-alcoholics. T h i s difference is often thought of as biological or metabolic, but many believe there is a distinct "alcoholic personality". 4) Alcoholics suffer from i r r e s i s t i b l e cravings, or compulsions, to drink alcohol. 5) Alcoholics suffer from a phenomenon called "loss of control" T h i s means that, having taken the f i r s t alcoholic drink, they are powerless to resist the r e s t . 6) Alcoholism is a permanent and i r r e v e r s i b l e condition. A n alcoholic is spoken of as "arrested" or "recovering", never as "cured". T h i s "remission" requires total and permanent abstinence from alcohol. Sobell and Sobell (1978) and Pattison et al propose the following premises to be consistent with a learned behavior, or environmental model of problem d r i n k i n g : 1) "Alcohol dependence" is a term applied to a variety of behavior patterns associated with problematic use of alcohol. 2) There is no dichotomy between problem d r i n k e r s and others, it is more useful to think of a continuum of alcohol use, ranging from non-problem to problematic. - 30 -3) The development of problematic d r i n k i n g is so variable as to disallow the concept of "progression". 4) Abstinence bears no necessary relation to rehabilitation. 5) Psychological and physical dependence are established, but not related, phenomena. An individual may experience a strong need to drink in some situations, but there is no evidence for "loss of control", "compulsions", or "physical c r a v i n g s " . 6) The problem d r i n k i n g population is multivariant, with more differences than similarities. 7) Alcohol problems are more strongly related to environmental influences than to biological predispositions. 8) Alcohol problems are usually associated with other life problems. For Cahalan (1976) a problem dri n k i n g model also implies description on an environmental level, not a medical one. Rather than a d r u g affecting a biologically predisposed individual, problem d r i n k i n g is conceptualized as the result of a complex interaction between an individual and his/her culture. It follows that the deviant drinkers can also construe their alcohol dependency in one of two ways. Those who perceive themselves as alcoholics may believe they are the helpless victims of a disease process. T h ey may expect to be treated as patients, and by doctors or members of the medical profession. They would believe they could never learn to control their use of alcohol, and would expect to fail if they t r i e d . They might characterize themselves as being "different" from other people, but identify strongly with other alcoholics. They might make statements such as, " A l l of us alcoholics - 31 -are good manipulators". They might not experience guilt o*ver antisocial behavior associated with alcohol impairment. They would expect to be "alcoholics" for the rest of their l i v e s . Problem d r i n k e r s might also choose that label because the characteristics of that model hold more appeal for them than do those of the disease model. They would then see their d r i n k i n g as an excessive, or harmful behavior which produces distressing consequences, and over which they seem to have lost control. They probably see their d r i n k i n g problem as due to personal problems, and would want therapy to address those issues as well as the d r i n k i n g per se. They may experience distress and guilt over d r i n k i n g related antisocial behavior, since our culture deems an individual to be blameworthy if knowledge and volition are present. Control Orientation in Alcohol Dependence If a person perceives a difference between the two models of alcohol dependence, and finds one more meaningful than the other, she/he must do so because one is more compatible with her/his existing beliefs. Perhaps the compatibility lies i n the relationship between specific beliefs about control over one's dependency and generalized expectation of control over the environment. A central difference between the disease model and the problem d r i n k i n g model is the concept of "control". A c c ording to the former model, an alcoholic has no control over his/her condition. It is caused b y an external agent, the alcoholic is said to suffer from a "compulsion" to drink, - 32 -and "loss of control" in stopping. Rehabilitation is not under self c o n t r o l , either; rather one must r e l y on "powerful others". The problem d r i n k i n g model does imply that the drinker has voluntary control (at least potentially so) over initiation and moderation of d r i n k i n g . Rehabilitation is a process of learning and r e i n f o r c i n g this control. Although traditionally "loss of control" over alcohol was thought to be mediated b y physiological variables, the work of Marlatt and others has shown that cognitive factors are more important. That i s , it is the deviant drinker's belief that he/she has consumed alcohol which initiates excessive d r i n k i n g , cravings, aggressive behavior, anxiety reduction .and, even at low doses, decrements in motor and. cognitive behaviors. Therefore, it may be that a person is attracted to the notion that alcohol produces "loss of control" because of a general perception of not being in control of the environment. The concept of "control orientation" as being an important personality trait comes from social learning theory, as described b y Rotter, Chance, and Phares (1972), and b y Phares (1975). In predicting behavior in a given situation, a significant variable is the person's expectation that the behavior will be successful, i . e . , will produce the desired outcome. "Control orientation" is one of the factors that mediate this expectation. A n individual's control orientation, or "locus of control", is somewhere on a continuum from "internal" to "external". Someone with an "internal locus of control" has a high expectancy of control over the environment, i . e . , they believe in response-outcome dependence. A n internal person will attribute success to his/her own efforts or enduring personality - 33 -characteristics. T h i s individual would agree with statements such as, "Life is pretty much what you make of i t . " In contrast, the person with an "external locus of control" has a generalized belief that outcomes are independent of behavior and mainly the result of luck, chance, or the intervention of powerful others. T h i s person would agree with statements such as, "The little guy can have no say in politics these days." Because of the obvious similarity between Rotter's "locus of control" concept and the notion of "loss of control" i n alcohol dependence, the dimension of Internality-Externality has been investigated extensively in this population. The main instrument used has been the Rotter Internal-External Locus of Control Scale (I-E Scale) as described b y Rotter et al (1972, Chap. 4 - 6 ) and Phares (1975, Chap. 4). The scale consists of 29 forced choice items; scoring is in the external direction (see Appendix B ) . Studies comparing locus of control of various groups of deviant drinkers with that of comparison groups have yielded equivocal r e s u l t s . Two reviewers (Rohsenov and O'Leary, 1978; Cox, 1979) agree that the problem with earlier studies lay in the inadequacy of the comparison groups. Alcoholic groups have been compared for externality to college students, c h u r c h members, and ex-alcoholic counsellors, and have been found to be more internal in all cases. However, factors other than alcohol can account for the unexpected direction of the I-E differences, since all of these comparison groups have characteristics which could be associated with an external locus of control. Butts and Chotlos (1973) compared a group of 74 alcoholics in treatment with a group of 68 men of comparable age, education, and socioeconomic class. - 34 -The alcoholic group was found to be significantly more external on the Rotter I-E Scale. T h i s is at variance with results reported b y Donovan and O'Leary (1975). They matched a group of 23 alcoholic patients with other (medical) patients and staff. No significant difference on the I-E Scale was found. S t i l l , the two review articles (Rohsenov et al; Cox) conclude that, i n cases of matched comparison groups, alcoholics do tend to be more externally focused than non-alcoholics. Another explanation for the inconsistent results described above could lie in the characteristics of the alcohol dependent population itself. Perhaps the within group variab i l i t y on control orientation is so large as to obscure differences from other groups. The review b y Rohsenov and O'Leary reported mean I-E scores for 12 studies comparing alcoholics with various control groups. The means range from 4.7 to 8.28 for the alcoholic groups, and from 2.3 to 9.5 for the comparison groups. Thus there is considerable range and overlap, supporting the interpretation of intragroup variance. Therefore, it might be a more useful task to investigate the nature of locus of control within the alcohol dependent population and to ask, "What are the differences between internal and external alcoholics/problem d r i n k e r s ? " In this vein, the study by Dillavou et al described earlier illustrates that it is useful to divide deviant drinkers into "internals" and "externals" at least on the basis of differential response to treatment. The implication here is that pretreatment assessment of locus of control should be one of the determinants of type of treatment. F u r t h e r investigation is needed of the interaction between degree of internality type and success of therapy. - 35 -A study b y Bowen and Twenlow (1978) found that I-E vscores were not related to dropout from treatment. Ninety alcoholic patients at a residential facility offering biofeedback training completed the Rotter I-E Scale, but it was not possible to predict those who left treatment before the end of the six-week period from their scores. T h i s is not p a r t i c u l a r l y s u r p r i s i n g . As the authors admit, internally oriented individuals and externally oriented ones may both leave treatment, but for different reasons. The former may leave because they believe they can control d r i n k i n g without therapeutic intervention. The latter may leave because they feel compelled b y some pressure. The above study, as well as several others, found that degree of internality increased d u r i n g treatment. However, O'Leary, Rohsenov, and Donovan (1976) found that increased internality d u r i n g treatment was associated with greater dropout from the aftercare program. S t i l l , the use of the I-E dimension to predict treatment dropout represents misuse of the construct. The question to be asked i s , "What led to the greater dropout rate from aftercare for those who showed the greatest decrease in I-E scores during treatment?" It may be that the aftercare program had features inconsistent with a perception of internal control, and the internal clients found these features unacceptable and perhaps threatening. Phares (1975) reviews evidence to show that internal individuals often reject information they consider to be "propaganda" . Aftercare programs are often heavily AA oriented, and clients are inundated with information about - 36 -the disease model, which they are told to accept and not question. It seems consistent with Phares' findings to predict that internal clients would f i n d this type of program untenable. Rotter (1975) cautions against the use of a general construct, such as control orientation, to predict behavior in specific, highly familiar situations. In these cases, behavior is more predictable from situational variables, such as reinforcement history for that specific behavior, and from motivation. T h i s line of reasoning has prompted the development of a locus of control scale specifically for d r i n k i n g . The "Drinking Related Locus of Control Scale" (DRIE) measures an individual's perception of control over alcohol. The test format is the same as that of the Rotter I-E Scale, with 25 forced choice items. One choice reflects a belief that it is possible to have self control over d r i n k i n g , while the other choice reflects a belief that d r i n k i n g is under the control of external factors (Donovan and O'Leary, 1978; Oziel, Obitz and Keyson, 1972). A detailed investigation by Donovan and O'Leary does indicate that the DRIE has v a l i d i t y for use with alcohol dependent populations. Alcoholics tested on the DRIE obtained significantly higher, i . e . , more external scores than a matched comparison group. Factor analysis of the scores indicated that the variance was the result of three factors. These were labelled i n t r a -personal control, e.g., control over adverse emotional states; interpersonal control, e.g., control