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THE IMPACT OF A RELATIONSHIP SKILLS TRAINING PROGRAM ON THE
COMMUNICATION AND PROBLEM SOLVING ABILITIES OF INDIVIDUALS IN
A MALE RESIDENTIAL SUBSTANCE ABUSE TREATMENT PROGRAM
By

Kristin L. Cox Humphrey

A DISSERTATION

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

DOCTOR OF PHILOSOPHY
Department of Counseling/Educational Psychology and Special Education

2006

ABSTRACT
THE IMPACT OF A RELATIONSHIP SKILLS TRAINING PROGRAM ON THE
COMMUNICATION AND PROBLEM SOLVING ABILITIES OF INDIVIDUALS IN
A MALE RESIDENTIAL SUBSTANCE ABUSE TREATMENT PROGRAM
By
Kristin L. Cox Humphrey
The biopsychosocial model acknowledges the interaction of biological,

psychological, and social influences that impact the exacerbation of addiction. This study
addresses the social influences by examining the impact of a relationship skills training
program on communication and problem solving abilities of males on probation in a
residential substance abuse treatment program. A psychoeducational intervention was
chosen instead of a counseling intervention under the assumption that clients need basic
knowledge of communication and problem solving before being able to pursue advanced
counseling work. Many clients do not yet possess such basic skills, so a
psychoeducational intervention was chosen in which such skills could be taught in a
short, easily-implemented, cost-effective manner. Six sessions of “Time-Out! For Men: A
Communication Skills and Sexuality Workshop for Men,” a psychoeducational .
intervention that specifically addresses relationships, was utilized as the intervention.
Using a randomized, control group, pre-test, post-test design, 80 participants were
randomly assigned to either the experimental (n= 42) or control group (N = 38). A
matched-sample t-test indicated a significant improvement in communication, problem
solving, and relationship coping skills learned between the pre-test and post-test in the
experimental group. However, such a significant improvement was not observed in the

control group. Additional analyses were performed, including an independent sample t-

test and a cluster analysis. Findings have large implications for substance abuse theory,

research, and practice.

Dedication
All of the hard work and sacrifice I have put into my education and into this
dissertation would mean nothing without the love and support of my family. My husband,
my mom, my dad, and my brother in particular have been there throughout my many
years of schooling rooting me on. Because of their unending, unconditional support, I

dedicate this to them.

iv

ACKNOWLEDGEMENTS

Many people have shaped me personally and professionally throughout my
doctoral career and who I will be eternally grateful. First, my husband always has been
there, whether it be to give me a shoulder to cry on, to give me that much needed
encouragement to continue on with my endeavors, or to be the first there to congratulate
me on my successes. My father, mother, and brother also have been ever-present
throughout my education and always have been there to listen and provide support during
those good days and not-so-good days.

I also cannot say enough about the faculty and staff in the Counseling Psychology
Department. During the transition our department has gone through, they always have
been there, if it is simply to be a listening board. Dr. Gloria Smith was the first faculty
member I met at Michigan State University, and she has provided me endless guidance,
support, and encouragement as an advisor, professor, and friend. The adjunct faculty
members in the department have also hugely impacted my career. Dr. Tom Novak, Dr.
Tawa Sina, Dr. Crewe, Dr. Robert Fabiano, Dr. Jean-Claude Dutes, and Dr. Sonja
Gunnings-Moton have each had an influence on my education and career from offering
me unique clinical and research experiences and giving me advice about my future
endeavors to going out of their way to help me out in any way that they could.

Dr. Shaun LaBlance is a colleague and friend of mine at Community Mental
Health. He helped me develop my idea for this dissertation from the beginning and

provided constant support and guidance as I continued writing and revising. He is a truly

kind person and a wonderful psychologist, and I am extremely gratefiil for the help and
advice he has given me with this dissertation specifically and with my career in general.
Finally, and most importantly, Dr. John Kosciulek has been a huge influence on
my professional career. As our program has gone through transition, my cohort members
and I had limited faculty to turn to during times of need. Dr. Kosciulek served for many
of us as not only a professor, advisor, and mentor with our studies but also as a main
source of personal support during this tough time. Although he is a professor in another
department, he always gave us his time and energy, as if we were part of his department.
It is evident that Dr. Kosciulek is truly passionate about his job working with and
mentoring students, and I am lucky enough to be one of his students. With this
dissertation specifically, Dr. Kosciulek has spent countless hours meeting with me,
providing me with revisions, and giving me endless guidance throughout this process. I
undoubtedly know that without him, this dissertation would not be the quality that it is.
He is truly one of the most dedicated and caring faculty members that I have met and
worked with, and I greatly value the help, guidance, and support that he has given me

throughout the past several years.

vi

TABLE OF CONTENTS

CHAPTER 1

INTRODUCTION ............................................................................ 1
Scope of the Problem. . . . . . . .. ....................................................... 4
The Intervention ...................................................................... 7
Purpose ................................................................................ 9
Research Questions .................................................................. 10

CHAPTER 2

LITERATURE REVIEW .................................................................... 11
Impact of Substance Abuse ......................................................... 12
Models of Substance Abuse Treatment ........................................... 22
Interventions Addressing the Significant Other/Marital Relationship ........ 27

CHAPTER 3

METHOD ...................................................................................... 39
Variables and Measures ............................................................. 43
Procedure .............................................................................. 48
Research Design and Data Analyses .............................................. 51

CHAPTER 4

RESULTS ...................................................................................... 54
Additional Analyses .................................................................. 57

CHAPTER 5

DISCUSSION ................................................................................. 62
Narrative Summary of Findings ................................................... 64
Relations of Results to Previous Research ....................................... 65
Implications for Theory, Research, and Practice ................................ 69
Future Research Needed ............................................................ 72

REFERENCES .............................................................................. 74

APPENDICES ................................................................................ 83
Appendix A — Participant Information Sheet .................................... 84
Appendix B — Communication Competence Scale .............................. 86
Appendix C — Problem Solving Inventory ........................................ 90
Appendix D - Multidimensional Intimate Coping Questionnaire ............. 94
Appendix E — Informed Consent Forms .......................................... 98
Appendix F — Outline of Each Psychoeducational Session ..................... 101

vii

Chapter 1
Introduction

The economic costs substance abuse yields to society are well known. Health
care costs and loss of work productivity are just two of the many examples of the
financial burden caused by substance abuse. A study prepared by the National Institute
on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism
(N IAAA) estimated the total economic cost of substance abuse to be $373.3 billion in the
United States in 2000. Of this amount, $212.6 billion was due to alcohol abuse alone.
These economic cost estimates include substance abuse treatment and prevention costs as
well as other healthcare costs, costs associated with reduced job productivity or lost
earnings, and other costs to society such as crime and social welfare. It is important to
note that these are likely conservative estimates due to the hidden nature of substance
abuse.

The necessity of substance abuse treatment is evident due to the extreme costs
substance abuse presents to society. However, many substance abuse services are
provided from a biomedical perspective (Kumpfer, Trunnell, & Whiteside, 1990), which
considers addiction an uncontrollable disease shared by all individuals with substance
abuse issues. The biomedical approach to substance abuse places little emphasis on
unique factors of the individual such as family, employment, and spirituality (Cloud &
Granfield, 2001) and places primary responsibility for the addiction on the individual.
According to Kumpfer et al. (1990), the biomedical model is a “mechanistic, linear
model, which does not account for the complex experiences of individuals or their social

context” (p. 56). Many substance abuse treatment programs have been criticized for

providing treatment from this type of uni-faceted model, as it is used at the “expense of
the humanity of the patient” (Engel, 1977, p. 131).

More recently, research has shown the need for more individualized, holistic
treatment when treating clients with substance abuse issues (Hanson, Venturelli, &
Fleckenstein, 2004). In 1999, NIDA developed 13 principles that delineate effective
substance abuse treatment. The third principle states, “Effective treatment attends to
multiple needs of the individual, not just his or her drug abuse” (Hanson et al., 2004, p.
99). This principle is further purported by NIDA through the statement that for treatment
to be effective it must address the client’s substance abuse along with “any associated
medical, psychological, social, vocational, and legal problems” (Hanson et al., 2004, p.
99).

These same authors report that the most successful treatment programs provide a
combination of therapy and other services to meet the individual needs of each client.
Holistic models of treatment have been termed by some researchers as the
biopsychosocial model of addiction (Engel, 1977, 1978, 1980; Downing, 1989; Fisher &
Harrison, 2000; Kumpfer, 1987) due to the importance of the biological, psychological,
and social aspects of the client. According to Kumpfer et al. (1990), the primary
stipulation of the biopsychosocial model is that the clinician conceptualizes the person in
relation to his or her total biopsychosocial environment. In addition, this model shifts the
locus of responsibility of the addiction from solely being on the individual, which is
implied by more uni-faceted models like the disease model, to also being exacerbated by

external factors, such as social and psychological influences.

The biopsychosocial model implies a comprehensive treatment modality, which
includes addressing family issues and conflict, particularly issues with one’s significant
other. However, little attention has been given to such issues in traditional substance
abuse treatment, and this is especially true for men (Dore, 1994; Hodgins, El-Guebaly, &
Addington, 1997; Ritter & Cole, 1992). This situation exists despite the fact that the
importance and effectiveness of incorporating family issues in treatment have been
thoroughly documented (Meyers, Apodaca, Flicker, & Slesnick, 2002; Waldron, 1997)
and that addiction often develops within a family context (Heath & Stanton, 1998).
According to Aviram and Spitz (2003), a relevant consideration for individuals in
substance abuse treatment is their relational ability, as significant relationships may
contribute to ongoing substance use as well as support recovery and abstinence.

Following the individualized focus of the biopsychosocial model, more recent
research has focused on the specific concerns of men and women separately so that the
needs of all clients in substance abuse treatment are met (Dore, 1994; Hodgins, El-
Guebaly, & Addington, 1997). However, most of the research and discussion about such
differences are focused on the unique needs of women in traditionally male-oriented
treatment programs (Schliebner, 1994). Communication, self-esteem, parenting,
sexuality, HIV/AIDS, abuse, and sexual health concerns are specific issues addressed in
interventions for women (Bartholemew, Rowan-Szal, Chatham, & Simpson, 1994;
Bartholemew et al., 2000). Similar issues are very pertinent to men as well.

Despite the fact that there is documentation of the importance of male-specific
programming in substance abuse treatment (Dore, 1994; Hodgins, El-Guebaly, &

Addington, 1997), few studies have actually examined their effectiveness in terms of

outcomes of specific interventions targeted for men (Bartholomew, Hiller, Knight,
Nucatola, & Simpson, 2000). Norwinski (1993) reported that self-esteem, intimacy, and
sexuality are key issues for men in recovery. However, this same researcher reports that
men can have difficulty admitting their needs, concerns, and fears because of male-
gender role socialization. In addition, other researchers have focused on “restrictive
emotionality” (Good, O’Neil, Stevens, Robertson, Fitzgerald, DeBord, Bartels, &
Braverman, 1995) and “nonrelational sexuality’ (Levant, 1997) as primary contributors to
men’s relationship and psychological difficulties and distress. Because of this rigid
socialization pattern, men may experience gender-role conflict and, therefore, may be
dissuaded from seeking a type of mutual intimacy that encourages social support (Ritter
& Cole, 1992). However, a strong, stable support system is positively correlated with
treatment outcomes and compliance (Aviram & Spitz, 2003) and can be an important
anchor for recovery (Bartholomew & Simpson, 2002), especially for men (Booth,
Russell, Yates, Laughlin, Brown, & Reed, 1992). Therefore, it is essential to address
such relationship issues with men in substance abuse treatment.
Scope of the Problem

Substance abuse is correlated with marital discord (O’Farrell, 1995). Partners of
individuals with substance abuse issues reported significant dissatisfaction with their
marital relationship and desired marked change in multiple areas of functioning that
affect relationship quality. Further, partners used maladaptive methods to address
relationship conflict and had already taken steps toward relationship dissolution (Fals-
Stewart & Birchler, 1998). In addition, problem drinking in one spouse is linked to

increased rates of psychological and physical problems among nondrinking spouses

(Moos, F inney, & Gamble, 1985), as well as higher rates of marital aggression,
separation, and divorce (Kantor & Strauss, 1990).

Role incompatibility theory (RIT) can be usefirl for explaining the consequences a
relationship can suffer when one partner is abusing substances. RIT emphasizes the
necessity of having relationship coping skills training as a part of treatment programs
(N ewcomb, 1994; Yamaguchi & Kandel, 1985). RIT proposes that involvement in
traditional social roles, such as being a partner in a marriage or committed relationship, is
antithetical to also maintaining nonconforming attitudes and being involved in socially
deviant behaviors, like substance abuse (Pals-Stewart, Birchler, & O’Farrell, 1999).
Further, when deviant behavior, like substance abuse, occurs chronically within a dyadic
relationship, role conflict eventually occurs. According to Fals-Stewart et al. (1999), for
a person who is involved in a relationship and abuses substances, this role conflict is
typically resolved by the deterioration or ending of the relationship, reduction or
termination of the substance abusing behavior, or modification of the relationship to
accommodate the deviant behavior. With effects on the marital relationship such as
conflict, aggression, and resulting relationship dissatisfaction and/or dissolution noted
consistently throughout research (Fals-Stewart and Birchler, 1998; Pals-Stewart, Birchler,
& O’Farrell, 1999), the need and value of incorporating relationship coping skills
training, such as communication and problem-solving training, in substance abuse
treatment is significant.

Much research has demonstrated that individuals with chronic addictions have
inadequate coping skills to resolve interpersonal conflict. For example, according to

Monti, Abrams, Kadden, and Cooney (1989), coping skill deficits are a major

predisposing risk factor for developing and maintaining addiction. More specifically, the
lack of proper social skill development or interpersonal coping skill deficits can be a
high-risk situation for abusive drinking (Marlatt & Gordon, 1985) and can increase the
likelihood for abusive drug and alcohol use (Monti et al., 1989). Communication skill
deficits have been associated with individuals with substance abuse, and training
programs focusing on improving such skills have been shown to be particularly effective
in promoting abstinence (Monti, Abrams, Binkoff, Zwick, Liepman, Nirenberg, and
Rohsenhow, 1990; Rohsenow, Monti, Binkoff, Liepman, Nirenberg, and Abrams, 1991).
In addition, deficiencies in social problem solving are present in those at risk for
substance abuse (Platt & Husband, 1993). Larson and Heppner (1989) found that a
sample of inpatient alcoholics appraised their problem solving as considerably more
negatively than nonclinical adults. Consequently, researchers also have suggested the
importance of incorporating problem solving training in substance abuse treatment
programs (Miller, 1992; Miller & Brown, 1997).

Pals-Stewart, O’Farrell, and Birchler (2004) espouse communication and problem
solving skills training as necessary components of substance abuse treatment that can aid
in enhancing relationship functioning and, thus, abstinence. Problem solving and
communication skills training will be the focus of the proposed project, as it is believed
that learning these specific coping skills will not only have a positive effect on
relationship functioning, but also on one’s recovery. Bartholomew and Simpson (2002)
hypothesized that offering men a program where relationship issues such as
communication problems can be openly and honestly discussed will make them feel

empowered to make changes that will foster stronger and more supportive relationships

and will thus promote their recovery. Given their potential significance in substance
abuse treatment and recovery, the proposed study will focus on problem solving and
communication skills.
The Intervention

While more and more substance abuse treatment research has focused on the
effectiveness of gender-specific program planning (Dore, 1994; Hodgins, El-Guebaly, &
Addington, 1997; Schliebner, 1994), the effectiveness of the method of delivery of such
interventions has not been thoroughly studied. According to La Salvia (1993), the focus
of most substance abuse treatment programs is on repairing clients’ ego function deficits.
However, she described this primary focus on ego strengthening as inadequate.
Khantzian (1988) stated that substance abusers need as much assistance with their self-
care problems as they need help with understanding their feelings about life. La Salvia
(1993) further stated that psychotherapy and psychodynamic group therapy may suffice
in addressing emotions, but a comprehensive, thorough addictions treatment program also
must include the basic set of tools necessary to solve life’s day-to-day problems. A
psychoeducational group, in particular, which is a specialized, task-oriented, didactic
group experience, can address both ego deficits and life skills. Therefore,
psychoeducational interventions have been found to be effective in addiction treatment
(Marlatt & Donovan, 1982; McAuliffe & Gordon, 1980). Such interventions are
particularly effective when they expand on traditional c0ping skills and problem-solving
training (La Salvia, 1993).

