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THE RELATIONSHIP OF VOCATIONAL IDENTITY AND OTHER MITIGATING
VARIABLES TO PROGRESS IN SUBSTANCE DEPENDENCE TREATMENT IN A
THERAPEUTIC COMMUNITY
By

Gary L. Hankinson

A DISSERTATION
Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Educational Administration

1997

ABSTRACT
THE RELATIONSHIP OF VOCATIONAL IDENTITY AND OTHER MITIGATING
VARIABLES TO PROGRESS IN SUBSTANCE DEPENDENCE TREATMENT IN A
THERAPEUTIC COMMUNITY
By

Gary L. Hankinson

The relationship of vocational identity and other mitigating variables such as age,
education, income, and length of stay in treatment to progress in substance dependence
treatment was explored in this study. The study was conducted in a therapeutic
community in a southeastern Michigan urban setting with adult male subjects diagnosed
with substance dependence. Progress in substance dependence treatment was measured
through the Recovery Attitude and Treatment Evaluator-Questionnaire Instrument
(RAATE-QI), which measured resistance to treatment planning, resistance to continuing
care, biomedical acuity, psychiatric / psychological problems, and social / familial /
environmental factors. Vocational identity was measured through the Vocational Identity
Scale of the My Vocational Situation (MVS) instrument.

Data were gathered on 102 subjects who were administered a MVS and a
RAATE-QI during the ﬁrst week of treatment and a second RAATE-QI during the fourth
to eighth weeks of treatment. Through stepwise regression analysis, the dependent
variable progress in substance abuse treatment dimension, biomedical acuity, was found
to have a statistically signiﬁcant relationship with a higher degree of vocational identity;
age was found to have a negative correlational relationship with the progress in substance

dependence treatment dimension. resistance to continuing care. Additional post hoc

analysis revealed differences between subjects who leﬁ treatment before the prescribed
discharge date and those who completed the initial questionnaires and the second set 4 to
8 weeks later in the categories of education and biomedical acuity.

The study results showed statistically signiﬁcant relationships between the
dependent variable progress in substance dependence treatment and vocational identity
and age, leading to guarded interpretations of the ﬁndings. The biomedical acuity
dimension might also have been measuring physiological and psychological craving,
which may be a factor in treatment retention and treatment progress. In attempting to
understand the sources of the unexplained variance, criminality, ethnicity, vocational
decidedness, motivation for treatment, drug of choice, learning style, and personality
traits may also be determinants of progress in substance dependence treatment. The
relationship of variables such as motivation for treatment to vocational identity needs
further study as do other issues related to progress in substance dependence treatment,
adult education considerations in substance dependence treatment settings, and vocational

issues.

C0pyright by
GARY L. HANKINSON
1997

This dissertation is dedicated to the memory of

Cas Heilman.

ACKNOWLEDGMENTS

I wish to thank the following members of my dissertation committee for their
patience and support: Dr. Ann Austin for her willingness to serve on the committee at a
late stage and her assistance with the transition of my program to a new advisor; Dr.
Michael Leahy for his guidance in proposal design and data collection; Dr. James Snoddy
for his initial encouragement and longstanding membership on the committee; and,
ﬁnally, Dr. John Dirkx for his encouragement, leadership, clear feedback, timely
responses, and willingness to assume the chairmanship of the committee. A very special
thanks posthumously to Dr. Cas Heilman, who served as my advisor and committee chair
for the duration of my program until the ﬁnal six months; for his counsel I will be forever
grateful. An additional thanks to Allen Bray for his accommodations to use his program
resources, and time, and the very special people who were the subjects of the study.

Thank you to my mother and father for their lifelong unconditional love and
support. My family has provided a decade of support during my educational pursuits. I
thank Ashley for our spruce tree discussion on what’s important in life. Thanks to
Stephanie for her reminders about being a good person and parent. Thanks to Brad for
his encouragement and intellectual challenges. And ﬁnally, thank you to my wife,

Suzanne, who has coordinated our family at all levels for the past 21 years. Her love,

vi

support, and patience have made this dissertation and our family possible.

vii

TABLE OF CONTENTS

LIST OF TABLES ...................................................... x

CHAPTER ONE

INTRODUCTION ....................................................... 1
Statement of the Problem ............................................ 3
Purpose of the Study .............................................. 12
Research Question ................................................ 13
Implications for Teaching and Learning ............................... l3
Signiﬁcance of the Study ........................................... 17
Limitations and Delimitations ....................................... 19
Summary ....................................................... 20

CHAPTER TWO

LITERATURE REVIEW ................................................. 22
Substance Abuse as a Social Problem ................................. 22
Intervention Strategies to Contend with Substance Dependence ............. 26
Substance Dependence Treatment .................................... 29
Developmental Perspectives on Substance Dependence ................... 35
Substance Dependence and Vocational Identity ......................... 42
The Need for Further Research ...................................... 46
Measurement of Vocational Identity .................................. 48
Measurement of Progress in Substance Dependence Treatment ............. 50
Implications of Adult Education for the Substance-Dependent Population . . . . 52
Summary ....................................................... 53

CHAPTER THREE

METHODOLOGY ...................................................... 55
Research Questions ............................................... 55
Research Design .................................................. 56
Data Collection .................................................. 60
Data Analysis .................................................... 66
Summary ....................................................... 68

viii

CHAPTER FOUR

RESULTS ............................................................ 69
Description of the Sample .......................................... 69
Findings ........................................................ 71
Findings of the Post Hoc Analysis .................................... 77
Summary ....................................................... 80

CHAPTER FIVE

DISCUSSION ......................................................... 82
Synopsis of the Study .............................................. 82
Discussion of the Findings .......................................... 83
Unexplained Variance ............................................. 87
Post Hoc Findings ................................................ 88
Summary of the Findings ........................................... 91
Implications for Practice ........................................... 91
Recommendations for Future Research ................................ 94
Limitations ...................................................... 97
Conclusions .................................................... 103

APPENDICES
Appendix A
Participant Letter ................................................ 104
Appendix B
Study Summary ................................................. 105
Appendix C
Subject Release Form ............................................ 106
Appendix D
Therapeutic Community Program Description ......................... 107

BIBLIOGRAPHY ..................................................... 117

ix

LIST OF TABLES

1- Correlation of Raw Scores RAATE-T1 and RAATE-T2 ...................... 72
2- One Sample t-test to Determine Differences in each RAATE-Q1 Dimension ...... 73

3- Multiple Regression Models for the Differences

in the First and Second RAATE Raw Scores ................................. 75
4- Summary of Multiple Regression Analysis for each Model .................... 76
5- T-test of RAATE-T1 only with RAATE-Tl & T2 Group ...................... 79
6- Chi-square test of income variable between RAATE-Tl and RAATE-T2 ......... 80
7- Income category distribution comparing RAATE-T1 and RAATE T2. ........... 80

CHAPTER ONE

INTRODUCTION

In the waking hours of an urban community hospital, two boys are born in
adjacent birthing rooms. Their names are Robert and William, and although many of
their family and life experiences will be similar, the ﬁnal chapters of their lives will be
dramatically different.

Robert, the third child in a family of two older brothers and one younger sister,
learns early that his mother is a stable and important force in his life because his father is
always away from home either, working or socializing with his friends. He grows up
depending on his older brothers as role models due to his father’s absence. Occasionally,
a teacher impresses him with knowledge about a subject such as science or relates
especially well with him. These periodic positive experiences serve as anchors whenever
Robert asks himself what he might want to do for a living when he ﬁnally grows u --
perhaps be a teacher or maybe a scientist.

William is also the third child in a family of two older brothers and a younger
sister. His father and his mother both work the day shift for a large fumiture
manufacturer. His father is a craftsman and shares his skills and knowledge with his
children, including them as helpers after school in his secondary carpentry business.
William believes he will eventually work for the same furniture company as his parents

1

2

do, but because of curiosities and rebelliousness, he goes through several phases of
exploration before he ﬁnally returns to his original preference-- to be a craftsman.

William and Robert meet at an early age in their neighborhood and share not only
their common birthday bond but also similar boyhood adventures in sports and eventually
girls. In their early teens, both ﬁnd other peers who share a curiosity for the effects of
alcohol, marijuana, and eventually cocaine. Both William and Robert ﬁnd profound
rewards in the euphoria of drugs their peer group enjoys. ,They both are “high” achievers
in the world of drugs, being able to tolerate large quantities of alcohol and drugs. Most of
their discussions and activities revolve around drugs, but even with their preoccupation
with drugs, the boys are able to graduate from high school, ﬁnd jobs at the local furniture
manufacturer, maintain employment, and begin to shape their lives with marriage and
children.

However, over time, both Robert and William fail to combine their drug-taking
lifestyle with family responsibilities. In addition, both ﬁnd themselves involved in
disciplinary procedures at work due to absenteeism and erratic behavior caused by drug
dependence. Over time, both become discouraged in their various attempts to quit using
drugs and alcohol through outpatient treatment and self-help groups. Finally, they both
ﬁnd themselves in treatment together in a local residential drug abuse program.

Following this treatment experience, the two men’s experiences no longer seem to
be parallel. Robert continues to struggle with his dependence and suffers repeated
relapses. William relapses once but quickly corrects his mistake by resuming attendance
at self-help groups and reestablishing contact with his outpatient aftercare program. He

begins a healthy and responsible relationship with his family and employer. Like his

3

father, he also starts an evening furniture repair business assisted by his children and his
spouse.

William occasionally visits with Robert at work and encourages him to keep
trying to, seek help, but Robert progressively worsens and appears to have lost hope.
William’s concern about Robert’s despair escalates into fear for his future. Thirty-ﬁve
years after their ﬁrst encounter in the nursery of the maternity ward, William ﬁnds
himself looking at Robert for the last time, this time in a parlor room of a funeral home.
Robert has died after rear-ending a tractor-trailer while under the inﬂuence of alcohol and

marijuana.1

Statement of the Problem

Success and tragedy commonly are found in the substance abuse treatment
process. Much like William and Robert, patients with similar ﬁnancial, employment, and
family resources will differ in their reaction to treatment approaches. Treatment
approaches are based on psychological, physiological, and sociological theories, which
are not easily tested because of the large number of variables that interrningle before,
during, and after treatment. Hubbard et al. (1989) reviewed treatment-eﬂ‘ectiveness
studies and concluded that changes in employment and psychological well being
associated with treatment participation are not well known. Frances and Miller (1991)
describe a paradox created when a substance-dependent patient resists treatment because

of a fear of addiction to a positive alternative such as attendance at a self-help group.

 

‘ The case description of Robert and William is a composite of several dramatic but
factual case histories disguised to protect the conﬁdentiality of the clients.

4

Consequently, questions continue to be raised about what differentiates one patient from
another in the response to treatment.

Even though some investigators have not clearly explained the relationship
between employment and substance dependence (Hammer, Ravndal, & Vaglum, 1985)
others such as Elliot (1992), Schwab and Dinitto (1993), Emener (1992), Westerrneyer
(1989) and Hammer et a1 (1989) have found vocational issues to be important. Hammer
et a1. indicated that the stability of a vocational plan and subsequent employment are
positive outcome indicators of progress in substance abuse treatment. In a survey of
recovering alcoholics in Alcoholics Anonymous, Emener found that respondents
emphasized the importance of employment and vocational development but reported a
lack of opportunities for improvement. Clarity of vocational identity provides a
foundation for strengthened self-esteem and self-conﬁdence which should improve the
chances for progress in substance abuse treatment. In this study the researcher sought to
gain a better understanding of the inﬂuence of vocational identity issues as they relate to

the response to substance dependence treatment.

Backgroundnfjheﬁmblem

In 1993, following its Household Survey, the National Institute of Drug Abuse
reported that an estimated 11.7 million Americans used an illicit drug during the month
preceding the survey. In addition, more than 23 million Americans were estimated to
have used cocaine at some time in their lives; uses in 1994 were estimated at 1.4 million
people and frequent users at approximately 800,000 (Facts About Cocaine, 1995).

According to the National Institute of Alcohol Abuse and Alcoholism, 1996, about 9% of

5

adults in the United States meet the diagnostic criteria for alcohol dependence and the
less severe medical disorder, alcohol abuse. Of these, more than 500,000 were treated in
1993 in more than 8,000 inpatient and outpatient alcohol treatment programs in the
United States. Studies sponsored by the NIAAA have reported relapse rates of more than
50% or more at 2 to 4 years aﬁer treatment (NIAAA, 1996).

Numerous efforts have been made to control the epidemic of drug abuse and
dependence. These initiatives have had varying degrees of success and failure, with little
consensus as to the best overall strategy to manage drug abuse and dependence.
Prevention efforts aimed at youths have some effect on use, especially if they are linked
with activities in which parents are taught how to approach children about drug abuse.
The above mentioned social controls inﬂuence use and abuse of illicit drugs, but there are
still those who abuse or become dependent on drugs, who need intervention to stop abuse
and/or dependence. However, few prevention programs have been found to consistently
reduce the number of their subjects who use drugs (W 1994).

Law enforcement personnel have fought a “war on drugs” championed by each
new wave of politicians in state and federal government. Law enforcement officers have
inconsistently and ineffectively controlled the ﬂow of illicit drugs into the US. In
previously untouched communities such as Fargo, North Dakota, the number of
Methedrine cases has quadrupled since 1994, and in a northeastern study it was estimated
that the teen murder rate had jumped by 320%, an outcome associated with the increase
in the sale and abuse of drugs (Bai, 1997). Although there are some signs of progress due

to reduction in overall use of cocaine and marijuana since the 1980's, there are new trends

6

in the use of heroin, methamphetamine, and a new synthetic narcotic called
methcathinone (W 1994).

A majority of jail and state prison inmates report that they were under the
inﬂuence of drugs or alcohol (or both) at the time of their current offense (2mm;
forecasting, 1994). In testimony submitted to the US. House of Representatives, Thomas
Constantine, Administrator for the Drug Enforcement Administration, stated that the US.
is spending $20 billion to keep people in jail and another $20 billion for new facilities
W 1994). Correctional efforts through probation programs, jails, and
prisons have resulted in housing those possessing or selling illicit drugs. However, this
approach is effective only as a warehousing effort, and most criminals revert to drug use
and crime following incarceration. In New York City, it costs $60,000 per year to keep
someone in jail. National statistics indicate that 70% of those incarcerated will return
within 3 to 5 years of their release We; 1994).

In the case example of Robert and William, neither apparently beneﬁted from
prevention efforts by their school system, nor did they experience incarceration as a
consequence of their drug use. It appears that the most signiﬁcant factors leading to their

entry into treatment were family and job motivators.

We:

Multiple theories have been formulated to address questions about why people
ingest the ﬁrst drink or drug, why some try drugs and some do not, why some who try
drugs do not become addicted and why others immediately become preoccupied with the

effects of the drug (Cloninger, Dinwiddie, & Reich, 1989; Frances, 1988; Frances &

7

Franklin, 1989; Vaillant, 1995). Related issues include the rituals of drug ingestion, the
social environment surrounding acquisition of the drug and the effect on the family, other
social consequences, genetic predisposition to alcoholism, and biomedical factors (Blum
et al., 1992; Cloninger et al., 1989; Frances & Miller, 1991; Frances, Miller & Balanter,
1989; Frances & Strauser, 1988; McGue, Shanna & Benson, 1996;).

Researchers have linked indicators such as genetic predisposition to alcoholism
through adoption studies looking at the alcohol use of adopted versus biological children
in families with and without alcohol abuse problems (Cloninger et al., 1989; McGue, et
al., 1996). Other researchers have focused on biochemical factors; for example, a
signiﬁcant amount of data suggests that drug-seeking behavior results from a series of
neurochemical reactions in the brain’s reward circuits. Such clear evidence of chemical
reactions have led to theories concerning common pathways for all addictive drugs, such
as alcohol, cocaine, and opiates (Blum et al., 1992).

Many treatment approaches apparently are effective and continue to be improved,
but questions about factors contributing to progress in substance abuse treatment remain
as challenges to maximizing treatment outcomes (Project MATCH Research Group,
1997; Vaillant, 1995). The approach to treatment usually is multifaceted, using resources
to help the patient understand all dimensions of dependence and dealing with physical
withdrawal, physical consequences, and cravings, which can be a combination of
profound physical, emotional, and cognitive forces leading to relapse. Drug dependence
results in the depletion of resources such as family support, ﬁnancial assets, work status,

and psychological strength. Treatment approaches usually strive to help the patient

8

replenish these areas by compartmentalizing the drug abuse problem and by refocusing on
tasks that can be accomplished in the short-term.

Substance abuse treatment tends to focus on physical factors such as withdrawal
or craving management, or on psychological issues such as self-esteem. The physical
problems are treated medically or through structured behavioral exercises that help the
patient relax or reassociate certain stimuli. These approaches are indigenous in their
rewards, and if medication and behavioral exercises are maintained and there are no
physical complications, positive treatment outcomes result (Frances & Miller, 1991).
Psychological interventions focus on self-esteem by ﬁrst recognizing the stigma of
addiction and disassociating the self from the addiction. If addiction and the associated
history of behaviors and outcomes can be separated from the self-concept, then there is a
chance to rebuild esteem. Self-esteem may be a causative factor leading to use and abuse,

or it may be a dynamic of the consequences of addictive behavior and outcome.

v t r 'v

Emphasis has been placed on understanding substance dependence from a
developmental perspective. This point of view inﬂuences approaches to treatment, as
well, with particular stress on the concept of identity. Primarily through the work of Erik
Erickson (1959), identity has become a central focus in developmental psychology.
According to this view, psychological growth stems from a ground plan, with different
dimensions maturing at different life stages. A key stage of development is in the area of
ego identity. Ego identity is deﬁned as a self-awareness that remains consistent when

portraying oneself to others (Erikson, 1973).

9

Marcia, Waterman, Matteson, Archer, and Orlofsky (1993) expanded further on
the concept of identity through the establishment of identity statuses. The developmental
process was assessed at different points in time to ascertain the current state of identity
development. This view assumed that the current status was important in understanding
current needs and planning treatment interventions. At any point in development, identity
status can change with regard to any number of identity domains. Identity domains
include sex role attitudes, religious beliefs, political beliefs, family priorities, career
priorities, marital beliefs, the role of the spouse, and vocational plans. Knowledge about
the status of identity in any domain should be helpful in understanding certain
psychological characteristics (Marcia et al., 1993).