over peer pressure to drink; general control. The fi r s t two factors were found to be the most powerful. - 37 -Changes in Cognitions During Alcohol T h e r a p y x-It has been shown that therapy for alcohol dependence was associated with changes in the underlying cognitive s t r u c t u r e s , although the relationship to outcome was unclear. Heather, Edwards, and Hore (1975) showed that alcoholics changed their construct system related to alcohol dependency dur i n g a 10 to 12 week inpatient treatment program. The measuring instrument used was a form of the r e p e r t o r y g r i d described b y Bannister and Fransella (1971). The elements presented to the subjects consisted of 10 roles relating to self perception and d r i n k i n g . Ten bipolar constructs were elicited b y asking subjects to describe how two roles were similar and also different from a t h i r d . Subjects were then asked to rate each role on each construct, according to a seven point scale. A 10 x 10 gri d was thus generated, a portion of which is illustrated i n F i g u r e 2. Two grids were completed with each of the 40 subjects in the study; one at admission, the other at discharge. Subjects were followed up six months later. The important measure considered was the "psychological distance" between any two roles, i . e . , how similarly they were construed, how this changed d u r i n g therapy, and whether this change was related to outcome. The most significant changes in construing d u r i n g therapy o c c u r r e d in relation to self-perceptions, in that subjects moved to closer identification with socially approved dr i n k i n g roles and f u r t h e r away from socially dis-approved roles. A n overall change factor, which was i n t e r p r e t e d as concern with "deviance over respectability" was related to relapse. Both maximal and minimal change (toward respectability) were pre d i c t i v e of relapse. - 38 -Figure 2 - Portion of Repertory G r i d \ Roles (elements) Constructs Gay/pompous Lives life/misses out Relaxed/anxious - 39 -The relapse rate of the "minimal" change group was not s u r p r i s i n g , since it was related to their perceived social deviancy. That the group which experienced the greatest change in self construction also had a poor prognosis was explained b y their "over identification" with normalcy, and hence a desire to be social d r i n k e r s . Two points about the above study are worth emphasizing: 1) the change in self construction observed to occur d u r i n g therapy cannot be said to be the result of therapy, since there was no control group; 2) the changes in construction of d r i n k i n g related roles were minimal, i.e . , subjects apparently d i d not elaborate their discriminations among constructs related to d r i n k i n g . T h ey appear to have moved from aligning themselves with deviant roles to i d e n t i f y i n g with socially approved roles. T h i s adaptation could be the result of the p a r t i c u l a r therapy program, which appears to have been quite traditional and AA oriented. Summary It seems worthwhile and justified, on the basis of previous research, to investigate alcohol dependence as a cognitive as well as a physiological process. Alcoholics and problem dr i n k e r s are influenced b y their expectations about alcohol as well as b y their self perceptions. There is a large amount of evidence to indicate that deviant d r i n k e r s do not constitute an homogeneous population. One interesting speculation is that a subgrouping could be made on the basis of the nature of their implicit theory about their alcohol dependency. It has been shown that cognitive factors are associated with differential response to therapy, and this could also be the case for alcohol dependency beliefs. - 4 9 -b) eliminate females from the analysis \ c) provide basic demographic data for comparison purposes d) establish d r i n k i n g role preference Two versions of this questionnaire were used; a 10 item one on the pretest and a six item one on the post test. Procedure Al l subjects were tested in groups of v a r y i n g sizes, ranging from about 12 to 30. At facility B, the investigator collected all of the data. At facility A the investigator collected data from one group, and the staff of the facility completed data collection on two other groups. The nature of the study was explained in general terms, and it was stressed that participation was voluntary and confidential. The instructions as described i n Appendix B were then given. Subjects generally completed the questionnaires i n 15 minutes; no one took longer than half an hour. The questionnaires were presented, stapled together, i n one of two orders: 1) Alcohol Beliefs, Locus of Control "Scale, MAST, demographic questions. 2) Locus of Control Scale, Alcohol Beliefs, MAST, demographic questions. These orders were given out randomly, so that about half the subjects completed the Alcohol Beliefs questionnaire and about half did the Locus of Control scale f i r s t . A pilot study was conducted to assess the psychometric soundness of the Alcohol Beliefs questionnaire, while the main study was performed to test the four hypotheses. Data were collected for these two studies i n the following way: 1. Pilot Group: There was a total of 104 men and women in this group. T h i r t y - f i v e of them were tested during the last week of their program. Eleven - 50 -were tested in the middle. These 46 subjects received only one test. F i f t y - n i n e male subjects were tested twice, once at the beginning, and once at the end of their program. Only the scores from the f i r s t session were used in the analyses for the pilot study. 2. Main study: This study was done using the pre and posttest data from the subjects described above. - 51 -C H A P T E R IV. x  R E S U L T S The results are presented in two sections: 1) The results of the psychometric operations performed on the "Beliefs About Alcohol Dependence" questionnaire, and the resu l t i n g decisions made. 2) The results of the study pertaining to the four hypotheses under investigation. A l l statistical analyses were done by computer, using the "Statistical Programs for the Social Sciences" package (SPSS). A l l calculations were rounded off to two decimal points; percentage figures were rounded off to the nearest whole number. 1. Beliefs About Alcohol Dependence Questionnaire These results were based on a sample of 104 people, six women and 98 men, from the two treatment facilities. These subjects were tested at various points in their treatment program; 59 completed at the beginning, 11 in the middle, and 34 in the final week. Appendix C (1) contains a description of how the sample answered the MAST and the demographic questions. The average client can be described as male, 37 years old, with an income of about $25,000 a year. He considers his d r i n k i n g to have been a problem for about 11 years, and scores in the expected range for alcoholics in the MAST. He is not a regular AA attender and prefers the label "alcoholic" rather than "problem d r i n k e r " to describe his d r i n k i n g role. The "Beliefs" questionnaire was assessed on re l i a b i l i t y and val i d i t y c r i t e r i a . - 52 -Nunnally (1978) writes that the most cr i t i c a l measure of rel i a b i l i t y for a new test is its internal consistency, which can be represented b y measuring how well the items correlate with each other. A high level of internal consistency indicates that the test items come from the same population and that respondents are answering on a similar basis, i.e., a high level internal consistency thus means low levels of internal and external sources of measurement e r r o r . The measure of internal consistency used i n this study was the K-R 20 version of coefficient alpha, as computed by the SPSS version 8 program, "Reliability" (K-R is the model for point-biserial data) . The 40 item Belief About Alcohol Dependence questionnaire was scored as two separate subscales, a 20 item "Disease" scale and a 20 item "Behavior" scale. The initial r u n on the computer program produced alphas of a=.58 for the Disease, and a=.47 for the Behavior scales, respectively. These scores are below acceptable levels, according to Nunnally, since he advises that other r e l i a b i l i t y coefficients are usually lower. Therefore, a number of measures were considered as c r i t e r i a for retaining reliable test items. Each individual item was considered in terms of its mean score, standard deviation, d i s t r i b u t i o n , and item-total correlation. These data are presented in Appendix D ( l ) , and are more accurately described below: Mean Score: "True" responses were encoded "1". "False" responses were encoded "0". The possible range of mean scores is 0 - 1. Standard Deviations: Range 0 - 1 . F r e q u e n c y Dis t r i b u t i o n : The percentage of time an item was responded to as true or false. - 53 -Item-total Correlation: Expressed as a point biserial coefficient, the probable level of each coefficient's chance occurrence was also determined (Glass and Stanley, 1970). The item-total correlation is a measure of consistency between a response on a particular item and the total score. As such, it is an important criterion for item selection. Nunnally states that an item-total correlation which has a 10% or less probability of o c c u r r i n g b y chance is acceptable in an exploratory study. For this sample size, according to Glass and Stanley, an item-total correlation of r =.16 is significant at p =.10. Fifteen disease items and 11 behavior items met this c r i t e r i o n . Of these 26 items, five had less than optimal frequency distributions and standard deviations. These five were answered as either true or false more than 80% of the time, and had Sd's below .40, which would lead to these items having poor discriminating power. A l l 26 items are contained in Table 1. Several tests of validity were applied to the Beliefs questionnaire. According to the rationale upon which it was constructed.,- this scale consists of two different sub tests which should be negatively correlated. That i s , people who adhere to disease beliefs should tend to disavow behavior beliefs. Table 3 contains the mean scores and standard deviations obtained by the total sample on each subscale. A " t " test for correlated samples indicated a significant difference between the means (t=8. 20,p<. 01). Behaviorally oriented beliefs were far more popular than disease ones. As predicted, there was a significant negative correlation between the two subscales (Pearson product-moment r=-.31, p<.01). Thus, the stronger the expressed adherence to behavioral - 54 -T A B L E 1 x "Alcohol Beliefs" Items which Met Item-total C r i t e r i o n Disease Items D--1 A person like me can never learn to drink socially. D--3 I feel I am different from non-alcoholics. D--4 I cannot feel good unless I am d r i n k i n g . D--6 The saying, "One drink, one drunk" applies to me totally. D--7 Maintaining sobriety is my chief g b a l i n l i f e . D-•8 My d r i n k i n g problem can best be described as a disease. D-•9 Only another alcoholic can really understand what I am going through. D-•10 We alcoholics metabolize alcohol differently than others do. D-•12 Staying sober is largely a matter of luck and getting the r i g h t breaks. D- 13 I feel powerless to control my d r i n k i n g . D- 15 I am sometimes forced into d r i n k i n g by circumstances beyond my control. D- 16 Alcoholics like me are born, not made. D- 17 Being an alcoholic is just something I'll have to live with the rest of my life D- 18 We alcoholics are sick people and should be treated as such. D- 19 I believe I was born with an addiction-prone personality. Behavior items B-2 With the proper help, I could learn to drink socially. B-3 There are just as many differences between me and the next alcoholic as there are between me and the next non-alcoholic. B-4 There is no such thing as an overpowering desire for alcohol, I know I just choose to give i n . - 55 -B-6 My alcohol addiction is not the result of a physi c a l difference. B-9 I don't think I have to be an alcoholic for the rest of ^ ny l i f e . B - l l I think a program of learning controlled d r i n k i n g would be more effective for me than taking antabuse. B-12 I often blame myself for not learning better self control when it comes to d r i n k i n g . B-13 Alcoholics like me are made, not born. B-14 It's no good saying other people force you to dr i n k , I know only I can decide when and how much to dr i n k . B-16 Sometimes I feel v e r y guilty over my lack of self control over alcohol. B-18 In this day and age anyone could become an alcoholic like I did. - 56 -T A B L E 2 "Alcohol Beliefs" Items which Discriminated Between  Alcoholics