“Time-Out! For Men: A Communication Skills and Sexuality Workshop for

Men,” develOped by the Institute of Behavioral Research at Texas Christian University

(Bartholomew and Simpson, 2002) and funded by NIDA, is one such intervention that
addresses communication and problem solving. This intervention, consisting of six 2-
hour sessions, is specifically targeted for men and addresses communication skills, self-
esteem, and problem solving in the context of helping men improve their intimate
relationships (Bartholomew & Simpson, 2002). There are two additional sessions in this
curriculum that focus on sexuality, specifically sexual myths and sexual stereotypes.
However, due to their irrelevance to the focus of this study, they have been eliminated
with the permission of the intervention’s creators. Because close, stable, supportive
relationships have been found to aid one’s recovery and treatment compliance (Aviram &
Spitz, 2003; Fals-Stewart, Birchler, and O’Farrell, 1999), the “Time Out! For Men”
intervention focuses on communication skills, such as listening, assertiveness, I-
statements, sharing feelings, and conflict resolution. The “Time Out! For Men”
intervention was designed to teach relationship coping skills, Specifically communication
and problem solving skills, in order for men to make changes that will lead to more stable
intimate relationships and a more successful recovery.
Definitions

Because of the multitude of terms used in addiction research, the following are the
definitions of the terms that will be used throughout this paper (American Psychiatric
Association, Diagnostic and Statistical Manual of Mental Disorders, 5:}: edition, 2000):

Substance Use - any use, particularly recreational use, of alcohol and/or

other drugs.

Substance Abuse — any pattern of substance use that results in repeated adverse
social consequences related to substance-taking, such as failure to meet work,
family, or school Obligations, interpersonal conflicts, or legal problems.
Substance Dependence/Addiction — substance use characterized by related
physiological and behavioral symptoms, including tolerance, or the need for
increased amounts of the substance to maintain the desired effects, withdrawal if
substance-taking ceases, and an inordinate amount of time spent in activities
related to substance use.
These terms are on a continuum with substance use being less severe than substance
abuse, and substance abuse being less severe than substance dependence/addiction.
However, in the substance abuse literature and in practice, it is common to use the terms
“substance abuse” to imply “substance dependence” or “addiction.” For example, when
someone is in inpatient “substance abuse treatment,” it is likely that the person is
diagnosed with a “substance dependence” issue, as inpatient care is the most intensive
form of substance abuse treatment, usually requiring a dependency diagnosis. Therefore,
unless otherwise noted, in this paper substance abuse will be used to imply substance
dependence or addiction. In other words, these terms will be used interchangeably unless
otherwise indicated.
Purpose of the Study
The purpose of this study was to test the effectiveness of a relationship skills
training program in enhancing the communication, problem solving, and relationship

coping skills of individuals in a male residential substance abuse treatment program.

Research Hypotheses
(1) A relationship skills training program will increase the communication skills of
individuals in a male residential substance abuse treatment program.
(2) A relationship skills training-program will increase the problem solving skills of
individuals in a male residential substance abuse treatment program.
(3) A relationship skills training program will increase the relationship coping skills

of individuals in a male residential substance abuse treatment program.

10

Chapter 2
Literature Review

Society pays a huge price for alcohol and other drug abuse. Although many of the
costs of substance abuse are immeasurable, such as broken homes and fatal illnesses,
NIDA and NIAAA (1998) estimated that alcohol abuse cost the United States $166.5
billion in 1995, and that drug abuse cost the nation $109.8 billion in 1995. The Office of
the National Drug Control Policy (2001) revised and updated NIDA-NIAAA’s substance
abuse cost figure from 1995, estimating that alcohol and drug'abuse cost the nation
$373.3 billion in the year 2000. This estimate includes substance abuse treatment and
prevention, healthcare, reduced job productivity or lost earnings, and crime. Society
continues to pay a great deal of money even after substance abusers and dealers are
caught, as it takes from $75 to $1500 per day to keep one person incarcerated. This study
performed by NIDA in 1998 also determined that 44 percent of these economic costs of
alcohol and other drug abuse are borne by those who abuse drugs and members of their
households.

In addition to the costs it presents to society, substance abuse also has a large
impact on the individual user and his or her family. Approximately 11.4 million
Americans use alcohol and/or other drugs, with 3.1% of these individuals over the age of
18 having been formally diagnosed as having a drug abuse disorder and 7.4% being
diagnosed with alcohol dependence (SAMHSA, 1994). One in every four families is
affected by alcohol-related problems, and according to MacDonald (1991), one in eight
American children has alcohol dependent parents. Further, it is estimated that alcohol

plays a role in one out of three failed marriages (Institute of Health Policy, 1993). This

11

relationship between the substance abuser and his or her spouse or significant other has
shown to be a crucial catalyst for recovery. However, this relationship can also lead a
substance abuser to relapsing and to be even further engrossed in addiction. Models that
have been developed depict the reciprocal relationship between substance abuse and
relationship dysfimction (F als-Stewart et al., 2004). Because the relationship between a
substance abuser and his or her partner is such a vital component in the abuser’s life,
interventions that have been used in substance abuse treatment programs to address this
relationship will be discussed. In addition, an intervention that focuses on teaching
relationship coping skills (i.e., communication and problem solving skills) that can
enhance one’s recovery will be proposed.

In this literature review, the following topics will be addressed: (a) the impact of
substance abuse on the individual, family, and significant other; (b) theoretical models
which describe the importance of addressing relationship issues in substance abuse
treatment; (c) interventions that have addressed the significant other relationship; ((1) the
importance of psychoeducational interventions in substance abuse treatment; (e) the
importance of relationship coping skills training in substance abuse treatment; and (f) the
“Time Out! For Men” relationship coping skills psychoeducational intervention.

The Impact of Substance Abuse
Substance Abuse and the Individual

Anyone can become dependent on alcohol and/or other drugs. Addiction does not
discriminate; it is an “equal-Opportunity affliction” (Hanson et al., 2005, p. 18). In other
words, addiction is found across all age groups, social classes, occupations, races, and

ethnicities. The United States Department of Health and Human Services (2003)

12

reported that an estimated 21.6 million persons aged 12 or older were classified with
substance abuse or dependence. This number equals 9.1 percent of the total United States
population. Of these individuals, 3.1 million were classified with dependence on or abuse
of both alcohol and illicit, or illegal, drugs, 3.8 million were dependent on or abused
illicit drugs but not alcohol, and 14.8 million were dependent on or abused alcohol but
not illicit drugs (SAMHSA, 2003). Those who do advance from recreational substance
use to abuse and dependence experience the symptoms of excessive use, constant
preoccupation with using and obtaining the substance, refirsal to admit excessive use, and
an over-reliance on the substance (Hanson et al., 2005). Such symptoms often result in
producing initial symptoms of withdrawal whenever the individual makes an effort to
stop taking the substance. Consequently, the substance abuser begins to neglect other
responsibilities, such as his or her family and job, in favor of using the substance.

Individuals who abuse alcohol and other drugs experience numerous
consequences as a result of this abuse. First, there are severe health risks associated with
substance abuse. Each year, more deaths and disabilities result from substance abuse
than from any other preventable cause (Brooks, 1997). Approximately 100,000 people
die as a result of alcohol, and more than 19,000 deaths are due to illicit drug abuse and
drug-related behavior (Institute of Health Policy, 1993). Health-related problems such as
liver disease, heart disease, lung disease, and infections, such as HIV and Hepatitis C, are
common among individuals who abuse substances (Brooks, 1997).

Substance abuse also has a large impact upon the user’s employment. Only fifty-
nine percent of adults who reported using an illicit drug in the previous month are

employed (SAMHSA, 1994). A large number of these individuals reported missing work

13

due to illness or injury, and some stated they have gone to work under the influence of
alcohol and/or other drugs. Higher health insurance costs, including more workers
compensations claims, decreased productivity, and high turnover rates are all associated
with employed individuals who abuse alcohol and/or other drugs.

Finally, individuals who abuse substances are more susceptible to involvement in
criminal behaviors and to being victims of crimes. According to Hanson, Venturelli, and
Fleckenstein (2004), there is a strong correlation between substance abuse and crime;
substance abusers are more likely to commit crimes, arrestees are often under the
influence of alcohol and/or other drugs while committing their crimes, and substance
abuse and violence are strongly connected. Between one-half and two-thirds of all
violent crimes, including murder, sexual assault, and domestic violence, involves the
abuse Of alcohol (SAMHSA, 1994). In addition, McNeece and DiNitto (1998) state that
substance abusers engage in high-risk activities, such as “hanging around bars drinking or
going into inner-city crack houses” (p. 199), that make them more susceptible to being
victims of crimes.

In addition to these substance-related consequences to the individual and society
as a whole, the substance abuser also has deficits in his or her ability to cope with
everyday life stressors. According to Wills and Shiffinan (1985), stress results from an
imbalance between environmental demands and an individual’s resources to cope with
those demands. Stressors may include major life events, such as a death in the family,
everyday hassles, and family and work concerns. Coping, on the other hand, is an
attempt to meet the demand in order to restore the balance in a person’s life (Monti,

Abrams, Kadden, & Cooney, 1989). Coping skills are developed to help protect

14

individuals from being psychologically banned by difficult experiences in their lives
(Pearlin & Schooler, 1978). According to Lazarus and Folkman (1984), there are two
types of coping: problem-focused coping and emotion-focused coping. Problem-focused
coping is designed to manage or alter the problem that is causing the distress, while
emotion-focused coping regulates emotional responses elicited by the problem (Lazarus
& F olkman, 1984). If the individual does not have adequate coping skills, both problem-
focused and emotion-focused, then alcohol and other drugs may be used as a coping
mechanism in an attempt to restore the equilibrium (Monti et al., 1989).

There is much documented evidence that substance abusers possess inadequate
coping skills, specifically interpersonal coping skills. According to O’Leary, O’Leary,
and Donovan (1976), prealcoholics, those with abusive drinking patterns who do not yet
meet criteria for alcohol dependence, can be considered deficient in interpersonal skills.
Bandura (1969) reported that this is a learned behavior, as in households where alcohol
and drug consumption is modeled across a variety of circumstances as a means to cope
with stress, children learn a similar pattern of substance abuse to cope with a variety of
situations. Monti et al. (1989) further stated that some children of problem drinkers learn
that heavy drinking is necessary for adequate coping in interpersonal situations.
Unfortunately, these children may never learn appropriate coping skills and carry such
deficits into adulthood (Monti et al., 1989). A lack of appropriate coping skills may lead
to additional interpersonal problems as the individual enters relationships with friends
and significant others.

Social learning theory (SLT) has been useful in explaining the link between

coping skills deficits in substance abusers and the maintenance of the substance abusing

15

behaviors. According to SLT, alcohol dependence is maintained in part as a means of
coping with stressful experiences in individuals with a limited repertoire of coping skills
(Abrams & Niaura, 1987). In addition, the factors considered to maintain alcohol abuse
include conditioned reactions to drinking-related stimuli and coping skills deficits
(Rohsenow, Monti, Rubonis, Gulliver, Colby, Binkoff, & Abrams, 2001). For substance
abusers, high-risk situations include increased urges to drink, psychophysiological
reactivity, decreased self-efficacy, and impaired coping skills (Abrams & Niaura, 1987;
Rohsenow, Monti & Abrams, 1995). Marlatt and Gordon (1985) stated that there is a
high risk for relapse when negative, interpersonal emotional states exist. According to
Rohsenow et al. (2001), focusing on coping skills in substance abuse treatment designed
to address such interpersonal difficulties is highly beneficial.
Substance Abuse and the Family

There are numerous definitions of family that vary due to culture and context.
The definition of family is not constant and can change according to different
circumstances. Sargent (1983) proposed one definition that is widely accepted. He stated
that family is “a group of people with common ties of affection and responsibility who
live in proximity to one another” (as cited in Brooks & Rice, 1997, p. 57). Sargent
(1983) reported that families have four primary traits. The first trait is nonsummativity,
or the family as a whole is greater than—and different from—the sum of its individual
members. The second trait is circular causality which holds that if one family member
changes his or her behavior, as with substance use, the others also will change, which in
turn causes successive changes in the member who changed initially. Next, each family

possesses a pattern of communication traits, which can be verbal or nonverbal, overt or

16

subtle means of expressing emotion, conflict, and affection. Finally, families strive to
achieve homeostasis, which portrays family systems as self-regulating with a primary
need to maintain balance. For instance, when one family member, especially a parent, is
a substance user, other members of the family will take on this parent’s responsibilities
that he or she is neglecting due to the substance use, such as cooking and taking care of
children, in order for the homeostasis of the family to be maintained.

When one family member has an addiction, each of the above four traits are
affected in some way, as addiction is described as a “family disease” (Brooks & Rice,
1997, p. 92). Addiction is described as a disease of the family because each family
member suffers the consequences of the using member’s addiction, and each plays some
role in maintaining the destructive relational patterns that result from addiction (Brown,
1985). Each member of the family struggles with the addiction in his or her own way
and, therefore, copes with the disease in a unique manner.

Alcoholism and drug addiction take a toll on families. However, because family
structures have become more complex, growing from the traditional nuclear family to
single-parent families, stepfamilies, foster families, and multigenerational families, when
a family member abuses substances, the effect on the family may differ according to the
structure (Center for Substance Abuse Treatment, 2004). For instance, according to
Brown and Lewis (1999), a parent of small children may try to compensate for
deficiencies that his or her substance-abusing spouse has developed as a consequence of
the substance abuse. Further, children may act as surrogate spouses for the parent who

abuses substances (Center for Substance Abuse Treatment, 2004), which is seen

17

commonly when the oldest child takes on responsibilities of cooking and cleaning, as the
parent who is responsible for these duties is preoccupied with substance abuse.

Children are particularly vulnerable to addiction when a parent abuses alcohol
and/or other drugs. In the United States, 8.3 million children live with a parent who is in
need of treatment for alcohol or drug dependency (SAMHSA, 2003). One in four
children under the age of 18 is living in a home where alcoholism or alcohol abuse is a
fact of daily life, and countless others are exposed to illegal drug abuse in their families
(SAMHSA, 2003).

The toll addiction takes on children can be substantial. Children of alcoholics
(COAs) are at significantly greater risk for mental illness or emotional problems, such as
depression or anxiety, physical health problems, and learning problems including
difficulty with cognitive and verbal skills, conceptual reasoning, and abstract thinking
(SAMHSA, 2003). Further, children whose parents abuse alcohol and/or other drugs are
almost three times more likely to be verbally, physically or sexually abused, and they are
four times more likely than other children to be neglected. Strong scientific evidence
also suggests that addiction tends to run in families. Children of alcoholics are four times
more likely than non-COAs to develop alcoholism or other drug problems (SAMHSA,
2003).

The effects of substance abuse also can extend beyond the nuclear family.
Feelings of abandonment, anxiety, fear, anger, concern, embarrassment, or guilt are
commonly experienced by extended family members to the point that they may ignore or
cut ties with the person abusing substances. Some family members may even seek legal

protection frOm the person abusing substances. In addition, the effects on families may

18

continue for generations. Intergenerational effects of substance abuse can have a negative
impact on role modeling, trust, and concepts of normative behavior, which can damage
the relationships between generations.