Vocational identity is a crucial part of psychological development and maturity.
For those who have not resolved this developmental question or for those involved in the
struggle to ascertain their vocational identity, discomfort and preoccupation can affect
their abilities to cope or grow in other areas. A clear vocational identity may enhance the
potential for more effective substance abuse treatment; conversely, a diffused identity
may adversely inﬂuence the effects of substance abuse treatment. The ﬁrst use of alcohol
or other drugs commonly occurs during adolescence, which is a very critical time
developmentally. Brown, Gleghom, Schuckit, Myers and Mott (1996) reported that
adolescents in substance abuse treatment disclosed that by the age of 11 they had tried
alcohol, that by 13 they were using it weekly, and that their initial use of other drugs such
as marijuana occurred on average within a year. During this period, m0st adolescents are
engaged in a struggle to establish their identity (Erikson, 1968). One of the most

signiﬁcant factors in this stage that will lead to autonomy and distinction of the ego from

10

parental association and control is the ability to exist with ﬁnancial independence. The
adolescent is faced with a challenge to ﬁnd short-term employment to meet immediate
gratiﬁcation for separation. The adolescent also is capable of delaying ﬁnancial
independence if he or she identiﬁes a future vocation that will lead to autonomy; e.g.,
college ﬁnanced by parents can serve as an exploratory or achieved stage, even though
employment in a job or profession has not yet occurred.

If, during this developmental phase drug abuse interferes with job-seeking
behavior or career planning, an important opportunity for fostering self-esteem has been
eroded. Finding a job, successfully interacting with fellow workers, accomplishing tasks,
and gaining ﬁnancial rewards combine to help develop positive self-esteem. Vocational
identity may also be distorted as a result of negative job experiences, such as disciplinary
actions for absenteeism due to drug abuse.

Consequently, the establishment of a vocational identity at an early stage or during
any stage of development is a positive event that will fortify self-esteem. Vocational
identity is an important contributor to self-esteem, and it is the antecedent to many other
aspects of a self-experience that should improve the effectiveness of substance abuse
treatment. However, as important as it may be developmentally, vocational identity is not
viewed theoretically or by practitioners as a predominant factor to consider during
substance abuse treatment. Although vocational identity has been mentioned as a
dimension to be considered in substance abuse treatment, it has not been closely
examined or extensively discussed in the research literature. The logic that an achieved
vocational identity is a signiﬁcant precursor to positive self-esteem has been established,

but its clear association with the acceleration of progress in substance abuse treatment has

11

not been clearly supported through research (Benshoff, J ankowski, Tariconi & Brenner,
1990). Treatment program clinicians sometimes attempt to reduce criminal activity and
increase productivity of the client. These programs are designed to help the client
develop speciﬁc goals and objectives that may be vocationally oriented. Treatment
programs may have special tracks that focus on vocational rehabilitation and help develop
job seeking skills. These services are considered ancillary and vary signiﬁcantly from
program to program (Hubbard et al., 1989).

Although treatment often works, employment or vocational issues are often
problematic and need attention during substance abuse treatment. These issues have been
commonly discussed but not extensively studied through research. In addition, the role of
vocational identity development as it relates to drug dependence has not received focused
attention in treatment or educational theories or through related research. Other variables
that may factor in as important in evaluating the effectiveness of treatment are age,
income, education, length of treatment, and type of treatment.

Once Robert and William entered treatment, the difference in their responses to
the treatment is unclear. The stability of William’s family and his seemingly achieved
vocational identity may have provided additional support, which allowed him to
concentrate on the fundamentals of treatment. Robert’s lack of focus vocationally may
have distracted him from attending to the therapy assignments, and not being a craftsman
may have differentiated him enough from William to make the difference between
rehabilitation and relapse. This research was undertaken to explore the link between

vocational identity and the readiness of the drug abuser to progress in treatment. No

12

answers are provided through these cases, only questions about the effectiveness of
treatment and each individual’s predisposition and ultimate success or failure.

In the case example of Robert and William, neither appeared to beneﬁt from
prevention efforts by their school systems nor did they experience incarceration as a
consequence of their drug use. It appears that the most signiﬁcant factors leading to their
entry into treatment were family and job motivators. An assessment of their identity
status may have revealed that stability had been established in William’s vocational
identity, whereas there was instability in Robert’s vocational identity. If such a discovery
had been made during treatment, a concentrated effort to intervene might have made a

difference and could have saved a life.

Purpose of the Study

The researcher’s purpose in this study was to investigate the relationship of
vocational identity and other mitigating variables to progress in substance abuse
treatment. Treatment progress was measured using the Recovery Assessment of Attitudes
Treatment Evaluator-Questionnaire Instrument (RAATE-Q1) (Lee, Hoffmann, & Smith,
1992), and vocational identity was measured through the use of My Vocational Situation
(Holland, Daiger, & Power, 1980) to determine the degree of achieved vocational identity
status.

The residential therapeutic community modality was selected because of its
controlled environment as compared to an outpatient program because of the accessibility

to clients in treatment for research purposes, and because the length of stay for treatment

13

was signiﬁcantly longer than inpatient care, other shortened residential treatment and

other modiﬁed forms of day treatment.

Research Question

This researcher explored the relationship of several independent variables to
several dependent variables that deﬁned progress in substance dependence treatment.
Speciﬁcally, the question investigated in this study was: What is the relationship of
vocational identity, length of treatment stay, years of education, age and income at time of
admission to speciﬁc measures of progress in substance dependence treatment? Progress
in substance abuse treatment was measured in terms of resistance to treatment planning,
resistance to continuing care, biomedical acuity, psychological and psychiatric problems

and social/farnily/environmental factors.

Implications for Teaching and Learning

De Leon (1994) considered many aspects of treatment in a therapeutic community
as primarily a learning process. Consequently, adult learning considerations must be
recognized when developing an educational and therapeutic strategy within the treatment
environment. The developmental view of the self building on experiences that eventuate
in an identity ties both learning theory and developmental theory together. Approaches to
learning include behavioristic, cognitive, humanistic and social learning theories
(Merriam & Caffarella, 1991).

In a treatment setting, there is potential to use all of these theoretical models.
There are signiﬁcant rewards through the provision of privileges (behavioral

reinforcement); conceptualization of the treatment philosophy or the steps of a 12-step

14

self-help group (cognitive structure); and motivation to learn the lessons of recovery to
change leading to self-actualization (humanistic), as well as the compliments of the peer
group when a successful step is taken during treatment (social learning). In each learning
theory category there are examples of the overlap of learning and therapeutic factors.
Maslow (1972), viewed learning as a form of self-actualization, and Merriam and
Caffarella (1991) noted that learning contributes to psychological health and is a form of
therapy. It is possible to conclude that if learning is a form of self-actualization, it is also
possible that self-esteem would improve if learning occurred.

Mezirow (1991) argued that psychology theorists and other research disciplines
interested in adult learning become trapped in theoretical models, each with its own frame
of reference for interpreting reality. He proposed an integration of thinking to synthesize
the ideas of each discipline in relation to adult learning. The common dimension that is
missing from each theory is the way adults ﬁnd meaning in their learning experience.
Meanings change structure when the individual becomes dysfunctional, and one must
either reestablish the original meaning or develop a new meaning to return to full
ﬁrnctioning. Mezirow’s transformational learning theory suggests a deep introspection
into assumptions about the meaning of experience for adults, leading not only to learning
but also to change. Mezirow’s construct is easily applied to substance abuse treatment
approaches that attempt to reforrnulate a person’s identity from “addict" to “recovering
person” through learning a new set of values and assimilating them as a new meaning for
day-to-day coping.

Cranton (1992) suggested that the child forms values and a perspective on the

world. It is assumed, however, that the adult already has developed values and is in the

15

process of transforming some of these values before, during, or after the learning process.
The context of the social situation will inﬂuence the leamer’s perception of the
environment, and the process can be inﬂuenced by the people, events, and changes in the
surrounding context. These factors can challenge the assumptions of the learner, who
will then process the new information and accept or reject that information or the prerrrise
upon which it is presented. Cranton emphasized that transforrnative learning is the
process of learning through critical self-reﬂection. Changes in perspectives and
eventually in values will lead to different assumptions that are critical for readiness to
learn and actions within the learning process. The developmental process of identity
formation and the transformational learning process have parallels through their use of a
framework surrounding values and assumptions. The self, in order to be distinguished
from others, must develop a set of values and assumptions that are tested and veriﬁed
early on to develop selfsameness (Erikson, 1967). The self in whatever context it lands
will continue to redeﬁne its essential characteristics, or, if challenged frequently enough
or dramatically enough, will change assumptions and perhaps a sense of identity.

Adult learning considerations should be used in designing programs for the
substance dependent population. This will improve comprehension and retention of
treatment concepts, which will lead to improved progress in substance dependence
treatment. Factors that inﬂuence the general adult population are likely also to be factors
for the substance-dependent person in treatment. Instructional settings, which determine
the support needed by learners (Merriam & Caffarella, 1991) differentiate between
whether instruction should be learner directed or teacher directed. Conclusions about the

adult as a self-directed learner can be expanded to the adult substance-dependent self-

16

directed learner. The principles of the drug culture, learned through social learning, can
be replaced with new concepts through self-directed searches of recovery and vocational
information. However, it is possible that the substance-dependent population is
signiﬁcantly different from the general adult population and may not have the same
capacity to engage in self-directed learning. Knowles (1990) described healthy adult
learners as having capability and maturity, as well as the desire for others to perceive their
strengths the same. When considering adult learning principles, these assumptions about
a healthy adult learner would not generally hold true for the substance abuser. However,
the implications Knowles (1990) described seem to maintain their validity in that the
substance-dependent person would also appreciate respect and the opportunity to plan and
carry out his or her learning experiences. The challenge for clinicians is to present self-
directed tasks to those in substance-dependent treatment with the appropriate timing.
Special attention to the limitations of the substance dependence population related to
learning barriers such as child care or lack of a clear plan may help improve treatment
effectiveness.

The view of adults as learners, interrelated with the problem of substance
dependence, can be analyzed through the developmental theory popularized by Sheehy
(1976), highlighting adult life in a series of predictable crises. Other models such as that
of Cross (1981) have tied personal factors such as physiology, aging, sociocultural
aspects, life phases, and personal psychology to the situational aspects of an adult’s life,
which dictate whether education will be pursued full time or part time and whether it is
compulsory or voluntary. The same considerations that motivate adults to learn are also

those that will help lead a person to treatment for substance dependence (Frankel, 1989).

17

An example of this interrelationship is occupational motivation, which may be a factor
leading to substance treatment and entering into some form of adult education or training.
The case example of Robert and William demonstrates that the substance dependence
problem might be resolved by combining vocational, educational, and treatment
resources. Cross (1981) and Merriam and Caffarella (1991) referred to the work of Miller
with force-ﬁeld analysis, Rubenson’s expectancy-valence paradigm, and Boshier’s
congruence model, among others all of which concerned how adults are motivated to
learn. These theories also have been used in the substance-dependence ﬁeld to help
describe the motivation of substance-dependent individuals. Practitioners in the ﬁeld of
substance dependence have applied these models clinically to illustrate human decision-

making behavior in substance-dependent people in treatment.

Signiﬁcance of the study

Substance dependence is a long-standing problem that has become ubiquitous in
American society. Concerns about the rehabilitation of substance-dependent focus not
only on their own well being but also on that of their network of family and ﬁ'iends. If
the substance abuser is rehabilitated, signiﬁcant others and the individual's associated
environments may improve proportionately. If leﬁ untreated, the substance abuser is
likely to lose employment or never to become legitimately employed. Other
consequences of chronic substance dependence include family disenfranchisement,
continued legal entanglements, and medical problems that could be life threatening.

Although the efficacy of substance dependence treatment is generally accepted, it

is not completely clear what characteristics of treatment have the least or the most effect.

18

NIAAA studied alcoholics through an 8 year clinical trial study, in which no signiﬁcant
difference in outcomes was found among therapeutic approaches. Although there was
progress in all of the treatment approaches, only one match, between patients with low
psychiatric severity and a 12-step self-help group approach, indicated that patients treated
with that approach abstained more from drugs and alcohol than those treated with
cognitive-behavioral therapy (Project MATCH Research Group, 1997).

Shorter inpatient stays have resulted in part from improved clinical technology,
allowing for more efﬁcient treatment in the medical detoxiﬁcation phase of treatment,
and tighter clinical case management, making treatment providers more accountable for
treatment plans and recommendations. These tighter controls and shorter lengths of stay,
as well as accountability to payers (insurance, governmental funding and employers),
have forced substance dependence professionals to evaluate the effectiveness of treatment
(Miller, 1992; Oss & Tidgewell, 1994). It is important to explore the signiﬁcance of the
vocational variable, in order to help improve treatment effectiveness. In addition,
continued examination of vocational identity will help develop this concept beyond
simply a caricature of Erikson's thinking (Vondracek, 1992); that is, psychological theory
may be applied in a clinical setting. With a common linkage and more research on the
interrelationships of vocational development and substance abuse, it may be found that
the vocational and substance abuse disciplines have common linkages to assist clients

with multiple problems such as substance dependence and unemployment.

19

Limitations and Delimitations

This study was focused on a ﬁnite time period during the initial stages of
treatment in a residential therapeutic community for substance abuse treatment. Subjects
were males who were primarily cocaine dependent, with a secondary alcohol dependency.
This narrow population and specialized treatment modality limited the conclusions that
could be drawn about the population of drug and alcohol abusers. In addition, the
subjects agreed to participate in the study, and only those who successfully participated in
treatment were given the full battery of instruments. This self-selection and subsequent
screening of successful subjects also limited the conclusions that could be drawn

concerning the results.

Deﬁnitions of Terms

The following terms are deﬁned in the context in which they are used in this
dissertation.

W: The young person, to experience wholeness, must feel a progressive
continuity between that which he has come to be during the long years of childhood and
that which he promises to become in the anticipated future; between that which he
conceives himself to be and that which he perceives others to see in him and to expect of
him. Individually speaking, identity includes, but is more than, the sum of all the
successive identiﬁcations of those earlier years when the child wanted to be, and often
was forced to become, like the people he depended on. Identity is a unique product,
which now meets a crisis to be solved only in new identiﬁcations with age mates and with

leader ﬁgures outside of the family (Erikson, 1968).

20
W: A measure found in the Recovery

Attitude and Treatment Evaluator- Initial Questionnaire, showing movement ﬁ'om high
scores in ﬁve dimensions, which include resistance to treatment, resistance to continuing
care, biomedical acuity, psychiatric / psychological acuity, and social / family /
environmental factors to progressively lower scores over the course of a treatment
episode (Lee, Hoffrnann, & Smith, 1992).

W: Presence of dysfunction related to a person's alcohol
and/or other drug use, despite knowledge of persistent or recurring social, occupational,
psychological or physical problems caused by use of the drug. In addition, there can be
recurrent use of alcohol and/or drugs in situations in which such use is physically
hazardous (American Psychiatric Association, 1994).

W: A clear and stable picture of one's goals, interests and talents
which is a portion of an individual's overall ego identity. Vocational identity is the clarity

of a person's vocational goals and self-perceptions (Holland, Daiger, et al., 1980, page 2).

Summary
Substance abuse is a long standing social problem that has assumed epidemic
proportions in the United States. Although a multitude of approaches have been used to
contend with the problem of substance abuse, such as prevention, incarceration, diversion
and treatment, there is no singular solution. Despite the attempts that have been made to
reduce the incidence of substance abuse, there is still a large population who need
treatment. Substance abuse treatment approaches vary, as do etiological theories.

Perspectives of treatment focus on the biomedical and the psychosocial aspects of the

21

substance abuser. In considering psychosocial variables, the developmental model
includes identity development which relates to the building of self-esteem, as an
important consideration. Self-esteem, or lack thereof, may be a causative variable related
to substance use and the consequences of addiction. A signiﬁcant aspect of identity
development is the dimension of vocational identity, but as important as it is theoretically
in developmental psychology, it is not a prevalent consideration in research or in theories
concerning substance abuse treatment. The treatment process is highly dependent upon
learning theory and application for adults both in the area of psychological development
and with reference to substance dependence. Research on relationships of progress in
substance abuse treatment to vocational identity, while considering the adult education
implications, may help in coordinating a more comprehensive and systematic approach

resulting in improved outcomes of substance abuse treatment.

CHAPTER TWO

LITERATURE REVIEW

The nature of the problem of substance dependence is reviewed in this chapter,
and the intervention strategies used to contend with the problem are explored. Further
focus is on treatment approaches for substance dependence, with particular emphasis on
the therapeutic community (TC) modality. Theories related to substance dependence are
examined, with emphasis on ego identity development. Through the examination of these
theories, a rationale is presented that provides the basis for scrutinizing of vocational
identity as one of the potential variables related to progress in substance dependence

treatment.

Substance Dependence as a Social Problem
The American Psychiatric Association In the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition, (DSM-IV), (1994) the American Psychiatric Association
deﬁned the criteria for substance dependence as follows:

A maladaptive pattern of substance use, leading to clinically
signiﬁcant impairment or distress, as manifested by three (or more) of the
following, occurring at any time in the same 12-month period:

1. tolerance, as deﬁned by either of the following:

a. a need for markedly increased amounts of the
substance to achieve intoxication or desired effect

22

23

b. markedly diminished effect with continued use of
the same amount of the substance
2. withdrawal, as manifested by either of the following:
a. the characteristic withdrawal syndrome for the
substance
b. the same (or a closely related) substance is taken to
relieve or avoid withdrawal symptoms
3. the substance is often taken in larger amounts or over a
longer period than was intended
4. there is a persistent desire or unsuccessful efforts to cut
down or control substance use
5. a great deal of time is spent in activities necessary to obtain
the substance (e.g., visiting multiple doctors or driving long
distances), use the substance (e.g., chain-smoking), or
recover from its effects

6. important social, occupational, or recreational activities are
given up or reduced because of substance use
7. the substance use is continued despite knowledge of having

a persistent or recurrent physical or psychological problem
that is likely to have been caused or exacerbated by the
substance (e.g., current cocaine use despite recognition of
cocaine-induced depression, or continued drinking despite
recognition that an ulcer was made worse by alcohol
consumption).

The preceding deﬁnition is further speciﬁed by differentiation between
physiological dependence and no physiological dependence, the stage of the course of
dependence such as early remission or partial remission, evidence of any type of
prescription drug treatment to cause adverse effects if substances were ingested and if in
any type of controlled environment such as inpatient treatment (American Psychiatric
Association, 1994, page 181).

Substance dependence is a problem because of its disruption of people’s lives, the
economic costs to both individuals and organizations, and its social impact which

manifests itself in the form of violence, crime, and other consequences. Pemanen,

(1993) and Stinson, Dufour, Steffens and DeBakey (1993) summarized research and

24

research methodology linking violence and mortality rates with alcohol dependence as
evidence of the disruptive effect it can have on society. The problem of substance
dependence exists despite numerous historical and current efforts at prevention,
correction, interdiction, and treatment. Because of the dramatic effect of substance
dependence on our culture, efforts to contend with the problem warrant ongoing
examination, with the goal of improving outcomes (Kleber, 1994).