and Problem D r i n k e r s Disease Items D - l A person like me can never learn to d r i n k socially. D-6 The saying, "One drink, one drunk" applies to me totally. D-7 Maintaining sobriety is my chief goal in l i f e . D-8 My d r i n k i n g problem can best be described as a disease. D - l l Often, other people drive you to d r i n k . D-13 I feel powerless to control my d r i n k i n g . D-17 Being an alcoholic is just something I'll have to live with the rest of my l i f e . Behavior Items B-2 With the proper help, I could learn to drink socially. B-5 My d r i n k i n g problem is due to a social cause, such as family u p b r i n g i n g . B-9 I don't think I have to be an alcoholic for the rest of my l i f e . B - l l I think a program of learning controlled d r i n k i n g would be more effective for me than taking Antabuse. B-19 T h e r a p y for my other personal problems is probably just as important as learning to control my d r i n k i n g . - 57 -T A B L E 3 Mean Score and Standard Deviations Obtained b y TotaKSample on Alcohol Beliefs Scale Disease Items Behavior Items n x Sd x Sd " t " 1 r 104 9.19 2.88 12.75 2.59 8.20* -.31* * p<-01 1 A l l " t " tests were two-tailed - 58 -beliefs, the weaker the adherence to disease beliefs. Scores on the behavior items accounted for 9.61% of the variance i n disease scores. The "Alcohol Beliefs" questionnaire should also discriminate between self-defined alcoholics and self-defined problem d r i n k e r s . Therefore, the sample of 104 was divided into two groups on the basis of their stated preference in d r i n k i n g role. T h i s yielded 72 "alcoholics" and 32 "problem d r i n k e r s " . Table 4 contains the mean sub test scores and standard deviations obtained b y these two groups on the "Alcohol Beliefs" test. "T" tests for independent samples indicated that the alcoholics' mean disease score was significantly higher than that of the problem d r i n k e r s (t = 2.67; p <.01) . The " t " test also showed that the problem d r i n k e r s scored significantly above the alcoholics on behavioral items (t = 2.81; p <.01). In terms of total sub scale scores, therefore, the Beliefs About Alcohol Dependence test discriminated between self-defined alcoholics and problem d r i n k e r s . Individual test items should also be v a l i d , i . e . , they should discriminate between alcoholics and problem d r i n k e r s . Thus, the mean scores for both groups on each individual item were computed. Mean scores and standard deviations for each test' item in both the behavioral and the disease sub scales are presented separately for each group i n Appendix E. Mean scores for alcoholics and problem drinkers on each test item were compared usi n g a " t " test for independent samples. A criterion level of p = .10 was again used i n determining which means were significantly different. A c c ording to this c r i t e r i o n seven disease items and five behavioral ones discriminated between - 59 -..TABLE 4 \. Mean Scores and Standard Deviations Obtained b y  Alcoholics and Problem D r i n k e r s on Alcohol Beliefs Scale Group Disease Behavior n X Sd x Sd Alcoholics 72 9.69 2.72 12 .26 2.37 Problem Drinkers 32 8.06 2.90 13 .84 2.76 1 t = 2. .67* t : = 2. 81* * p <01 1 A l l " t " tests were two-tailed - 60 -alcoholics and problem d r i n k e r s . These 12 items are described in Table 4. B y chance, one would expect two discriminant items out of 20 at the 10% le v e l . Therefore, obtaining seven out of 20 for the disease scale and five out of 20 for the behavior scale exceeds the chance expectation. It was decided to use the "item-total correlation" as the single criterion for item selection in the "Alcohol Beliefs" questionnaire. Item-total correlations significant at the 10% level are described b y Nunnally as sufficient i n an in i t i a l , exploratory study for selecting test items. T h i s procedure yielded 26 items for analysis, a 15 item disease scale, and an 11 item behavior scale. Five items of the 26 selected did not have optimum standard deviations and frequency d i s t r i b u t i o n . However, this may have resu l t e d i n part from the discrepancy i n the size of the two groups, i.e. , there were twice as many alcoholics as problem drinkers.n If these numbers were equalized, perhaps responses to these items would be more equally d i s t r i b u t e d . There are three test items which discriminated between alcoholics and problem d r i n k e r s , but d i d not meet the item-total correlation c r i t e r i o n , and they were thus excluded. Of these, item D - l l in fact could be r e g a r d e d as a behavioral item, since it was agreed to significantly more often b y the problem d r i n k e r s than the alcoholics. Item B-5 was excluded because the obtained item-total correlation was negative, although significant (r = - .18, p = .10). Thus, while problem d r i n k e r s agreed with this statement and alcoholics disagreed, they d i d so according to a different basis from which they answered the rest of the test. The t h i r d item, D-19, obtained an item-total correlation which approached significance (r = .11; where r = .16, p = .10). - 61 -The SPSS (version 8) program "Reliability" was again used to compute the internal consistency of the 26 item Alcohol Beliefs test. The analysis was done separately for the 15 item disease scale and the 11 item behavior scale. Appendix D (2) presents the item-total correlation of each item, the overall subscale alpha and, for each item, the total subscale alpha if that item were deleted. As can be seen, the overall internal consistency is improved considerably over the 40 item test, p a r t i c u l a r l y for the behavior scale (26 item behavior a=.62, disease ct=.60). Nunnally indicates that, depending on test usage, alphas of .70 or .80 are desirable, but it was felt the obtained scores made the instrument acceptable for use in an exploratory study. A c c o r d i n g to the revised "Reliability" program, three of the 26 items di d not meet the established item-total c r i t e r i a , i . e . , they were below r =.16, p =.10. As can be seen from the table in Appendix D (2), the deletion of these items would not result in any discernible improvement in the overall internal consistency of the test. Two items, if deleted, would not affect the alpha at all, while the deletion of the t h i r d would improve the internal consistency b y a=.01. These items were therefore retained. 2. Results of the Main Study These results were based on a sample of 59 men who completed their four week treatment program and were given a pretest and a posttest. Demographic characteristics of this sample are described in Appendix C (2). The samples for the two treatment centres are described separately. On all - 62 -but one of the variables there was no noticeable difference between these two groups. Th i s sample does not appear different from the sample of 104 subjects used i n the pilot study, and the description applied to those subjects appears valid for the smaller as well. There was a difference between facilities A and B in stated d r i n k i n g role preference. Subjects from the former group b y far p r e f e r r e d the "alcoholic" label (69% of the time) to the "problem d r i n k e r " label (31%). Subjects from the latter group chose both labels equally often. The reasons for this difference were not investigated, but the discrepancy may have influenced some of the resu l t s , as will be discussed later. The sample was fu r t h e r compared b y div i d i n g subjects into self-defined alcoholics and problem d r i n k e r s . Appendix C(3) compares these two groups on the demographic variables, age, income, problem h i s t o r y , MAST scores, and AA involvement. "T" tests for independent samples were performed to compare the mean scores for the two groups on all of these variables. Two "t " values approached significance, indicating that on two independent variables the two groups may have come from different populations. Problem drinkers tended to be younger (t = 1.93; p = .06) and reported a shorter problem his t o r y (t = 1.92; p = .06) than the alcoholics. The two variables could be related, since younger people may have been d r i n k i n g for a shorter period of time. It is interesting to note, however, that the severity of alcohol problems, as measured b y the M A S T v was not different for the two groups. - 63 -T A B L E 5 V Mean Scores of Alcoholics and Problem D r i n k e r s on the Behavior Sub Scale Pretest Posttest Group n x Sd x Sd 111" Alcoholics 37 7.54 1.77 7.14 1.64 1.59 Problem Dr i n k e r s 32 8.59 2.11 8.18 1.50 .96 1 t .1.96* 2.50** * p <. 10 ** p<.05 1 A l l " t " tests were two-tailed - 64 -T A B L E 6 \ Mean Scores of Alcoholics and Problem Dr i n k e r s on the Disease Sub Scale Pretest Posttest Group n x Sd x Sd " t " Alcoholics 37 9.05 2.54 7.43 1.97 1.87* Problem Drinkers 22 5.96 2.65 5.77 2.72 .34 i t 2.99*** 2.50** * p<.10 ** p <.05 *** p <.01 1 A l l " t " tests were two-tailed - 65 -Hypothesis I: Self-defined problem dr i n k e r s will score higher than self-defined alcoholics on the behavioral items of the Beliefs About Alcohol  Dependence questionnaire. Alcoholics will score higher on the disease items of this questionnaire. The mean scores and standard deviations obtained b y both alcoholics and problem d r i n k e r s on the behavioral items of the "Alcohol Beliefs" test are described i n Table 5. Both pretest and posttest scores are given. "T" tests for independent sample were done to compare mean scores, p r e and post:for both groups. On the pretest, the difference between the alcoholics' mean score and that of the problem drinkers approached significance (t = 1.96; p = .06). On the posttest. the difference between the two groups was significant (t = -2.50; p = .02). In terms of absolute differences, the alcoholics scored an average of one test item below the problem d r i n k e r s on both pretest and posttest. However, the behavior sub scale contained only 11 items, and the mean difference between the two groups was consistent enough to reach statistical significance. Scores obtained b y alcoholics and problem d r i n k e r s on the pretest and posttest of the disease items are reported in Table 6. The disease sub scale contained 15 items, and the differences between groups are larger than those obtained on the behavior sub scale. On the pretest, the mean difference between the two groups would have oc c u r r e d by chance less than one in 100 times (t = 2.99; p = .005). Alcoholics scored, on the average, about three items above the problem d r i n k e r s on the pretest, and almost two items higher on the posttest (t = 2.50; p = .02). There would appear to be a clearer distinction between alcoholics and - 66 -problem d r i n k e r s on the disease items than there is on the behavior items. Hypothesis II: Self-defined problem d r i n k e r s will score significantly below self-defined alcoholics on the Rotter Locus of Control Scale, indicating a greater degree of inte r n a l i t y for problem d r i n k e r s . Mean scores on pretest and posttest of the Rotter Scale for alcoholics and problem d r i n k e r s are reported in> Table 7. "T" tests for independent samples were performed to compare the two groups on both the pretest and the posttest. On the pretest, alcoholics scored s i g n i f i c a n t l y below the problem dr i n k e r s (t = 2.23; p = .03). On the posttest the difference between the means was also significant (t = 2.80; p = .01). Thus, i n fact, the results were opposite to those predicted, i . e . , alcoholics showed a much greater degree of internality than d i d problem d r i n k e r s . Part of the rationale for investigating locus of control scores for deviant d r i n k e r s was that it was assumed that there was a relationship between specific beliefs about alcohol dependence and general beliefs about control over response-outcome contingencies. Thus, there should be correlations among the three independent variables, d r i n k i n g role preference, alcohol beliefs, and locus of control. T h i s proved not to be the case, as is illust r a t e d b y Table 8.. Locus of control scores d i d not correlate significantly with either disease belief items or behavior belief items on the Beliefs About  Alcohol Dependence questionnaire. Tests of correlation were performed between total locus of control scores and total belief scores, for pretest and posttest data, and separately for each fa c i l i t y . The same operations were performed to correlate locus of control scores and behavioral scores. The - 67 -Pearson product-moment correlation test for continuous data"- was used in all instances. None of the chance probabilities associated with any of the correlations in Table 8 reached significance at the 10% l e v e l . Thus the relationship diagrammed in Figure 1, Chapter III, is more correctly represented b y Figure 1 in this chapter. While d r i n k i n g role preference was related to alcohol beliefs and locus of control, the latter two variables were not related to each other. Hypothesis III. Both alcoholics and problem d r i n k e r s will show significant increases in behavior beliefs d u r i n g the treatment program, as measured by the Beliefs About Alcohol Dependence questionnaire. There will be minimal or negative change in the disease beliefs as measured by the same questionnaire. Pretest and posttest scores for both groups were compared usi n g a " t " test for correlated samples. Table 5 describes the results for the behavior belief items. Neither alcoholics nor problem d r i n k e r s showed any significant change from pre to posttesting (alcoholics, t = 1.59; problem d r i n k e r s , t = .96). Table 6 describes the results of " t " tests performed on pretest and posttest means for the disease belief items. The problem d r i n k e r s showed no significant change (t = .34). The difference in mean scores for the alcoholics' group approached significance (t = 1.87; p = .07). Thus, the alcoholics tended to decrease their preference for disease oriented beliefs about alcohol dependence d u r i n g treatment. The changes i n behavior beliefs d u r i n g treatment are illustrated graphically in Figure 2, while Figure 3 illustrates changes in disease beliefs. In summary, v e r y little support was found for the t h i r d hypothesis. - 68 -T A B L E 7 Means and Standard Deviations of Locus of Control Scores for Alcoholics and Problem Drinkers Pretest Posttest Group n x Sd x Sd t Alcoholics 36 1 5.89 3.77 3.25 3.03 4.89** Problem Drinkers 22 8.41 4.39 6.09 4.11 4.46** t = 2.23* t = 2.80** * p S . 