It is evident that the substance abuser suffers from personal impairment and
contributes to the impairment of his or her family (McNeece & DiNitto, 1998).
Similarly, other family members, such as the substance abuser’s spouse or significant
other, can develop individual impairment (i.e., codependency) and contribute to the
impairment of the family. Likewise, this family dysfunction can exacerbate each
individual family member’s problems (McNeece & DiNitto, 1998). This reciprocal
process of family dysfunction, specifically between the substance abuser and his or her
spouse or significant other, is the focus of the next session of this literature review.
Substance Abuse and the Significant Other

Regardless of the type of substance, substance abuse affects numerous couples
and families throughout the world (Pascoe, 2001). Woititz (1979) reported that each
alcoholic affects at least six other people directly. One person directly involved is the
client’s spouse or significant other. Addiction can destroy an intimate relationship due to
its devastating economic and psychological consequences. For instance, an excessive
amount of money may be spent for substance use, and the partner who is not abusing
substances often must assume the provider role. Psychological consequences may
include denial or protection of the person with the substance abuse problem, chronic
anger, stress, anxiety, hopelessness, inappropriate sexual behavior, neglected health,

shame, stigma, and isolation (Center for Substance Abuse Treatment, 2004).

19

Intimate relationships have the potential to enhance or diminish psychological and
physical health through specific coping efforts (Hansson, Jones, Carpenter, & Remondat,
1986-87). For instance, effective social support-related coping in close relationships can
reduce the risk for physical and mental impairment (Coyne, Aldwin, & Lazarus, 1981),
while maladaptive coping strategies such as those possessed by individuals with
substance abuse issues, adversely affect psychological health (Aldwin & Revenson,
1987). In addition, marital happiness is a function of different methods of coping
(Bowman, 1990). Positive approach c0ping and effective problem solving, for example,
tend to increase marital satisfaction (Bowman, 1990). Avoidant problem solving
activities, on the other hand, often lead to marital dysfunction (Noller, Feeney, Bonnell,
& Callan, 1994). Such an avoidant style of coping is a characteristic of individuals with
addiction.

According to F als-Stewart, O’Farrell, and Birchler (2004), the causal relationship
between substance abuse and relationship discord are intricate and reciprocal. Couples in
which one partner abuses alcohol and/or drugs have significant relationship problems,
including high levels of relationship dissatisfaction, instability, and verbal and physical
aggression (Fals-Stewart, Birchler, & O’Farrell, 1999). Newcomb (1994) found that
current substance abuse is associated with reduced dyadic adjustment and general
relationship quality in non-clinical samples. Further, Wilsnack and Wilsnack (1993)
determined that poor marital functioning was associated with incongruent alcohol
consumption patterns (i.e., infrequent drinking wife with a frequently drinking husband

or vice versa). With clinical samples, a number of studies have concluded that alcoholic

20

couples have distressed relationships (McCrady, Stout, Noel, Abrams, & Nelson, 1991;
O’Farrell & Birchler, 1987).

In a study of dyadic adjustment and relationship satisfaction among couples, Fals-
Stewart, Birchler, and O’Farrell (1999) found that for couples with one substance-
abusing partner, a higher percentage of days abstinent during the year before treatment
was correlated with a higher level of relationship satisfaction. In addition, one year
following treatment, a higher percentage of days abstinent was associated with
relationship stability for these same couples. In general, the partners in a relationship
with someone abusing substances were significantly dissatisfied with their relationships,
desired marked change in multiple areas of functioning that influenced relationship
quality, and had taken several steps toward ending the relationship (Fals-Stewart &
Birchler, 1998). Finally, Pals-Stewart and Birchler (1998) compared couples with a
substance-abusing husband and non-substance abusing, distressed couples. These
researchers concluded that the substance-abusing couples had higher scores on 3 of the 5
subscales of the Clinician Rating of Adult Communication (CRAC), including
Abusiveness, Problem Solving Skills, and Attribution of Blame, and a higher total score
on the CRAC.

According to Maisto, O’Farrell, Connors, McKay (1988), relationship dysfunction
is correlated with increased substance abuse and post-treatment relapse among drug
abusers and alcoholics, and this cycle continues to be perpetuated. This cycle has been
termed the “destructive cycle” by Fals-Stewart et al. (2004) and illustrates the reciprocal
nature of substance abuse and relationship problems. This destructive cycle illustrates

how relationship and family difficulties including poor communication and problem

21

solving often form the basis for excessive substance use (F als-Stewart et al., 2004).
Heath and Stanton (1998) report that addiction can be maintained and even worsened by
family interactions. Enabling and codependency, for instance, foster the continuation of
substance abuse by one partner covering up the substance use and its consequences for
the using partner (Hanson et al., 2004). Therefore, it is important to have an intervention
that focuses on improving relationship functioning by enhancing problem solving and
communication Skills. In addition, because most relapses have been found to occur in
interpersonal situations and negative affect situations, communication skills training can
be extremely valuable for individuals with substance abuse issues (Marlatt & Gordon,
1985)
Models of Substance Abuse Treatment

The Biopsychosocial Model

According to the Department of Health and Human Services, which conducted an
integrated report of the provision of services in the Northwest Territory in 2002, there are
at least 15 conceptual models of addiction. The plethora of models is indicative of the
lack of agreement between experts in the field as to the etiology of alcohol and other drug
problems. Models, such as the disease model, which indicates a biological basis for
addiction, and the sociocultural model, which dictates predominantly a societal influence
on addiction, are very specific as to the cause of addiction. However, such models lack
attention to other factors such as psychological and family components, which also play a
part in addiction. The limitation of such models is that variables affecting substance
abuse often interact with each other and cut across multiple levels (Donovan & Marlatt,

1988).

22

As an understanding of addiction has evolved and knowledge has been acquired
through research, the mechanisms of the causes and persistence of substance abuse have
been expanded. According to the Substance Abuse and Mental Health Services
Administration (SAMHSA, 2002), it is now evident that multiple factors can be
associated with initiation and maintenance of chemical use and dependency. No single
explanation appears adequate in most cases. Likewise, across the range of persons
affected by substance abuse, there are wide variances in precipitating factors and
motivations for continued use (SAMHSA, 2002). To address the multitude of factors
exacerbating substance abuse and the variability among individuals, a more holistic
model, called the biopsychosocial model, has gained broad acceptance in the field (Fisher
& Hanison, 2000; Downing, 1989). Engel (1977) originally developed the model to
Specifically address multiple causes of mental illness. However, in the past decade this
model has gained increased recognition in the field of substance abuse. The
biopsychosocial model depicted in Figure 1 describes addiction as a primary illness,
which progresses developmentally from increasing tolerance and dependency to a
progressive loss of control to erosion of bio-psycho-social health (SAMHSA, 2002).

Figure 1. The Biopsychosocial Model

. Biological ‘
, (Genetic & brain chemical imbalance influences)

Social Psychological
(Family, peer, & work (Mental Health
influences) influences, such as

M depression & anxiety)

23

 

This model considers the interactions of biological, psychological, cognitive, social,
developmental, environmental, and cultural variables to explain addiction (Fisher &
Harrison, 2000). For instance, biological causes of substance abuse include a possible
hereditary component, and recent research is also pointing to an altering of brain
chemistry in those with addictions. Substance abuse also may begin and continue
because individuals experience psychological and emotional problems. Finally,
substance abuse may originate in social situations. It is through social interactions that
substance use and abuse often is learned and reinforced. Further, addiction is often
correlated with multiple social problems, including family dysfunction, unemployment,
and poverty. Such a multifaceted model shifts the locus of responsibility of the addiction
fi‘om solely being on the individual, which is implied by more uni-faceted models like the
disease model, to also being exacerbated by extemal factors, like relationship
dysfunction.

The biOpsychosocial model provides a structure for the provision of substance
abuse treatment services. Because treatment providers do not believe that any one
approach adequately describes the causes or suggests a single preferred treatment for
substance abuse disorders, this model provides practitionerswith a way to understand the
multifaceted problem of addiction (Wallace, 1989). Fisher and Hanison (2000) state that
the biopsychosocial model dictates that people working in the field of addictions need to
thoroughly assess clients, develop multiple hypotheses to explain the client’s problem,
avoid forcing clients to fit a rigid definition of addiction, and use a variety of
interventions to address cooperatively the needs of the client. A biopsychosocial

approach necessitates comprehensive services and appropriate patient-treatment

24

matching. A continuum of treatment and supportive services is necessary to adequately
meet the variety of needs presented by addicted persons (SAMHSA, 2002).
Specific relationship-focused models

It is hypothesized that substance abuse and relationship issues have a complex and
reciprocal relationship (Fals-Stewart et al., 2004). In a relationship in which one partner
abuses substances, Significant relationship dissatisfaction and dysfunction arises. In
addition, instability and sometimes verbal and physical aggression are a part of the
volatility (Pals-Stewart et al., 1999). Likewise, relationship problems are related to
increased problem substance use and relapse following treatment (Maisto et al., 1988).
To depict this give-and-take, mutual relationship between problematic relationship issues
and substance abuse, Pals-Stewart et al. (2004) developed the destructive cycle model
illustrated in Figure 2.

Figure 2. The Destructive Cycle of Addiction

Arguments About Past Use
Nagging Behavior
Caretaking \
Substance Abuse Relationship Dysfunction

Lack of Caring Behaviors
Poor Communication and
Problem Solving
According to this model, the cycle of addiction is perpetuated because

marital/relationship and related family problems often form the basis for excessive

substance use. Such relationship problems include a lack of caring behaviors, poor

25

communication, and poor problem solving. Next, there can be ways in which the
partner’s or other family members’ responses to the substance abuse unintentionally
promotes ensuing use (Fals-Stewart et al., 2004). For instance, when a partner is co-
dependent, or equally dependent on assuming the caretaker role, to his or her using
partner, he or she is enabling the using partner to continue his or her substance abuse by
not giving the user negative consequences for this type of dysfunctional behavior.

To counteract this destructive cycle, Fals-Stewart et al. (2004) developed an
additional model, called the “constructive cycle” depicted in Figure 3 below:

Figure 3. The Constructive Cycle of Addiction

 

 

 

 

 

Communication Relationship

Skills Training Enhancement Increase in
Problem Solving Caring
Substance Abuse Recovery Enhanced Relationship Function
Standard Continuing
Substance Abuse Recovery Plan
Treatment Self-Help Recovery

Support Contract

In this model, the components needed for substance abuse recovery which lead to the
mending of relationships are illustrated. In substance abuse recovery, typical treatment
interventions are needed, which include a continued recovery plan, a recovery contract,
self-help support, and traditional substance abuse treatment, such as counseling. For
these interventions to aid in enhancing relationship functioning, Pals-Stewart et al. (2004)

state that additional treatment components are needed, such as problem solving skills

26

training, communication skills training, and interventions focused on relationship
enhancement and increasing caring behaviors. In the constructive cycle, combining
traditional substance abuse treatment methods that are provSided in most treatment
programs, such as recovery contracts and counseling with interventions addressing
relationship needs, such as communication skills and problems solving training, further
promotes and enhances recovery. Two of the primary components in this model,
problem solving skills and communication skills training, provide the basis for this study.

Interventions Addressing the Significant Other/Marital Relationship
Couples-focused interventions

Much of the research that has addressed and investigated the significant other/
spousal relationship in individuals with substance abuse issues has focused on
interventions that have directly involved the spouse with their substance abusing partner.
Such couples-focused interventions have been associated with greater marital satisfaction
and increased rates of abstinence. Marital/couples therapy has been most often
investigated and found to be particularly effective in the treatment of adult problem
drinkers (Meyers et al., 2002), and interest in conjoint interventions became popular
through successful efforts with alcoholic couples (Aviram & Spitz, 2003).

O’Farrell (1995), for instance, found that marital treatment yields better outcomes
than individual treatment during the 12 months following the conclusion of treatment.
Behavioral marital therapy (BMT), which has a relationship and a substance abuse focus,
in particular has shown to reduce marital and/or drinking deterioration during long-term
recovery better so than individual treatment (Meyers et al., 2002). O’Farrell, Cutter,

Choquette, FlOyd, and Bayog (1992) concluded that couples receiving BMT remained

27

significantly improved on marital and substance abuse outcomes throughout the 2-year
follow-up. In a study performed by Pals-Stewart, Birchler, and O’Farrell (1996), couples
that received behavior couples therapy (BCT) as a supplement to individual-based
treatment had better relationship outcomes, including more positive dyadic adjustment
and less time separated, than couples in which husbands received individual treatment
only. The husbands in the BCT group also reported fewer days of substance use, longer
periods of abstinence, fewer substance-related arrests, and fewer substance-related
hospitalizations through the 12-month follow-up.

BCT has also been shown to be effective with women. Winters, F als-Stewart,
O’Farrell, Birchler, and Kelley (2002) randomly assigned 75 manied or cohabitating
females to either a BCT group or an equally intensive individual-based treatment
condition. Those who received BCT reported fewer days of substance use, longer
periods of continued abstinence, lower levels of alcohol, drug, and family problems, and
higher relationship satisfaction.

Substance abuse is associated with relationship conflict and dissatisfaction.
Substance abuse interventions focusing on couples and relationship concerns have shown
consistently to be effective in comparison to equally intensive individually based
interventions to address such relationship conflict. The above findings indicate that it is
important to address relationship issues with an individual who has an addiction.
However, according to SAMHSA (2002), the implementation of family interventions is
still relatively rare. There is a common belief that there is too much expense, including
costs for training and additional staff, associated with adding this component to

treatment, and many agencies and/or therapists are unable or unwilling to provide such

28

services (Meyers et al., 2002). According to McCrady et al. (1991), in many cases a
therapist’s own clinical experiences may dictate his or her beliefs about treatment and the
way it should be conducted. In addition, without extensive empirical validation, many
therapists may believe the therapy they provide is efficacious, and, therefore, there is no
need to provide additional interventions that require more training and funding (Meyers
etal., 2002). More recent research, however, has substantiated that family and couples
interventions are more cost-effective across an extended period of time. For instance,
Fals-Stewart, O’Farrell, and Birchler (1997) concluded that BCT was more cost—
beneficial than individual based treatment (IBT). O’Farrell, Choquette, Cutter, Floyd,
Bayog, Brown, Lowe, Chan, and Deneault (1996) also found similar results in
demonstrating that BMT is more cost-effective than individual-based treatment alone.

Despite data demonstrating its cost-effectiveness, many substance abuse treatment
programs do not have additional staff to incorporate relationship interventions in addition
to the traditional approaches already utilized, and/or treatment programs do not have staff
trained to provide marital and couples interventions. However, there are interventions,
such as psychoeducational approaches, that do not require additional training to
administer and can address relationship and couples issues. In addition, due to chronic
substance abuse, many substance abusers may not have the necessary foundational skills,
such as communication skills and other coping skills, to be able to fully benefit from and
engage in therapy interventions. Such foundational relationship coping skills, including
communication and problem solving skills, can be better learned through

psychoeducational approaches.

29

Psychoeducational Approaches

With increasing research in the area of couples therapy being performed in
substance abuse settings, it is evident that addressing relationship and family issues has a
positive impact on abstinence rates and relationship satisfaction. However, there is a
dearth of research that addresses relationship issues using other modalities such as
psychoeducational treatment that could be equally beneficial for the client. According to
La Salvia (1993), much of substance abuse counseling or therapy is focused on repairing
ego function deficits. However, she reported that focusing solely on ego strengthening in
substance abuse treatment is inadequate. Khantzian (198 8) stated that substance abusers
need as much assistance with their self-care problems as they need help with
understanding their feelings about life. La Salvia (1993) further stated that
psychotherapy and psychodynamic group therapy may suffice in addressing emotions,
but a comprehensive, thorough treatment plan for addictions also must include the basic
set of tools necessary to solve life’s day-to-day problems. A psychoeducational group in
particular, one that is a specialized, task-oriented, didactic group experience, can address
both ego deficits and life skills. Psychoeducational interventions have been found to be
beneficial in addiction treatment (Marlatt & Donovan, 1982; McAuliffe & Gordon,
1980).