In remarks made to the Information, Justice, Transportation and Agriculture
Subcommittee of the Committee on Government Operations, House of Representatives,
103rd Cong, 2d Sess. 1 Wages, 1994) Chairman and Representative Gary A.
Condit stated that the United States spends more than $20 billion annually to combat its
drug problem. With only 5% of the world’s population, the US. consumes two-thirds of
the world’s supply of cocaine. Although progress is being made in reducing overall drug
use, certain drugs such as heroin, marijuana, LSD, PCP, mescaline, and Methedrene are
making comebacks. The gains in cocaine use have been primarily with recreational users,
and although its use decreased dramatically from 1986 to 1992, cocaine overdoses
increased.

In 1993, following its Household Survey, the National Institute of Drug Abuse
reported that an estimated 1 1.7 million Americans used an illicit drug during the month
preceding the survey. In addition, more than 23 million Americans were estimated to
have used cocaine at some time in their lives; in 1994 users were estimated at 1.4 million
people and frequent users at approximately 800,000 (Facts about Cocaine, 1995). Since

1990, Baltimore and New York both have experienced large increases in the number of

herion cases appearing in emergency rooms W, 1994).

25

According to the NIAAA about 9% of adults in the United States meet diagnostic
criteria for alcohol dependence and the less severe medical disorder, alcohol abuse. Of
these, more than 500,000 were treated in 1993 in more than 8,000 inpatient and outpatient
alcohol treatment programs in the United States. Studies sponsored by the NIAAA have
reported relapse rates 50% or more at 2 to 4 years after treatment (NIAAA, 1996).

As McLellan, Woody, and Metzger (1996) reported, the Robert Wood Johnson
Foundation has estimated that alcohol abuse costs society approximately $99 billion
annually and that abuse of drugs costs approximately $67 billion annually. According to
McLellan, Rice and the Robert Wood Johnson Foundation (1994) reported that one-
eighth to one-sixth of all deaths in the US. can be traced to alcohol or drug abuse. Also,
the Children’s Defense Fund reported in 1994 that more than three-fourths of all foster
children in this country are the offspring of alcohol- and/or drug-addicted parents
(McLellan et al., 1996).

Gerstein and Harwood cited in McLellan et al., 1996, stated that current statistics
indicate that as many as 75% of federal prisoners meet diagnostic criteria for substance
dependence disorders. In addition, McLellan et al. reported that half of the street crimes
against property are committed while the perpetrator is under the inﬂuence of alcohol
and/or drugs or by someone who intends to use the proceeds of the crime to buy alcohol
or drugs.

Saxe, Dougherty, Esty and Fine (1983) reported that federal minimum-security
prison cells cost approximately $42,000 per cell to build and $28,000 to $32,000 to

maintain each year. In addition, the cost of probation ranges from $9,000 to $14,000 per

26

year, with recidivism rates from 40 % to 60 % resulting in incarceration due to probation
violations.

Cost estimates can be further described by examining the effects of drug use,
which also affect the spread of infectious diseases like AIDS, hepatitis and tuberculosis.
Due to the bartering of sex for drugs, sexually transmitted diseases are also related to drug
dependence. The cost of health care is affected both directly and indirectly by the
substance dependent person’s accessing care for the treatment of substance dependence
and related diseases and injuries. Substance-dependent persons use health care services
up to 10 times as often as non addicted persons, and their family members use services up
to ﬁve times as often as families whose members have no substance dependency

(McLellan et al., 1996; Saxe et al., 1983).

Intervention Strategies to Contend with Substance Dependence
Methods to intervene with substance use, abuse, and dependence have had varied
successes and failures; there is little consensus on the best overall approach. It is clear
that the complexities of the problem prevent absolute solutions resulting in eradication of
substance use, abuse, and dependence, but there continues to be optimism that control or

containment of the problem is possible.

EntreetismaLAnntQaehes
Most criminally active drug abusers are poor candidates for treatment if long-term
abstinence is the primary treatment goal, and most prison-based drug treatment programs
are not effective in reducing recidivism rates (Gerstein & Harwood, 1990). Such ﬁndings

imply that, for certain criminals and perhaps due to certain program designs, correctional

27

intervention and substance abuse treatment are not likely to be effective. On the other
hand, a small number of prison-based therapeutic communities have had positive
outcomes.

Metzger, Cornish, and Woody (1990) evaluated the effects of naltraxone, a
narcotic antagonist for opiate dependence, with federal probationers and two other study
groups with standard and enhanced probation experiences. A narcotic antagonist negates
the euphoric effect of any narcotic drug; without the psychological reward, the substance-
dependent person is less likely to use the drug and can attend more fully to the goals and
activities of treatment. Only 23% of the naltraxone group were incarcerated during the 6
months following the study as compared to 55% of the enhanced-probation group. This
ﬁnding indicated the positive effect of treatment compared to probation with increased
supervision and accountability. This study demonstrated the effectiveness of treatment in
conjunction with incarceration or probation and illustrated the failure of the corrections

system to curtail substance abuse independent of treatment interventions.

Interdiclion
Although there have been several initiatives to curtail trade in illegal drugs and
many have been effectual, there are also many examples of ineffective efforts. In August
1994, in testimony before the House of Representatives Subcommittee on Information,
Justice, Transportation, and Agriculture, references were made to the heroin trade on both
the West and East coasts ﬂourishing at near-record levels. Methamphetamine production

is up, with evidence of more than 350 methamphetamine labs being uncovered in 1993 in

California alone WW5, 1994).

28
Brexentien

Sussman and Johnson (1996) suggested that signiﬁcant progress has been made in
the science of prevention in the last 20 years. However, although there has been a steady
decline in the use of most drugs, there seems to be a resurgence due to an increase in
advertising and a lack of anti-drug messages in the media. Sussman and Johnson also
pointed to inadequate application of research ﬁndings in the area of science and practice
of prevention. This observation was supported by Gottfredson (1997), who criticized
high-proﬁle programs such as boot camps and midnight basketball for being ineffective
and praised a public school program, the Social Problem Solving curriculum. The
researchers’ premise was that high-proﬁle programs receive public attention and funding,
even though they are not as effective as others. Yet these programs are retained due to
inadequate research funding and evaluation methods.

Kleber (1994) indicated that the impact of prevention is difficult to measure but
that it appears to have a signiﬁcant effect in combination with the restriction of drug
supply. However, the change in use has been seen primarily with non-addicts use rather
than the addicted population. Kleber also stated that, in general, there had been a decline
illegal drug users to 11.4 million in 1992, which reﬂects a dramatic cultural shift (NIDA
Notes, 1997). Even with the dramatic decrease in substance abuse and dependence, there
are still many problems stemming from substance abuse in our society such as crime,
child neglect, family violence, school dropouts, AIDS, health care costs, homelessness,
urban decay, and economic costs to employers (Kleber, 1994; Pemanen, 1993).

Control over hours of alcohol sales, location of sales and taxes to increase costs

are effective preventive measures. In addition, the mass media and educational programs

29

send messages to children and young adults to refrain from initial alcohol/drug use or to
seek help if occasional use develops into a problem pattern (Frances & Miller, 1991 ).
There is evidence that efforts to prevent, control, and punish illegal acts related to
substance dependence have reduced overall substance use, abuse, and dependence.
However, laws alone are not enough to curtail the drug abuse epidemic. Rather, laws
must be supplemented by socially integrated programs that provide treatment along with

effective law enforcement and other societal monitoring (Westermeyer, 1976).

Substance Dependence Treatment

Substance dependence treatment appears to enhance certain correctional
interventions and their subsequent outcomes. The National Institute of Justice reported on
initiatives to combine substance dependence treatment with violence-reduction therapy
even though the effects and other outcomes of such initiatives warrant further study (Drug
WW, 1994). Treatment appears to have the most immediate effect
on those with the problem who have come forth to receive help. The purpose of
treatment is to reduce or eliminate drug use among those who seek treatment each year
and to lessen criminal activity that supports or surrounds addiction (Hubbard et al., 1989).

As indicated in the preceding examples, treatment is an effective intervention and
is an enhancement when used in conjunction with certain criminal populations and
correctional approaches. Treatment offers the major source of hope for many people who
are substance dependent who may have tried other alternatives, either through their own
volition or through the coercion of the criminal justice system. Kleber (1994)

recommended the expansion of substance abuse treatment as the most cost-effective

30

method to decrease the number of hard-core addicts but he also recommended ﬁrrther
research to determine which treatments work best with various types of substance

dependence.

D n re

The treatment process generally comprises three phases beginning with
detoxiﬁcation from the physiological addiction. Rehabilitation follows, with multiple
approaches to educate and provide appropriately timed interventions and therapy.
Continued care serves to prevent relapse or to provide immediate intervention to prevent
sudden deterioration into substance dependence (Frances & Miller, 1991). The treatment
process may occur in several different settings, or it may take place within the same
setting, depending on the unique set of circumstances surrounding the community’s
resources and the needs of the individual.

Treatment settings are highly variable, but they can be categorized into two basic
categories: outpatient and protective environments. Although there are other approaches
to help substance dependents, such as self-help groups and religious movements, they
were not deﬁned as treatment settings for purposes of this study. However, they are in
fact treatment supports and can often be found integrated into both outpatient and
protective settings.

Outpatient treatment is for individuals who have stabilized medically and no
longer experience severe psychological symptoms and craving; such treatment consists
primarily of individual and group therapy. In the outpatient modality, the patient is

monitored for treatment progress and compliance through self-report instruments, clinical

31

interviews and urinalysis for drug and alcohol use. Certain narcotic antagonists or
maintenance drugs such as methadone can be administered in outpatient treatment
(Administrative Rules, 1978). Other outpatient treatments include partial hospitalization
(day treatment) and intensive outpatient care. These treatments incorporate variations of
the daytime residential schedule but do not include the overnight stay and may not require
daily contact.

Protective settings can be in hospitals, where medical assistance for withdrawal
symptoms is provided or emergency psychiatric intervention for suicidal and/or homicidal
patients is available. Substance dependence treatment units are secured to prevent
unauthorized drugs (legal or illegal) from entering the unit. Often visitors are restricted,
as are telephone calls to people other than family members. The initial physical
examination may include a search of the person’s belongings and his or her body for
drugs (See Appendix D). These approaches have proven effective in improving the
treatment program completion rates and outcomes (Lavelle, Harnmersley, & Forsyth,
1991)

Another protective level of care is the residential program. In such a program, the
rehabilitative services are delivered by social workers, counselors, and/or psychologists,
with medical staff such as nurses and/or physicians providing support. The treatment
modalities are primarily group treatment, didactics, recreational activity, family education
and individual counseling.

Residential treatment has guidelines pertaining to security and visiting hours,
much like inpatient hospital programs. Both of these treatment settings provide

protection for substance-dependent persons from outside inﬂuences and from their own

32

tendencies to hide their drug use from their family or friends. Through structured time,
both day and night, the substance-dependent individual is less likely to use drugs, thus
allowing a successful detoxiﬁcation process to occur. This allows the substance-
dependent person to stabilize both physiologically and psychologically so that the issues
that led into admission in treatment can be addressed.

O’Brien, Alterman, Walter, Childress, and McLellan (1990) compared the
effectiveness of day-hospital treatment with residential treatment of cocaine-dependent
patients and found that the completion rate for residential treatment was twice that for day
treatment. Residential programs differ in their intensity of service and length of stay.

The residential treatment modality with the most intensive schedule and the longest
length of stay is the therapeutic community (TC). The members of a substance
dependence residential program are likely to have issues related to vocational identity
(DeLeon, 1995). Researchers have found positive outcomes with residential treatment
(NIDA Notes, 1997).

The TC was chosen as the setting for this study because it provides a treatrrrent
population that is more likely to be experiencing vocational identity issues than outpatient
and short-term inpatient treatment population. It is also more likely to make measurable

changes due to the longer duration of treatment.

B I] . C .
DeLeon (1995) described the TC as having unique characteristics as a social-

psychological treatment for substance dependence and as distinguishable by its systematic

treatment approach and the use of the TC community as the “teacher” and “therapist.”

33

Frankel (1989) referred to the TC as a learning environment that reculturalizes the
individual from a deviant identity to a positive identity.

Although there is no consensus about matching treatment with symptoms and
what treatment is the most cost effective, most substance-dependence practitioners
generally agree that TCs are designed for the more chronic and resource-depleted
substance dependents. Bleiberg, Devlin, Croan, and Briscoe, (1994) found that length of
stay in a TC was a positive indicator of a successful outcome. One group who stayed in a
TC for 1 month was compared with another group who stayed 6 months. The group with
the longer stay showed success through negative urinalysis, self-report of drug abstinence,
fewer days drinking, and no current legal problems over 1 year following treatment. The
longer treatment enabled the 6 month group to attend 72 encounter groups as compared to
8 for the 30-day group and 48 small-group therapy sessions as compared to 12 for the 30-
day group. Bleiberg et al. theorized that the longer treatment gave group members more
time to practice new skills, more exposure to positive staff role models, and more time to
gain insight. In addition, the additional time away from their drug-culture environment,
whether it was in the workplace or in their neighborhood, gave members an opportunity
to distance themselves psychologically from that environment. The skills learned in
therapy could also be learned in self-help groups while in treatment, and there was more
time to analyze and practice the concepts before being released from the TC.

De Leon (1995) indicated the need to organize the essential elements of the TC to
assist in understanding and researching the methods employed in the TC approach. He
indicated that many approaches have been developed using the TC principles, but no

structure has been developed that lends itself to a thorough understanding. De Leon

34

reported that the Therapeutic Communities of America reported an estimated 80,000
admissions yearly into TCs, which provide a range of family, educational, vocational,
medical, and mental health services to a widely diverse treatment population. Not only
are substance-dependence paraprofessionals and professionals involved in TCs, but other
professionals are involved, including those from the mental health, medical, and
educational disciplines.

De Leon (1995) credited many authors and researchers, such as Yablonsky (1965),
Casriel (1966), and Kooyman (1992), with formulating the basic tenets on which the
framework of TC theory has been built. The TC can be portrayed as having distinct
concepts, assumptions, philosophy/ideology, program features, and clinical practices that
can be described and studied.

The TC perspective in treatment assumes that an artiﬁcial social/psychological
environment is set up, wherein the residents in treatment not only receive treatment but
also teach the therapeutic concepts, policies, and procedures. The TC values certain
correct behaviors, which are reinforced, and punishes drug-seeking and related anti-social
behavior through personal and program sanctions, including discharge from the TC.

De Leon (1995) observed that treatment is not “provided” but is “made available” to the
residents in treatment, who may choose to participate in work details to keep the facility
in order and clean, may participate in community meetings, and may enter encounter
groups and participate in recreational activities. If individuals do not participate, their
motivation will be questioned and eventually they might be discharged if they are seen as

simply “doing time.” The TC is a powerful social force of which the substance-dependent

35

may become a part, providing an opportunity to trade the street social skills and personal

values for the TC’s skills and values.

Developmental Perspectives on Substance Dependence

Practitioners and theorists have looked at substance dependence as a
developmental issue (Damon, 1983). Such a view requires an understanding of the
perspective of Erikson, who formulated a developmental stage model ( Erikson, 1959).
Theory in the area of developmental psychology has focused on Erikson's ego
development model, which proposes that development occurs in stages. This
conceptualization is referred to as the epigenetic principle. Derived from the growth of
organisms "in utero," this principle states that anything that grows has a ground plan, and
that out of this ground plan the parts arise, each part having its time of special
ascendancy, until all parts have arisen to form a ﬁrnctioning whole. Psychological
developmental theory assumes that there is a succession of potentialities for signiﬁcant
interaction with others at a culturally deﬁned rate and sequence, which governs the
growth of the personality (Damon, 1983).

According to the developmental substance-dependence theory, individuals tend
not to develop beyond the stage of development they are in when the use of a substance or
its addiction begins (Pepper, 1992). They are "ﬁxated" in or likely have not successfully
completed the developmental tasks of their current stage of development or other
subsequent stages. Consequently, practitioners focus on an individual's developmental
tasks and refer to a "14—year-old in a 34-year-old body" if the individual became

substance dependent at the age of 14 (Napier, 1990).

36

Kellogg (1993) proposed that recovery ﬁ'om substance dependence be viewed
from a multiple identity perspective. He cited the development of theory in the area of
substance dependence recovery that has proposed a psychodynamic and social model. In
this model, a group afﬁliation is developed that has its own perspective, its own thought
and behavioral norms. The self redeﬁnes with each change in membership and may
maintain two separate identities simultaneously. This is evidenced by the substance-
dependent person’s beginning treatment in a drug-free treatment group and returning to
the drug-using peer group, which results in a struggle to decide which values to retain and
which to reject. Frankel (1989) referred to rites of passage in identity development from
an anthropological perspective, whereby the cultural environment deﬁnes a substance:
dependence identity. Depending on the sociocultural context, the identity can be
transformed from being an “addict” identity to being a “positive" identity.

Although the focus of this study was on vocational identity and substance
dependence, it is essential to review psychological developmental theory, from which
vocational identity theory and much of substance dependence theory has evolved. Both
of these theories had their origins in Erie Erikson's work in ego psychology, which

evolved from Freudian psychology.

Eguldenmx
Erikson (1959) referred to a "personal identity," which is based on two
simultaneous observations: (a) the immediate perception of one's selfsameness and its
continuity over time and (b) the perception that others recognize this selfsameness and its

continuity over time. He further deﬁned ego identity as the awareness that there is a

37

selfsameness and continuity to the ego's synthesizing methods and that these methods are
effective in safeguarding the sameness and continuity of one's meaning for others.

The development of ego identity is a process integrated into an overall
developmental model that includes the following sequential stages: trust versus mistrust,
autonomy versus shame and/or doubt, initiative versus guilt, industry versus inferiority,
identity versus identity conﬁrsion, intimacy versus isolation, generativity versus
stagnation, and integrity versus disgust and/or despair (Damon, 1983; Erikson, 1968;
Marcia et al., 1993).

Development of ego identity begins during adolescence and marks the end of
childhood and the beginning of adulthood. Marcia et al. (1993) stated, "Identity
formation involves a synthesis of childhood skills, beliefs, and identiﬁcations into a more
or less coherent, unique whole that provides the young adult with both a sense of
continuity with the past and a direction for the ﬁrture,” (p. 3). Marcia et al. viewed
identity as having three dimensional aspects: structural, phenomenological, and
behavioral. Identity is structural because it ﬁts into the overall psychodynamic
developmental process. Theoretically, it is necessary to resolve the identity crisis in order
to function more fully in other areas such as intimacy and generativity. The
phenomenological aspect refers to either having an identity or not having a sense of
identity and its qualitative characteristics. The behavioral aspect refers to what others
observe of one's identity. According to Marcia cited in Lapsley and Power (1988),
Erikson’s most signiﬁcant contribution in the area of developmental psychology is the

structural model of identity.

38

Since Erikson's theorization, many researchers such as Marcia have reshaped the
concepts into segments that can be observed and measured. Much of the interest is in
whether a person has achieved an identity. Developmental psychologists using the
epigenetic constructs assume that each stage of growth must somehow be resolved before
full attention is given to subsequent developmental stages.