0 5 ** p6 .01 Note: A l l " t " tests were two-tailed 1 Scores for one subject were not usable. - 69 -T A B L E 8 Correlations Between Locus of Control Scores \ and Disease Belief Scores, and Between Locus of Control Scores and Behavior Beliefs Scores Disease Beliefs Behavior Beliefs Fac i l i t y Pretest Posttest A r = .05 r = .03 Pretest Posttest r = .20 r = .12 - 70 -F IGURE 1 Schematic Representation of Relationship Among- Drinki n g Role, Beliefs About Alcohol, and Locus of Control 1. D r i n k i n g Role Preference 2. Beliefs About Alcohol Dependence 3. Locus of Control g Commonality - 71 -FIGURE 2 Changes in Behavior Belief During Treatment IX O o 10 8 6 4 2 0 .» Problem D r i n k e r s Alcoholics x x Pre Post FIGURE 3 Changes in Disease Beliefs During Treatment ix o o 10 2 0 x Alcoholics Problem D r i n k e r s x Pre Post - 72 -Behavioral beliefs did not change for either group. There was a minimally significant decrease in disease beliefs for the self-defined alcoholics, but this was not the case for the problem d r i n k e r s . Reasons for these results will be discussed in Chapter V. Hypothesis IV. Both alcoholics and problem d r i n k e r s will show significant increases in internality d u r i n g treatment, as measured by the Rotter Locus of Control Scale. The fourth hypothesis was supported: both groups became significantly more internally oriented during treatment. Table 7 describes the mean scores and standard deviations on pretest and posttest locus of control scores, for both alcoholics and problem dr i n k e r s . The changes in mean scores on pretests and posttests are illustrated graphically in F i g u r e 4. (Note that on the Rotter test, lower scores indicate an internal locus of control, higher scores are indicative of an external locus.) "T" tests for correlated samples were performed to compare pretest and posttest means for both groups. The differences in pretest and posttest scores were hig h l y significant for both alcoholics (t = 4.89, p <.001) and problem d r i n k e r s (t = 4.46, p < .001). The mean locus of control scores obtained b y both groups on the pretest are similar to scores reported for deviant d r i n k e r s elsewhere (Rohsenov and O'Leary, 1978) . The mean score of the problem d r i n k e r s on the posttest is also within that range (8.28 - 4.70). However, the alcoholics' mean posttest score (x = 3.25) seems unusually low. To investigate further the relative effects of d r i n k i n g role preference and treatment location on locus of control scores, two analyses of variance were performed, one on the pretest data, and one on the posttest. Tables - 73 -9 and 10 present the results of these analyses. The ANOVA on the pretest scores indicated a significant main effect for d r i n k i n g role preference. Alcoholics as a group were significantly more internal than problem d r i n k e r s , regardless of which treatment centre they came from. The differences between the two drinker groups was significant at the 4% level, which was consistent with the " t " test results described in Table 7. There was no effect for treatment centre, and no interactive effect. Thus, on day one alcoholics at facilities A and B had significantly lower scores (n = 26, x = 5.73, and n = 10, x = 6.0) than problem d r i n k e r s at facilities A and B (n = 12, x = 7.75, and n = 12, x = 9.2 r e s p e c t i v e l y ) . On the posttest ANOVA, both main effects were significant at the 1% l e v e l . Clients from facility A scored significantly below clients from facility B, indicating the former groups were more internal . Alcoholics were significantly more internal than problem d r i n k e r s , as had been the case on the pretest. There was no interactive effect between the two variables. Thus, the most internal group were the alcoholics at facility A (n = 26, *x = 2..58) . The most external group were the problem drinkers: at facility B (n = 10, x = 7.9). The mean score of the problem d r i n k e r s at facility A was almost the same as that of the alcoholics at facility B (n = 12, "x = 4.58, and n = 10, x = 5.00 r e s p e c t i v e l y ) . It is of interest to note the differences between the explained amounts of variance on the two ANOVAs. On the pretest ANOVA, the amount of variance explained b y the two independent variables was not significant when compared to the amount of err o r variance. However, on the posttest scores the two independent variables do account for a significant amount of the variance in scores. It could be concluded that, after treatment, clients become a more - 74 -homogeneous group with respect to how they scored on the locus of co n t r o l . t e s t . • V ' The change i n I-E scores d u r i n g treatment does i n p a r t seem to be a s p e c i f i c treatment effect r a t h e r than due to n o n s p e c i f i c f a c t o r s , s u c h as general h e a l t h . T h i s conclusion was reached b y examining the d i f f e r e n c e s between treatment c e n t r e s . While there was no d i f f e r e n c e i n I-E scores between f a c i l i t y A and f a c i l i t y B on the p r e t e s t , there was su c h a d i f f e r e n c e on the p o s t t e s t . T h u s , the dif f e r e n c e between the two c e n t r e s , i n favour of great e r i n t e r n a l i t y f or f a c i l i t y A cli e n t s on the p o s t t e s t , can be s a i d to r e s u l t from a treatment effect. - 75 -FIGURE 4  Changes in Locus of Control Score,  B y Treatment Location and D r i n k i n g Role Preference Legend: Facility B alcoholics -# Facility B problem drinkers Facility A alcoholics _^ Facility A problem drinkers - 76 -T A B L E 9 v ANOVA Results for Locus of Control Scores (Pretest) Source of Variation Sum of Squares DF Mean Square F Main effect 98.13 2 49.06 2.98 Treatment Cen. 11.70 1 11.40 .69 Dri n k i n g Role 73.12 1 73.12 4.44: Interaction T-centre x d r i n k e r 2.41 1 2.41 .15 Explained 100.54 3 33.51 2.03 Residual 889.059 54 16.46 Total 989.597 57 17.36 p = < . 10 p = < .05 - 77 -T A B L E 10 ANOVA Results for Locus of Control Scores (Posttest) Source of Variation Sum of Squares DF Mean Square Main effect 210.13 Treatment Cen. 99.92 D r i n k i n g Role 72.62 Interaction T-centre x drinker 2.48 Explained 212.61 Residual 576.16 Total 788.77 2 1 1 1 3 54 57 105.07 9.85* 99.92 .9.37* 72.62 6.81* 2.48 70.87 10.67 13.83 .23 6.64* * p <.01 - 78 -C H A P T E R V  DISCUSSION This study was undertaken to investigate whether different beliefs about alcohol dependency exist within an addicted population, and what some of the parameters of those differences may be. While some significant results were found, their interpretation and significance is limited b y factors peculiar to this study. In this section, the meaning of the results, as well as their limitations, are discussed. Differences Between Alcoholics and Problem Dr i n k e r s Twelve items on the Beliefs About Alcohol Dependence questionnaire clearly discriminated self-confessed alcoholics from problem d r i n k e r s . Alcoholics indicated that they believed they have an i r r e v e r s i b l e disease, that they have no control over their d r i n k i n g , and that their only choice is abstinence. Taken together, these statements seem to fit with the disease theory implications, p a r t i c u l a r l y as regards "loss of control" and a disease process. In comparison, problem d r i n k e r s had a less i r r e v e r s i b l e view of their dependency. They believed their d r i n k i n g problems were learned behaviors, related to other personal problems, and saw social d r i n k i n g as an alternative. Perhaps the tendency to "behavioral v e r s u s disease oriented" views of their problems is illustrated by the pattern of responding on item D - l l . Although constructed as a disease item, problem d r i n k e r s more often agreed with the statement, "Often, other people drive you to drink." Since alcoholics believe that it is the disease that "causes" their d r i n k i n g , they would not blame other people. The higher endorsement of this item by the problem d r i n k e r s - 79 -is consistent with an environmental view of alcohol dependency. There were fifteen test items that d i d not discriminate between the two groups. Alcoholics and problem drinkers agreed that the initiation of d r i n k i n g is l a r g e l y a matter of personal choice and r e s p o n s i b i l i t y . Both groups indicated that they experience guilt over poor self control, but they also felt alcohol dependency could happen to anyone, and that it is not an inherited condition. On other items, both groups were concerned with perceived differences from non-alcoholics. Alcoholics achieved higher total disease belief scores than d i d problem d r i n k e r s . The latter obtained higher behavioral scores. These differences, although statistically significant and in the predicted direction, were of small magnitude. It appears that, while there are differences among deviant d r i n k e r s , the belief systems involved are complex and multivariant, and perhaps the p r e f e r r e d role label is only one factor in these differences. The Complexity of Control The conclusion that the belief systems of alcohol dependent persons are multivariant is perhaps best illustrated by a discussion of the concept of "control". Control, both in the sense of specific beliefs about control over d r i n k i n g behavior, and i n the sense of general beliefs about control over the environment, is a complex issue. Alcoholics, i . e . , those who believe they have a disease with associated loss of control over d r i n k i n g , also perceived themselves to be in control of other spheres of their l i v e s . In comparison with problem d r i n k e r s , alcoholics scored significantly more toward the internal extreme of the Rotter Locus of Control test. In fact, - 80 -their scores seemed extreme when compared with other reference groups as well. It may be that the alcoholics are overcompensating for their perceived difficulties with alcohol. Construing all the unmanageable parts of their lives as part of a disease process leaves them free to expect that they are in control of e v e r y t h i n g else. It is as if they say to themselves, "Once this alcoholism is cured, the rest of my! life will be under my own control." It seems that this construction of the meaning of control would have functional value to the individual, because it allows the maintenance of self esteem, some reduction in guilt, and the possibility for change to a less troublesome l i f e . The compensatory explanation could account for the apparent discrepancy between the alcoholics' belief that they control the initiation of d r i n k i n g , but that they have no control over the amount drunk. Thus, the disease "takes over" after d r i n k i n g has begun, but the person is stil l i n charge up to that point. T h i s line of reasoning is congruent with the AA folklore, which teaches that the alcoholic chooses the fi r s t drink, but suffers from "loss of