A psychoeducational group in addiction treatment must expand on traditional
coping skills and problem-solving training (La Salvia, 1993). In a psychoeducational
group, the group leader presents and leads discussions and activities on topics such as
relationship communication, money management, and childcare. The therapeutic process

of the group then addresses the feelings of success, failure, and ambivalence clients have

30

or may experience surrounding these areas and skills. Involving the family, specifically
the significant other, and/or addressing family issues in this stage of treatment, is
desirable, as many of the skills learned in psychoeducation apply to the family and
marital relationships. Goldstein and Miklowitz (1995) note that psychoeducational
approaches are useful in providing communication training, coping strategies, and
problem solving skills.

Relationship Coping Skills

Coping skill deficits are a major predisposing individual risk factor for developing
and maintaining addiction. Such skill deficits interact with situational demands and
genetic susceptibility to decrease an individual’s ability to cope effectively (Monti et al.,
1989). Monti et a1. (1989) identify two major categories of factors that can increase the
risk of alcohol abuse or of relapse after a period of abstinence. These are intrapersonal
and interpersonal factors. Interpersonal factors include marital/relationship and family
supports, work relationships, and friend/peer supports. Intrapersonal factors are
characteristics within the individual and include perceptions, expectations, cognitions,
and mood.

Interpersonal factors can have an enormous influence on one’s recovery. They can
promote abstinence and help maintain recovery, but also can be a trigger for relapse.
According to Bandura’s cognitive-social learning approach to drug and alcohol abuse
(1969, 1977, 1986), interpersonal issues, such as social skill deficits, can limit
alternatives of action in a social situation, minimize one’s subjective feeling of control
over the situation, and can decrease the individual’s access to desired resources, such as

coping skills. Further, Bandura (1986) posits that substance abuse is largely the result of

31

having few of these coping strategies to deal with situations that are appraised as stressful
and having expectations that a substance will help in coping. For instance, when an
individual with. addiction has an argument with his or her significant other, because of
lack of development of specific interpersonal skills, he or she is not aware of different
ways to handle the situation, does not feel in control, and does not have the necessary
coping skills to help resolve the situation. Therefore, the individual turns to what is
familiar and predictable to solve the problem, their substance of choice. Likewise, such
interpersonal deficits may prevent the person from Obtaining social and emotional
support from others that may be necessary to maintain abstinence (Monti et al., 1989).
This can help explain why many individuals with addiction have no supports or have
strained relationships, as they do not have the skills to interact interpersonally in an
effective manner.

In the past, research on cOping and interpersonal support has tended to be
conceptually and empirically separate (Greenglass, 1993). More recently, however,
research has emerged linking coping and social support in order to evolve an
interpersonal therapy of coping with stress. Hobfoll, Dunahoo, Ben-Porth, and Monnier
(1994) discuss the interpersonal, interactive, nature of coping and social resource
acquisition. Wills (1990) developed the Functional Support Model, which posits that
close relationships can help a person cope with stress, as these relationships can help an
individual disclose and discuss problems and share concerns. This model indicates that
close relationships contribute to well being through increasing the use of more effective

coping skills. However, with individuals with substance abuse issues, when a significant

32

relationship is full of conflict, this relationship will not be an effective source of coping
for the individual and will not promote the use of effective coping skills.

Not having these proper coping skills to interact with peers and family members,
including one’s significant other, can be a high-risk situation for increased substance
abuse. According to Marlatt and Gordon (1985), situations can be conceptualized as
high-risk for drinking if the individual does not have the necessary coping skills for the
situation at hand and if drinking has been learned through conditioning as a response that
provides at least some short-term relief (i.e., stress relief from an argument with a
spouse). Such situations include interpersonal anger and frustration, which can occur
often in relationships in which one spouse or partner is using alcohol and/or other drugs.
Further, if the impairment in social skills is chronic over the course of psychosocial
development (which is typically the case with chronic substance abusers), the
individual’s potential for abusive drinking and drug using may increase (Monti et al.,
1989).

Lazarus (1965) was one of the first researchers to propose a behavioral approach
to the treatment of alcohol and drug abuse. He also was a pioneer in the introduction of
c0ping skills to traditional substance abuse treatment. Lazarus (1965) introduced a
behavioral approach to substance abuse treatment which included seven components. In
addition to medical attention to treat the physical symptoms of addiction, he proposed
assertiveness training to help the client cope with interpersonal stressfirl situations,
behavioral rehearsal to develop interpersonal coping skills, and marital therapy to help

the client’s partner modify his or her role in maintaining the drinking behaviors.

33

A number of studies have determined that specific coping skills training
interventions are more effective than standard substance abuse treatment (Monti, Abrams,
Binkoff, Zwick, Liepman, Nirenberg, & Rohsenow, 1990). Eriksen, Bjomstad, and
Gortestam (1986) found social skills training to be more effective than a control group in
increasing the number of days abstinent and the number of days attending work following
discharge from treatment. Oei and Jackson (1980) determined that both individual and
group social skills training in comparison to traditional supportive therapy resulted in
significantly greater reduction in alcohol abuse following discharge. In addition, the
group format was found to show quicker skills acquisition. Monti, Abrams, Binkoff,
Zwick, Liepman, Nirenberg, and Rohsenhow (1990) compared communication skills
training with cognitive-behavioral mood management training among 69 inpatient male
alcoholics. Although both groups improved in the skills presented in the training, the
participants that received communication skills training improved more on skills related
to alcohol-specific high-risk situations (p < .05). In a similar study, Rohsenow, Monti,
Binkoff, Liepman, Nirenberg, and Abrams (1991) implemented communication skills
training with 100 inpatient alcoholics and found this training to be equally effective as
mood management cognitive-behavioral training, but the communication skills training
had the advantage of benefiting a broader spectrum of patients. Finally, differential
improvement using communication skills training has been particularly noteworthy
among patients with lower education, higher urge to drink, or lower socialization
(Cooney, Kadden, Litt, & Gerter, 1991; Rohsenow et al., 1991).

Implementing communication skills interventions is beneficial, as there is a

linkage between individuals with substance abuse issues and problems with assertiveness.

34

Assertiveness has been continuously shown to be particularly difficult for substance
abusing individuals. Sturgis, Best, and Calhoun (as cited in Monti et al., 1989) identified
a link between assertiveness deficits and abusive drinking patterns. In addition, Hamilton
and Maisto (1979) compared problem drinkers and non-problem drinkers on scales of
assertiveness and social discomfort. Although there were no differences between the
groups on assertiveness, problem drinkers reported more discomfort in situations that
required them to be assertive.

In addition to communication skills deficits, individuals with addiction have also
shown a lack of competency in social problem solving (Marlatt, 1979). According to
Platt and Husband (1993), populations at high risk for substance abuse have deficits in
problem solving and social skills. These researchers report that there are two ways in
which poor problem solving skills and social skills can be related to substance abuse.
First, deficiencies in these skills can lead to failures in interpersonal areas that can lead to
substance use. Second, individuals with such deficits may find themselves unable to
negotiate their way out of Situations that carry a high risk of substance abuse.

Descriptive research has shown that individuals progressing well through their
recovery programs exhibit more skills in problem-solving scenarios (Appel & Keastner,
1979). More recent research has concluded that families with adolescents who abuse
alcohol and/or other drugs often lack skills in family problem solving and in coping with
simple, everyday problems (Hops, Tildesley, Lichenstein, & Ary, 1990). Such a lack of
problem solving skills has also been exhibited among young adults (Fromme & Rivet,

1994) and college students (Evans & Dunn, 1995) who abuse alcohol.

35

There also have been studies conducted measuring self-appraised problem-solving
abilities, which have indicated a relationship between problem-solving competencies and
substance abuse. Heppner and Peterson (1982) suggested that problem-solving appraisal,
or the perception of one's problem-solving ability, is an important component of the
coping process. Cameron and Michenbaum (1993) noted that effective coping
predisposes an adequate repertoire of skills for dealing with life problems, such as
substance abuse, and the use of such skills may depend initially on self-perceived
efficacy as a problem solver. Elliot, Johnson, and Jackson (1997) found that self-
appraised ineffective problem solving was associated with retrospective accounts of
substance abuse among undergraduates. Such a relationship was also supported with a
sample consisting of adult children of alcoholics (Wright & Heppner, 1991). In a clinical
sample of inpatient alcoholics, Larson and Heppner (1989) found that these individuals
appraised their problem solving considerably more negatively than nonclinical adults.

With both descriptive and self-report studies supporting a relationship between
substance abuse and problem solving skills deficits, it would appear beneficial to
incorporate such skills training in substance abuse treatment. According to Platt and
Husband (1993), problem-solving skills training in substance abuse treatment is designed
to provide clients new skills that will allow them to maintain their abstinence. Other
studies also support such skills training in substance abuse treatment by reporting that
interventions that incorporate training in self-control, social skills, stress management,
and problem solving are crucial in recovery and in coping with concurrent social,
personal, and health problems that co-occur with substance abuse (Miller, 1992; Miller &

Brown, 1997).

36

Time Out! For Men Intervention

“Time Out! For Men: A Communication Skills and Sexuality Workshop for Men”
(Bartholomew & Simpson, 2002) is a psychoeducational cun'iculum developed as part of
the NIDA-funded Drug Abuse Treatment Assessment and Research (DATAR) project
' conducted by the Institute of Behavioral Research at Texas Christian University. The
intervention was designed to aid substance abuse treatment providers in working with
men who have sexuality and relationship issues. This six-session, psychoeducational
curriculum addresses communication skills, such as listening, assertiveness, expressing
feelings, and conflict resolution. Sexual health concerns and sexual functioning and
human sexual response are also discussed in two additional sessions, but these have been
eliminated for the purposes of this study with permission from the intervention’s creators.
Such a curriculum not only allows clients to improve their communication and problem
solving skills, but also provides a forum to examine gender roles and socialization issues.

Bartholomew, Hiller, Knight, Nucatola, and Simpson (2000) conducted a study
examining the efficacy of the “Time Out! For Men” intervention with 122 male felony
probationers who were court-mandated to a 6-month residential substance abuse
treatment program in lieu of incarceration. This study indicated a significant increase in
the experimental group’s (n = 64) knowledge of communication, sexuality, sexual health,
and gender-role and socialization issues (p < .0001) in comparison to the control group (n
= 58). Participation in the intervention was also associated with a reduction in attitudes
associated with rigid socialization and rigid role conflict (p < .003) in comparison to the

control group.

37

It has been shown that individuals with a chronic history of substance abuse are
likely to have under-developed coping skills, specifically interpersonal and relationship
coping skills, such as communication and problem-solving skills. As illustrated by the
destructive-cycle model developed by F als-Stewart et al. (2004) described above, the
inclusion of relationship coping skills training in substance abuse treatment focusing on
two components of the model, problem-solving and communication Skills training, can
enhance relationship functioning. Since relationship dissatisfaction and conflict can be
high-risk situations for continued substance abuse and/or relapse after a significant period
of abstinence, and individuals with addictions likely do not have the necessary skills to
cope with such conflict when it occurs, incorporating an intervention, like “Time Out!
For Men” in traditional substance abuse treatment to teach such skills is likely to be
beneficial to the individual, his recovery, and his relationship with his spouse or

significant other.

38

Chapter 3
Method
Participants

The sample in this study consisted of men in the residential substance abuse
facility, House of Commons. The House of Commons, a component of Community
Mental Health Authority of Clinton, Eaton, and Ingham Counties, located in Mason,
Michigan, with a capacity of 40 beds, is a high-intensity residential program designed to
address significant problems with living skills experienced by adult males with substance
abuse and criminal conduct. The facility offers a variable length of stay up to 90 days.
Referrals to House of Commons originate from several sources, the Michigan
Department of Corrections Office of Community Corrections, the Michigan Department
of Corrections Substance Abuse Services, the Mid-South Substance Abuse Commission
with funding for indigent individuals, and Central Diagnostic and Referral Services, a
referring agency for those with Medicaid or without any insurance.

The House of Commons uses a cognitive-behavioral approach to teach clients
strategies for self-improvement and change. Treatment is specific to maintaining
abstinence and preventing relapse, but the program also vigorously promotes social
responsibility and positive character change. Some of the treatment groups that are
implemented on a daily basis include anger management, relapse prevention, and a group
focused on learning and working through the 12 steps of Alcoholics Anonymous. In
addition, the House of Commons relies on the treatment community as a therapeutic

agent that introduces and reinforces appropriate social values and behaviors. The

39

program also focuses on reintegration of the clients into the greater community with
specific emphasis on employment and education.

Because both an experimental and control group were used in this study, the
participants were chosen to participate in the study based on their legal status. Both
clients on probation and those on parole are accepted at House Of Commons. Due to
court system requirements and judge mandate, those clients on probation must stay at
House of Commons 60-90 days. Those on parole are required to undergo treatment for
30 days or less. Due to the duration of the intervention being three weeks, a significant
time constraint would have been introduced if the clients on parole were included in the
study. In addition, because this study included random assignment, using a more
homogenous group ensured better equality of the groups. Therefore, only clients on
probation were utilized in the study and were randomly assigned to either the
experimental or control group. To document the similarities between the groups and to
be able to describe the sample, specific demographic information, including age, race,
education, number of attempts in substance abuse treatment, and relationship status were
collected from each participant (see Appendix A for Participant Information Sheet).
Because of the constraints of this study, diagnoses were not Obtained from the clients.
However, in general, the sample was comprised of participants diagnosed with alcohol
dependence or polysubstance dependence (i.e., addicted to more than one substance). The

following tables summarize the similarities between the groups:

40

Table l.Descriptive Statistics for the Experimental and Control Groups

 

 

 

 

Exp. Ctl. Exp. Ctl.
Mean SD
N 42 38
Age 35.52 37.61 9.766 11.726
Ed Level 11.87 12.28 1.436 1.758
Txt Attempts 2.86 3.00 3.842 3.353

 

Table 2. Frequency Table of Race for the Experimental and Control Groups

 

 

 

 

Exp. Ctl. Exp. Ctl.
Frequency Percent
1 (White) 21 24 51.2 63.2
2 (Black) 13 12 31.7 31.6
4 (Hispanic) 4 1 9.8 2.6
7 (Multiracial) 3 l 7.3 2.6
Total 41 38
Missing 1 0

 

41

Table 3. Frequency Table of Relationship Status for the Experimental

 

 

 

 

and Control Groups
Exp. Ctl. Exp. Ctl.
Frequency . Percent
1 27 21 64.3 55.3
2 1 5 1 7 35 .7 44.7
Total 42 38

Missing 0 0

 

In a relationship =1, Not in a relationship=2

Each client that is considered for admission to the House of Commons is assessed
for and diagnosed with substance abuse or dependence using the Addiction Severity
Index (ASI) (McLellan, Luborsky, O’Brien, & Woody, 1980). The A81 is a semi-
structured interview designed to address seven potential problem areas in substance-
abusing patients: medical status, employment and support, drug use, alcohol use, legal
status, family/social status, and psychiatric status. The ASI provides an overview of
problems related to substance, rather than focusing on any single area. The ASI has been
shown to be consistently valid using criterion (.54 to .95) and construct validity (.45 to
.73) and reliable using a test-retest measure (.92) and an interrater measure (.89 to .92).
Because residential substance abuse treatment is the most intense of treatment
interventions in terms of length of stay and provision of services, every client admitted to
the House of Commons meets criteria for Substance Abuse or Dependence.