This focus on whether the identity has been achieved has resulted in substantial
study in the area of identity status. The individual is seen as having reached an achieved
status if there has been an exploratory phase resulting in a resolved crisis whereby the
individual decides on an identity. The exploratory phase is also referred to as a
moratorium stage, in which individuals gather information about themselves and about
how others see them and are in the process of deciding what will be their commitment.
This exploration and the process leading to a commitment regarding one’s identity is
considered an identity crisis.

Another identity status is foreclosure which is characterized by the individual's
acceptance of an external authority's direction, recommendation or belief system. The
external authority is most often a parent, but it could also be a teacher or another
professional after the individual reaches adulthood. Often preadolescents are foreclosed
because of their dependence on external authorities. The diffusion status is indicative of
individuals who are uncertain and confused about their identity even after undergoing a
decision-making period (moratorium).

Some have criticized the ego identity formulation as being too global and have
proposed more focused study of the domains of identity, which have been categorized in

as few as three domains: vocation, ideology, and family (Erikson, 1968). Archer and

39

Waterman (1983) have observed that as the domains have been considered, several more
have emerged; these include vocational plans, religious beliefs, political ideologies, sex-
role orientation, values, and family roles.

It is possible for an individual to be in a different identity status for any number of
domains. For instance, a person may be foreclosed in religious beliefs and in moratorium
for vocational development; i.e., he or she may be highly religious due to strong parental
upbringing about religious choice but may be undecided about a career. Consequently, it
is helpful to assess a person's identity status in several domains when planning treatment
and intervention (V ondracek, 1992).

Erikson acknowledged the importance of vocation in the development of identity,
which has led to theory and assessment models in the area of career identity (Holland et
al., 1980; Marcia et al., 1993; Vondrasek, 1992). Career identity is deﬁned as a clear and
stable picture of one's goals, interests, and talents (Holland et al., 1980). Expanding on
this conceptualization, vocational identity is an individual's perception of his or her own
vocational aptitude, skills, knowledge, developmental level, and actualization.
Awareness of these dimensions depends in part, on feedback from authorities in the
individual’s environment such as parents, teachers, trainers, employers, customers, and
fellow workers. People’s awareness of these dimensions will vary, depending on the
resources that are available to help measure their strengths and weaknesses and their

inherent abilities to ﬁrnction in general.

40
Snbstanceﬂependeneeandldenﬁu

Adams (1995) described the process of moving from one stage to another through
the metaphor of launching. He explains it as a qualitative process whereby a landing is
predetermined by the trajectories of the launch. As an example, those who are diffused
tend to stay isolated, which inhibits intimacy. This status may be reﬂected in behavioral
pathology either through borderline personality disorders or substance dependence.
Rosanti (1995) categorized subjects enrolled at an eastern university as having a “diffuse
avoider” ego identity after reviewing their strategies for problem solving, which were
ineffective and maladaptive. These diffuse avoider subjects showed no signs of cognitive
planning and scored low in self-efﬁcacy. Collum and Pike (1976) found these same
traits to be prevalent in substance-dependent persons who often experienced a weakened
sense of identity before dependence and during treatment. These same individuals were
considered borderline personalities and during addiction possessed a powerful sense of
identity as being an “addict.” The premise that there may be multiple identity statuses and
even dual identities was reinforced by Dryer (1995) who proposed the existence of a
mainstream identity and a subcultural or bicultural identity. His illustration was focused
on linguistic cultures, but such a premise also can be applied to the drug culture alluded
to by Collum and Pike. Kellogg (1993) also referred to multi-identity theory, whereby a
substance-dependent person can have a coexisting recovering identity and a street drug
identity.

According to Schumrurn and Hartman (1988), many substance abusers are adult
children of alcoholics who experience difﬁculties in the areas of intimacy, trust, self-

esteem, addictive behaviors and career decision making. To further validate this

41

contention, Hartman and Fuqua (1983) found that adult children of alcoholics using
services in an urban university counseling center appeared to develop personality traits
that paralleled the personality constructs that were like chronic career indecision.

Benshoff et al. (1990) stated that vocational variables have long been associated
with substance dependence, either as antecedents to substance dependence or as
important supports increasing the probability of continued abstinence. However, the
association has been loosely deﬁned, and vocational development dynamics and
substance dependence have not been closely examined.

Taking into account the common characteristics of adult children of alcoholics,
such as trait anxiety, identity confusion, and extemalized locus of control, Schumrum and
Hartman (1988) proposed a model demonstrating how growing up in an alcoholic
dysfunctional family may lead to chronic career indecision. A child of an alcoholic is at
increased risk as a youngster to experience violence, ﬁnancial difﬁculties, physical
illness, and injuries. This consistent uncertainty continues into adulthood, even though
the adult is no longer living in the alcoholic environment. Adult children of alcoholics
tend to adopt roles to survive, rather than resolving the crises of development. By
avoiding conﬂict, they sacriﬁce development of an identity (Schumrum & Hartman,
1988). Galinsky and Fast (1966) found that making a vocational choice is a way to
express one's identity, and if there has been only superﬁcial identity development through

playing roles, then career choices and vocational identity are likely to be impaired.

42

Substance Dependence and Vocational Identity

Even though much of ego identity is developed during the adolescent stage, many
issues are still under consideration for years to come. Through life experiences, an
identity crisis can occur, resulting in states of diffusion or moratorium. Career
development is a dimension that is likely to vary in adults, due to the instability of job
markets and rapid technological advances. Add other crises to an adult’s life, such as
substance dependence and stability of ego identity is threatened.

In the last decade, researchers have associated substance dependence and
vocational variables (Benshoff et al., 1990; Hoffman & Miller, 1992; Lea], 1990; Leung
& Sakata, 1990; Livingston, Randall, & Wolkstein, 1990; Powers, 1978; Shipley, Taylor,
& Falvo, 1990). Groah, Goodall, Kreutner, Sherron, and Wehman (1990) recommended
that a thorough assessment of history and patterns of substance dependence be coupled
with supportive employment services. Researchers in this area often have recommended
improved and more frequent studies of both vocational rehabilitation and substance
dependence (Benshoff et a1, 1990). Such research may help determine causal factors of
substance dependence and the supports necessary for establishing lasting recovery.

Some writers have viewed addiction as a vocation in and of itself because the task
of obtaining the drug may totally absorb an individual, much like a full-time job. A street
heroin addict has been described as "an active, busy person, preoccupied primarily with
the economic necessities of maintaining his real income--heroin" (Pittel, 1974, p. 233).
The street culture associated with illicit drug use is not necessarily a counter culture when
one considers the economy of obtaining substances. It takes a great deal of

resourcefulness to maintain enough income to support an addiction to heroin or cocaine.

43

These same skills potentially could be applied to more socially acceptable actions, such as
legitimate employment or education. If the proper conditions exist, such as individual
motivation, community support, and viable options, individuals may ﬁnd legitimate
employment attractive.

There is a need to assess career interests, aptitudes, and values and to identify
different phases of career development (Powers, 1978; Super, 1957). It is not clear how
much assessment is performed in these areas or how skilled substance dependence and
vocational rehabilitation professionals are in identifying this information. Although it is
commonly believed that young substance abusers who have jobs or vocational training
might be able to reduce their substance dependence, it appears that work alone is not
enough to ensure long-term recovery. Hammer et al. (1985) found that additional
vocational training was necessary for substance-dependent clients to develop skills that
would enable them to ﬁnd employment in other than unstable unskilled jobs. Such jobs
tend not to enhance self-concept, whereas improved self-concept is a likely positive force
in preventing substance dependence.

Theoretical models have been proposed to help drug abusers make the transition
from illegal activities into legitimate vocational options (Powers, 1978). Ginzberg,
Super, and Hershenson (cited in Powers, 1978) and Erikson, Holland, Marcia and
Grotevant (cited in Straube, 1990) agreeing that identity development and its subpart,
career identity, are developmental processes. During this process certain competencies
are developed, such as self-appraisal, knowledge of occupations, selection of goals,
planfulness, and problem solving (Crites, 1969, 1973; Powers, 1978). Powers suggested

that there is a strong need to expand vocational criteria for success beyond job placement

44

to include job training, job placement, measures of job performance, and career

satisfaction.

Substance Dependence Treatment and Vecatienal Semiees

Clients in treatment often state that their greatest unmet needs are in the area of
vocational and educational services and, further, these needs are not adequately addressed
in their treatment programs (Livingston, 1981). Part of the reason a program might not
attend to such problems is professional’s view that vocational issues are addressed by job
placement counselors, rehabilitation specialists, and so on. Lack of attention to
vocational issues may be associated with the substance dependence treatment program's
lack of experts or resources to tackle vocational issues; there is no funding or no staff
training to address the issues. Local community resources to help individuals with
vocational problems might not be available. The economy might also be a factor in that
few jobs are available for those who are helped or it is relatively easy to ﬁnd unskilled or
semi-skilled employment.

Perhaps most important, employers and even personnel in job training programs
often have negative attitudes toward individuals with employment and substance
dependence problems. Unreliability and social stigmas often prevent the substance
abuser’s being considered for training or employment. These attitudes also may be
shared by substance dependence treatment professionals, many of whom would rather
avoid issues related to vocational identity because they are not interested in that
dimension of the individual or they believe there is little chance for rehabilitation in the

vocation. Another factor may be timing. The client may think that ﬁnding a job is a

45

more immediate need than dealing with other psychological issues. The substance
dependence treatment professional may believe the psychological issues must be dealt
with ﬁrst before vocational issues are considered.

However, Livingston et al. (1990) found that when such services were provided,
criminality was reduced and there was an increase in employment and earnings. Due to
limited funding, Livingston et al. has proposed that an organized work-study program be
developed for rehabilitation-specialist students to share the burden of vocational service
delivery in the short term. In the long term, the program would develop awareness and a
more sophisticated group of rehabilitation counselors dealing speciﬁcally with substance
dependence.

As an example of such a program, a two-day course was offered to Employment
Service staff in the United Kingdom who were working with people with substance
dependence problems (Gossop & Birkin, 1994). The course was designed to help staff
members identify drug and alcohol problems, assess their severity, and refer clients to
specialized agencies when necessary. Six month follow-up on a sample of the trainees
showed substantial improvements in staff members’ conﬁdence in working with
substance abusers and their willingness to intervene with such clients. Although progress
in substance dependence treatment was not clearly measured in the study, the
improvements in the delivery system were apparent.

Once substance abusers are treated for medical and psychological problems
associated with their addiction, treatment is often considered completed. Vocational
issues may be seen as an important aftercare problem area, but by the time the substance-

dependent person is in aftercare, the treatment supports have dwindled or vanished.

46

Without these supports, the substance abuser escapes accountability, which often results
in underemployment or unemployment. Individuals who never have sought or found
permanent employment commonly are found in this group. These "vocational virgins"
(Elliot, 1992) have never sought employment, for a variety of reasons. It is possible that
if vocational issues were seen as primary and concurrent with substance dependence

treatment, a commitment would be made to a productive vocational plan.

The Need for Further Research

Treatment approaches are based on psychological, physiological, and sociological
theories, which are not easily tested because of the large number of variables that
intermingle before, during, and after treatment. Consequently, questions continue to be
raised about what differentiates one patient from another in their response to treatment.
Treatment approaches are apparently effective and continue to be improved, but it is
necessary to explore the factors contributing to progress in substance dependence
treatment in order to maximize treatment outcomes (Kleber, 1994; McLellan et al., 1996).

Substance dependence results in the depletion of resources such as family support,
ﬁnancial assets, work status, and psychological strength. Treatment approaches usually
strive to help the patient replenish these areas by compartmentalizing the drug
dependence problem and by refocusing on short-term accomplishable tasks. Often
employment or vocational issues are problematic and need attention during substance
dependence treatment. These issues are commonly discussed but not extensively studied
through research. In addition, the role of career identity development as it relates to drug

dependence has not received focused attention in treatment theories or research.

47

Researchers on substance dependence have referred to vocational development
and many treatment modalities that are designed around vocational models (Hammer et
a1, 1985; Livingston et a1, 1990). However, many substance dependence treatment
professionals minimize vocational issues because the treatment population is employed or
do not see vocational issues as a major concern relative to other treatment issues
(Thompson, 1990). Substance dependence treatment providers tend not to use career
development tools/models and lack career development training. They may not be
connected with community/state vocational rehabilitation resources, which could assist
with vocational assessment and intervention strategies (Frohman, 1987).

If individuals are struggling in their ego identity and career identity developmental
stage and begin using chemicals or, possibly more signiﬁcantly, become addicted, it is
possible that their psychological development will be affected. Developmental theorists
would say these individuals are "ﬁxated" in whatever stage their addiction was
manifested and will remain so until they address the substance dependence. To
understand vocational identity, it is essential to review psychological developmental
theory. In addition, substance dependence treatment theories need further elaboration,
with a focus on developmental ideas.

Those without stable vocational goals, a satisfactory job, a clear educational or
vocational plan, and reinforcing experiences in the world of work, are likely to have less
intellectual and emotional focus on treatment because of their preoccupation with
satisfying more basic needs. Many substance abuse treatment approaches eventually
explore complex emotional and spiritual issues, but the substance-dependent person’s

preoccupation with developmental tasks related to career identity development may

48

detract from the treatment effect. It has been theorized that if one’s basic needs have
been satisﬁed and developmental tasks such as establishing a career identity have been
accomplished, then the effects of treatment for that person will be more pronounced.

Treatment progress is achieved in small increments and is measured as job-
seeking behavior, enrollment in educational pursuits, reestablishment of positive
relationships with family members, attendance at self help meetings, completion of
assignments issued by treatment professionals, compliance with rules and guidelines of
the treatment facility, abstinence from drugs including alcohol, and changes in attitude
toward recommended alternatives to substance dependence.

Even though vocational issues have a well-established relationship with substance
dependence, it is unclear how they work together; consequently, it is important to explore
this relationship further. Continued efforts to measure the variables associated with these

two phenomena will help in describing their relationship more precisely.

Measurement of Vocational Identity
Erikson’s theory concerning ego identity is highly philosophical and does not
provide clearly measurable constructs. However, a number of researchers have attempted
to measure identity. Tan, Kendis, Fine, and Rorac (1977) developed a 12-item Ego
Identity scale, and Marcia’s identity status construct has been subjected to research using
a variety of instruments (Damon, 1983). Particular aspects of identity such as vocational
identity have also been examined by a variety of researchers, through both theoretical

development and empirical studies (Healy, Tullier & Mourton, 1990; Holland,

49

Gottﬁedson & Power, 1980; Lopez, 1989; Munley, 1977; Salomone & Mangicaro, 1991;
Savickas, 1985; Tinsley & Bowman, 1989; Vondracek, 1992).

Vocational identity status can be measured through interviews or through
objective analysis of subjects’ verbalization of their plans for the future (Raskin, 1994).
Conducting the interviews and analyzing data from audio tapes often is time consuming;
written instruments are available that can provide the pertinent information.

Holland, Gottfredson, et al., (1980) developed an l8-item true-false vocational
identity scale, which is part of the My Vocational Situation (MVS) instrument. This has
been found to have a high degree of reliability and validity (Tinsley & Bowman, 1989),
and because of its ease of administration it is used extensively with a variety of
populations. It is possible to categorize vocational identity as being in the category of
either achieved or nonachieved states through the use of the scale. Other instruments and
methods can be used to measure vocational identity in other status categories such as
exploratory, moratorium, foreclosed, or diffused (Marcia et al., 1993). However, the
MVS is commonly used to assess the degree of vocational identity that has been
developed due to range of scores that is possible with the instrument. Because vocational
identity can change, the scale scores can be interpreted as falling into a nominal “yes” or
“no” category or on a continuum related to high or low degrees of vocational identity.
This ﬂexibility of the instrument reﬂects the nature of the phenomenon of vocational

identity, which can change when crises of adult life intervene.

50

Measurement of Progress in Substance Dependence Treatment

Many theorists and practitioners have viewed alcoholism and drug dependence as
uniform, often omitting individual differences in personality or cognitive style (L. Miller,
1991). By looking at an individual's unique cognitive and personality traits, practitioners
might better understand and perhaps predict a client’s substance dependence relapse.
Miller found that relapsers do poorly in tests of language, abstract reasoning, planning,
and cognitive ﬂexibility. These functional areas are also important for any individual
who needs vocational development. If both substance dependence and vocational
rehabilitation issues are addressed with this population, it is likely that improved
treatment efﬁcacy will follow.

However, W.R. Miller (1992) found that several approaches have shown
measurable differences in outcome, including the community reinforcement approach. In
this approach, several strategies, such as a job search and placement, are used to ensure
employment. This has proven more effective than traditional residential inpatient
treatment and outpatient treatment (Azrin, 1976; Azrin, Sisson, Meyers, & Godley, 1982;
Hunt & Azrin, 1973; W.R. Miller, 1992). Such an approach without the traditional
substance dependence treatment threatens grounded treatment philosophy and certain
types of professionals such as certiﬁed addiction counselors, who would likely propose
that vocational development is just one dimension of recovery. Another issue that
challenges community approaches is funding viability. If the community reinforcement
approach is effective, how can it be ﬁnanced? Currently, there are few, if any, third-party
insurers who reimburse for vocational rehabilitation. Much criticism has been leveled

against substance dependence treatment approaches; some researchers have concluded

51

that there is no overall difference in effectiveness among different modalities or even
between treatment and no treatment at all (Annis, 1986; Holder, Longabaugh, Miller, &
Rubonis, 1991; W.R. Miller, 1992; W.R. Miller & Hester, 1986).

The Project MATCH Research Group ( 1997) focused on particular treatment
methods matched to client attributes and found that substantial treatment had been
provided and signiﬁcant improvements achieved. In attempts to discriminate between
methods, only one attribute, psychiatric severity, showed a signiﬁcant relationship with
treatment interaction. In addition, clients who were low in psychiatric severity were
abstinent longer after l2-step facilitation treatment than after cognitive behavioral
therapy. The Project MATCH Research Group recommended that those assessing
substance dependence treatment consider psychiatric severity when matching patients.
But, because of the lack of robust results, the research group considered the treatments
studied to be equally effective despite their philosophical differences.