control" after that. It is also an important rationale for the belief that abstinence is necessary. Thus, this study indicates that some deviant drinkers do indeed have a hig h l y polarized construct with respect to expectations about control over alcohol. There is still a sizeable group of deviant d r i n k e r s for whom the control construct is not as clearly crystallized. In this study they were those clients who p r e f e r r e d the role label "problem d r i n k e r " to describe their dependency. T h e y were not as clear about what part of the d r i n k i n g process was under their control, and their general expectation about their ability to control their - 81 -l i v e s r a n g e d from low to average. It i s i n t e r e s t i n g to note that the average age and l e n g t h of problem h i s t o r y r e p o r t e d b y t h i s group, was lower than that r e p o r t e d b y the alcoholics, although the s e v e r i t y of alcohol involvement was the same. T h i s may lead one to suspect that i t i s l e n g t h of e x p o s u r e to the disease model which produces the adherence to i t s views. Changes D u r i n g Treatment Spe c i f i c b e l i e f s about alcohol dependency d i d not change d u r i n g the treatment program, while general b e l i e f s about c o n t r o l d i d . Two f a c t o r s may have c o n t r i b u t e d to t h i s f i n d i n g : the limitations of the "Alcohol B e l i e f s " t e s t , and the nature of the treatment programs themselves. Based on the invest i g a t o r ' s personal e x p e r i e n c e , as well as on examination of the l i t e r a t u r e p r o v i d e d , i t seems that the programs may of f e r more education i n s e l f c o n t r o l t h a n i n models of alcohol dependence. T h i s seems p a r t i c u l a r l y t r u e of the program at F a c i l i t y A, which also had the hi 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 . The program at t h i s treatment centre appears to place a major emphasis on the in d i v i d u a l ' s a b i l i t y to make choices and to accept r e s p o n s i b i l i t y f o r those choices. Limitations Generalizations about the r e s u l t s of t h i s s t u d y are limit e d b y the n a t u r e of the sample used and b y the psychometric soundness of the "Alcohol B e l i e f s " q u e s t i o n n a i r e . Alcohol treatment c e n t r e s tend to v a r y widely i n the n a t u r e of the programs they o f f e r , and with r e s p e c t to the t y p e of c l i e n t s t h e y admit. T h e r e f o r e , both the pre and post treatment d i f f e r e n c e s o b s e r v e d may not have o c c u r r e d with a d i f f e r e n t sample of treatment c e n t r e s . The s t u d y d i d not - 82 -consider women subjects, or drop outs from treatment, except on the pilot study. L a s t l y , the majority of clients in the sample were i n the moderate to severe range of alcohol dependence, and the results may have been different had a more mildly involved population been tested. For example, it would be interesting to assess the alcohol dependence beliefs of a sample of clients at an outpatient facility o ffering a controlled d r i n k i n g program. Although some attempts were made to establish v a l i d i t y and reliability for the Beliefs About Alcohol Dependence questionnaire, this test can only be considered an exploratory one at this stage. This limitation could have contributed to the small magnitude of the differences found, both between the alcoholics and problem drinkers groups, as well as to the lack of significant pre/post treatment differences. Therefore, although this questionnaire points to the possibility that some interesting differences exist, it needs f u r t h e r develop-ment before it would be useful in either research or clinical settings. Implications for Future Study The re s u l t s of the present study add to the empirical knowledge base about the belief systems involved in alcohol dependence, but the clinical implications need to be investigated experimentally. T h i s future research would be a two stage process, consisting of refinement of the measuring instrument, and hypothesis investigation. To develop a questionnaire that is valid in assessing self perceptions related to alcohol dependence, a rigorous psychometric process needs to be followed. A large pool of test items needs to be developed, and piloted on a large sample of alcohol dependent populations. A wide range of reliability - 83 -and validity c r i t e r i a needs to be applied to the items, • and appropriate test items selected for the final scale. T h i s scale would then be f u r t h e r tested on a sample population, to determine normative scoring patterns. The results would also be factor analyzed to determine whether there is a statistical basis for grouping clusters,of items. These groups of items and the r e s u l t i n g "factors" would then describe the main constructs of the belief systems that deviant d r i n k e r s have about their alcohol dependency. The second stage would involve experimental manipulation of clinical behaviors. The test would be used to divide an appropriately selected alcohol dependent sample into two groups, those who have a disease oriented view of their dependency and those who have a behaviorally oriented view. Half of each group would be randomly assigned to a therapeutic program congruent with their beliefs, while half would be assigned to an incongruent program. Outcomes for all four groups would be compared to determine whether belief systems are an important determinant of treatment effectiveness. A post treatment measure would also include possible changes in belief systems, and a possible treatment/belief interaction. Summary This study suggests that the alcohol dependent population is heterogeneous with respect to what they believe about their addiction. F u r t h e r research is needed to investigate the clinical usefullness of this f i n d i n g . C u r r e n t research i n the addictions field seems to be increasingly focussed on the relationship between clients' beliefs and treatment fit (e.g., Gossop, Eiser, and Ward, 1982; Lyons, Welte, Brown, Sokolow, and Hynes, 1982). Hopefully, all - 84 -these investigations will contribute to the development of improved assessment techniques for clients with alcohol and drug problems. - 85 -BIBLIOGRAPHY v. Alcoholics Anonymous. New York: Works Publishing, 1939. Alden, L y n n . Prevention strategies in alcohol abuse, IN Davidson, P.O., and Davidson, S. (eds.), Behavioral Medicine: Changing Health  L i f e s t y l e s . New York : Brunner/Mazel, 1980. Bannister, D. and Fransella, F. Inquiring man: a theory of personal  constructs. London: Penguin Press, 1971. Borg, W.R. and Gall, M.D. Educational Research. New York: Longman, Inc., 1979. Bowen, W.T. and Twenlow, W. Locus of control and treatment dropout in alcoholic population, B r i t i s h Journal of Addiction. 1978, 73, 51 - 54. Butts, S.V. and Chotlos, J . A comparison of alcoholics and non-alcoholics on perceived locus of control, Quarterly Journal of Studies on Alcohol, 1973, 34, 1327 - 1332. Cahalan, D. Problem Drinkers (2nd ed.). 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I'll Quit Tomorrow. New York: Harper and Row, 1973. Kell er, M. The oddities of alcoholics, IN Pattison, E.M., Sobell, M., and Sobell, L. Emerging Concepts of Alcohol Dependence. New York: Springer, 1977. \ Kelly, G. The Psychology of Personal Constructs. New York: Norton, 1955.. Lef court, H.M. Locus of Control: C u r r e n t T r e n d s i n T h e o r y and Research. New York: John Wiley and Sons, 1976. Lyons, J.P., Welte, J.W., Brown, J . Sokolow, L., and Hynes, G. Variation in treatment outcome: differential impact upon specific subpopulations, Alcoholism Clinical and Experimental Research, 1982, 6^.333 - 343. MacAndrews, C. A retrospective study of drunkenness-associated changes in the self-depictions of a large sample of male out-patient alcoholics, Addictive Behaviors, 1979, 4^_ 373, 381. McClelland, D . C , Davis, W.N., Kalin, R., and Wanner, E. The D r i n k i n g Man. New York: Free Press, 1972. Maltby, K. 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Pacifica, a residential treatment facility, brochure available from 811 Royal Avenue, New Westminster, B.C. Paredes, A. The history and concept of alcoholism, IN T a r t e r and Sugerman (eds.), Alcoholism: Interdisciplinary Approaches to an E n d u r i n g Problem. Reading, Mass.: Addison-Wesley, 1976. Paredes, A., Gregory, D., and Rundell, O.H. Empirical analysis of alcoholism services delivery systems, IN Y. Israel et al (eds), Research Advances in Alcohol and Drug Problems, v.6... New York: Plenum Press, 1981. Pattison, E.M., Sobell, M. and Sobell, L. Emerging Concepts of Alcohol  Dependence. New York: Springer, 1977. Pendery,. M., Maltzmann, I., and West, J. Controlled d r i n k i n g b y alcoholics? Science, July/ 1982. Phares, E . J . Locus of Control i n Personality. Morristown, N.J.: General Lea r n i n g Press, 1975. Pokorny, A.D., Miller, B.A. and Kaplan, M.B. The b r i e f MAST: a shortened version of the Michigan Alcoholism Screening Test, American Journal  of P s y c h i a t r y , 1972, 129, 118 - 121. Pomerleau, O., Pertshuk, M., and Stinnett, J. A c r i t i c a l examination of some c u r r e n t assumptions i n the treatment of alcoholism, Journal of Studies on Alcoholism, 1976, 37^ 849 - 867. Rebuta-Burditt, J . The Cracker Factory, New York: Bantam Books, 1977. - 89 -Richard, P. and Bur l e y , P. Alcoholics' beliefs about and attitudes to controlled d r i n k i n g and total abstinence, Journal of Social and Clinical Psychology, 1978, 17, 159 - 163. Rohsenov, D.J. and O'Leary, M.R. Locus of control research on alcoholic populations: a review , International Journal of the Addictions, 1978, 13, (1), 55 - 78. Roman, P.M. and T r i c e , H.M. The sick role, labelling theory, and the deviant* d r i n k e r , IN Pattison, E.M., Sobell, M., and Sobell, L. Emerging  Concepts of Alcohol Dependence. New York: Springer, 1977. Room, R. A farewell to alcoholism? A commentary on the WHO 1980 expert committee report, B r i t i s h Journal of Addiction, 1981, 76, 115 - 123. Rotter, J.B. Generalized expectancies for internal versus external control of reinforcement, IN Rotter, Chance and Phares (eds.), Applications of  a Social Learning Theory . New York: Holt Rinehart, 1972. Skinner, H.A. Assessment of alcohol problems, IN Y. Israel et al (eds.), Research Advances i n Alcohol and Dru g Problems , v. 6. New York: Plenum Press. T a r t e r , R.E. and Schneider, D.U. Models and theories of alcoholism, IN Ta r t e r and Sugerman (eds.), Alcoholism: Inter d i s c i p l i n a r y Approaches  to an En d u r i n g Problem... Reading, Mass. : Addison-Wesley, 1976. Tolor, A., and Tamerin, J.S. The attitude toward alcoholism instrument, a measure of attitudes toward alcoholics and the nature and causes of alcoholism, B r i t i s h Journal of Addiction, 1975, 70, 223 - 231. Tournier, R.E. Alcoholics Anonymous and the tyr a n n y of treatment: paper presented at the Society for the Study of Problems, annual meeting, Chicago, September, 1977. T r i c e , H. and Roman, P. Delabeling, relabeling and alcoholics anonymous, Social Problems, 1972, 20^ 539 - 547. Vic t o r i a Life Enrichment Society. "Residential Programs, 1982", brochure available, 101 Island Highway, Vi c t o r i a , B.C. You've Come a Long Way, Katie, Canadian Broadcasting Corporation., Toronto, 1978. - 90 -APPENDIX A Literature provided by the Two Treatment Centres - 91 -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 211 - 101 Island Highway Victoria, B.C. V9B 1E8 RESIDENTIAL PROGRAMMES 1982 The Victoria Life Enrichment Society is a non-profit society. The goals of the Society, as stated in its 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 li v e . (b) To promote programmes for change for people who must modify their l i f e styles due to illness dr. natural process. (c) To train professionals and others in 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 is as important to health as is the presence or absence of any specific illness. The Society defines health, not in relation to illness or disease, but in relation to personal fulfillment. In the individual, this means that "health" is always something more than the absence of a diagnosible illness and likewise "family health" i s always something more than the absence of sickness in one or more of its 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 is currently offering residential p r o g r a m m e s 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 is 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 of a chemical as a means of altering one's experience of self 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 - is any use of alcohol that results in 