In addition, to assure that these clients meet the diagnostic criteria of the
Diagnostic and Statistical Manual of Mental Disorders-IV- Text Revision (DSM-IV-TR)

(American Psychiatric Association, 2000) for Substance Abuse or Dependence, the

42

ASAM (American Society of Addiction Medicine) criteria (Hoffrnann, Halikas, Mee-
Lee, & Weedman, 1991) are used by the House of Commons. The ASAM criteria were
designed to ensure a voice for substance abuse practitioners in defining a continuum of
care. The main elements of the ASAM Criteria consist of six assessment dimensions used
to define biopsychosocial severity of the client in order to guide placement. Further,
when such dimensions are assessed, there are four levels of care that describe the
intensity of service that needs to be provided. The six assessment dimensions include
acute intoxication and/or withdrawal potential, biomedical conditions and complications,
emotional/behavioral conditions and complications, treatment acceptance/resistance,
relapse potential, and recovery environment. The four levels of care, named to be
descriptive of the intensity of service, are Outpatient Treatment (Level 1), Intensive
Outpatient/Partial Hospitalization (Level II), Medically Monitored Intensive Inpatient
Treatment (Level III), and Medically Managed Intensive Inpatient Treatment (Level IV).
To meet criteria for Level III or Level IV of care, a client must have a significant
substance abuse or dependence problem affecting most, if not all, areas of his or her life.
The House of Commons is a Level III facility, as it is a residential, or inpatient facility,
and there are medical personnel, including psychiatrists and nurses, that provide services
to the clients.
Variables and Measure
Communication

Communications skills training in substance abuse treatment has been established
as extremely important (Pals-Stewart et al., 2004), as those with substance abuse issues

possess inadequate interpersonal coping skills (Abrams & Niaura, 1987; Rohsenow et al.,

43

2001). Not only can including such training promote abstinence, but it can also enhance
relationship functioning (Pals-Stewart et al., 2004). According to the Communications
skills glossary, communication skills are learned patterns of communicating with others.
Communication skills include the ability to read and comprehend information, the ability
to express ideas effectively in written and Spoken form, and the ability to listen
attentively (UA Fort Smith, 2005). In this study, communication Skills knowledge were
operationally defined by a higher score on the Communication Competence Scale.

The Communication Competence Scale (CCS) (W iemann, 1977) is a 36-item
questionnaire that measures one’s perceived knowledge and use of communication skills
(See Appendix B for CCS). The participant responds to each question using a 5-point
Likert-type scale ranging from Strongly Agree (5) to Strongly Disagree (1). Scores range
from 36 to 180, and individuals high in CCS (108) are generally more sensitive, flexible,
and assertive communicators than those lower in CCS. In addition, the higher the score,
the more competent a communicator the individual perceives himself/herself to be. With
permission from the author, a modified version of the CCS was used in which the
directions were altered to instruct participants to respond to the questions based on how
they communicate in their intimate relationship. The questions were not altered.

The CCS contains five subscales, including general communicative competence,
affiliation/support, social relaxation, behavioral flexibility, and empathy. Initially 57
Likert-type items were written and pretested by Wiemann (1977); those showing the
greatest between-treatrnent discrimination were retained. In a post hoc analysis of the
revised instrument, its reliability using Cronbach’s alpha was estimated at .96. Wiemann

(1977) used Friedman’s Estimation of the Magnitude of Experimental Effect to calculate

44

statistical power. Power was determined to be .74, indicating more than sufficient
protection against Type 11 error. In addition, a factor analysis was performed, and Factor
1, general communicative competence, accounted for 82.8 percent of the variance.
Problem Solving

Substance abusers have been shown to have inadequate problem solving skills
(Marlatt, 197 9), and the development of such skills has been determined to be crucial for
one’s recovery (Platt & Husband, 1993) and essential for relationship satisfaction (F als-
Stewart et al., 2004). According to Huitt (1992), problem solving is a process in which
one perceives and resolves a gap between a present situation and a desired goal, with the
path to the goal blocked by known or unknown obstacles. In this study, the possession of
problem solving skills knowledge was operationally defined by a lower score on the
Problem Solving Inventory.

The Problem-Solving Inventory (PSI) (Heppner, 1982) is a 35-item self-report
measure in a 6-point Likert style format (Strongly agree to Strongly disagree) (See
Appendix C for PSI). The PSI is designed to assess an individual’s perceptions of his or
her capabilities with regards to problem solving behaviors and attitudes. In other words,
this measure assesses one’s level of self-efficacy as a problem solver. The PS1 provides a
single, general index of Problem-Solving Confidence (self assurance while engaging in
problem solving activities), Approach-Avoidance Style (a general tendency to either
approach or avoid problem solving activities), and Personal Control (determines the
extent of control one has over their emotions and behaviors while solving problems).
High scores indicate general negative self-appraisal. With permission from the author, a

modified version of the PS1 was used in which the directions were altered to instruct

45

participants to respond to the questions based on how they problem solve in their intimate
relationship. The questions were not altered.

An estimate Of internal consistency was computed for each of the three factors
and the total inventory (n = 150), which are as follows: problem solving confidence, or =
.85; approach-avoidance style, a = .84; personal control, a = .72; total inventory, a = .90.
Test-retest reliability was established by administering the inventory to an additional
sample on two occasions two weeks apart. The test-retest reliabilities were as follows:
problem-solving confidence, r = .85 ; approach-avoidance style, r = .88; personal control,
r = .83; and the total inventory, r = .89.

Estimates of concurrent and construct validity were established through several
means. Scores on the three factors and the total PSI were correlated with the Level of
Problem Solving Skills Estimate Form (LPSSEF), specifically with students’ ratings of
their levels of problem solving Skills (rs = -.44, -.29, -.43, and -.43, respectively), and
students’ perceived satisfaction/dissatisfaction with their problem-solving skills (rs = -
.42, -.24, -.39, and -.42, respectively). All correlations were statistically significant (p<
.0001). Therefore, scores on the PSI correlate moderately well with scores on a simple
self-rating scale. Other research studies have further corroborated the concurrent,
discriminant, and construct validity of the PSI.

Relationship Coping Skills

There is much documented evidence that substance abusers possess inadequate
coping skills, specifically interpersonal coping skills. Alcohol dependence, for instance,
has been found to continue in part as a means of coping with stressful experiences

(Abrams & Niaura, 1987). In addition, the factors considered to maintain alcohol abuse

46

include coping skills deficits (Rohsenow, Monti, Rubonis, Gulliver, Colby, Binkoff, &
Abrams, 2001). Finally, Marlatt and Gordon (1985) stated that there is a high risk for
relapse when negative, interpersonal emotional states exist. Coping may be problem-
focused or emotion-focused (Folkman & Lazarus, 1988), but coping behaviors used to
manage intimate relationship stress may differ from those that are used to cope with other
common life problems (Pollina & Snell, 1999). In this study, the possession of
relationship coping skills was operationally defined by a higher score on a modified
version of the Multidimensional Intimate Coping Questionnaire (MICQ) (Pollina &
Snell, 1999).

The MICQ consists of 100 items and 25 subscales. COPE (Carver, Scheier, &
Weintraub, 1989), a well-researched general coping skills inventory, was the basis for the
first 15 subscales. The Coping Inventory for Stressful Situations (C188) and the Marital
Coping Inventory (MCI) were used to prepare items for ten additional subscales. Where
necessary, Pollina and Snell (1999) re-worded items from these instruments to reflect
relationship stressors. With the MICQ, participants are asked to think about their current
intimate relationship and indicate how much each statement describes them using a 5-

point Likert scale from 0 (not at all characteristic of me) to 4 (very characteristic of me).

Nine subscales of the MICQ (see Appendix D for the modified version of MICQ)
were utilized in this research study. This modified version of the MICQ more directly
corresponds to the “Time Out! For Men” curriculum than does the entire lOO-item
questionnaire. The nine subscales which constituted the 36 items include: positive

I‘einterpretation and growth (a = .82), active coping (a = .71), seeking social support for

instrumental reasons (a = .84), acceptance coping (a = .61), focus on and venting of

47

emotions (or = .81), behavioral disengagement (a = .73), restraint c0ping (a = .71), self-
bolstering (a = .81), and emotional expression and reaction (a = .71).

Principal components analysis was utilized by the authors to determine whether
any of the coping strategies assessed by the MICQ would form conceptually similar
groupings representing broad coping dimensions. Six factors emerged and accounted for
68.8 percent of the variance in MICQ total scores. The six factors include having a
problem-solving orientation with some efforts to reduce negative affect (28.2%), an
orientation towards escaping from problems rather than confronting them (15,7%),
emotional orientation towards relationship issues (7.8%), focus on devoting greater time
to relationship issues (6.7%), social support coping mechanisms (6.0%), and escape
orientation including humor coping (4.4%).

Procedure

Following receipt of UCHRIS (University Committee on Research Involving
Human Subjects) approval, study procedures began, as consent from House of Commons
to conduct a research study with its clients had already been obtained by the director of
the facility and the Community Mental Health Authority. Although participation in all
activities is mandatory at House of Commons, participation in this intervention was

voluntary. The following procedure outlines the direction of this study:

 

 

Week 1 o Discussed study with clients at the House of
Commons in the weekly business meeting in which
all clients were in attendance. A sign-up sheet with
an office number and times I would be available was
given during my discussion of the study so that those
interested could sign up and come by to get more
information about the study, Sign the consent form
(see Appendix E), fill out the questionnaires, and for
those in the experimental group, get informed of the
day and time the intervention was to begin.

 

 

 

48

 

0 During these “office hours,” all clients were
randomly assigned to the experimental and control
groups. Regardless of group assignment, the consent
form was explained in verbal and written form, and
each participant signed the consent form, filled out
the Participant Information sheet, and completed the
three questionnaires (CCS, PSI, and MICQ).

0 Those in the control group were given a date and
time to come back in three weeks (after the
conclusion of the intervention) to complete the same
three questionnaires and also to go through the
intervention if they chose.

0 All client data was stored in a locked file drawer in
the facility’s records room that I only had a key to.

 

Week 24 o Began 6-session intervention (2 sessions weekly)
with the experimental group.

0 All client data was stored in a locked file drawer in
the facility’s records room that I only had a key to.

 

Week 4 o Intervention concluded.

Each participant in the experimental group
completed the same three questionnaires during the
last session of the intervention.

0 Each participant in the control group completed the
same three questionnaires at the pre-designated date
and time described above, and they went through the
intervention if they chose.

0 Questionnaires were stored in a locked file drawer in
the records room that I only had a key to.

 

 

Week 5 - Completion 0 Same above procedures were performed until an
adequate sample size was obtained.

 

 

 

The intervention, “Time Out! For Men” (Bartholomew & Simpson, 2002),
consists of six sessions designed to address relationship issues, including listening,
assertiveness, expressing feelings, and conflict resolution. The six sessions that were
presented to the participants are as follows (see Appendix F for a detailed outline of each

session):

49

Session 1: A New Outlook on Relationships —Exploration of new ways of
thinking about love and intimacy will be made and personal goals for improving
relationships will be developed.
Session 2: An Assertive Attitude — Skills for effective communication will be
introduced, particularly using assertiveness and I-Statements in relationships.
Session 3: Listening — Listening is presented as a skill that can improve
relationships and facilitate self-growth.
Session 4: Talking It Over — Feelings and Needs - Openness and self-expression
in relationships is presented as a helpful tool to facilitate communication.
Participants are aided in identifying and accepting feelings as normal and
instructed on how the inappropriate management of feelings can result in a
communication breakdown.
Session 5: Talking It Over — Resolving Conflict — A model for conflict resolution,
highlighting solutions rather than blame, is introduced. The importance of
“fighting fair” and active problem solving is emphasized.
Session 6: Making Relationships Work — The importance of self-esteem is
emphasized and affinnations are introduced as a positive self-help technique. In
addition, relationship skills and the application of those skills are reviewed to
conclude the intervention.

Two sessions were conducted each week and were two hours in duration. Therefore, the

intervention took three weeks for participants to complete.

50

Research Design and Data Analyses

The purpose of this study was to assess the efficacy of a relationship skills
training program for enhancing communication, problem solving, and coping skills
among males in a residential, substanceabuse treatment program. An experimental
research design was thus required. The most appropriate and useful design to test the
research hypotheses of interest in this study was a randomized, control group, pre-test,
post-test design (Leedy & Onnrod, 2001). As per Figure 4 below, the aim of a research
study in which such a design is used is to show that two groups are equivalent with
respect to a particular variable prior to the treatment, thus eliminating initial group
differences as an explanation for post-treatrnent differences. In this study, the intention
was to show that the experimental and control groups were equivalent with respect to
communication, problem solving, and coping, and thus eliminate initial group differences

as an explanation for difference following the delivery of the “Time Out! For Men”

 

 

 

 

program.
Figure 4. Research Design
Group Time >
Group 1 Observation Treatment Observation
Group 2 Observation __ Observation

 

 

 

 

 

In accord with the purpose of the investigation and the nature of the experimental,
randomized, control group, pre-test, post-test research design, t-tests for a difference
between two, paired groups were used to test the three research hypotheses of interest.

The following statistical null hypotheses were tested:

51

1. There is no significant difference between experimental group pre-test and post-
test scores on the Communication Competence Scale.

2. There is no significant difference between experimental group pre-test and post-
test scores on the Problem Solving Inventory.

3. There is no significant difference between experimental group pre-test and post-
test scores on the Multidimensional Intimate Coping Questionnaire - Modified.

As recommended by Cohen (1988) and Lipsey (1990), a pre-analysis statistical
power estimate was conducted to determine the appropriate alpha level and sample size
requirements under the condition of an assumed small effect size. Given an alpha level
of .05 and assuming a small effect size, the pre-analysis power estimate yielded a power
of .79 for testing the research hypotheses using paired sample t-tests. A statistical power
approaching .80 is considered adequate for rejecting a null hypothesis if it were false
(Cohen, 198 8). The t-tests were therefore planned at the .05 alpha level, assuming a
small effect size, and with the requirement of a sample size of approximately 33
experimental group participants.

Because the coping measure used in this study is a modified version of the
Multidimensional Intimate Coping Questionnaire (Pollina & Snell, 1999) for which the
psychometric properties are unknown, exploratory data analyses were conducted on this
instrument to evaluate its utility in the investigation. First, an internal consistency
reliability analysis was conducted. Second, to examine the possibility whether the
modified version of the Multidimensional Intimate Coping Questionnaire used in the
present study contained subscales meaningful to the process of relationship coping, a

cluster analysis Was conducted. It was anticipated that the sample size in this study

52

would prevent a valid application of factor analysis. Ward’s method was used because at
each step it produces hierarchical clusters that minimize within-cluster variance and
maximize between-cluster variance. A visual inspection of the resulting dendrogram and
numerical output was conducted to determine the most parsimonious cluster solution. To
evaluate the meaning of the clusters, the content of the items that loaded on the clusters
were inspected and compared to the MICQ, as developed and presented by Pollina and

Snell (1999).

53

Chapter 4
Results
The purpose of this study was to test the effectiveness of a relationship skills
training program in enhancing the communication, problem solving, and relationship
coping skills abilities of individuals in a male residential substance abuse treatment
program. The following are the research hypotheses tested in this study:

(1) A relationship skills training program will increase the communication skills of
individuals in a male residential substance abuse treatment program.

(2) A relationship skills training program will increase the problem solving skills of
individuals in a male residential substance abuse treatment program.