A common dynamic in substance dependence treatment is the patient's denial of
the severity of the problem. An individual may be on the verge of losing employment, a
marriage, ﬁiendships, and lifelong possessions and still continue to minimize the role that
substance dependence plays in these life disasters. These same dynamics carry over to
the person's immediate relationships, which is why it often takes several years for the
consequences of substance dependence to catch up with the substance abuser (Gastﬁiend,
F ilstead, Reif, Najavits, & Parrella, 1995). Even after entering treatment, the substance
abuser resists information and interventions that challenge long-held beliefs that he or she
can control the use of alcohol and other drugs. It is this defense that is often the single

most difﬁcult hurdle preventing efﬁcacy of the rehabilitation process. The substance

tar-3r

ltl‘t‘.
p311:

and

52

dependence treatment professional often is able to intuitively deduce a patient’s level of
resistance to treatment. However, reliable measures are helpful not only in detecting the
level of resistance, but also in providing evidence of resistance with which to confront the
patient about his or her resistance relative to that of others in treatment. Having a valid
and reliable measure may also help in treatment planning, with regard to allocation of
resources for each objective during and following treatment.

The Recovery Attitude and Treatment Evaluator-Initial Questionnaire (RAATE-
QI) is a questionnaire was designed to measure resistance to treatment, continuing care,
acuity of biomedical problems, acuity of psychiatric / psychological problems, and the
degree to which the psychosocial environment is supportive of or detrimental to recovery
(Mee-Lee & Hoffmann, 1987; Smith, Hoffmann, & Nederhoed, 1992). High resistance to
treatment might indicate that certain resources should be held back until there are
indications that the person is more amenable to treatment. Such an additional resource
that might be ill timed at a high stage of resistance is vocational counseling. On the other
hand, the attractiveness of vocational development may function as a motivational tool to
help reduce resistance to treatment, either as a reward or as an activity that serves a

therapeutic function to reduce resistance.

Implications of Adult Education for the Substance-Dependent Population
Adults have unique needs that must be considered when developing educational
Plans (Cross, 1983; Knowles, 1990). The measurement of progress in substance
dependence treatment and vocational identity, as well as the implications of the ﬁndings,

iIlrplicitly requires that educational issues be considered. The tendency of the TC is to

53

rely heavily on educational methodology to develop plans for therapeutic intervention and
vocational strategies. Both outpatient and protective settings rely on psychoeducational
groups to convey information about treatment philosophy, problem solving, medical
information, and other pertinent topics. La Salvia (1993) studied the efficacy of
psychoeducational groups with clients with an addiction disorder in an outpatient setting.
The approach used was a didactic-style group with assigned tasks, much like that of a
school classroom. Even though La Salvia did not evaluate adult learning considerations,
the didactic groups appeared to better meet the needs of the subjects than traditional
psychotherapy. De Leon (1995) emphasized the importance of the patient in the TC
learning concepts associated with recovery and described this learning as part of the
therapeutic process. Frankel (1989) emphasized the process of learning new meanings,
beliefs, and deﬁnitions in a TC, which will lead to the client’s transformation into a
recovering identity. It is clear that approaches to substance dependence and vocational

development are interwoven into the adult education tapestry.

Summary
Substance dependence has received a signiﬁcant amount of attention due to its
dramatic consequences for individuals and the society. The strategies to contend with
this problem have been examined from several perspectives, including prevention,
criminality, interdiction and treatment.
Certain common elements of substance dependence can be extracted from the
myriad of issues; these include descriptions of signs and symptoms, theoretical constructs

related to etiology, and therapeutic interventions based on research theory.

54

Developmental theory views the development of ego identity as an important dimension
to consider in understanding and treating substance dependence. A part of identity
development that seems to be related to substance dependence is vocational identity.
Adult vocational identity can change due to technological advances and crises in adult
life.

Further understanding of the relationship between vocational identity and
substance dependence is important, in order to treat substance dependence most
effectively and to provide proper vocational services for the substance-dependent
individuals. Progress in substance dependence treatment and vocational identity can be
measured and their relationship explored to further improve approaches to both. In
addition, it is necessary to keep in mind the implications of adult education for this

population because educational methods are used in the delivery of services.

CHAPTER THREE

METHODOLOGY

The researcher’s purpose of this study was to investigate the relationship of
vocational identity and other mitigating variables to progress in substance abuse
treatment. This chapter contains the research questions posed in the study, an overview
of the research design, a description of the sampling procedure and the instrtunents used
to measure progress in substance abuse treatment and vocational identity, and a

discussion of the procedures used in collecting and analyzing the data.

Research Questions

This researcher sought to determine whether there is a relationship between
progress in substance abuse treatment and vocational identity. In the initial design of the
study, hypotheses were developed based on the assumption that the subjects would fall
into dichotomous groups of either achieved or nonachieved vocational identities. In this
design the researcher would test hypotheses related to each RAATE-Q1 measure of
progress in substance abuse treatment in relation to the grouping of the subjects into
dichotomous groups as determined by Holland, Daiger, et al.’s (1980) My Vocational
Situation (MV S) instrument. The study design was changed to a correlational design

after initial ﬁeld testing.

55

56

A post hoc analysis was conducted, comparing the RAATE-T1 only group (N =
94), which left treatment before taking the second RAATE-Q1, and the RAATE-T2 group
(N = 102), which took the ﬁrst and second RAATE-Q1. The possibility exists that there
was a difference between the two groups, and the primary study group was not randomly
selected due to the differences between the two groups.

The researcher explored the relationship of several independent variables to
several dependent variables that deﬁned progress in substance dependence treatment.
Speciﬁcally, the question investigated in this study was: What is the relationship of
vocational identity, length of treatment stay, years of education, age and income at the
time of admission to speciﬁc measures of progress in substance dependence treatment?
Progress in substance abuse treatment was measured in terms of resistance to treatment
planning, resistance to continuing care, biomedical acuity, psychological and psychiatric

problems, and social/family/environmental factors.

Research Design
IheRqulatiQn
The residential therapeutic community modality was selected because of its

controlled environment as compared to an outpatient program, because of the
accessibility to clients in treatment for research purposes, and because the length of stay
for treatment was signiﬁcantly longer than inpatient care, more traditional residential
treatment, and modiﬁed forms of day treatment. A complete description of the
philosophy of therapeutic residential treatment programs, the treatment process, and the

experience of the researcher is included in Appendix D.

57

Adult males from an urban area in southeastern Michigan who had been
diagnosed as substance dependent and admitted to a long-term residential TC for
substance abuse treatment were given information about the study design and were asked
to volunteer for the study. This information was presented in the ﬁrst few days of
treatment and included several requirements for participating in the study, which are
noted below:

1. Upon admission to the TC, the subject candidate had a diagnosis of

substance dependence as deﬁned under the guidelines of the DSM IV
(American Psychiatric Association, 1994).

2. Either before or during the stay in treatment, the subject was employed or
employable (currently not on long-term disability from work or through
governmental designation).

3. The subject showed willingness to participate in the study voluntarily, as
evidenced by his signature on the human subject release form.

4. The subject was male and 18 to 55 years of age.

Sample
The sample was determined through self-selection by the subject candidates and
by the program staff, who prescreened the candidates to meet the minimum criteria. This
study focused on indicators of progress in treatment while the subjects were in treatment
in a residential setting. Initially, the researcher also had intended to survey subjects in
halfway houses at multiple locations, but due to poor cooperation by personnel at those

treatment facilities, the subjects who completed both the baseline questionnaires (MV S

58

and RAATE-T1) and the second RAATE-Q1 (RAATE-12) originated from only one
residential treatment program.

Upon admission to the treatment program, the subjects were initially screened by
clinical personnel trained in substance dependence treatment. These clinicians all met
minimum credentialing requirements of the State of Michigan Department of Public
Health, Center for Substance Dependence Services, as Certiﬁed Addiction Counselors or
possessed a bachelors or masters degree in a human service ﬁeld such as nursing,
psychology, social work, and/or counseling.

During the intake process, a detailed biological, psychological, and social history
assessment was conducted to determine the person’s eligibility for the treatment program
and to begin to develop short- and long-term treatment needs and goals. During this
process, the individual's vocational status was assessed through a series of questions to
determine employment status, educational level, and need for additional training and/or
education. This contact preceded any by the researcher but established compliance with
criteria of the substance dependence diagnostic code(s), as well as the individual’s
eligibility for the study and interest in participating.

To qualify for admission into residential or halfway-house treatment, a patient not
only must meet the criteria for a substance dependency diagnosis but also must have a
severity of illness that meets the guidelines for intensity of service. Measurement of the
criteria relies on the patient’s self-report and possibly an evaluation by a physician or an
external independent clinical agency.

This measurement included an assessment of the individual’s ability to abstain

from the use of mood-altering substances without a protective environment that would

59

control the availability of such substances and would restrict the person’s movement into
the environment outside the TC. Previous abstinence in outpatient settings, current
cravings, stability of family support and consequences such as incarceration or
employment termination if the patient was unsuccessful also were considered. The
individuals who qualiﬁed for the treatment program in this study met the criteria for
residential treatment because they had failed previous outpatient treatment; were unable
to stop using substances without signiﬁcant and prolonged intervention; were in jeopardy
of incarceration if they did not successfully complete the residential program; were
participants in an employer-sponsored job-jeopardy program, which required their
involvement in the treatment program to retain employment; were experiencing profound
cravings for their substance of choice; and/or were experiencing signiﬁcant family
problems and may have bankrupted their ﬁnancial resources to the extent that shelter was
not available (see Appendix D).

During this portion of the assessment process, the substance dependence treatment
staff gave a brief informational letter and study summary to the subject candidate,
explaining the research project (see Appendixes A and B). After reading and discussing
the project with the staff person, the subject was asked whether he wished to participate;
if he did, he signed the subject release form (see Appendix C).

The intake and assessment process lasted approximately 1 week to orient the
patient to the program rules. During this time of orientation, subjects were given the ﬁrst
battery of instruments, usually in a classroom setting. Some subjects who were not given
the informational packet at intake were oriented to the study in the classroom setting and

were given the questionnaires to complete once they signed the release form.

60

Data Collection
Data were collected by treatment program professional staff who were trained to
proctor the two questionnaires at admission and after at least 4 weeks of substance
dependence treatment. The speciﬁcs of the design and the instruments are detailed in the

following pages.

Imtmmentatien

Two questionnaires, the RAATE-Q1 (Mee-Lee et al., 1987) and the MVS
(Holland, Daiger, et al., 1980), were administered during the ﬁrst week of admission into
a residential program for substance dependence treatment. The MVS instrument was
used to measure the strength of vocational identity in relation to other variables such as
age, income, education, and length of treatment. The different dimensions of progress in
treatment were measured by the RAATE-Q1. Between the fourth and eighth weeks of
treatment, those who were successfully participating in the treatment program were again
administered the RAATE-Q1 to measure progress in treatment. The group taking the
second RAATE-Q1 was designated as RAATE-T2 to differentiate it ﬁ'om the group that

took only the ﬁrst MVS and the RAATE-Q1, hereafter referred to as RAATE-T1.

IheMMS

Vocational identity was measured with the Vocational Inventory Scale of the
MVS. This scale was designed to measure the relationship between vocational behavior
and personality. Vocational identity can be construed as a developmental variable in that
it relates to progress in ego-identity formation and the degree of vocational development

(Savickas, 1985). It has been hypothesized that vocational identity relates most to the

61

developmental task of crystallizing career preferences or identifying what one likes to do.
Its developmental nature makes the construct dynamic in that there is an internal process
of self-evaluation (or lack of) in which the individual examines vocational issues that lead
to choices or preferences regarding a career (Savickas, 1985).

The Vocational Inventory Scale of the MVS is used to measure the degree to
which individuals have a clear and stable picture of their goals, interests, personality, and
talents. According to Savickas (1985), the scale evolved from research on the correlates
of indecision. Respondents are asked to respond either "true" or "false" to 18 items; the
score is the number of "false" responses. A high score is indicative of individuals who do
not need career guidance because they are well organized, self-conﬁdent, and competent
to handle life situations (Savickas, 1985). Individuals who score high on the scale are not
tense or diffused.

In addition to the Vocational Inventory Scale, the MV S also contains
supplemental questions that identify the subject’s need for information and the barriers to
career development. More ﬂexible than the scale, these questions explore of some of the
issues facing the individual, with a more open-ended infonnation-gathering technique.
Although data were not compiled from these questions, the researcher checked for
internal reliability on a number of “false” responses. For example, if a subject had a large
number of false responses, indicating a highly achieved status, but indicated a need for
vocational and educational information and other resources, there would have been
justiﬁcation to reexamine whether this person was, in fact, in the achieved status category
or was instead in another status category, such as exploratory or diffused crisis status; the

converse applies for a low number of false responses. The MVS is quantitatively bent

62

toward validating vocational achievement and cannot discriminate among the
nonachieved statuses (diffused, moratorium or foreclosed) referred to by Marcia et al.
(1989). It does add supplemental information to identify a subject’s need for information
and barriers that, if overcome, could lead to the person’s having vocationally achieved
status (Holland, Daiger, et al., 1980).

In terms of internal consistency, the scale had reliability coefficients of .86 to .89
for samples of male and female high school students and college students/workers
(Holland, Daiger, et al., 1980). A study comparing the Vocational Identity Scale of the
MVS with the Ego Identity Scale and the Medical Career Development Inventory
indicated that the Vocational Identity Scale related signiﬁcantly to both of the
corresponding scales. The strongest association was with crystallization of a career

choice (Savickas, 1985).

IheRAAIE—QI

The RAATE-QI was designed to assess the individual's attitude toward treatment
and continuing care. The questionnaire uses 94 true/false items measuring ﬁve key
dimensions to produce a clinically relevant and useful severity proﬁle of the patient for
making decisions regarding placement, continued stay, discharge, and treatment planning
(Smith et al., 1992).

The RAATE-Q1 was developed in response to the need for more consistent and
objective measures of key dimensions critical to treatment planning and placement of
patients into appropriate levels of care (Smith, et al. 1992). Few instruments are available

to objectively measure the variables necessary to do effective treatment planning. When

63

data are gathered or measured, the data usually are not uniform either within or among
agencies. The RAATE-Q1 provides an opportunity to measure and compare pertinent
variables with similar populations and measures parameters such as denial and
interpersonal issues (Smith et al., 1992).

The RAATE-Q1 was administered during the ﬁrst week of admission and 4 to 8
weeks later to those subjects who were successfully participating in treatment, to measure
changes in the individual's resistance to treatment and continuing care. Treatment refers
to the activities that occurred while the individual was in the residential treatment
program. Continuing care refers to the set of activities that occurred following treatment
to provide support to the individual and reinforce the progress made during treatment.
Resistance to treatment and continuing care was a predictor of the potential effectiveness
of treatment. Consequently, the researcher thought that treatment progress and resistance
to treatment and continuing care would correlate negatively with each other.

The RAATE-Q1 quantiﬁes ﬁve major categories including the above-mentioned
resistance to treatment and resistance to continuing care. Acuity of biomedical problems,
acuity of psychiatric/psychological problems, and social/family/environmental status are
additional categories measuring severity of illness. Once a baseline is established, each
indicator can be measured to identify a subject’s movement toward either high severity
or low severity. If a subject shows an overall movement toward less severity following
treatment, this can be considered an indicator of positive treatment progress. If a subject
shows no movement toward or away from the level of severity identiﬁed at initial testing,
this can be considered an indicator of no treatment progress. Finally, if a subject shows

movement to higher severity, this would indicate negative treatment progress.

64

Between 4 to 8 weeks following the administration of the initial questionnaire, the
subject was given the RAATE-Q1 if the clinical staff considered him to be successﬁrlly
participating in the treatment program. Successful participation was deﬁned as
completing tasks related to the agreed-upon treatment plan and complying with the
program requirements.

The ﬁve dimensions of the RAATE-Q1 have been found to have the following
test/retest internal consistency reliability: Resistance to Treatment, .74 and .85;
Resistance to Continuing Care, .78 and .87; Biomedical Acuity, .63 and .80; Psychiatric
and Psychological Acuity, .77 and .73 ; and Social/Family and Environmental Status, .75
and .85. The original instrument designers tested subjects 14 days following the ﬁrst
questionnaire; there were no concerns with repeated-measure issues. W. Mehrens
(personal communication, May 16, 1997) stated that practice effects are not of concern in

attitudinal surveys such as the RAATE-Q1.

t - ll ’ c

The administration of the questionnaires was proctored by either a professional
counselor or a trainee who had been given an informational packet about the study and
an orientation about the study and the administration of the questionnaires. Once the
subjects completed questionnaires, the proctor collected them and stored them in a
secured ﬁle in the treatment facility until the researcher picked them up. The facility staff
maintained a conﬁdential log of when the subjects completed the questionnaires to keep
track of when subjects should take the next battery. The target date for taking the

RAATE-T2 was 30 days from when the initial questionnaires were completed, but

65

administration of the RAATE-T2 varied due to programmatic changes, staff assignment
changes, or schedule problems. When a subject left treatment early due to involuntary
discharge or against medical advice, that individual was dropped from the study. A
master log was maintained to determine whether the subject was re-admitted to treatment,
and no subjects were kept in the study if they were readmitted and had participated in the
study earlier.

The RAATE-T2 was either taken again in the classroom with other subjects who
had taken the ﬁrst battery or individually in the same classroom proctored by the staff
who had previously administered the questionnaires. These completed questionnaires
were secured in a conﬁdential ﬁle until the researcher could pick them up. In the original
design of the study, the questionnaires were to be given at 30-day intervals and on the
ﬁnal day of treatment. This design proved to be difficult to follow, due to the lack of
continuity of the treatment program staff involved with the study the subjects’ frequent
early departure from treatment. Consequently, after subjects had taken the RAATE-T2,
the data collection was complete.

Some subjects’ questionnaires did not contain all of the requested demographic
information; the researcher contacted a treatment program representative to obtain the
missing data Some subjects did not answer the questionnaire items completely or
answered the questions with suspicious patterns, e.g., giving alternating “true” and “false"
responses and giving the same response to all of the questions. The RAATE-Q1 Manual
(Mee—Lee et al., 1992) warned test administrators about such patterns, and these subjects

were also eliminated from the study.

66

Data Analysis

During the preliminary analysis, subjects were separated into two differentiated
groups based on the results from the MVS instrument. Subjects with a score of 10 or
more false responses on the MV S were designated as having an achieved vocational
identity; those giving fewer than 10 false responses were designated in the nonachieved
vocational identity group. Microsoft Excel Version 4.0 and SPSS Version 7.5 were used
to array data and to conduct statistical tests.

While tabulating the data, it was apparent that many scores were clustering
around the cut-off of 10 or more to determine achieved status. Because of the ﬁne line
between the score of 10 to determine achieved status and 9 to determine nonachieved
status, the variable was treated as a continuous variable rather than a nominal variable.
Yen (1997) stated that data are lost when variables are dichotomized. Mehrens and
Lehmann (1987) made the same point saying that grouping data into categories causes
one to lose information and precision. Thus, even though researchers have used the MV S
instrument to group subjects into achieved and nonachieved groups (Ryan-Jones, 1990),
this investigator decided that counting the number of false responses on the MVS and
viewing that score as a continuous variable would reveal more about the data. Other
researchers have used the score on the identity scale of the MVS as a continuous variable
and then employed multiple regression statistical analysis to develop vocational
development models. For example, Graef, Wells, Hyland and Muchinski (1985)
evaluated vocational indecision using the MVS score as a continuous variable.