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 is that they are at their best when they experience themselves as being in control of their lives. We believe i t i s good for people to experience themselves as being free or self directing. We take the position that for the most part people choose to do the things they do and that i t is reasonable that they should be accountable for the f a i r and lo g i c a l consequences o f their decisions. At V.L.E.S. we believe that people need to recognize that they are responsible to one another and responsible for themselves. Being responsible to others we c a l l Social 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 that what I am and w i l l become i s mostly up to me". [Another assumption about people that 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 that when a person i s c l e a r l y and accurately aware of her/his motives and the available 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 to make decisions that are personally constructive and u s u a l l y accept-able to others*] 1 i i Nature of the Problem The programme i s based on the b e l i e f that the most useful way of conceptualizing chemical dependency i s as a l i f e s t yle problem. The abuse of alcohol or 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 only 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 to l i f e i s t h e i r capacity f o r s e l f deception. The most common problem i s denial of t h e i r power to choose t h e i r behaviour and/or a refusal to be responsible f o r the choices they make. Viewing chemical abuse as a l i f e s t y l e problem implies that stable recovery requires much more than a simple separation from the chemical. In most instances i t requires a fundamental change i n the person's approach to l i f e . Consistent with the above, we believe that while chemically dependent people do not choose to become chemical abusers or problem drinkers, they do choose, to behave i n a manner which maintains t h e i r problem, and that 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 that change i s possible. This means be l i e v i n g that given the r i g h t set of circumstances an i n d i v i d u a l can and - 94 -will make different choices. The change programme is in 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 is 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 in the V.L.E.S. Community The ability of people to relate to one another in 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 in 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 is 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 of existence or to c o n t r o l behaviour through a set of r u l e s . The programme t r i e s to deal with problem behaviour as i t occurs using i t as an opportunity f o r l e a r n i n g . Any person whose behaviour p e r s i s t e n t l y v i o l a t e s the ba s i c p r i n c i p l e s of the community w i l l have the opportunity of e x p l a i n i n g her/ his conduct t o h i s peers and f a c i n g t h e i r judgement. When i t becomes apparent t h a t a resident has no i n -t e n t i o n of l i v i n g by the values o f the community and/or has no i n t e n t i o n of t r y i n g t o change h i s / h e r approach to l i f e then he/she w i l l be given the opportunity of e x p l a i n i n g to the group why he/she should remain i n the community. i i The Role of S t a f f and S i g n i f i c a n t Others A chemical dependent approach t o l i f e does not develop i n a vacuum or occur overnight. I t evolved through i n t e r a c t i o n with others over a long p e r i o d o f time. Change, t h e r e f o r e , w i l l also take time and require i n t e r a c t i o n with others. I t i s d i f f i c u l t 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 her/his l i f e without understanding and support from others. The V.L.E.S. programme creates o p p o r t u n i t i e s f o r the i n v o l v e -ment of the parents, spouse, c h i l d r e n , (where appropriate) employers and any other s i g n i f i c a n t people i n the person's l i f e . We consider i t a great value t o the process of recovery (change) i f a l l the s i g n i f i c a n t people w i l l respond or r e l a t e t o the recovering person i n a co n s i s t e n t f a s h i o n . i i i R e l a t i n g to the Problem Person At ViL.E.S. we believe i t i s helpful t o approach the troubled person in such a manner as to constantly frustrate any attempts on h i s / h e r part to pursue a dependent and irresponsible approach to l i f e . This can best be accomplished when the staff of 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 others should refuse to do anything f o r the i n d i v i d u a l t h a t he/she i s capable of doing f o r him/her s e l f . (Small favours r e f l e c t i n g goodwill excepted) 2) S t a f f and others should refuse to r e l a t e t o the i n d i v i d u a l i n terms of him being s i c k or h e l p l e s s . 3) S t a f f and others should refuse to provide or condone mood modifying chemicals, ( i . e . stimulants, t r a n q u i l i z e r s , s l e e p i n g p i l l s , a l c o h o l , etc.) 4) S t a f f and others should refuse to accept or appear t o accept any r a t i o n a l i z a t i o n f o r something l e s s than a t o t a l commitment of the i n d i v i d u a l to her/his programme of recovery. 5 ) Apart from questions p e r t a i n i n g to the p r o v i s i o n of informa-t i o n , s t a f f should refuse to answer a l l questions, p a r t i -c u l a r l y , "should I?" questions. 6) S t a f f should constantly emphasize the i n d i v i d u a l ' s power and r i g h t to choose. 7) S t a f f and others should ensure that the i n d i v i d u a l has the opportunity of fac i n g , immediately, the f a i r and l o g i c a l consequences of his choice. 8) S t a f f and others should respect the i n d i v i d u a l ' s r i g h t to choose t o r e j e c t the values of the programme, namely r e s p o n s i b i l i t y , honesty, respect f o r s e l f and others and •his/her r i g h t to choose a drunken l i f e s t y l e . (The f a i r and l o g i c a l consequences of such a d e c i s i o n would be t o ask the i n d i v i d u a l t o leave the 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 pretend he has no choice or to make choices and evade t h e i r consequences. The a t t i t u d e of 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 be responsible t o the c l i e n t as opposed t o being responsible f o r - 97 -him/her. They w i l l assume no r e s p o n s i b i l i t y f o r the c l i e n t ' s recovery. They should, however, be w i l l i n g to share themselves, t h e i r knowledge, experience and opinions with him/her. i v The S t a f f The s t a f f i s composed of seven i n d i v i d u a l s who are deeply committed to the p r i n c i p l e s on which the programme i s based and h i g h l y experienced i n the f i e l d of chemical dependency. P r o f e s s i o n a l l y , they c o n s i s t of 3 p s y c h o l o g i s t s , 2 part-time physicians, and two t r a i n e d l a y counsellors and one sec r e t a r y -r e c e p t i o n i s t . v Programme Structure Every e f f o r t i s made within the constr a i n t s of the f a c i l i t y t o create a therapeutic community based on the values p r e v i o u s l y mentioned. A l l behaviours are judged and dealt with i n r e l a t i o n -ship t o stated programme values. The approach to the i n d i v i d u a l i s h o l i s t i c so that a l l h i s behaviour w i l l be considered l e g i t i -mate data to be dealt with. The i n i t i a l recovery process has a duration of approximately twelve months, c o n s i s t i n g of four major phases or emphasis. The in - r e s i d e n c y period w i l l be f o r four weeks and w i l l normally cover the f i r s t three phases, which are: a) Recognition and acceptance - The emphasis during t h i s phase i s t o help the i n d i v i d u a l t o recognize and then accept his current s t y l e or approach to l i f e . The work during t h i s phase i s aimed at i n c r e a s i n g awareness of the current s i t u a t i o n by i d e n t i f y i n g damaging defences and destroying the.system of r a t i o n a l i z a t i o n . This i s considered a c r u c i a l phase as the beginning of change s t a r t s with the recogniti o n and acceptance of "what i s " . In most instances, t h i s phase has s t a r t e d before the i n d i v i d u a l enters the programme• - 98 -b) Exploration and discovery - The emphasis during this phase is 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 is 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 parti-cipate in what he will become. d) The reconstruction - This is the post-residential phase, during which time the individual is faced with the real l i f e experience of developing, consolidating, and expanding his new approach to l i f e . It is hoped that he will 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 in a sequential fashion. They are presented as a convenience in communicating the major emphasis to be covered in the programme.) vi Follow-up The V.L.E.S. programme offers continued support beyond the residential phase in the form of a newsletter and by making available "renewal experiences" in 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 in 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 in their own community. - 99 -D Programme Methods Within the general therapeutic m i l i e u , the f o l l o w i n g s p e c i f i c methods are employed: 1) Thorough p h y s i c a l and psycho-social assessment, followed by s p e c i f i c recommendations regarding d i e t , exercise programme, e t c . 2) Group therapy - one three-hour session per day, Monday to F r i d a y , f o r four weeks. These are i n t e n s i v e small group psycho-therapy sessions conducted by s t a f f members. 3) Lecture - d i s c u s s i o n . Includes information and interchange of ideas on a l c o h o l and drug dependency, personal and s o c i a l 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 , values and new d i r e c t i o n s f o r coping with l i f e . 4) Yoga exercise and r e l a x a t i o n t r a i n i n g ( s t r e s s reduction) 5) Evening programme (4 nights a week, 7 p.m. t o 9 p.m.) includes relevant f i l m s , self-awareness e x e r c i s e s , i n t r o d u c t i o n to A. A. 6) Personal r e s p o n s i b i l i t y - planning use of "free-time", keeping d a i l y j o u r n a l , developing s p e c i f i c plans f o r the future, o r g a n i -zing a case conference during the t h i r d week of the programme. 7) I n d i v i d u a l and marital 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 f o r married c l i e n t s ) 9) Sixteen A. A. meetings are made a v a i l a b l e during the course o f the programme• E Admission The programme i s designed to provide help to i n d i v i d u a l s who have developed a harmful dependency on what we have c a l l e d the s o c i a l l y acceptable or legitimate drugs, namely alcohol, t r a n q u i l i z e r s and sleeping p i l l s . ' . -100. -Factors favouring s u i t a b i l i t y : 1) A reasonably stable work record 2) An i n t a c t home, i f married, or the p o s s i b i l i t y ovf achieving one 3) A r e c o g n i t i o n by the applicant of the need f o r change. 4) Absence of 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 with f u l l p a r t i -c i p a t i o n i n the programme 5 ) A w i l l i n g n e s s t o l i v e without mood modifying chemicals, at l e a s t f o r the duration of the programme. Refusal t o make or keep t h i s commitment w i l l be s u f f i c i e n t reason t o deny admission or f o r expu l s i o n . 6) Drug f r e e and not i n withdrawal. (Applicants who a r r i v e i n -t o x i c a t e d or i n withdrawal w i l l not be admitted.) 7) P h y s i c a l l y and mentally capable and w i l l i n g t o look a f t e r s e l f and being responsible f o r s e l f . What the Programme i s Not The V.L.E.S. programme does not o f f e r c u s t o d i a l or medical care. No one who i s unable oi- u n w i l l i n g t o look a f t e r h i m s e l f / h e r s e l f or who requires any kind of supervision should be r e f e r r e d . The programme does not beli e v e the problem person i s a v i c t i m of powers beyond his/her c o n t r o l and, therefore, does not provide a f a c i l i t y appropriate to the needs of the he l p l e s s and g r o s s l y dependent person. Physical F a c i l i t i e s The programme i s housed i n the Craigflower Motel, located on the Gorge Waterway, at the i n t e r s e c t i o n of Craigflower and Admirals Road i n V i c t o r i a . A R E S I D E N T I A L T R E A T M E N T C E N T R E 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 P R C3? 