(3) A relationship skills training program will increase the relationship coping skills
of individuals in a male residential substance abuse treatment program.
Descriptive statistics of the study variables (Pre CCS = Pre-test of

Communication Competence Scale, Post CCS = Post-test of Communication
Competence Scale; Pre PSI = Pre-test of Problem Solving Inventory, Post PSI = Post-test
of Problem Solving Inventory; Pre MICQ = Pre-test of Multidimensional Intimate
Coping Questionnaire, Post MICQ = Post-test of Multidimensional Intimate Coping

Questionnaire) are presented in Table 4.

54

 

Table 4. Descriptive Statistics of Study Variables for Experimental and Control Groups

 

 

 

 

Exp. Ctl. Exp. Ctl.
Mean SD

Pre CCS 130.05 132.29 . 16.49 16.81
Post CCS 138.36 134.24 15.43 16.68
CCS Range 36-180
Cronbach’s 0.81 0.86
alpha
Pre PSI 101.67 103.55 26.68 14.53
Post PSI 87.40 101.18 22.13 14.01
PSI Range 35-210
Cronbach’s 0.76 0.88
alpha
Pre MICQ 113.86 118.55 16.33 15.21
Post MICQ 127.70 120.37 15.17 15.90
MICQ Range 36-175
Cronbach’s 0.63 0.92
alpha

 

Note: Improved performance on the PS1 is indicated by a lower score on the PSI, while higher scores on the
MICQ and CCS indicate improved performance.

A correlational matrix of the post-test study variables is provided in Table 5. All
three measures have moderate and statistically significant relationships. This finding
suggests that the constructs of communication, problem solving, and relationship coping
skills are correlated, yet distinct.

Table 5. Correlational Matrix of the Post-Test Study Variables in the Experimental Group

 

Post CCS Post PSI Post MICQ
Post CCS -.53** .53"
Post PSI -.66**

Post MICQ

 

** Correlation is significant at the 0.01 level (2-tailed).

55

Results Related to Research Hypothesis One

As shown in Table 6, in a paired-sample (within group) t-test, there was a
statistically significant difference for the experimental group (n = 42) on learning
communication skills (t = -4.24, p < .0001) based on pre- and post-test CCS scores. For
the control group (n = 38), there was no statistically significant difference (t = -l .02,

p = .32) between pre- and post-test CCS scores.

Table 6. Communication Skills Ability Differences Among the Experimental and Control

 

 

 

 

Groups
Experimental Cont—r01
M 52 if I M SD. if .t.
PreCCS— -8.31 12.72 41 -4.24* -1.95 11.81 37 -1.02
Post CCS
*p<.ooor

Results Related to Research Hypothesis Two

As shown in Table 7, in a paired-sample (within group) t-test, there was a
statistically significant difference for the experimental group (n = 42) on learning
problem solving skills (t = 4.28, p < .0001) based on pre- and post-test PSI scores. For
the control group (n = 38), there was no statistically significant difference (t = 1.54,

p = .13) between pre- and post-test PSI scores.

56

Table 7. Problem Solving Skills Ability Differences Among the Experimental and

 

 

 

 

Control Groups
Experimental Co_ntr_o_l
M SD (If t M S_D (if t
PrePSI— 14.26 21.61 41 4.28* 2.37 9.50 37 1.54
Post PSI
*p<.0001

Results Related to Research Hypothesis Three

As shown in Table 8, in a paired-sample (within group) t-test, there was a
statistically significant difference for the experimental group (n = 42) on learning
relationship coping skills (t = -5 .47, p < .0001) based on pre- and post-test MICQ scores.
For the control group (n = 38), there was no statistically significant difference (t = -1.33,
p = .19) between pre- and post-test MICQ scores.
Table 8. Relationship Coping Skills Ability Differences Among the Experimental and

Control Groups

 

 

 

Experimental my;
M S_D (if t M S_D. if I
PreMICQ— -13.8316.38 41 -5.47* -l.82 8.39 37 -1.33
Post MICQ
*p<.0001
Additional Analyses

 

Independent sample t-tests also were conducted on both the pre-test measures and
the post-test measures to further examine the impact of the intervention in influencing the

development of problem solving, relationship coping, and communication Skills. An

57

independent sample t-test was conducted using pre- and post-test PSI data. As shown in
Table 9, there was no statistically significant difference between the experimental and
control groups (t = -.40, p = .69) on pre-test PSI scores. However, there was a
statistically significant difference between the experimental and control groups (t = -3.36,
p = .001) on post-test PSI scores.

Table 9. Problem Solving Skills Ability Differences Between the Experimental and

 

 

Control Groups

I IE 2
Pre PSI -.40 78 .69
Post PSI -3.36 78 .001

 

Next, an independent sample t-test was conducted using the pre-test and post-test
scores of the MICQ. As shown in Table 10, there was no statistically significant
difference between the experimental and control groups (t = -l .33, p = .19) on the pre-test
MICQ scores. However, on the post-test of the MICQ, there was a statistically
significant difference between the experimental and control groups (t = 2.11, p = .04).

Table 10. Relationship Coping Skills Ability Differences Between the Experimental and

 

 

Control Groups

t M n
PreMICQ -l.33 78 .19
Post MICQ 2.11 78 .04

 

Finally, an independent sample t-test was conducted using the pre-test and the

post-test scores of the CCS. As shown in Table 11, on the pre-test CCS scores, there was

58

no statistically significant difference between the experimental and control groups
(t = -.60, p = .55). In addition, on the post-test of the CCS, there was no statistically
significant difference between the experimental and control groups (t = 1.15, p = .26).

Table 11. Communication Skills Ability Differences Between the Experimental and

 

 

Control Groups

I it." 2
Pre CCS -.60 78 .55
Post CCS 1.15 78 .26

 

A modified version of the MICQ was used incorporating the subscales that were
most meaningful to relationship coping. Cluster analysis of the 36 items in the modified
version of the MICQ yielded a 6-cluster solution. The six clusters were distinct and
interpretable based on the substance abuse treatment and coping research. The number of
clusters was determined using strategies reported by Hair, Anderson, and Tatham (1987).
Initial cluster analyses resulting in two to six clusters were inspected to determine the
number of clusters that incorporated the information most relevant to clinical substance
abuse treatment, research, and theory (i.e., the biopsychosocial model). In addition,
examination of intercluster distances for each of these six steps found that the great
successive distance difference occurred between the five- and six-cluster solution.

The clusters were labeled as follows: (a) Cluster 1 — acceptance coping style, (b)
Cluster 2 — emotional coping style, (c) Cluster 3 — avoidance coping style, ((1) Cluster 4 —
action-oriented coping style (e) Cluster 5 — self-promoting, and (f) Cluster 6 - self-
awareness and (expression. The six clusters represent styles and strategies individuals in

a relationship use to respond to and cope with difficult or stressful events that occur in

59

intimate relationships. The relationship coping clusters and individual items from the
MICQ comprising each cluster are presented in Table 12. The Cronbach’s alpha for the
36 items on the modified version of the MICQ was .84, indicating a high level of internal
consistency in the measurement of relationship coping skills with the sample in this
study.

Table 12. Relationship Coping Style Clusters and Corresponding Items

 

Acceptance coping style
I learn something from the stressful experience.
I do what has to be done, one step at a time.
1 learn to live with it.
I reassure myself that I can cope with the situation.
I bolster my self-confidence by telling myself that I can deal with the problem.
I get used to the idea that it happened.
I accept the reality of the fact that it happened.
I accept that this has happened and that it can’t be changed.

Emotional coping style
I restrain myself from doing anything too quickly.
I start feeling anxious, tense, and unsettled.
I feel a lot of emotional distress, and I find myself expressing those feelings a
lot.
I find I can’t concentrate on my work or other interests.
I get upset and let my emotions out.

Avoidance coping style
I give up the attempt to get what I want.
I reduce the amount of effort I’m putting into solving the problem.
I hold off doing anything about it until the situation permits.
I admit to myself that I can’t deal with it, and quit trying.
I just give up trying to reach a desirable resolution.
I start feeling that I am a failure.
I start feeling depressed and blue.

Action-oriented coping style
I try to get advice from someone about what to do.
I talk to someone to find out more about the situation.
I talk to someone who could do something concrete about the problem.
I take additional action to try to get rid of the problem.
I ask people who have had similar experiences what they did.
I take direct action to get around the problem.

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Self-promoting
I try to see it in a different light, to make it seem more positive.
I keep my self-esteem up by saying positive things to myself.
I provide myself with reassurance that I can cope with the situation.
I look for something good in what is happening.
I force myself to wait for the right time to do something.
I make sure not to make matters worse by acting too soon.

Self-awareness and expression
I try to grow as a person as a result of the stressful experience.
I concentrate my efforts on doing something about it.
I let my feelings out.
I get upset, and am really aware of it.

 

61

Chapter 5
Discussion

The purpose of this study was to test the effectiveness of a relationship skills
training program, “Time Out! For Men,” in enhancing the communication, problem
solving, and relationship coping skills of individuals in a male residential substance abuse
treatment program. This Discussion chapter addresses the following areas: (a) limitations
of the study, (b) narrative summary of findings, (0) relation of results to previous
research, (d) implications for theory, research, and practice, and (e) future research
needed.

Limitations of the Study

The first limitation was potential measurement issues. For instance, the reliability
and construct validity of the Communication Competence Scale (CCS) may have been
affected by modifications being made in an effort to enhance the fit of the measure for the
study. More specifically, the instructions on the CCS were altered slightly to fit the
context of this study. Similarly, the instructions were altered slightly on the Problem
Solving Inventory (PSI).

A potential second limitation was that the participants were also receiving
interventions at the House of Commons in which communication skills were addressed,
including in anger management and relapse prevention groups. Receiving such
information concurrently may have yielded a similar improvement in learning
communication skills and, therefore, perhaps influenced insignificant findings between

the experimental and control groups.

62

A third limitation of this study was its limited external validity, or the degree to
which the findings of the proposed investigation can be generalized across persons, times,
and settings. Given the convenience and volunteer nature of the sampling procedure,
study results are not generalizable to all individuals who participate in House of
Commons treatment programs (i.e., individuals on parole) or other substance abuse
treatment programs. The cross-sectional nature of data collection procedures allows only
for interpretation of results concerning participants at the time of the study. Given this
limitation, results cannot be generalized beyond the sample used in this investigation.

The results of this study may have been influenced by the House of Commons
agency and the group leader. More specifically, House of Commons was very receptive
to having this researcher come to the facility and offer the intervention to its clients. The
climate was very positive, and this atmosphere made the data-gathering process simple
and unproblematic. Other agencies may not be as receptive and open to the research
process making data collection more difficult. In addition, this researcher has extensive
clinical experience working with clients with substance abuse issues in a community
mental health setting and, consequently, understands the personality needed to elicit
positive client participation. Other researchers without such experience may not be as
successful in engaging clients, which would likely affect the efficacy of the intervention.

A final limitation of this study is the lack of a long-tenn follow-up component for
evaluating the efficacy of the intervention. Results suggest that participant
communication, problem solving, and relationship coping skills increased as a result of
the “Time Out! For Men” program across a three-week time period. However, the study

yielded no data in relation to whether such skills were retained, whether the participants

63

incorporated the skills in their relationships, and whether such skills helped promote their
long-term abstinence.
Narrative Summary of Findings

Among the individuals who participated in the “Time Out! For Men”
psychoeducational intervention (i.e., experimental group), there was a significant
improvement in their communication skills, problem solving skills, and general
relationship coping skills from the pre-test to the post-test. However, there was not a
significant improvement in communication, problem solving, and general relationship
coping skills from the pre-test to the post-test for the participants who did not receive the
intervention (i.e., control group). This finding is particularly noteworthy because the
material in the intervention pertaining to relationship skills did not significantly overlap
with the standard treatment programming provided at House of Commons. Rather, staff
at House of Commons reported that the material complemented their programming well,
and participants made similar comments with the majority rating each session as “very
good” to “excellent” on post-session satisfaction questionnaires.

Study participants in the experimental group improved Significantly on problem
solving and general relationship coping skills acquisition when compared to individuals
who did not participate in the intervention. However, there was not a statistically
significant improvement in communication skills acquisition of those who participated in
the intervention when compared to individuals who did not participate in the intervention.
As mentioned above, this finding may be attributed in part to the low reliability of the
measure used to assess communication skills, the CCS. Further, participants not

receiving the intervention also participated in other groups at the House of Commons

64

treatment program, such as anger management, in which similar communication skills
were presented. This situation may have contributed to a similar increase in
communication skills acquisition across the groups and, therefore, introduced a confound
in this study.
Relation of Results to Previous Research

Pals-Stewart et al. (2004) describe a model for substance abuse treatment, the
constructive cycle of addiction, that depicts the necessary components for the mending of
strained relationships that can result from substance dependence. In substance abuse
treatment and recovery, typical treatment interventions are needed, which include a
continued recovery plan, a recovery contract, self-help support, and counseling (Fals-
Stewart et al., 2004). Such interventions are offered at the House of Commons.
However, according to F als-Stewart et al. (2004), for these interventions to aid in
enhancing relationship functioning, additional treatment components are necessary, such
as problem solving skills training, communication skills training, and interventions
focused on relationship enhancement and increasing caring behaviors. In this
constructive cycle, combining traditional substance abuse treatment methods that are
provided in typical treatment programs like House of Commons, such as recovery
contracts and counseling, with interventions addressing relationship needs, such as
communication skills and problem solving training, further promotes and enhances
recovery. This study introduced the relationship treatment components of
communication and problem solving skills training to a traditional treatment program in

an efficacious manner. In addition, this study illustrated that a psychoeducational

65

intervention could effectively complete the constructive cycle of addiction in which
traditional treatment modalities are combined with skills training.

A number of studies have determined that specific coping skills training
interventions are more effective than standard substance abuse treatment in teaching such
skills (Monti et al., 1990). Oei and Jackson (1980) determined that both individual and
group social skills training in comparison to traditional supportive therapy resulted in
significantly greater reduction in alcohol abuse following discharge. In addition, the
group format was found to show more rapid skills acquisition than individually-focused
approaches. Monti et al. (1990) compared communication skills training with cognitive
behavioral mood management training among 69 inpatient male alcoholics. In this study,
participants who received communication skills training improved more on skills related
to alcohol-specific high-risk situations than those who did not receive the training.
Finally, Rohsenow et al. (2001) examined the effects of one exposure treatment (CET)
compared to a meditation-relaxation control, and communication skills training (CST)
compared to an education control when all were added to intensive treatment programs
for alcoholics. Participants who received either CET or CST had fewer heavy drinking
days in the first 6 months than the participants who did not receive either treatment. 3
Further, CST resulted in fewer alcohol-related problems reported at 12 months. The
present study, similar to the findings of Monti et al. (1990), Oei and Jackson (1980), and
Rohsenow et al. (2001), demonstrated the value of specific coping skills training. In
addition, the current study extended the research by focusing specifically on coping Skills

in relationships and not only general social or communication Skills.

66

In addition to communication skills deficits, individuals with addiction also have
shown a lack of competency in social problem solving (Marlatt, 1979). Further,
according to Platt and Husband (1993), populations at high risk for substance abuse have
deficits in problem solving and social skills. These researchers reported that there are two
ways in which poor problem solving skills and social skills can be related to substance
abuse. First, deficiencies in these skills can lead to failures in interpersonal areas that can
lead to substance use. Second, individuals with such deficits may find themselves unable
to negotiate their way out of situations that carry a high risk of substance abuse. Such
data indicate the importance of the possession of problem solving skills, not only in one’s
interpersonal relationships, but also in more expanded life contexts in which a person
encounters situations that make them more susceptible to relapse. Elliot, Johnson, and
Jackson (1997) also found evidence to support the importance of incorporating problem
solving skills training in substance abuse treatment when they concluded that self-
appraised ineffective problem solving was associated with retrospective accounts of
substance abuse among undergraduates. Again, having an easily-implemented treatment
component in which problem solving skills are presented such as “Time Out! For Men”
incorporated in a traditional substance abuse treatment program will aid clients in
acquiring such crucial skills that will help them better cope with and/or avoid high risk
situations such as relationship conflict.