Consequently, the researcher decided to examine the data using statistical tests in

which the number of false responses was treated as a continuous variable, rather than

67

dividing the group into nominal categories of achieved and nonachieved vocational
identity statuses. A one-sample t-test was performed to verify change between the
RAATE-Tl and the RAATE-T2. Once change from the baseline to the second test was
established, stepwise multiple regression statistical analysis was used to determine how
the number of false responses on the MVS and other variables might relate to progress in
substance abuse treatment. The qualitative explanation of the results was enhanced by
viewing a high number of false responses as a relative measure of vocational identity; i.e.,
the higher the number of false responses, the more conﬁdent one can be that the status is
achieved as opposed to nonachieved.

The models for the stepwise regression were developed by choosing variables on
which data were collected in the study that were of interest and relevant to predicting
progress in substance dependence treatment. These categories were the number of false
responses on the MVS, income level, education in years, age, and length of treatment stay
between the ﬁrst and second administrations of the RAATE-Q1. A model was developed
for each RAATE-Q1 treatment progress category, and then each model was statistically
run on the collection of variables, with treatment progress as the dependent variable.
Because the researcher was particularly interested in the MVS variable the model, each
model included the number of false responses on the MVS. The regression was run,
dropping the least signiﬁcant variable until only statistically signiﬁcant predictor
variables remained in the model along with the scores on the MVS measure.

After data were collected on all subjects, a post hoc analysis was conducted with
the subjects who took only the ﬁrst battery of the MVS and RAATE-Q1 (RAATE-T1) and

those subjects who took both the ﬁrst battery and the second RAATE-Q1 (RAATE-T2).

68
Summary
The methods by which data for the study were collected and analyzed were
described in this chapter. A total of 244 male residents age 19 to 51 in substance
dependence treatment completed the RAATE-T1 questionnaire and the MVS; of that
number 102 completed the RAATE-T2. The resulting data, along with information on
the 94 subjects who did not complete treatment, was used in the statistical analysis. The

results of the data analyses are presented and discussed in Chapter IV.

CHAPTER FOUR

RESULTS

This chapter contains the results of the statistical analyses conducted to explore
the relationship of vocational identity and other variables to progress in substance
dependence treatment. The characteristics of the sample are described ﬁrst, followed by

the results of the data analyses.

Description of the Sample

Of the 244 male subjects who took the initial battery consisting of the MVS and
the RAATE-Q1, 48 were eliminated from the study due to various reasons. Twenty-two
were eliminated because their questionnaires were incomplete or other information was
missing, rendering their results unreliable; 18 were from other treatment programs; and 8
did not ﬁt within the duration-of-treatment guidelines of at least 4 weeks but no more
than 8 weeks in treatment. Of the subjects who took the initial battery, 102 completed the
RAATE-Q1 the second time (RAATE-T2 study group), as well. These 102 subjects
comprised the study group, whose treatment progress was compared with other
independent variables. Ninety-four subjects were eliminated ﬁ'om the second RAATE-Q1
(RAATE-T2 study group) portion of the study because they were no longer in treatment

but information on these subjects was used in the post hoc analysis.

69

70

The age range of subjects in the RAATE-T2 group (N = 102) was from 19 to 49
with a mean of 36.34 years (SD = 6.97). The distribution of ages was as follows: ages
19-25, 7.8%; ages 26-30, 15.7%; ages 31-35, 15.7%; ages 36-40, 31.4%; ages 41-45,
20.6%; and ages 46-49, 8.8%. The mean years of education was 12.23 (SD = 1.66), with a
range from eighth grade to 4 years post high school. The sample consisted primarily of
African Americans; 85.3% of the sample were African American; 11.8% were White, 2%
were Native American, and 1% were Hispanic. Forty-ﬁve percent of the sample were in
the lowest income category of less than $10,000 per year, 16.7% were in the $10,000 to
$20,000 category, 14.7% were in the $20,001 to $30,000 category, 11.8% were in the
$30,001 to $50,000 category, and 11.8% were in the top category of over $50,001 of
income per year before to treatment.

The age range of subjects in the RAATE-T1 group (N = 94) was from 19 to 51,
with a mean of 35.46 years (SD = 7.1 l). The distribution of ages was as follows: ages
19-25, 7.4%; ages 26-30, 16%; ages 31-35, 30.9%; ages 36-40, 20.2%; ages 41-45, 17%;
and ages 46-49, 8.5%. The mean years of education was 11.55 (SD = 1.93), with a range
from fourth grade to four years post high school. The sample consisted primarily of
African Americans; 75.5% of the sample were African American; 22.3% were White,
1.1% were Native American, and 1.1% were Asian. Thirty-one percent of the sample
were in the lowest income category of less than $10,000 per year, 16% were in the
$10,000 to $20,000 category, 16% were in the $20,001 to $30,000 category, 24.5% were
in the $30,001 to $50,000 category, and 12.8% were in the top category of over $50,001

of income per year before treatment.

71
Findings
A correlation of all the scores between the RAATE-T1 and the RAATE-T2 was
performed. As shown in Table l, the RAATE-Q1 scores were positively correlated -

between the RAATE-Tl and RAATE-T2.

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To determine whether change occurred in any of the RAATE-Q1 dimensions of
treatment progress, a one-sample t-test was performed on each mean of the difference in
scores for each RAATE-Q1 dimension. As shown in Table 2, all dimensions showed
change from RAATE-Tl to RAATE-T2 with the exception of the resistance to treatment
planning dimension. Consequently, this dimension was not included in the model
because no change occurred. The dimension of psychiatric and psychological problems
was not signiﬁcant with the raw scores, but because it was signiﬁcant with the scaled

scores it was included in the model.

Table 2: The Results one sample t-test to determine differences in scores on each
RAATE-Q1 dimension

 

 

RAATE-Q1 Dimension t-test df p value Mean

result (one-tailed) difference
Resistance to Treatment Planning 0.535 101 .287 .1250

1.116 101 .133 .1250
Resistance to Continuing Care 2.672 101 .004 .7396

2. 4 01 I 01 .009 .3229
Biomedical Acuity 3.538 101 .000 .6354

2.538 101 .007 .3333
Psychiatric "Id Psychological 1.172 101 .122 .2813
Problems

1.763 101 .040 .1771
Social, Family and Environmental 2.194 101 .015 .6563
Factors

2.939 101 .002 .4583

 

Note. Top bold score for each dimension is the raw score and bottom italicized score is
the scaled score.

74

A multiple regression model was constructed, with the difference in the RAATE-
T1 and RAATE-T2 scores as the dependent variable. The predictors were the number of
false responses on the MVS, years of education, income level, age, and duration of

treatment. Table 3 shows the standardized [3 coefficients, the t—score, and the degree of

signiﬁcance for the four models.

75

Table 3: Multiple regression models for the differences in raw scores on the ﬁrst and
second RAATE-Q1 raw scores (N = 102)

 

 

Model Beta t—value p value
Dependent Variable (A RRZ)

False responses on MVS 0'7 -164 .870
Income -.077 -.763 .447
Treatment duration -l63 1.692 .094
Age -.204 -l .996 .049
Dependent Variable (A RR3)

False responses on MVS 236 2.303 .023
Years of education .027 .257 .797
Income -.02.?. -.213 .832
Treatment duration '023 -.231 .818
Age -.008 -.O76 .940
Dependent Variable (A RR4)

False responses on MVS '-0 l 6 --157 .875
Years of education .042 .391 .697
Income .106 1.034 .304
Treaunent duration . l 24 1221.225
Age .058 .558 .578
Dependent Variable (A RR5)

False responses on MVS '-0 l 0 -.095 .924
Years of education .087 .810 .420
Income .097 .936 .352
Treatment duration --007 -.072 .943
Age .029 .278 .781

 

Note; ARR2 = Change score in treatment progress dimensions of resistance to continuing
care plan; ARR3 = Change score in treatment progress dimension of biomedical acuity;
ARR4 = Change score in treatment progress dimension of psychiatric and psychological
problems; ARRS = Change score in treatment progress dimension of social, family, and
environmental factors.

76

Table 4: Summary of multiple regression analysis for each model (bl = 102)

 

 

Model Beta t-score p value 32
(two tailed)

Dependent Variable (A RRZ) .042
False Responses on MVS .015 .157 .876

.012 .125 .901
Age -.204 -2.063 .042

-.211 -2.137 .035
Dependent Variable (A RR3) .059
False Responses on MVS .236 2.494 .014

. 189 1.928 . 05 7
Dependent Variable (A RR4) .000
False Responses on MVS -.012 -.122 .903

.026 .256 .799
Dependent Variable (A RR5) .000
False Responses on MV S .013 .129 .898

.074 .743 .459

 

Note, AR = Change score for each dimenson, with sealed scores on bottom; MVS = My
Vocational Situation; R2 value is for the entire model and describes the proportion of
variance explained by the model.

The ﬁrst model, testing the signiﬁcance of the predictors on resistance to
continuing care, showed no signiﬁcant relationship with the number of false responses on
the MVS. The negative relationship with age was statistically signiﬁcant. The 32 value
of .042 indicates that 4.2% of the variance was explained by the model.

The second model, testing the signiﬁcance of the predictors on biomedical acuity
in substance dependence treatment progress showed a positive signiﬁcant relationship
with the number of false responses on the MVS. The 32 value of .059 indicates that 5.9%
of the variance was explained by the model.

The third model did not show any signiﬁcant relationship between the predictors

77

and psychiatric and psychological problems in substance dependence treatment progress,
as evidenced by the R2 value of .000.

The fourth model did not show any signiﬁcant relationship between the predictors
and social, environmental and familial factors of substance dependence treatment
progress.

These ﬁndings indicate that there is a signiﬁcant amount of the variance could be

explained by variables untested by the models brought forth in this study.

Findings of the Post Hoc Analysis

The RAATE-T1 and RAATE-T2 groups were compared to determine whether
were factors other than chance led to early departure from substance dependence
treatment. As indicated in Table 5, an independent two-tailed t-test showed signiﬁcant
differences between the two groups in the areas of education (12 < .010) and income (12 <
.034) and on the RAATE-Q1 dimension of biomedical acuity (p < .042). Because of the
ordinal characteristics of the income variable, further analysis was done using the chi-
square statistic. The ﬁndings showed differences in category one and four and are
represented in Table 6. The income groupings also are shown in Table 7. The chi-square
test further validated the t-test given that the same p—value was found for both.

In the area of education, the RAATE-T1 group had a lower educational level, with
a mean of 11.55 and a standard deviation of 1.93, compared to a mean of 12.22 and a
standard deviation of 1.66 for the RAATE-T2 group. The RAATE-T1 group had a higher
income level, with a mean of 2.72 (stated in terms of income-level category, not actual
income) and a standard deviation of 1.43, compared to the RAATE-T2 group, with a

mean of 2.28 and a standard deviation of 1.44. The RAATE-Q1 dimension of biomedical

78

acuity showed the RAATE-T1 group with a higher mean of 2.92 and a standard deviation
of 1.83, compared to the RAATE-T2 group with a mean of 2.42 and a standard deviation
of 1.61.

The variables showing no difference between groups were age, vocational
identity, and RAATE-T1 scores for resistance to treatment planning, resistance to
continuing care, psychiatric / psychological problems and social / familial / environmental
problems.

Although some statistically signiﬁcant differences were found between the two
groups, this difference was not enough to allow one to state conclusively that the

RAATE-T2 study group was self-selected by factors other than chance.

79

Table 5: T-test of the RAATE-T1 and the RAATE-T2 groups“ (11 = 196)

 

 

t-score df p value mean
difference

Education 2.61 5 1 94 .010 .6723
Age .880 194 .380 .8857
Income -2. 129 194 .034 -.4391
MVS falsesb 1.140 194 .256 .7424
R1 1.59 194 .113 .5947
1.319 .189 .2397

R2 .327 194 .744 .1325
. 700 .485 . 1272

R3 -2.047 194 .042 -.5040
-1.885 .061 -.3048

R4 -1.063 194 .289 -.3650
-.819 .414 -.1141

R5 .722 194 .471 .3784
1.394 .165 .3000

 

Note, R1 = RAATE dimension of resistance to treatment planning; R2 = RAATE
dimension of resistance to continuing care; R3 = RAATE dimension of biomedical
acuity; R4 = RAATE dimension of psychiatric and psychological problems; R5 =
RAATE dimension of social / environmental / familial factors; ‘ Comparison of RAATE-
QI done on only the RAATE-T1 for each group; b MVS = My Vocational Situation false
responses; Scaled scores for RAATE dimensions are in the row below the bold raw
scores and are italicized.

80

Table 6: Income category distribution of subjects in RAATE-T1 and RAATE-T2 (N;
196)

 

 

Income Category RAATE-T2 RAATE-Tl
Less than $10,000 46 29
$10,001 to $20,000 17 15
$20,001 to $30,000 15 15
$30,001 to $50,000 12 23
Over $50,001 12 12

M = 102 H = 94

 

Table 7: Chi-square test of income variable between RAATE-T1 and RAATE-T2
(N, = 196)

 

Chi-square value df p-value

 

4.453 1 .035

 

Mote: Mantel-Haenszel chi-square test.

Summary

In this chapter a description of the sample was provided, with observations about
the sample’s signiﬁcant characteristics. A statistical analysis was performed to explore
the relationship between subjects’ progress in substance abuse treatment and other
variables such as vocational identity, age, years of education, income at the time of
admission to treatment and length of stay in treatment.

The multiple regression analysis indicated that two variables in two different
models were statistically signiﬁcant. The model for the dependent variable, continuing
care, found older age to be a predictor of positive treatment progress. The model

accounted for 4.2% of the variance. In addition, the MVS (number of false responses)

81

model with the dependent variable, biomedical acuity, described 5.9% of the variance.
Although these ﬁndings were signiﬁcant, other unmeasured factors might have the
potential to explain the variance.

In addition, in the post hoc analysis, ﬁndings indicated differences between two
groups, RAATE-T1 and RAATE-T2, but robust differences were not evident. The
differences in the categories of education, income, and vocational identity were

signiﬁcant and warrant further discussion.

CHAPTER 5

DISCUSSION

In this chapter a discussion of the study ﬁndings is presented. Limitations of the
study are elucidated, and implications for practice with substance abuse treatment
professionals, rehabilitation professionals and educators are explored. Finally,

recommendations for future research will be presented.

Synopsis of the Study

In this study the writer explored the relationship of vocational identity and other
variables to progress in substance dependence treatment. The research question was:
What is the relationship of vocational identity, length of treatment stay, years of
education, age, and income at time of admission to speciﬁc measures of progress in
substance dependence treatment? These measures of treatment progress were resistance
to treatment planning, resistance to continuing care, biomedical acuity, psychiatric and
psychological problems, and social / familial / environmental factors as measured by the
Recovery Attitude and Treatment Evaluator Questionnaire (RAATE-Q1) (Mee-Lee et al.,
1992). Vocational identity was measured by the My Vocational Situation (MV S)

instrument developed developed by Holland, Daiger et al. (1980).

82

83

Data were collected on 196 of the subjects who were administered the RAATE-Q1
and the MVS during the ﬁrst week of treatment (RAATE-T1). Of these 196, 102
successfully participated from the fourth week to the eighth week and were administered
a second RAATE-Q1 (RAATE-T2) to measure progress in substance dependence

treatment from the ﬁrst week in treatment.

Discussion of the Findings

The regression models showed relationships between the substance dependence
dependent variables, resistance to continuing care and age, and between the dependent
variable, biomedical acuity, and the predictor, high vocational identity. Although
signiﬁcant, the relationships described only 4.2% of the variance for the resistance to
continuing care model and 5.9% of the biomedical acuity model. In addition, the
comparison of the RAATE-T2 and RAATE-T1 groups revealed some signiﬁcant
differences in individual categories of age, education, income, and biomedical acuity. It
appears that the RAATE-T1 group tended to be younger and less educated, had a higher
income, and perceived themselves to have more medical problems than did the RAATE-
T2 group. The models did not provide an explanation for a signiﬁcant amount of
variance. Analysis of the unexplained variance may provide an understanding of the

dynamics of substance dependence.

E. 1. 1
Using stepwise regression with the RAATE-T2 study group, it was found that a
high number of false responses on the MVS was signiﬁcantly related to the RAATE-Q1

dimension, biomedical acuity. In the ﬁnal regression model, the beta coefficient for the

84

number of false responses on the MVS in relation to the biomedical acuity score was
.242, with a t-score of 2.494 (p < .014).

The relationship between the number of false responses on the MVS and
biomedical acuity indicated that those with a more developed vocational identity made
more progress in the dimension of biomedical acuity (i.e., those with a higher achieved
vocational identity perceived themselves as making more progress in resolving
biomedical concerns).

Self-perceptions of biomedical acuity can be interpreted in many different ways.
The perceptions may be totally unrelated to substance dependence; it is also possible that
the perceptions are psychosomatic and have nothing to do with substance dependence:
Complaints may be related to symptoms of physical withdrawal from the substance of
dependence, or the dependency may have a lasting physical effect on the individual.
Finally, the individual could be experiencing physically-induced cravings for the
substance of dependence.

Making more progress in this dimension is complex in that a better understanding
of the baseline scores needs to occur. If the original score on the RAATE-Q1 is high,
meaning a high level of severity of illness, then the acuity may be such that progress will
be slow due to the nature of the illness. For example, withdrawal symptoms are different
for different drugs and may be more severe, depending on the amount previously ingested
and the duration of substance dependence without detoxiﬁcation (Hubbard et al., 1989;
Vaillant, 1995) As previously observed, the baseline RAATE-Q1 scores for subjects with
lower vocational identity scores were higher than the scores of subjects with higher

vocational identity scores in the area of biomedical acuity; this could mean that the

85

medical problems of the former group were more severe. If more severe medical
problems take longer to resolve, it may be possible that these problems are inherently
more difﬁcult to resolve. Consequently, the severity of illness at onset of treatment needs
to be considered along with the amount of progress. With subjects who had less severe
biomedical acuity and a high vocational identity, the progress may have been facilitated
by the lesser nature of the biomedical obstacles (Hubbard et al., 1989; Vaillant, 1995).

Another crucial aspect of this relationship is the potential measurement of craving
portrayed by the biomedical acuity dimension. Flowers et al. (1993) suggested that health
surveys can serve as craving measurements. Therefore, one could conclude that the
higher the achieved vocational identity, the more progress had been made in reducing the
potential for craving.

The characteristics of an achieved vocational identity that would lead to this
concise relationship with craving could be related to how the individual is organized in
terms of decision making. Newman, Fuqua, and Seaworth (1989) theorized that anxiety
is a factor in career decision making, and Schrumrun and Hartman (1988) found career
indecision to be a factor for children of alcoholics. The distraction of more severe
biomedical acuity or craving may interfere with vocational decision making, which could
result in a less established vocational identity.