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 treatment program to both men and women who are chemically dependent. The program i s s u i t e d to those addicted i n d i v i d u a l s whose l i f e s t y l e shows a degree of 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 -ated by current or recent fmployinert. I . THERAPEUTIC MODEL: The program i s psychosocial i n i t s conceptual framework. Treatment i s based upon the b e l i e f that behavior i s leerr.ed end that i n d i v i d u a l s have the a b i l i t y to change t h e i r behavior. The f a c t o r s c o n t r i b u t i n g to chr.nrs ere numerous and sometimes idiosyncra-t i c . Seme which v;o hold as r.cst in,--.-tent ere: a. an awareness of c n e s e l f , b. acceptance of 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 , c. a respect and expectation 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 to make changes, d. a t r a n s l a t i o n of values ar.d f e e l i n g s i n t o b&haviors and a c t i o n s , and e. a cooperative e f f o r t between c l i e n t and t h e r a p i s t towards treatment goals. I I . GOALS OF TR3ATM.~:iT: The goal of tre^tmr-mt at Po.cifica i s t h ~ development of a s a t i s f y i n g l i f e s t y l e f r e e of c h . n i c a l uzo (alcohol c r other drugs). We b e l i e v e that abstinence from char ice.io i s beet ;=ccor.pl i shed as p a r t of a l i f e s t y l e chance, rather 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 that a d d i t i o n a l l i f e s t y l e che.^rz are suppertiva of abstinence, we do not hold that treatr.ent should " i r n c r o " th.3 a d d i c t i o n by focusing e x c l u s i v e l y on other l i f e s t y l e i c r u e s . Thus crr.siderrhl-> t i n e i s spent examining the a d d i c t i v e behavior, po.rticulr.rly the consequences of such behavior. Prob-lems of d e n i a l are ?ddr^scecl, alone with c o n f r o n t a t i o n of the consequences (personal, medical, s o c i a l , c.r.pIc^-T^r.t) of cher.ical dependency. Given the time l i r . i t s c f the procram, an i d e a l outcome of treatment i s a c l i e n t who hrs a strong ce-'.iitr-T.t to abstinence, i s more aware not only i n terms of h i s dependency, bv.t cf hir.celf as a person, and has i n the l a t t e r stages of treatr.ent begun to 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 -I I I . THERAPY FORMAT: Therapy i s conducted on a group b a s i s . During the f i r s t f o u r to f i v e days a l l of the i n d i v i d u a l s admitted on that p a r t i c u l a r admission remain to -gether f o r the i n i t i a l phase of the program. This phase includes o r i e n t a -t i o n , assessment, education regarding dependency problems, and an introduc-t i o n to group therapy. The large admission group (15 to 19 persons) i s then divided i n t o two smaller groups (average s i z e 8 c l i e n t s ) f o r the remainder of the program. C l i e n t s are i n group each morning from 9:00 to 12:00, and each afternoon from 2:00 to 4:30. Some evening sessions are a l s o held two or three times a week. Individual therapy i s not offered during the program l e s t i t undermine the group process. However, should a c l i e n t experience extraordinary d i f -f i c u l t y i n the program, or be seen to be making no progress, he would be seen on an i n d i v i d u a l b a s i s to discuss the issue with 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 often most h e l p f u l on such occasions i f the r e f e r r i n g agent i s able to attend a meeting with 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 or the r e f e r r a l source wish a "Going home conference", 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 source may be arranged by contacting the c l i e n t ' s c o u n s e l l o r i n the second week of treatment. IV. COMPONENTS OF TREATMENT: A. Therapeutic Techniques As noted e a r l i e r , the primary mode of therapy at P a c i f i c a i s based upon the group process. Depending upon the p a r t i c u l a r group and the nature 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 therapeutic approaches are pur-sued. Some sessions are h i g h l y structured, i n v o l v i n g s p e c i f i c exercises to help increase c l i e n t s ' awareness or s k i l l l e v e l s . In other instances c l i e n t centered, g e s t a l t , or behavioral approaches are pursued. No one therapeutic technique i s adhered to, to the e x c l u s i o n of a l l others. The reason f o r t h i s i s t h r o e - f o l d : (1 ) we b e l i e v e that not e.ll problems and concerns are best d e a l t with i n the samo way (2) c o u n s e l l o r s possess a v a r i e t y of s k i l l s and techniques (3) c l i e n t s respond d i f f e r e n t i a l l y to various techniques and approaches Often i t cannot be predicted which p a r t i c u l a r techniques or e x p e r i -ences w i l l have the greatest impact i n an i n d i v i d u a l case. Thus, with-out becoming e c l e c t i c to the point of being c o n t r a d i c t o r y or s e l f - d e f e a t -ing, we do consciously o f f e r a v a r i e t y of therapeutic 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 Inclusion of family members, or others p e r s o n a l l y involved i n the c l i e n t ' s l i f e i s an important aspect of the program. Such people are - 103 -encouraged to p a r t i c i p a t e i n the program on at l e a s t two s p e c i f i c occa-sions (currently the second Tuesday and t h i r d Friday of treatment). Our aim i n t h i s area i s not to provide family or m a r i t a l c o u n s e l l i n g per se, but to: through information increase the family's understanding of the prob-lem , and the process of recovery provide counsellors with a c l e a r , and perhaps more accurate p i c t u r e of the c l i e n t and h i s circumstances gain material f o r confrontation i f t h i s i s appropriate by encouraging c o n s t r u c t i v e feedback from f a m i l i e s regarding the impact of the c l i e n t ' s behavior, a s s i s t the c l i e n t i n over-coming d e n i a l In those instances when i t i s impossible f o r family members to at-tend on the s p e c i f i c family days, i n d i v i d u a l consultations can be ar-ranged . C. A l c o h o l i c s Anonymous A l l c l i e n t s are introduced to A . A . while at P a c i f i c a . Following an o r i e n t a t i o n to the A . A . program i n the f i r s t week of treatment, c l i e n t s are encouraged to attend A . A . meetings i n the community while they are completing 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 habits and r e g u l a r exercise are basic aspects of a healthy l i f e s t y l e . Meals at P a c i f i c a are prepared with reference to a well balanced d i e t . N u t r i t i o u s snack foods ( f r u i t , yogurt, cheese) are a v a i l a b l e between meals along with j u i c e s , milk, and decaffeinated c o f f e e . Exercise i s not a mandatory p a r t of treatment, but 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 are a l s o encouraged to use commu-n 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 incorporate 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 required to p a r t i c i p a t e , as p a r t of t h e i r own i n d i v i d u a l exercise program. Our primary purpose i n o f f e r i n g yoga i s to provide c l i e n t s with a non-chemical form of s t r e s s management. I n s t r u c t i o n sessions are twice weekly. Both the l e v e l of complexity and p h y s i c a l demand are t a i l o r e d to the i n d i v i d u a l c l i e n t . E. Medical Care Medical coverage i s provided to a l l c l i e n t s by the program's consult-ing p h y s i c i a n . Each c l i e n t completes a medical 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 admission. In some instances where there i s concern regarding the i n d i v i d u a l ' s medical c o n d i t i o n , a c o n s u l t a t i o n with the physician may ba arranged p r i o r to admission. Should any med-i c a l emergency a r i s e during an i n d i v i d u a l ' s stay at P a c i f i c a , i t would be handled by the physician and/or by r e f e r r a l to the emergency depart-ment of the Royal Columbian H o s p i t a l . Medication i s r a r e l y prescribed. - 104 -APPENDIX B Questionnaires and Tests Completed by Respondents a) Beliefs About Alcohol Dependence b) Rotter Internal-External Locus of Control Test c) Michigan Alcoholism Screening Test (MAST) (short form) d) Demographic Information Questionnaire e) Instructions read aloud Questionnaire A, pg. ] - 105 -Instructions: The following statements are some beliefs that people may have about their alcohol problems. Please circle "T" if 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. T F 5. My drinking problem is due to a physical cause, such as an 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. T F 8. My drinking problem is due to a social cause, such as family upbringing. T F 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 ife. 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 if they're not alcoholics. T F 17. I don't think I have to be an alcoholic for the rest of my T F l ife. 18. Only another alcoholic can really understand what I'm going through. T F -106 - pg. 2 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. T F 28. 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 29. I am sometimes forced into drinking by circumstances beyond my control. T F 30.. Alcoholics like me are born, not made. T F 31. Being an alcoholic is just something I' l l have to live with for the rest of my life. T F 32. A counsellor or a therapist, not a medical doctor, should deal with alcohol problems. T F 33. 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 learn-ing 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 it . T F 38. In this day and age, anyone could become an alcoholic like I did. T F 39. Therapy for my other personal problems is probably more important than learning to control my drinking. T F 40. I know that alcohol is just an excuse for my irresponsible behavior. T F QUESTIONNAIRE B, pg.' 1 - 107 -I n s t r u c t i o n s : T h i s i s a q u e s t i o n n a i r e to f i n d out the way i n which c e r t a i n important events i n our s o c i e t y a f f e c t people. Each item 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 the a l t e r n a t i v e you b e l i e v e t o be more t r u e as f a r as you are concerned, and 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 C h i l d r e n get 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 too much, b 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 arents are too easy w i t h them. 2. * Many o f the unhappy t h i n g s i n people's l i v e s are p a r t l y due t o bad l u c k , b People's m i s f o r t u n e s r e s u l t from the mistakes they make. 3. a One o f the major reasons we have wars i s because people don't take enough i n t e r e s t i n p o l i t i c s , b There w i l l always be wars, no matter how hard people t r y t o prevent them. 4. a I n the long run, people get the r e s p e c t they deserve i n t h i s w o r l d . b 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 worth o f t e n passes unrecognized, no matter how hard he t r i e s . 5. a The i d e a t h a t t eachers are u n f a i r t o stu d e n t s i s nonsense. b Most students don't r e a l i z e the e x t e n t t o which t h e i r grades are i n f l u e n c e d by a c c i d e n t a l happenings. 6. a Without the r i g h t breaks one cannot be an e f f e c t i v e l e a d e r . b Capable people who f a i l t o become l e a d e r s have not taken advantage o f t h e i r o p p o r t u n i t i e s . 7. P> No matter how hard you t r y , some people j u s t don't l i k e you. b People who can"t get o t h e r s t o l i k e them don't understand how t o get a l o n g w i t h o t h e r s . 8. a H e r e d i t y p l a y s the 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 . b I t i s one's experiences i n l i f e which determines what they're l i k e . 9. a I have o f t e n found t h a t what i s going t o happen w i l l happen. b T r u s t i n g t o f a t e has never worked out as w e l l f o r me as making a d e c i s i o n t o take a d e f i n i t e course o f a c t i o n . 10. a In the case o f the w e l l prepared student t h e r e i s r a r e l y i f ever such a t h i n g as an u n f a i r t e s t , b Many times exam q u e s t i o n s tend t o be so u n r e l a t e d t o the course work t h a t s t u d y i n g i s r e a l l y u s e l e s s . - 108 -a Becoming a success i s a matter of hard work, luck has l i t t l e o r nothing to do with i t . b Getting a good job depends mainly on being i n the r i g h t place a t the r i g h t time. a 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 , b This world i s run by the few people i n power, and there i s not much the l i t t l e guy can do about i t . a When I make plans, I am almost c e r t a i n that I can make them work, b I t i s not always wise to plan too f a r ahead, because many things turn out^to be a matter of good or bad fortune anyhow. There are c e r t a i n people who are j u s t no good. There i s some good i n everybody. 