To teach skills such as communication and problem solving, this study used a
psychoeducational intervention, “Time Out! For Men.” According to La Salvia (1993),
however, much of substance abuse treatment is focused on repairing ego function

deficits, which can be inadequate, rather than on developing certain necessary skills via

67

psychoeducation. Substance abusers need as much assistance with their self-care
problems as with understanding their feelings about life (Khantzian, 1988). La Salvia
(1993) further stated that psychotherapy and psychodynamic group therapy may suffice
in addressing emotions, but a comprehensive, thorough treatment plan for addictions also
must include the basic set of tools necessary to solve life’s day-to-day problems. A
psychoeducational group, in particular, which is a specialized, task-oriented, didactic
group experience, can address both ego deficits and life skills. Psychoeducational
interventions have been found to be beneficial in addiction treatment (Marlatt &
Donovan, 1982; McAuliffe & Gordon, 1980). In this study, the “Time Out! For Men”
psychoeducational intervention was found to be effective in teaching life skills, including
communication and problem solving, with the goal of providing clients with the
necessary tools to cope with stress and conflict in their relationships.

Bartholomew et al. (2000) conducted a study examining the efficacy of the “Time
Out! For Men” psychoeducational intervention with 122 male felony probationers who
were court-mandated to a 6-month residential substance abuse treatment program in lieu
of incarceration. This study indicated a significant increase in the experimental group’s
knowledge of communication, sexuality, sexual health, and gender-role and socialization
issues in comparison to the control group. The present study used a similar sample,
males on probation in a residential substance abuse treatment program, and also found an
increase in clients’ knowledge of communications skills for those who participated in the
intervention. However, the current study expanded beyond the Bartholomew et al.

(2000) investigation to include the constructs of problem solving skills and general

68

relationship coping skills and psychometrically sound pre- and post—test measures to
assess such skills.
Implications for Theory, Research, and Practice

The findings in the present study have implications for theory, research, and
practice. The biopsychosocial model is becoming the dominant model in substance abuse
treatment theory. This model considers the interactions of biological, psychological,
cognitive, social, developmental, environmental, and cultural variables to explain
addiction (Fisher & Hanison, 2000). Further, this model provides practitioners with a
way to understand the multifaceted problem of addiction (Wallace, 1989). Traditionally,
the field of substance abuse treatment has adhered to a disease model, which solely
implies a biological basis for addiction. Although the biological component should not
be neglected, it is not the only component or aspect of an individual. The limitation of
unifaceted models, like the disease model, is that variables affecting substance abuse
often interact with each other and cut across multiple levels (Donovan & Marlatt, 1988).
Neglecting the psychological and social aspects of addiction will likely lead to clients not
receiving the most comprehensive substance abuse treatment. In addition, uni-faceted
models, like the disease model, place sole responsibility on the substance abuser, while
the biopsychosocial model also recognizes the influence of external factors, like
relationship dysfunction, on the exacerbation of addiction. The present study provides
additional data to support the biospsychosocial model. The importance of the social
component, which includes one’s relationship with his or her significant other, is further
supported as a crucial component in substance abuse treatment. Not only does this study

lend credence to the importance of addressing social components in substance abuse

69

treatment, it also illustrates the simplicity and cost-effectiveness of attending to this
component using a psychoeducational modality.

This study also informs clinical substance abuse research. Much of the research
performed on clinical populations is survey research. Although valuable, the field of
substance abuse counseling is in much need of experimental research which supports
effective treatment modalities. The lack of empirically-supported treatment designs is
likely one reason why many substance abuse treatment facilities continue to rely on
traditional treatment modalities, such as the 12-step support group models of Alcoholics
Anonymous (AA) and Narcotics Anonymous (NA). NA and AA are support groups, not
treatment groups. They are useful adjuncts to treatment but are not treatment. It is
imperative to have various treatment options in order to have better client-treatment
matching. Perhaps, the most effective method for validating substance abuse treatment
interventions, such as “Time Out! For Men,” is through experimental research.

As mentioned previously, much of clinical substance abuse treatment focuses on
repairing ego deficits and other therapeutic work, which typically can only be performed
by a licensed counselor or therapist. However, many clients do not have the basic skills
to participate in such advanced therapeutic work, as they have never learned skills such
as communication due to substance abuse which began at a young age. As one
participant in the present study commented after the first group session in which
communication skills were covered, “1 can’t believe how much of this material I don’t
know.” In essence, beginning advanced therapy work with a client (and his or her
significant other) may be counterproductive because such work requires basic skills that

many clients do not yet possess. The present study illustrated that clients in a male

70

QT

residential substance abuse facility can learn such skills in a brief, short-tenn intervention
format, which would enable them to not only incorporate such skills in their
relationships, but also to move on to more advanced relationship therapy/counseling.

Many substance abuse facilities, including House of Commons, have attempted to
incorporate relationship counseling components as a part of their treatment programming.
However, according to the director of House of Commons, the cost to hire a licensed
therapist to do such work does not justify the less than stellar outcome of such
interventions. Unsuccessful therapy outcomes may be due in part to the lack of client
communication and problem solving skills. Further, the director reported that time is a
big issue, since staff at the facility are required to do the required treatment programming
(i.e., treatment planning, recovery contracts, and relapse prevention groups) with little
time to do additional work. The “Time Out! For Men” program can be helpful for
addressing these types of real-world substance abuse treatment issues by allowing for a
brief intervention format, which can be implemented by a paraprofessional.

Finally, substance abuse treatment program staff need to be made aware that
substance abuse/dependence is a symptom of an underlying issue. Whether the issue is a
relationship problem or another issue, such as low self-esteem, depression, or anxiety,
focusing solely on the substance abuse behavior is not going to resolve the addiction.
Rather, substance abuse treatment programs need to focus on such core issues that
originally led to the addictive behavior patterns. In this study, the social component of
the biopsychosocial model was shown to be a valuable component in substance abuse
treatment. Although the connection was made between addictive behaviors and

relationship dysfunction, substance abuse behavior was not a focus of the “Time Out! For

71

Men” intervention. Giving attention to the symptom and not the underlying issue is
doing a potentially huge disservice to clients needing substance abuse services. The
findings of the present and other studies (Bartholomew et a1, 2004; Monti et al., 1990)
suggest that clients may benefit from services that do not focus solely on their substance
abusing behaviors. Adhering to the biopsychosocial model, it seems clear that addressing
the biological (family substance abuse history, brain chemistry, etc.), the psychological
(counseling and medications for depression, anxiety, etc.), and the social (family issues,
employment, etc.) is needed rather than solely presenting traditional techniques that
address only the substance using behavior.
Future Research Needed

There are three primary areas in which the substance abuse treatment field would
benefit from future research in this area. First, the study performed specifically on the
“Time Out! For Men” intervention by Bartholomew et al. (2000) and this present study
both used a sample consisting of men on probation in a residential substance abuse
facility. To expand the available data on “Time Out! For Men,” future research should
test its effectiveness in an outpatient sample. Such a study would increase the external
validity of the intervention because the participants would have the opportunity to return
home after each session to practice what they have learned with their significant others.
Testing the effectiveness of the intervention with a sample of men not court-ordered to
treatment also may enhance the generalizability of the intervention.

Gathering longitudinal data is a second area of research that would be valuable.
While the present study illustrated the value and effectiveness of incorporating a

psychoeducational, relationship coping skills intervention, it did not possess a follow-up

72

component to determine whether the participants retained the skills developed during the
intervention. In addition, it would be useful to determine whether such skills, if retained,
were found to be helpful when relationship conflict arises. Finally, while relationship
conflict has been established as a main. contributing factor to substance abuse relapse
(Maisto et al., 198 8), the present study did not determine whether such skills prevented an
imminent relapse when relationship conflict presented. Addressing all of these areas in a
longitudinal study would provide additional evidence regarding the effectiveness of
“Time Out! For Men” as a relationship coping skills development tool. Assessing and
comparing relationship satisfaction and general relationship functioning among
participants and their significant others before and after the intervention also would
illustrate the value of incorporating relationship skills interventions, such as “Time Out!
For Men,” in traditional substance abuse treatment programs.

The intervention used in this study implies that relationship coping skills,
specifically communication skills, are universal. More specifically, it addresses
communication from a Western perspective and does not take into account that such
relationship skills vary across cultures. A final area of beneficial research would be to
examine cultural differences in communication patterns in relationships and to design and

validate an intervention that is culturally sensitive.

73

References

Abrams, D. B., & Niaura, R. S. (1987) Social learning theory. In H.T. Blane, & K.E.
Leonard, (Eds.), Psychological Theories of Drinking and Alcoholism,
pp. 131—178 (New York, Guilford Press).

Aldwin, C.M., & Revenson, T.A. (1987). Does coping help? A reexamination of the
relation between coping and mental health. Journal of Personality and Social
Psychology, 53, 337-348.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.

Appel, P.W., & Kaestner, E. (1979). Interpersonal and emotional problem solving
among narcotic drug abusers. Journal of Consulting and Clinical Psychology, 47,
1125-1127.

Aviram, R.B., & Spitz, HI. (2003). Substance abuse couple therapy: Clinical
considerations and relational themes. Journal of Family Psychotherapy, 14 (3), l-
18.

Bandura, A. (1969). Principles of behavior modification. New York: Holt, Rinehart, &
Winston.

Bandura, A. (1977). Social learning theory. New York: Prentice Hall.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory.
Upper Saddle River, NJ: Prentice Hall.

Bartholomew, N.G., Hiller, M.L., Knight, K., Nucatola, D.C., & Simpson, DD. (2000).

Effectiveness of communication and relationship skills training for men in
substance abuse treatment. Journal of Substance Abuse Treatment, 18, 217-225.

Bartholemew, N.G., Rowan-Szal, G., Chatham, L.C., & Simpson, DD. (1994).
Effectiveness of a specialized intervention for women in a methadone program.
Journal of Psychoactive Drugs, 26, 249-255.

Bartholomew, N.G, & Simpson, DD. (2002). Time Out! For Men: A communication
skills and sexuality workshop for men. (Available at www.ibr.tcu.edu)

Booth, B.M., Russell, D.W., Yates, W.R., Laughlin, P.R., Brown, K., & Reed, D. (1992).
Social support and depression in men during alcoholism treatment. Journal of
Substance Abuse, 4, 57-67

Bowman, ML. (1990). Coping efforts and marital satisfaction: Measuring marital
coping and its correlates. Journal of Marriage and the Family, 52, 463-474.

74

Q3

Brooks, C.S., & Rice, KR (1997). Families in recovery: Coming fill] circle. Baltimore:
Paul H. Brookes.

Brown, S. (1985). Treating the alcoholic: A developmental model of recovery. New
York: John Wiley & Sons.

Brown, S., & Lewis, V. (1999). The Alcoholic Family in Recovery: A Developmental
Model. New York: Guilford Press.

Carver, C.S., Scheier, M.F., & Weintraub, J .K. (1989). Assessing coping strategies: A
theoretically based approach. Journal of Personality and Social Psychology, 5 6,
267-283.

Center for Substance Abuse Treatment. (2004). Substance Abuse Treatment and Family
Therapy. Treatment Improvement Protocol (TIP) Series, No. 39. DHHS
Publication No. (SMA) 04-3957. Rockville, MD: Substance Abuse and Mental '

Health Services Administration.

Cloud, W. & Granfield, R. (2001). Natural recovery from substance dependence: Lessons
learned for treatment providers. Journal of Social Work Practice in the
Addictions, 1(1), 83-104.

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2“Cl ed.).
Hillsdale, NJ: Erlbaum.

Cooney, N. L., Kadden, R. M., Litt, M. D. & Gerter, H. (1991) Matching alcoholics to
coping skills or interactional therapies: two-year follow-up results, Journal of
Consulting and Clinical Psychology, 59, 598—601.

Coyne, J.C., Aldwin, C., & Lazarus, RS. (1981). Depression and coping in stressful
episodes. Journal of Abnormal Psychology, 90, 439-447.

Donovan, D.M., & Marlatt A. (1988). Assessment of addictive behaviors. New York,
NY: Guilford Press.

Dore, J. (1994). A model of time-limited group therapy for men: Its use with recovering
addicts. Group, 18, 243-258.

Downing, C. (1989). Triad: The evolution of treatment for chemical dependency.
Independence, MO: Herald House/Independence Press.

Elliot, T., Johnson, M.O., & Jackson, R. (1997). Social problem solving and health
behaviors of undergraduate students. Journal of College Student Development,
38, 24-31.

75

Engel, G.L. (1977). The need for a new medical model: A challenge for biomedicine.
Science, 196, 129-136.

Engel, G. L. (1978). The biopsychosocial model and the education of health
professionals. Annuals New York Academy of Sciences, 310, 169-181.

Engel, G. L. (1980). The clinical application of the biopsychosocial model. The
American Journal of Psychiatry, 13 7, 535-544.

Eriksen, L., Bjomstad, S., & Gortestam, KG. (1986). Social skills training in groups for
alcoholics: One-year treatment outcome for groups and individuals. Addictive
Behaviors, 11, 309-329.

Evans, D.M., & Dunn, NJ. (1995). Alcohol expectancies, coping resources, and self-
efficacy judgments: A replication and extension of Cooper et al.’s 1988 study in a
college sample. Journal of Studies in Alcohol, 56, 186-193.

Pals-Stewart, W., & Birchler, GR. (1998). Marital interactions of drug-abusing patients
and their partners: Comparisons with distressed couples and relationship to drug-
using behavior. Psychology of Addictive Behaviors, 12 (1), 28-38.

Pals-Stewart, W., Birchler, G.R., & O’Farrell, T.J. (1996). Behavioral couples therapy for
male substance-abusing patients: Effects on relationship adjustment and drug-
using behavior. Journal of Consulting and Clinical Psychology, 64, 959-972.

Pals-Stewart, W., Birchler, G.R., & O’Farrell, T.J. (1999). Drug-abusing patients and
their intimate partners: Dyadic adjustment, relationship stability, and substance
use. Journal of Abnormal Psychology, 108(1), 11-23.

Pals-Stewart, W., O’Farrell, T.J., & Birchler, GR. (1997). Behavioral couples therapy
for male-substance abusing patients: A cost outcomes analysis. Journal of
Consulting and Clinical Psychology, 65 (5), 789-802.

Fals-Stewart, W., O’Farrell, T.J., & Birchler, GR. (2004). Behavioral couples therapy
for substance abuse: Rationale, methods, and findings. Science and Practice
Perspectives, 30-43.

Fisher, G.L., & Harrison, TC. (2000). Substance abuse. Information for school
counselors, social workers, therapists, and counselors. (2"d ed.). Needham
Heights, MA: Allyn & Bacon.

Fromme, K., & Rivet, K. (1994). Young adults’ coping style as a predictor of their

alcohol use and response to daily events. Journal of Youth and Adolescence, 23,
85-97.

76

Goldstein, M.J., & Miklowitz, DJ. (1995). The effectiveness of psychoeducational
family therapy in the treatment of schizophrenic disorders. Journal of Marital
and Family Therapy, 21(4), 361-376.

Good, G.F., O’Neil, J .M., Stevens, M., Robertson, J.M., Fitzgerald, L.F., DeBord, K.A.,
Bartels, K.M., & Braverman, DC. (1995). Male gender role conflict:
Psychometric issues and relations to psychological distress. Journal of
Counseling Psychology, 42, 3-10.