This research calls for a review of the sequencing of intervention with substance
dependence. The profound craving and consuming aspect of substance dependence
seems to overwhelm all other dimensions of identity, which is why most substance
dependence professionals profess that, before any other problem can be addressed,

including psychiatric ones, the substance dependence issue must be recognized and a

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strategy developed to contend with it. This research may be indicating that having a
vocational identity can be a precursor to prevention of craving. If so, then sequencing the

approach to dependence may need a new look.

13' 1. 2
Age was negatively correlated to resistance to continuing care. In the ﬁnal
regression model, the beta coefficient for age in relation to the resistance to continuing
care score was -2.04 with a t-score of -2.063 (p < .014). The negative relationship
between age and resistance to continuing care means that the older the subject, the more
likely he was to make more progress in treatment in the area of continuing care.
Continuing care requires a commitment to following through on recommendations that
are time and energy consuming. It is possible that the older subjects might also have had
more relapse experience or treatment failures, whereby the recommendations for
continuing care were more meaningful to them than to the younger subjects. It may also
be possible that the older substance-dependent person is more receptive to continuing
care alternatives due to the nature of the activity; i.e. the 12-step self-help groups in that

geographic area might have had an older population.

E. 1 3
There were no other signiﬁcant relationships between the predictors of age, years
of education, and treatment duration and any of the other RAATE-Q1 dimensions as a
dependent variable. In the original design of the study, it was hypothesized that all of the
dimensions of progress in substance dependence treatment would have a signiﬁcant

relationship to vocational identity. But there was no reason to expect that only age and

87

the biomedical acuity dimension would be found signiﬁcantly different from the other
dimensions. It may be that with the type of population found in a TC, which often has
residents with long periods of chronic substance dependence, the gains in treatrrrent
progress are found after a longer treatment stay. De Leon (1995) indicated that the ﬁrst 8
weeks of TC experience are viewed as an orientation phase leading into a treatment
phase. Even though the therapeutic process was having an effect on the subject during
that time, it might not have been integrated into the person’s thinking about issues related
to continuing care and treatment planning. The delay in understanding treatment
concepts or associating them with their own self-reality may show up later for those who

have a more developed vocational identity.

ll 1 . 1 If .
There was a signiﬁcant amount of unexplained variance in the models tested
through multiple regression. Given other research in this area, there are many possible
explanations for this result. Lavelle, Hammersley, and F orsyth (1991) attempted to
explain substance use through personality traits and found that shrewdness, tough-
mindedness, anxiety, experience seeking, and motivation for the future were traits that
distinguished the drug addict from a student population and a homeless population.
These traits did not match those previously considered, such as anti-social personality, or
earlier developmental traits, such as precocity, leadership, and curiosity. This
relationship between personality and substance dependence may offer an explanation for

some of the variance in the model through the use of a personality proﬁle instrument.

88

Other vocational variables such as vocational maturity and career decidedness
may have deﬁned the vocational traits of the subjects more precisely. Graef, Wells,
Hyland, and Muchinsky (1985) found that vocational identity and vocational maturity
were subcomponents of vocational decidedness, and all of them were positively
correlated.

A more precise or different measurement of the identity variables may have
provided another perspective with the model. Jones, Hartrnann, Grochowski, and Glider
(1989) found differences between adolescent substance abusers in treatment and students
in school using the objective measure of ego identity status. Their ﬁndings showed that
the students in treatment were psychologically less mature than those students in the
school sample.

Other variables that could have contributed to the unexplained variance include,
job classiﬁcation of the subjects, ethnicity, educational performance, criminality,

motivation for treatment, learning styles, coping skills and aptitude.

Post Hoc Findings
Because 94 subjects did not complete the second RAATE-Q1 questionnaire,
additional post hoc analysis was done to compare the two groups, RAATE-T1 (N = 94)
and RAATE-T2 (M = 102). The two groups were analyzed to determine whether there
were differences that might offer an explanation for the RAATE-T2 group results. An
independent two-tailed t-test was used to compare the RAATE-T1 group to the RAATE-

T2 group, to see if there were any overall differences between the groups. This statistical

89

analysis was done to determine whether there was a difference between the two groups

before their departure from treatment.

B H E. 1 I
There was a signiﬁcant difference (p < .01) between the groups in the area of
education, the RAATE-T1 group had showing a lower mean of 11.55 (SD 1.93) as
compared to the RAATE-T2 group, with a mean of 12.22 (SD 1.66). A possible
explanation for this difference could be the attraction of the TC’s philosophical approach,
which encourages contemplation of ideas and rewards introspection, both of which are
aspects of education and characteristics of those who have an afﬁnity for more education
(Cross, 1983; Knowles, 1990). Knowing the educational development needs of each
group would be helpful in analyzing this data to determine adult education strategies.
Perhaps the material presented to the group was at an inappropriate reading level and
caused frustration, or the subject might have missed certain important cognitive data that

could have helped in the prevention of relapse.

E H E. 1 2
Biomedical acuity was the second category on which the two groups differed
signiﬁcantly (p < .042). The mean for the RAATE-T1 group was 2.92 (SD 1.83), and the
mean for the RAATE-T2 group was 2.42 (SD 1.61 ). This difference indicates that the
RAATE-T1 group perceived themselves as having more medical problems and physical
complaints than did the RAATE-T2 group. In the previous analysis of biomedical acuity,

the ways in which physical problems or the perceptions of physical problems can be

90

interpreted were discussed. If any of the factors related to physical concerns were valid,
then it is logical to assume that the physical condition or at least the perception of the
physical condition might have been a factor inﬂuencing the RAATE-Tl group to leave
treatment before their planned date of discharge. Dusoe as cited in Blieberg (1994) found
that subjects who left substance dependence treatment against medical advice oﬁen
reported less employed time at the time of admission and that those who were identiﬁed
as employment stable stayed in treatment longer. Contrary to the ﬁndings in this study
with regard to biomedical acuity, Dusoe also found that there was no difference between
groups in terms of medical complaints. However, the level of treatment was intensive
inpatient, and the substance of choice of the subjects in that study was not matched to the
substance of choice for this study’s population.

Flowers et al. (1993) indicated that craving is a primary cause of relapse and can
be measured through health ratings. Because craving due to health concerns was a
possibility in this situation, the individual questions were reviewed in the post hoc
analysis to determine whether any related directly to physical craving. In reviewing the
questions on the RAATE-Q1 that were used to categorize the biomedical dimension, two
questions were found that related indirectly to the possibility of craving, but no questions
asked a question about craving directly. Of the questions that measured the other
dimensions of treatment progress, none related directly to craving or even coping with
craving.

It might be argued that craving is not a sign of negative treatment progress and
that decision making as it relates to the craving is the more important measure of

progress. The RAATE-Q1 does not appear to measure this, on face value, and there have

91

been no corroborating studies comparing the RAATE-Q1 to other instruments measuring
desire to use substances. Even though there is no direct connection between the RAATE-
Q1 and other instruments, ﬁndings such as those of Flowers et al. (1993) help retain the

possibility that craving could be a factor in this circumstance.

Summary of the Findings
When considering all of the variables on which the RAATE-T1 and RAATE-T2
groups were compared, there appeared to be no substantial overall difference between the
two groups. When combined with other research such as that by Condelli (1994); Dusoe
in Bleiberg et al. (1994); McLellan et al. (1996), who described differences between
groups of patients who stayed in treatment and those who did not, the results from this

study supplemented other ﬁndings, which will help in theoretical development.

Implications for Practice

Overall, this study has raised a number of important questions. For example,
questions remain about why subjects left before their prescribed discharge, whether there
were unmeasured variables that differentiated the two groups, whether there are measures
other than the RAATE-Q1 that might have detected treatment progress and what
observable signs and symptoms about the substance abuse treatment biomedical acuity
progress dimension are related to achieved vocational identity? All of these questions
are important theoretically and lead to discussion about important considerations for
practice.

Substance dependence professionals may beneﬁt from having objective

standardized information about vocational identity and treatment progress. The data

92

gathered in this study met such criteria, and yet the clinical staff at the treatment program
did not request any of the information gathered on their clients. This response might have
been a result of many factors, such as poor communication with the staff about the
study’s value, the workload of the staff, forestalling their inquiry about any supplemental
information, or the staffs apathy about the data. This lack of response from professional
staff was from the treatment program that was the most cooperative and supplied the 196
subjects used in the ﬁnal analysis. As noted in the methodology section, three other »
programs failed to comply with their agreement to participate in the study citing staff
workload as the reason for discontinuing involvement in the study. Substance
dependence clinical staff spend a signiﬁcant portion of their time on paperwork to meet a
variety of regulatory requirements, so being presented with more forms and data is not a
popular suggestion. However, if these forms contained valuable information, were ﬁlled
out mainly by the client, and were easily scored either by computer or a trained volunteer,
could the quality of treatment be improved?

Knowledge of the importance of biomedical acuity should alert practitioners in the
ﬁeld that a variable or set of variables may predict eventual treatment compliance,
progress, and outcome. The measure of biomedical acuity and vocational identity needs
to be operationalized through assessment methodology and treatment approaches.
Practitioners need a clear set of signs and symptoms to identify progress in treatment that
are standardized to predict craving and other signs of relapse. An additional measure of
progress or readiness to progress, such as the MVS, might provide a more complete view

of the substance-dependent person.

93

Another professional affected by these ﬁndings is the rehabilitation counselor,
who must handle cases in which substance dependence is either a primary or a secondary
disability. If vocational identity is a signiﬁcant factor in treatment progress, then the
rehabilitation counselor is a key component in the overall recovery of the substance-
dependent client. The rehabilitation counselor is an important supplement to a substance
dependence treatment program as an outside resource, as is the case with many treatment
programs today. The rehabilitation counselor could also serve as an internal consultant to
help fortify a vocational-identity-building program if this is seen as a signiﬁcant factor
leading to progress in substance dependence treatment.

Educational professionals are a key factor in understanding the importance of
vocational identity in predicting treatment progress, and possibly in preventing substance
dependence, as well. The majority of prevention has occurred in schools, which will
continue to be the primary vehicle for formal programs in the near future, according to
Donaldson et al. (1996); educators are the primary professionals assigned to carry this
out. This may also mean using educators as consultants in treatment settings to assist
with educational programming for vocationally oriented activities.

The ﬁndings from this study have focused on the biomedical acuity dimension.
Thus, medical involvement by both physicians and nurses is key to monitoring the
physical condition of patients, as well as in prescribing possible remedies to prevent

craving if it is anticipated.

94

Recommendations for Future Research

Several questions about certain variables were not answered with the instruments
used in the study. The methodology of using questionnaires to gather information about
both the vocational identity and treatment progress indicators did not provide an
opportunity for clinical evaluation and exploration of certain ambiguous information. The
potential would exist to gather more clinical information if a researcher were to use the
clinical interview format of the RAATE, referred to as the RAATE-CI. It would also be
helpﬁrl to use other treatment progress instruments and vocational measures to further
validate the instruments with the substance-dependent population. If repeated, the study
should include other independent variables such as marital status, criminal incidences
with current legal status veriﬁed by outside source, current job classiﬁcation if employed,
previous treatment experiences with type of treatment and length of stay, psychiatric
diagnosis if applicable and medications.

This study concerned progress in treatment, but questions about the impact of the
therapeutic setting at different intervals surfaced during the course of the study. Whether
treatment itself has a direct and timely effect on progress in treatment and vocational
identity is a question raised by this research. Because the study was conducted with a
closed TC, a variety of intracommunity issues could have affected the progress not only
of individuals but also of the group. Correlations of progress indicators with changes in
the community and administration of the RAATE could have revealed data about how the
TC affects the progress of the individual. For example, at one point in the data-collection

phase, the subjects were under a “house-ban," which restricted their privileges (see

95

Appendix D); this would have been likely to inﬂuence their attitudes about certain
dimensions measured by the RAATE-Q1.

In the original study design, more than one treatment facility was identiﬁed in
which to gather data. The question still remains about differences in treatment program
approaches, either within the same level of care or between levels of care. A larger
sample size with different treatment locations would be helpful in comparing treatment
approaches.

In addition, a second measurement of the vocational identity status, which might
have changed over the course of treatment, would help in evaluating the degree of change
experienced by the subject in relation to vocational issues. Such an assessment could
help in program evaluation if a vocational development component were available.

Kleber (1994) recommended that the federal government allocate more research
dollars to improve treatment and prevention of substance abuse and dependence. As
examples of existing valuable efforts, he referred to research in process related to brain
chemistry, new medications, behavioral interventions, and even an anti-cocaine vaccine.
He also recommended studies that evaluate individualized treatment or match the
treatment with the type of substance dependence problem to determine the most cost-
effective approach. The ﬁndings from this study support his recommendations, especially
as they relate to exploration of medical interventions that may diminish the physical
craving for substances.

In addition, researchers need to continue to strive to ﬁnd a speciﬁc craving
inventory or intervention tool to prevent craving leading to relapse, or that can predict a

potential relapse. As a result of this research, questions have surfaced regarding whether

96

there is a measure of craving or biomedical acuity that predicts progress in treatment,
likelihood of relapse or long-term outcome. Physical manifestations can also be a result
of stress-induced disorders, and certain stress inventories may be correlated with the
RAATE or other inventories. Research is needed that correlates these instruments or
consolidates them into one more efﬁcient instrument.

This study was designed to examine a substance-dependent population
independent of ethnicity as a contributing variable. Of the 196 subjects in the study, 81%
were Aﬁ'ican American. According to Dent, Sussman, Ellickson, Brown, and Richardson
(1996), cultural sensitivity is necessary in prevention efforts, but there also is a need to
develop a more consistent deﬁnition of ethnicity. The same can be said for treatment
approaches, especially with Aﬁican American males. In this regard, Wade (1994)
recommended a biopsychosocial approach supplemented by special cultural
considerations. Of interest to this study, Wade also stated that African American males
differ ﬁ'om the general population in terms of higher unemployment rates and low self-
esteem due to other environmental factors. Lauver and Jones (1991) found that ethnic
groups differed with regard to gender in relation to self-efﬁcacy and interest in relation to
occupational choice. There is a need to focus on ethnic groups both with regard to both
substance dependence and vocational variables.

Because there was a difference in the educational level of the RAATE-Tl group,
there are questions about the educational and vocational needs of the subjects. This is a
factor ﬁom both a programmatic and an individual perspective. The substance-dependent
individual needs to be seen as an adult learner as well as a patient in treatment, to

determine barriers to learning the treatment concepts. The adult learner is also concerned

97

about developing a vocational identity; thus, an individualized plan that helps accomplish
career goals is also necessary. Research that considers whether and how substance
dependence treatment programs evaluate the adult learner and how programmatic designs
take into account the adult learning principles that help in developing standards to
improve instruction and treatment.

The attitude of substance dependence professionals concerning the nature of
substance dependence and the status of patients under their care should also be
investigated. The instruments employed in this study could also be used to compare

clinical staffs’ impressions for congruency and for validation of treatment strategies.

Limitations

This study resulted in modest ﬁndings about the differences in subjects leading to
varying degrees of progress in substance dependence treatment. The ﬁndings themselves
limit the conclusions that can be drawn about vocational identity and substance
dependence. These ﬁndings provide an opportunity to think about what was not found
that might have been expected, and to examine the design of the study so as to improve
the methodology for future studies.

This study was restricted to the therapeutic experience and treatment progress
while in a substance dependence TC. The study focused on males who were chronic
relapsers who had lost many of their social supports. The TC is seen as one of the last
stops before incarceration, and due to managed care and insurance limitations, referrals to

just self-help supports may be the next and only alternative to treatment. Consequently,

98

one cannot draw conclusions about the general substance-dependent population from the
results of this study.

The focus on the treatment experience itself limited the conclusions that could be
drawn about overall outcome. The ﬁndings in this study are speciﬁc to only the treatment
period in a TC. The TC is a protective environment, and the overall outcome for each of
the subjects is not known beyond the study period. Welte, Hynes, Sokolow, and Lyons
(1981) found that, when studying treatment outcome, one of the most common errors is
using short follow-up time periods. Even though this study was not about treatment
outcome but about progress in treatment, there is value in knowing whether short-term
interventions have long-term effects.

A signiﬁcant number of subjects (N, = 94) did not complete treatment as
prescribed and left before to taking the second RAATE-Q1. Because of the RAATE-Tl
group’s departure from the study, a signiﬁcant amount of information was lost that could
have been revealing about the relationship between vocational identity and the
dimensions of treatment progress or posttreatrnent experience. It is not clear whether
these subjects relapsed to pretreatment baseline levels of substance dependence or
whether other signiﬁcant events occurred. In addition to the outcome of the RAATE-T1
group, the causative variables leading to departure from treatment were not available;
these might have shown a relationship with the variables examined in this research.

The approach of using the MVS as a measure of vocational identity limited the
options related to identity status to only a gradient achieved and nonachieved in the
vocational category. It did not examine processes such as decision making, which from a

treatment perspective would be helpful in developing interventions. Raskin (1989) stated

99

that identity status is a frame of reference that must be matched with the decision-making
process in order to understand willingness to take action on vocational tasks.

Vocational identity was chosen as a focus for this research, but a more
comprehensive evaluation of identity would have enriched the ﬁndings. Vocational
identity is just one dimension of identity and provides a limited view of the individual.
Other dimensions of identity in areas of religion, moral values, and family would have
revealed a more comprehensive picture of the substance-dependent individual than just
vocational identity. Using Marcia’s et al. (1993) approach in identifying status
categories, richer data might have been provided if other instruments had been used to
differentiate among achieved, moratorium, diffused, and foreclosed statuses in a variety
of dimensions.

It takes a substantial amount of time for one to develop an identity and a status
evaluation at one point in time does not take into account the developmental dynarrrics,
which provide a wealth of information. The TC attempts to dramatically change coping
techniques and other factors to prevent relapse, but implicit in this process is a change in
identity.

This researcher looked only at males in substance dependence treatment.
Waterman (1985) stated that several studies on identity in adolescents have shown more
similarities than differences between males and females. There is a signiﬁcant population
of females who seek treatment for substance dependence, and they might have potential
vocational identity issues. Pruitt (1992) studied Hispanic reentry female community
college students with regard to career indecision and vocational identity. His ﬁndings

revealed that level of education and paid work experience were related to higher

100

vocational identity and career indecision. Research comparing females to males in terms
of identity, progress in substance dependence treatment, and different treatment
interventions would be beneﬁcial.

Predominantly African-American males were represented in this study. Wade
(1994) indicated that there are cultural variables that inﬂuence the design of treatment
programs for African Americans. Ethnic comparisons related to identity, vocational
choice, and progress in treatment could provide insight into the sociocultural and ethnic
variables that are important to consider in treatment design, educational planning, and
vocational development. Pruitt (1989) found that Hispanic females tied ethnicity closely
to vocational choice, and Lea] (1990) found correlations between substance abuse and
vocational issues for Hispanics. Dryer (1995) also indicated that there are important
cultural considerations to keep in mind in analyzing identity statuses.