15. a In my case, g e t t i n g what I want has l i t t l e o r nothing to do with luck, b Many times we might j u s t as well decide what to do by f l i p p i n g a c o i n . 16. a Who gets to be the boss o f t e n depends on who was lucky enough to be i n the r i g h t place f i r s t . b Getting people to do the r i g h t t h i n g depends on a b i l i t y ; luck has l i t t l e or nothing to do with i t . 17. a As f a r as world a f f a i r s are concerned, most o f us are the v i c t i m s o f f o r c e s we can n e i t h e r understand, nor c o n t r o l , b By taking 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 the people can c o n t r o l world a f f a i r s . 18. a Most people don't r e a l i z e the extent to which t h e i r l i v e s are c o n t r o l l e d by a c c i d e n t a l happenings, b There i s r e a l l y no such thin g as "bad luck." 19. .a One should always be w i l l i n g to admit one's mistakes, b I t i s u s u a l l y best to cover up one's mistakes. 20. a I t i s hard to know whether or nor a person l i k e s you. . b How many f r i e n d s you have depends on how nice a person you are. 21. a In the long run the bad things t h a t happen to us are balanced by the good ones. b Most misfortunes are the r e s u l t of lack of a b i l i t y , ignorance, l a z i n e s s , or a l l three. 22. a With enough e f f o r t we can wipe out p o l i t i c a l c o r r u p t i o n . b I t i s d i f f i c u l t f o r people to have much c o n t r o l over the 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 Sometimes I can't understand how teachers a r r i v e a t the grades they g i v e . b There i s a d i r e c t connection between how hard I study and the grades I get. - 109 - pg. 3 24. a A good leader expects people to decide f o r themselves what they should do. b A good leader makes i t c l e a r to everybody what t h e i r jobs are. 25. a Many times I f e e l that I have l i t t l e i n f l u e n c e over the things that happen to me. b I t i s impossible f o r me to think that luck or chance plays an important r o l e i n my l i f e . 26. a People are l o n e l y because they don't t r y to be f r i e n d l y . b There's not much use i n t r y i n g too hard to please people, i f they l i k e you, they l i k e you. 27...a There i s too much emphasis on a t h l e t i c s i n high school, b Team sports are an e x c e l l e n t way to b u i l d c haracter. 28. a "What happens to me i s my own doing. b Sometimes I f e e l that I don't have enough c o n t r o l over the d i r e c t i o n my l i f e i s t a k i n g . 29. a Most of the time I can't understand why p o l i t i c i a n s behave the way they do. b In the long run the people are responsible 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 l e v e l . - 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 5. 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 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 9. Have you ever been in a hospital because of drinking? yes no 10. Have you ever been arrested for drunk driving or driving after drinking? yes no - I l l -guebi lunnaire L) Please answer the following questions; the information will not be used to identify you in any way. 1. Today's date v 2. Name of facility you are attending 3. Date you entered this facility 4. Your birthdate 5. Sex: Male Female 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 1 0 . Print the first two letters of your last name - 112 -GENERAL INTRODUCTION You are being asked to participate i n a study of alcohol problems. This study is part of an M.A. thesis being conducted b y Joanne Pallett through U.B.C. \ The purpose of the study, in general terms, is that it is an investigation of what people i n treatment centres believe about various current issues, including alcohol problems. It is hoped that the results will help i n p r o v i d i n g better assessment procedures for therapists. Your part in the study would involve two, 30 minute, periods of your time, one now, and one toward the end of your stay here. You would be asked to complete a four part questionnaire. The questionnaires are filled out anonymously, i n a group. Your name does not go on them, and no attempt will be made to ide n t i f y you. A n y questions? (If people have specific questions about the nature of the study, explain that this would bias their answers, and that such questions can be answered after the second session.) At this point, those who may wish to do so, may leave. Also, those who are there for the treatment of a dependency problem other than alcohol, may also leave. SPECIAL I N S T R U C T I O N S [Before d i s t r i b u t i n g the questionnaires.] These are all questions of personal opinions or beliefs. T here are no r i g h t or wrong answers. A l l the questions are of the type that ask you to pick "A" or "B"; "True" or "False". Sometimes it is h a r d to make a choice, since both alternatives may be true. However, t r y to pick the one that is what you believe most of the time. T r y to answer every question. The questionnaires are not all i n the same order; you are all getting the same questions, just in different orders. Please do them in the order i n which they are presented. That i s , do page 1 f i r s t , then go on to page 2, and so f o r t h . Please work at your own pace, and hand your questionnaire i n when ready. Thank you. - 113 -APPENDIX C Tables pertaining to description of sample  used in study - 114 -Table 1. Description of Sample of 104 Subjects Used in Pilot Study, by Age and Income * Facility Number Age Income Male Female Total n 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 Total 98 6 104 102 39.60 12.69 96 2.92 1.23 Table 2. Description of Sample of 104 Subjects Used in Pilot Study,  by Length of Alcohol Problem, MAST, AA Involvement, and D r i n k i n g Role Preference * Facility Length of Alcohol MAST AA D r i n k i n g Role Problem Short form Involvement Preference n X Sd n X Sd No %No Yes %Yes n Ale. ** o 0 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 Total 101 11.11 7.25 104 20. 04 5.76 77 45 26 25 67 68 32 32 * The total number of subjects in each category did not always reach 104, since some subjects did not answer some of the questions on the demographic questionnaire. ** Ale. = Alcoholic, P.D. = Problem Drinker - 115 -Table 3 . Description of 59 Subjects Used in Main Study Length of * Drinking Role Age Income Dependency MAST A A Involve . Ale. P.D . ** n Sd n x Sd n x Sd n x Sd n x Sd n -8 n 39 4 1 . 1 0 9 . 9 7 3 9 2 . 9 5 1 . 2 3 39 1 1 . 5 4 8 . 8 3 39 1 8 . 7 2 6 . 5 5 3 9 . 2 6 . 4 4 2 7 69 12 31 B 20 3 9 . 9 5 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 5 . 3 6 2 0 . 1 0 . 3 1 10 50 10 50 AA involvement was encoded : 0 = "no", 1 = "yes". Ale. = Alcoholic, P.D. = Problem Drinker. Table 4 . Description of Alcoholics and Problem D r i n k e r s L g t h . of Age Income Depen'cy MAST AA Involve. * Dri n k i n g Role n x Sd x Sd x SD x Sd x Sd Alcoholics 3 7 4 2 . 7 5 9 . 5 8 3 . 0 2 1 . 1 3 1 2 . 9 2 8 . 6 4 2 0 . 4 9 5 . 8 3 . 2 4 . 4 4 Problem D r i n k e r s 20 3 7 . 2 7 1 1 . 0 6 2 . 5 0 1 . 2 6 8 . 9 5 7 . 0 5 1 7 . 7 3 6 . 5 7 . 1 4 . 3 5 * AA involvement was encoded: 0 = "no", 1 = "yes". - 116 -The following is a more detailed description of the demographic variables i n Tables 1 , 2, 3 and 4. Age This was encoded as the subject's age in years on the f i r s t day of the month of the test. Income For convenience's sake, yearly income was encoded in the following way: Yearly income - Code < $10,000 - 1 > $10,000 < S20,000 - 2 > $20,000 < $30,000 - 3 > $30,000 < $40,000 4 > $40,000 - 5 Length of Alcohol Problems T h i s was encoded as the number of years respondents indicated their d r i n k i n g had been a "problem". MAST (short form) Thi s test was used as an index of severity of alcohol problems. Pokorny, Miller and Kaplan (1972) reported that 55% of the alcoholics they tested scored i n the 18 - 25 point range. Only 11 of their 60 subjects scored below that range. AA Involvement Subjects were asked whether they considered themselves to be regular AA attenders, to ascertain degree of commitment to i t . While the vast majority (77% of the total sample) said they were not regular AA members, vi r t u a l l y all of the sample indicated they had been to at least one AA meeting (this is one of the MAST questions). In Table 1, AA involvement is simply encoded as percentages of "yes" and "no" answers. In Tables 2 and 3, AA involvement was encoded numerically - zero indicated "no" and one, "yes". - 117 -D r i n k i n g Role Subjects had three choices: "alcoholic", "problem dri n k e r " , or "neither". The fi r s t two labels were elaborated b y definitions (Questionnaire D, Appendix B ) . The majority chose the "alcoholic" label. ^Furthermore, this was a remarkably stable choice. For those who completed two tests, only two . v . ' - ' subjects out of 59 changed their d r i n k i n g role preference after three weeks. These subjects were labelled as "alcoholics" since that was their choice at the pretest. Of'the" 59 "subjects who has a pretest and a posttest, a fu r t h e r three did not make a choice on the pretest. Two of these chose the "alcoholic" label on the posttest, while one made no choice on either test. These three subjects were all encoded b y the computer as alcoholics. - 118 -APPENDIX D Reliability Estimates for "Beliefs About Alcohol Dependence" Scale - 119 -Table D (1) Reliability Estimates for 40 Item "Alcohol Beliefs" Scale,  computed in data obtained from 104 subjects Disease Sub Scale Behavior Sub Scale Item Mean 1 S d 2 Frequency 3 Item - *• %:F T Total Correlation Item Mean Sd % :F T Item-Total Correlation 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 -.18* 6 .51 .50 49 51 _ 25*** 6 .74 44 26 74 . 21** 7 .78 .42 22 78 . 19** 7 .82 39 18 82 .01 8 .78 .42 23 78 25*** 8 .78 42 22 78 -.07 9 .62 .49 38 61 . 19** 9 .60 49 40 60 .26*** 10 .53 .50 47 53 _ 34*** 10 .56 50 43 57 . 14 11 .30 .46 69 31 -.01 11 .39 49 61 38 t 3^ *** 12 .05 .22 95 5 .21** 12 .87 34 13 86 41*** 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 20 a = .58 K-R 20 a = .47 Standardized a = .57 Standardized a = .50 Mean - The were encode* arithmetic mean for each d "0", "True" responses item ranges from were encoded "1" 0 to 1. "False" responses 1. Standard deviation - range 0 Frequency - The percent of time a n item was answered "True" and "False" AH figures rounded to the nearest whole number. * p<.10; ** pg.05; *** pS.01 - 120 -T A B L E D(2) Reliability Estimates on 26 Selected Items for "Alcohol Beliefs" Scale , computed on data obtained from 104 Subjects \ Disease Scale Behavior Scale Item Item-total 1 a if item Item Item-total a if item correlation deleted correlation deleted 1 .24** .58 2 _ 30*** .59 3 .20** .59 3 .22** .61 4 2 7 * * * .58 4 _ 3 5 * * * .58 6 .28*** .57 6 . 23** .61 7 .24** .58 9 ^^*** .56 8 .28*** .59 11 4 5 * * * .56 9 . 21** .58 12 _ 41*** .58 10 _ 2 9 * * * .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 K-R 20a=. 62 17 .21** .59 Stan dardized a =.62 18 .16* .60 19 .26*** .58 K-R 20a =.60 Standardized a =.60 1 *p<.10; **pS.05; ***p<.01 - 121 -APPENDIX E Individual Item Scores Obtained b y Alcoholics and Problem Dr i n k e r s on "Beliefs About Alcohol Dependence" and Problem Dr i n k e r s on Beliefs Scale Scale Alcoholics Problem Dr i n k e r s " t " 3 \ Disease l Sd 2 Sd -i .88 .33 .38 .49 5.24** 2 .15 .36. .16 .37 -.04 3 .65 .48 .59 .50 .56 4 .21 .40 .19 .40 .24 5 .82 .39 .75 .44 .77 6 .63 .49 .25 .44 3.88*** 7 .85 .36 .63 .49 2.29** 8 .85 .36 .63 .49 2.29** 9 .63 .48 .59 .50 .30 10 .56 .50 .47 .51 .81 11 .19 .40 .56 .50 -3.65*** 12 .03 .16 .09 .30 -1.18 13 .51 .50 .31 .47 ]_> Q7** 14 .65 .48 .59 .50 ! 56 15 .15 .36 .25 .44 -1.10 16 .15 .36 .19 .40 -.42 17 .73 .44 .56 .50 1.68* 18 .71 .46 .56 .50 1.40 19 .26 .44 .25 .44 . 15 20 . 10 .30 .09 .30 .06 Behavior.; 1 .28 .45 .38 .49 -.95 2 .09 .30 .50 .51 -4.18*** 3 .65 .48 .78 .42 -1.38 4 .50 .50 .63 .49 -1.19 5 .21 .40 .41 .50 -1 9 7 * * 6 .71 .46 .81 .40 -1.18 7 .83 .38 .78 .42 .60 8 .82 .38 .69 .47 1.39 9 .51 .50 .78 .42 -2,81*** 10 .58 .50 .53 .51 .49 11 .29 .46 .59 .50 -2.92*** 12 .85 .36 .91 .30 -.87 13 .79 .41 .78 .42 .12 14 .94 .23 .88 .34 1.06 15 .86 .35 .78 .42 .94 16 .99 .12 .94 .25 1.07 17 .33 .48 .47 .51 -1.28 18 .76 .43 .78 .42 -.19 19 .51 .50 .69 .47 -1. 70* 20 .76 .43 .75 .44 .15 1 Mean scores - range 0 (False) to 1 (True) Standard deviation, range 0 to 1 3 * pS.10; ** p^.05; *** pS ,'01 

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