The MVS and other identity instruments have been used with college student
populations, but they have not been used extensively with substance-dependent
populations. As Holland, Daiger, et al. (1980) recommended, it would be valuable to use
the instrument more to establish norms with this population.

The RAATE-Q1 is designed to measure substance dependence in general, but an
items review indicated that the term “alcohol” is used most often followed by other drug
references. In addition, reference in the questionnaire to self-help meetings is exclusively
to Alcoholics Anonymous, as opposed to other drug-oriented self-help groups, such as
Cocaine Anonymous or Narcotics Anonymous. After interacting with the treatment
program staff and the subjects, it was clear to the researcher that the focus of the TC was

primarily on those with a cocaine dependence, with alcohol as a secondary disorder. In

101

reviewing the RAATE-Q1, it was evident that the questions were designed for an alcohol-
oriented population. This is oﬁen the case with much of the substance abuse literature
and in the designs of treatment programs, due to the diversity of drugs of choice.
Research and clinical approaches have evolved from a focus on one drug such as alcohol
or heroin, to a comprehensive approach that encompasses all drugs with terminology such
as chemical dependence or substance dependence. Although such terminology may be
convenient, efﬁcient, and logical, subjects might not identify with questions that do not
mention their drug of choice. Consequently, questions might have different weights for
different subjects, and the data could be skewed accordingly. Closer scrutiny of the use
of the RAATE with populations that abuse substances other than alcohol as the primary
disorder need to be designed with the entire population in mind or focused on the
particular population’s street drug language or frame of reference.

The RAATE has not been used extensively in the ﬁeld of substance dependence
treatment, and few researchers have used the instrument since 1995. More studies
designed to objectively measure treatment progress in all levels of care would help
determine the value of the instrument for future research or for practice application.

Because the setting of this study was in a heavily industrialized area related to the
automobile industry, the majority of the subjects who were employed in the study held
positions in that industry. The effect of the subjects’ current occupations on their identity
was not measured, nor were the cultural and environmental effects of the manufacturing
enviromnent. In casual conversations with the researcher, the subjects and the staff of the
treatment program, regularly commented about the factors in the work environment that

led to use of substances and treatment failure often being caused by peer pressure upon

102

return to work. Many of the workers had started their careers immediately following high
school in a manufacturing plant that paid higher wages than most jobs for college
graduates in the local area. Although the wages and beneﬁts were relatively good, job
dissatisfaction was often an issue, which could lead to an identity of being a “shoprat”-- a
prisoner of the economic beneﬁts but a lifetime of ﬁ'ustration through by never pursuing
the career one fantasized about in adolescence. This employment situation may be the
foundation for use, abuse and eventual dependence on substances and certainly warrants
more study.

Vocational identity was reviewed from a status perspective, but its qualitative
aspects were not examined. The subject’s type of profession, level of advancement. and
other dynamics of professionalism are variables of interest, which might also make a
difference in the rate of progress in treatment and in the actual treatment design. A
comparison of different treatment populations deﬁned by vocational choice may yield
data about identity development but also about treatment progress. The data would be
enriched by identifying the status of vocational identity and the professional status.

A few of the subjects had less than an eighth-grade education, and although the
treatment staff indicated they had not observed reading problems in the subjects, there
was no objective measurement of reading comprehension to validate the treatment staff s
clinical judgment. To provide conﬁdence in the data, more information on subjects’
reading comprehension and other aptitudes would be helpful.

In this study, the researcher did not look closely at identity after the initial
measurement of status was done. It was assumed that identity changes slowly and that

changes would have been minimal over the short duration of the study. Measurement of

103

the quality and status of identity and measurement of the changes tied to the progress in
treatment could be analyzed. Transformational learning concepts could also be studied,
examining of the meaning adults attach to learning new ways of coping with life issues

and possibly to changing identity while in treatment.

Conclusions

As a result of this exploratory study, additional information has been gleaned
about the relationship of vocational identity and other mitigating variables to progress in
substance dependence treatment. The study has raised questions about the relationship of
the biomedical acuity dimension of progress in substance dependence treatment to
vocational identity. The possibility exists that a substance-dependent person with a high
degree of vocational identity might make more progress in the area of biomedical acuity
during the course of early treatment in a TC environment. This is signiﬁcant in terms of
substance dependence treatment because of the implications for craving, which may lead
to relapse. This study has illustrated several relationships regarding progress in substance
dependence treatment, vocational identity and educational issues with adults that warrant

ﬁrrther research.

APPENDICES

APPENDIX A

APPENDIX A

PARTICIPANT LETTER

Dear

 

The following describes the design of the research and your involvement in the project:

Step One: Review the requirements of the study described in the Study Summary
(see attached sheet),

Step Two: If you wish to participate, sign the release to participate in the study.

Step Three: During your individual treatment session you will be given two forms to
ﬁll out with the assistance of your therapist.

Step Four: Upon successful completion of the program and prior to your discharge,
you will ﬁll out one of the forms you ﬁlled out at the beginning of your
treatment.

The total time you will spend ﬁlling out forms will be no longer than approximately 60
minutes.

Thank you for your interest in the study and your willingness to participate.
Sincerely,
Gary Hankinson

Doctoral Candidate
Michigan State University

104

APPENDIX B

APPENDIX B

STUDY SUMMARY

The vocational identity and substance dependence study is designed to explore the re—
lationship between substance dependence treatment progress and vocational identity.

If you are employed or employable and are a patient in the residential treatment program,
you are a potential participant in this project. This study will ask you questions about
your progress in treatment and your views about your vocational experiences and plans.

This study will require you to be available for two sessions to ﬁll out two questionnaires,
one occurring early in your treatment and the second one in the later part of your
treatment prior to successful completion of the program. There will be questions asked
about how you see yourself, how you feel about treatment, how you feel about continuing
care, and how you are progressing in treatment in accomplishing your treatment
objectives.

If at any time you wish to no longer participate in the study you may decline to continue.
You will be required to sign a release of information to participate in the study so that the
researcher may discuss your case with your therapist. All information will be kept con-
ﬁdential and no information about individual participants will be revealed in the study
summary.

Further questions about the study may be answered by your therapist. Thank you for your
interest and future cooperation.

105

APPENDIX C

APPENDIX C

CLIENT RELEASE TO ENGAGE IN RESEARCH AND F OLLOW-UP

I, hereby authorize Gary L. Hankinson,
Michigan State University doctoral candidate, to administer questionnaires to determine
my status re: drug and /or alcohol use, career development and satisfaction with my life.

The purpose and need for such disclosure is to assess my career development and the
effectiveness of my recovery plan. This information will be used in cumulative fashion
or in case study write-ups which will insure the conﬁdentiality of the discussions with the
researcher.

This consent is subject to revocation at any time except in those circumstances in which
the program or the researcher has taken certain actions on the understanding that the
consent will continue unrevoked until the purpose for which the consent was given shall
have been accomplished. However, any consent given Subpart C, Federal Register,
Volume 40-number 127, July 1, 1975, shall have a duration no longer than that
reasonably necessary to effectuate the purpose for which it is given.

Without the expressed revocation this consent expires for the following speciﬁed reason:
Date:

Event two years after termination date:

Condition:

Client's Signature:
Date:

Witnessed by:
Date:

106

APPENDIX D

APPENDIX D

THERAPEUTIC COMMUNITY PROGRAM DESCRIPTION
Setting

The facility was tucked away in an urban business/residential neighborhood with
schools, laundromats, apartment buildings, houses and party stores. After dark this was
not considered a safe area, and special precautions were taken to watch vehicles parked in
the lot or on the street. The facility itself was a 100-year-old converted apartment
building that now was able to hold approximately 110 substance-dependent residents in
semi-private rooms. The grounds were well manicured, with ﬂowers and trimmed
bushes, and residents in treatment kept the facility clean and orderly. The age of the
building was obvious; updates had taken the form of a new paint job, but not remodeling.

As one approached the entrance, a resident in treatment who wore a name tag
including only his ﬁrst name approached, sometimes in the parking lot but always at the
front entrance. After hours this entrance was locked, and entry to the facility was granted
only if a visitor had an authorized contact in the facility. On more than one occasion this
was a painful procedure, which resulted in waiting in the winter cold for 20 minutes for

the staff member to be reached to authorize entry.

107

108
Population
The population in the facility included male (80%) and female (20%) residents.

Approximately 80% of the residents were African American, and approximately 60%
were unemployed or underemployed. The primary drug of choice for more than 80% of
the residents was cocaine; alcohol was the second choice most of the time. Other drugs
of choice included heroin and marijuana. Approximately 50% of the residents had an
existing legal problem that needed resolution, and almost all of those who were employed

indicated that they had job performance or status issues.

Schedule of Activities

Each day the residents awoke at 6 am. and participated in physical exercise at
6:30 am. Between 7 am. and 9 am. breakfast was prepared and served while the
residents attended to other personal needs, and senior residents performed inspections of
the living quarters. At 9 am. all of the residents gathered for a morning meeting, at
which issues surrounding the atmosphere of the therapeutic community (TC) were
discussed. Residents brought up speciﬁc issues; usually paid staff were not present
unless they wanted to sit in or had something important to say relevant to the topic of the
day. This meeting was held to help plan the day and could serve as a motivational base
for positive thoughts, with expressions about coping with life. There was often singing
by the group or by individuals to help energize the group.

Didactics started at 10 am. with a structured group presentation and discussion of
a topic relevant to substance dependence, such as AIDS or parenting. The quality and

content of these didactics were highly variable due to the training and preparedness of the

109

presenters. Residents who did not participate in didactics during the 10 am. time slot
were scheduled at 1 pm. instead. During these alternative times, the residents who were
not in the didactics were on work detail, cleaning the house or preparing food for the
scheduled noon lunch.

At 2 pm. there are different types of meetings and specialty groups; most of the
residents could spend this time until 3 pm. in reﬂection. At 3 pm, each resident
attended a 1-to 2-hour group therapy session, facilitated by their assigned counselor, until
the dinner hour from 5 pm. to 6 pm. The evening schedule was highly variable and
could consist of family visits, group therapy, specialty groups (gender speciﬁc as an
example), recreational activities, Narcotics Anonymous meetings, or other self-help
groups. Usually at 9:30 pm. there was an evening meeting of all of the residents to recap
the day and “dc-charge” the group from the strain of the day. At 10 pm, free time was

available, and at 1 1 pm. the residents were conﬁned to their rooms for the night.

Program Rules

The program had primarily two categories of rules: procedural rules and cardinal
rules. The procedural rules governed the day-to-day operations of how to perform a
particular function, such as requesting a pass. The cardinal rules were related to the core
substance-free philosophy of the TC; without them, it would have been difficult to
provide an orderly and effective environment. The cardinal rules were as follows: No
drugs or alcohol, no physical acts or threats of violence, no stealing, and no sexual
contact. Violation of any of the cardinal rules, or even knowing of someone else’s

violation without exposing the infraction, was grounds for termination as a resident.

110

Philosophy of Treatment

The program philosophy statement was written in ﬁrst person so that the residents

could more easily internalize the concepts. The statement read:
I am able to change the lemon of my life into lemonade.
I came here out of darkness in order to stop running from
myself. As an individual, I avoided conﬁ'onting myself and
being confronted by others. Thus, I was alone searching for
a happiness that was only within myself. Nowhere else but
here at the Program will I begin to face reality.
Only by being honest with myself and others, by being
responsible for my actions, and being here when someone
turns to me, will I begin to grow. Only by facing myself
and others and by changing will I at last change my life.
In this house with my brothers and sisters 1 will at last take
root and grow into a human being endowed with honesty,
dignity and pride.

In further discussion about the philosophy of treatment, a counselor at the facility
stated that the program was not a building with walls, but an idea, a community, a way of
life, an attitude, a behavior, and a level of attention and awareness. He proposed a
metaphor of the “91 st day of Treatment” which builds its premise around carrying the

learning and awareness of treatment beyond the treatment setting into real life

experiences (B. Bracco, personal communication, 1996).

Therapeutic Community Treatment Activities
There were different types of groups and/or activities that occurred regularly
within the TC, that when viewed as a whole, composed up the essence of the TC. These

activities were as follows:

111

Brews; 4 times weekly, residents met with their primary therapist
and other group members to discuss issues related to their treatment plans.
Residents were encouraged to share feelings and to provide observations
about each other in terms of their progress in treatment.

W5; 2 times weekly, the residents were encouraged to
express their feelings through the use of methods not always socially
acceptable, such as through the use of profanity. The staff attended the
group and might be confronted by the resident. The goal of the group was
to resolve situations so that the parties involved understood the reasons for
the conﬂict and had the opportunity to fully express their feelings. Prior to
the group, the resident wrote a “slip” that described the circumstances
which led to their need to express their feelings. In the slip, the person(s)
involved in the situation were identiﬁed and were requested to be present
at the encounter group. The group served to resolve conﬂict within the
community and might surface treatment issues for certain people due to
the nature of the conﬂict. Some staff members viewed the encounter
group as a measurement of the condition of the TC and explained that the
quantity and quality of the encounters represented the degree to which
feelings were expressed. The more feelings expressed directly about
situations and conﬂicts the more likely the residents were honestly coping
with their own problems as individuals and collectively as a community.
Marathons; These groups rarely occurred, but when they were scheduled,

their purpose was to wear down the defenses of the group members to help

112

surface more underlying feelings not normally recognized during day-to-
day living. In duration for 24 to 72 hours, the entire TC community might
have participated or a subgroup such as the senior residents might have
been involved.

WW5; These groups helped the resident contend with
the problems unique to each gender and were created on an ad hoc basis.
Sexist or abusive comments by males in the community or seductive
mannerisms by females might prompt the clinical staff to consider the
creation of a gender speciﬁc group to analyze the origins of such behavior.
Specialjntewps; As in the gender speciﬁc group, special interest
groups were deﬁned by the proﬁle of the population in the TC at any time.
Veterans groups and parenting groups were frequently formed during the
course of the study to help certain residents gather speciﬁc information
about parenting or in the case of the veterans group, to have a peer group
that might understand previous trauma and its impact on the individual.
MW Each day an educational presentation was provided for 1
and one-half hours about topics such as AIDS, parenting, the effects of
alcohol and drugs on the body and many other topics designed to motivate
the resident to change or to provide needed information meant to prevent
mistakes following release from treatment.

W The resident was assigned job responsibilities to
help the TC stay self-sufﬁcient and to help the resident to learn to accept

responsibilities. Job responsibility was determined based upon the

10.

11.

113

resident’s ability to perform functions and their need for certain treatment
challenges. Responsibilities were given to each individual which
exploited their talents. For example, the procurement of donations was
often assigned to those with the ability to sell and communicate. Job tasks
were assigned to help the resident learn about themselves and to develop
skills necessary for independent living.

W31; Although referred to as therapy, this activity was
mandatory for those with less than a highschool education and consisted of
structured classroom activity with a tutor and teacher to prepare for the
GED.

Indmdyaljounsehng, After the initial assessment and the development of
a treatment plan, the resident was seen by a therapist as necessary and no
less than once per week to help maintain accountability related to meet
treatment goals.

W Family members were encouraged to be involved with the
program through structured activities usually on the weekends. When
special issues surfaced with certain residents, the family was asked to
participate in group sessions. These treatment sessions were designed to
resolve family conﬂicts which might cause relapse.

Wm Alternative forms of activity that did not include use
of substances was provided through excursions into the community to play

basketball or enjoy simple activities such as utilizing park facilities.

114

12. W The residents were taught that in order to help

themselves they must help others. The culture of the recovering
substance-dependent provides an environment that inspires residents to
want recovery for themselves. An expression, “In order to keep it, you
must give it away,” helped the residents understand that the sharing
process was necessary and that self-centered thinking would only lead
back to the use of substances.

13. W This was a consequence of a rule violation and
requires the resident to perform a task or to lose a privilege for a certain
time period. The TC was highly dependent upon discipline to maintain
order and to remind the residents of deviant behavior. This was evident by
the long list of different learning experience types which are named but
not deﬁned in the following: ghoul squad, G.I., house ban, privilege ban,
contract ban, communications ban, personal relating ban, coffee ban, pool

ban, essay, pinochio report, count to ten, baby bottle, and paciﬁer.

Therapeutic Jargon and Techniques
There were a variety of focused techniques which are described with the TC’s
own language. Some of the techniques are described below:
1. Contract; A contract was a type of learning experience which was imposed
for a major rule violation such as leaving the TC against the advice of
staff. The contract was usually punitive with consequences consisting of

menial tasks such as washing dishes, walls or ﬂoors. A contract might be

115

very dramatic in that a rule violation might have occurred with no
admission of guilt. As an example, illegal drugs might have been found
on the premises. If no one admits to the rule violation, the entire resident
population of the TC could be subject to suffer the consequences of the
violation. The concept of “my brother’s keeper,” was discussed with the
TC residents and all of the names of the residents were put into a hat with
one resident’s name drawn who paid the consequences for the entire
community. This experience was atypical of the rules of society whereby
most rule violations do not have consequences. If a resident can be
punished for someone else’s action, the vigilance level increased to
prevent such violations. Other examples of contracts are named but not
deﬁned in the following list: dish tank, think room, pay-me-no-mind, walls
and ﬂoor, bum squad, spare parts, tidy bowl, talk ban, awareness, relating,
relating table, and after 5 contract.

Harem; A verbal reprimand was used by staff to explain to a resident how
their behavior was inappropriate. This usually resulted in the resident
standing at attention so that they at least appeared to listen to each word of
the reprimand. Examples of haircuts are named but not described in the
following list: stern confrontation, reﬂection, karom shot, disappointment,
ridicule, smoker, positive stroke, and round robin.

Ihebench; The resident was asked to sit on a bench to reﬂect on a
disciplinary action related to inappropriate behavior. The bench was used

as a cooling off period following a haircut or preceding a haircut.

116

4. Limbo; This was a motivational tool to inspire those who appeared to have
stagnated in their treatment progress. The resident had no responsibilities
and no privileges and was used to determine the resident’s motivation for

continued treatment.

Adult Education Issues

The residents were provided information verbally and through the use of written
handouts. In addition, video and audio media were used to communicate treatment
concepts and factual information about problems associated with substance dependence.

The residents were asked about their reading skills and for some, their inability to
read or comprehend was clearly evident. However, a thorough assessment of the
residents’ reading level and other comprehension did not occur. Consequently, the
residents with learning deﬁcits were not given special attention or accommodations to
improve retention of the treatment concepts. The design of the groups and didactic
presentations was not altered to attend to individualized instructional requirements nor

did it consider the special barriers and needs of adult learners.

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