Greenglass, E. (1993). The contribution of social support to coping strategies. Applied
Psychology: An International Review, 42, 323-340.

Hair, J .J ., Anderson, R.E., & Tatham, R.L. (1987). Multivariate data analysis with
readings (2"d ed.). New York: MacMillan.

Hamilton, F ., & Maisto, SA. (1979). Assertive behavior and perceived discomfort of
alcoholics in assertion-required situations. Journal of Consulting and Clinical
Psychology, 47, 196-197.

Hanson, G.R., Venturelli, P.J., & Fleckenstein, AB. (2004). Drugs and society (8th ed.).
Boston: Jones and Bartlett.

Hansson, R.O., Jones, W.H., Carpenter, B.N., & Remondat, J .H. (1986-87). Loneliness
and adjustment in Old age. International Journal of Aging and Human
Development, 24, 41-53.

Harwood HJ, Fountain D, Livermore G. The Economic Costs of Alcohol and Drug Abuse
in the United States, 1992. Rockville, MD: National Institute on Drug
Abuse/National Institute on Alcohol Abuse and Alcoholism, May 1998.

Heath, A.W., & Stanton, MD. (1998). Family-based treatment: Stages and outcomes. In
R]. Frances et al. (Eds.), Clinical textbook of addictive disorders (pp. 496-520).
New York: Guilford.

Heppner, P.P., & Peterson, CH. (1982). The development and implications of a personal
problem-solving inventory. Journal of Counseling Psychology, 29, p. 66-75

Hobfoll, S. E., Dunahoo, C. L., Ben-Porth, Y., & Monnier, J. (1994). Gender and coping:
The dual-axis model of coping. American Journal of Community Psycholog, 22,
49-82

Hodgins, D.C., El-Guebaly, N., & Addington, J. (1997). Treatment of substance abusers:
Single or mixed gender programs? Addiction, 92, 805-512.

77

Hoffmann, N.G., Halikas, J .A., Mee-Lee, D., and Weedman, R.D. Patient Placement
Criteria for the Treatment of Psychoactive Substance Use Disorders. American
Society of Addiction Medicine, Washington, DC, 1991.

Hops, H., Tildesley, E., Lichtenstein, E., & Ary, D. (1990). Parent and adolescent
problem solving interactions and drug use. American Journal of Drug and
Alcohol Abuse, 16, 239-258. _

Huitt, W. (1992). Problem solving and decision making: Consideration of individual
differences using the Myers-Briggs Type Indicator. Journal of Psychological
Type, 24, 33-44.

Institute Of Health Policy. (1993). Substance Abuse: The nation ’s number one health
problem-Key indicators for policy. Waltham, MA: Brandeis University for the
Robert Wood Johnson Foundation, Heller Graduate School.

Kantor, G.K., & Strauss, MA. (1990). The “drunken bum” theory of wife beating. In
M.A. Strauss and RI. Gelles (Eds.), Physical violence in American families (pp.
203-224). New Brunswick, NJ: Transaction.

Khantzian, E.J. (1988). The primary care therapist and patient needs in substance abuse
treatment. American Journal of Drug and Alcohol Abuse, 14 (2), 159-167.

Kumpfer, KL. (1987). Special populations: Etiology and prevention of vulnerability to
chemical dependency in children of substance abusers. In B.S. Brown & A.R.
Mills (Eds.), Youth at high risk for substance abuse. US. Government Printing
Office: Washington, DC.

Kumpfer, K.L., Trunnell, E.P., & Whiteside, HQ (1990). The biopsychosocial model: .
Application to the addictions field. In R.C. Engs (Ed.), Controversies in the
addiction field. Dubuque: Kendal-Hunt.

Larson, L. M., & Heppner, P. P. (1989). Problem-solving appraisal in an alcoholic
population. Journal of Counseling Psychology, 36, 73-78.

La Salvia, T.A. (1993). Enhancing addiction treatment through psychoeducational
groups. Journal of Substance Abuse Treatment, 10, 439-444.

Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.

Leedy, P.D., & Orerd, J .E. (2001). Practical research: Planning and design (7th ed.).
Upper Saddle River, NJ: Prentice-Hall.

Levant, RF. (1997). Nonrelational sexuality in men. In R.F. Levant & GR. Brooks

(Eds.), Men and sex: New psychological perspectives (pp. 9-27). New York: John
Wiley and Sons.

78

Lipsey, M.W. (1990). Design sensitivity: Statistical power for experimental research.
Newbury Park, CA: Sage.

MacDonald, D. (1991). Parental alcoholism-A neglected pediatric responsibility.
American Journal of Diseases in Children, 145, 609-610.

Maisto, S.A., O’Farrell, T.J., Connors, G.J., & McKay, J .R. (1988). Alcoholics’
attributions of factors affecting their relapse to drinking and reasons for
terminating relapse episodes. Addictive Behaviors, 13 (I), 79-82.

Marlatt, GA. (1979). Alcohol use and problem drinking: A cognitive-behavioral
analysis. In P.C. Kendall & S.D. Hollon (Eds.), Cognitive-behavioral
interventions: Theory, research, and procedures. (pp. 319-355). New York:
Academic Press.

Marlatt, G.A., & Donovan, D.M. (1982). Behavioral psychology approaches to
alcoholism. In E.M. Pattison & E. Kaufman (Eds.), Encyclopedic handbook of
alcoholism. New York: Gardner Press.

Marlatt, G.A., & Gordon, J .R. (Eds). (1985). Relapse prevention: Maintenance
strategies in the treatment of addictive behaviors. New York: Guilford Press.

McAuliffe, W.E., & Gordon, RA. (1980). Reinforcement and the combination of
effects: Summary of a theory of opiate addiction. In D. J. Lettieri, M. Sayers, &
H.W. Wallenstein (Eds.), Theories of addiction (pp. 137-141). Rockville, MD:
National Institute of Drug Abuse.

McCrady, B.S., Stout, R.L., Noel, N.E., Abrams, D.B., & Nelson, HF. (1991).
Effectiveness of three types of spouse-involved behavioral alcoholism treatment.
British Journal of Addictions, 86, 1415-1424.

McLellan, A.T., Luborsky, L., O’Brien, C.P. & Woody, GE. (1980). An improved
diagnostic instrument for substance abuse patients: The Addiction Severity Index.
Journal of Nervous & Mental Diseases, 168, 26-33.

McNeece, C.A., & DiNitto, D.M. (1998). Chemical dependency: A systems approach.
Boston: Allyn & Bacon.

Meyers, R.J., Apodaca, T.R., Flicker, S.M., & Slesnick, N. (2002). Evidence-based
approaches for the treatment of substance abusers by involving family members.
The Family Journal: Counseling and Therapy for Couples and Families, 10 (3),
281-288.

Miller, W.R. (1992). The effectiveness of treatment for substance abuse: Reasons for
Optimism. Journal of Substance Abuse Treatment, 9, 93-102.

79

Miller, W.R., & Brown, SA. (1997). Why psychologists should treat alcohol and drug
problems. American Psychologist, 52, 1269-1279.

Monti, P.M., Abrams, D.B., Binkoff, J .A., Zwick, W.R., Liepman, M.R., Nirenberg,
T.D., & Rohsenow, DJ. (1990). Communication skills training, communication
skills training with family and cognitive behavioral mood management training

for alcoholics. Journal of Studies on Alcohol, 51, 263-270.

Monti, P.M., Abrams, D.B., Kadden, R.M., & Cooney, N.L. (1989). Treating Alcohol
Dependence: A coping skills training guide. New York: Guilford Press.

Moos, R.H., Finney, J .W., & Gamble, W. (1985). The process of recovery from
alcoholism 11: Comparing spouses of alcoholics and matched community controls.
In E.M. Freeman (Ed.), Social work practice with clients who have alcohol
problems (pp. 292-314). Springfield, IL: Charles C. Thomas.

National Institute on Drug Abuse & National Institute on Alcohol Abuse and
Alcoholism. The Economic Costs of Drug and Alcohol Abuse in the United
States, 1992. September 1998.

Newcomb, MD. (1994). Drug use and intimate relationships among women and men:
Separating specific from general effects in prospective data using structural
equation models. Journal of Consulting and Clinical Psychology, 62, 463-476.

Noller, P., Feeney, J.A., Bonnell, D., & Callan, VI. (1994). A longitudinal study of
conflict in early maniage. Journal of Social and Personal Relationships, 11, 233-
252.

Norwinski, J. (1993). Hungry hearts: 0n men, intimacy, self-esteem, and addiction.
New York: Lexington Books.

Oei, T.P.S., & Jackson, PR. (1980). Long-term effects of group and individual social
skills training with alcoholics. Addictive Behaviors, 5, 129-136.

O’Farrell, T.J. (1995). Marital and family therapy. In R.K. Hester & W.R. Miller (Eds.),
Handbook of alcoholism treatment approaches: Effective alternatives (pp. 195-
220). Boston: Allyn & Bacon.

O’Farrell, T.J., & Birchler, GR. (1987). Marital relationships of alcoholic, conflicted,
and nonconflicted couples. Journal of Marital and Family Therapy, 13, 259-274.

O’Farrell, T.J., Choquette, K.A., Cutter, H.S.G., Floyd, F.J., Bayog, R., Brown, E.D.,
Lowe, J., Chan, A., & Deneault, P. (1996). Cost-benefit and cost-effectiveness
analyses of behavioral marital therapy as an addition to outpatient alcoholism
treatment. Journal of Substance Abuse, 8(2), 145-166.

80

r0

4i

O’Farrell, T.J., Cutter, H.S.G., Choquette, K.A., Floyd, F.J., & Bayog, RD. (1992).
Behavioral martial therapy for male alcoholics: Marital and drinking adjustment
during two years after treatment. Behavior Therapy, 23, 529-549.

Office Of National Drug Control Policy. The Economic Costs of Drug Abuse in the
United States, 1992-1998. September 2001.

O’Leary, D.E., O’Leary, M.R., Donovan, D.M. (1976). Social skill acquisition and
psychosocial development of alcoholics: A review. Addictive Behaviors, 1, 111-
120.

- Pascoe, W. (2001). Restoration of intimacy and connection in the treatment of couples
with substance abuse issues. In B]. Brothers (Ed.), Couples, intimacy issues, and
addiction (pp. 33-49). New York, NY: Haworth Presss.

Pearlin, L., & Schooler, C. (1978). The structure Of coping. Jaurnal of Health and
Social Behavior, 19, 2-21.

Platt, J.J., & Husband, SD. (1993). An overview of problem-solving and social skills
approaches in substance abuse treatment. Psychotherapy, 30, 276-283.

Pollina, L.K., & Snell, W.E. (1999). Coping in intimate relationships: Development of
the multidimensional intimate coping questionnaire. Journal of Social and
Personal Relationships, 16, 133-144.

Ritter, A.J., & Cole, M.J. (1992). Men’s issues: Gender role conflict and substance abuse.
Drug and Alcohol Review, 11, 163-167.

Rohsenow, D. J ., Monti, P. M. & Abrams, D. B. (1995). Cue exposure treatment for
alcohol dependence. In DC. Drummond, S. Glautier, B. Remington, & S. Tiffany
(Eds.), Addiction: cue exposure theory and practice. London: Wiley & Sons.

Rohsenow, D.J., Monti, P.M., Binkoff, J .A., Liepman, M.R., Nirenberg, T.D., & Abrams
D. B. (1991). Patient-treatment matching for alcoholic men in communication

skills versus cognitive-behavioral mood management training. Addictive
Behaviors, 16, 63- 69.

Rohsenow, D.J., Monti, P.M., Rubonis, A.V., Gulliver, S.B., Colby, S.M., Binkoff, J .A.,
& Abrams, DB. (2001). Cue exposure with coping skills training and
communication skills training for alcohol dependence: 6- and 12-month
outcomes. Addiction, 96, 1161-1174.

Ryglewicz, H. (1991). Psychoeducation for clients and families: A way in, out, and
through in working with people with dual disorders. Psychosocial Rehabilitation
Journal, 15(2), 79-89.

81

Schliebner, CT. (1994). Gender sensitive therapy: An alternative for women in
substance abuse treatment. Journal of Substance Abuse Treatment, 6, 51 1-515.

Substance Abuse and Mental Health Services Administration (SAMHSA). (1994). Cost
of addictive and mental disorders and eflectiveness of treatment (DHHS
Publication SMA 2095-94). Rockville, MD: Author.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2002). United
States Department of Health and Human Services. www.samhsa.gov.

Waldron, HE. (1997). Adolescent substance abuse and family therapy outcome: A
review of randomized trials. In T.H. Ollendick & R. J. Prinz (Eds.), Advances in
clinical child psychology (pp. 199-234). New York: Plenum.

Wallace J. (1989). A biopsychosocial model of alcoholism. Social Casework, 70(6),
325-332.

Wiemann, J. M. (1977). Explication and test of a model of communicative competence.
Human Communication Research, 3, 195-213.

Wills, T. A. (1990). Social support and interpersonal relationships. In M. S. Clark (Ed.),
Review of personality and social psychology ,Vol. 12, (pp. 265-289). Newbury
Park, CA: Sage.

Wills, T.A., & Shiffrnan, S. (1985). Coping and substance use: A conceptual
framework. In S. Shiffrnan & T.A. Wills (Eds.), Coping and substance use (pp.
3-24). New York: Academic Press.

Wilsnack, S.C., & Wilsnack, R.W. (1993). Epidemiological research on women’s
drinking: Recent progress and directions for the 19905. In E.S.L. Gomberg & T.D.
Nirenberg (Eds.), Women and substance abuse (pp.62-99). Norwood, NJ: Ablex.

Winters, J., Pals-Stewart, W., O’Farrell, T.J., Birchler, G.R., & Kelley, ML. (2002).
Behavioral couples therapy for female substance-abusing patients: Effects of
substance use and relationship adjustment. Journal of Consulting and Clinical
Psychology, 70(2), 344-355.

Woititz, J. (1979). Marriage on the rocks. New York : Delacorte Press.

Wright, D.M., & Heppner, PP. (1991). Coping among nonclinical college age children of
alcoholics. Journal of Counseling Psychology, 38, 465-472.

Yamaguchi, K., & Kandel, DB. (1985). On the resolution of role incompatibility: A life
event history analysis of family roles and marijuana use. American Journal of
Sociology, 9, 1284-1325.

82

Q)

APPENDICES

83

I- r0

 

APPENDIX A

Participant Information Sheet

84

ID#
Participant Information Sheet
Please answer the following questions:

1. What is your age?

2. What is your race/ethnicity?
White

Afiican American/ Black
American Indian
Hispanic

Asian

Unknown

Multi-racial

Arab American

are: rm en 9'!»

3. What is the highest grade you completed in school?

4. How many times have you attempted substance abuse treatment (include both
inpatient and outpatient treatment)?

5. Are you currently in an intimate relationship?

a. If yes, how long have you been in your present relationship?

b. If no, how long ago was your most recent relationship?

85

APPENDIX B

Communication Competence Scale

86

‘3‘

 

 

 

ID#
Communication Competence Scale

The following are statements about how people generally communicate with others.
Answer each item as it relates to your general style of communicating in your
personal relationship(s). Complete the questionnaire by indicating the extent to which
you agree or disagree with each statement by noting whether you:

(5) strongly agree

(4) agree

(3) are neutral or undecided
(2) disagree

(1) strongly disagree

fl

. I find it easy to get along with others.

N

. I adapt to changing situations.

U.)

. I treat people as individuals.

&

. I interrupt others too much.
5. Others find it “rewarding” to talk with me.

6. I deal with others effectively.

\1

. I am a good listener.

00

. My personal relationships are cold and distant.
9. I am easy to talk to.

10. I won’t argue with someone just to prove I am
right.

1 1. My conversation behavior is not “smoot .”
12. I ignore other people’s feelings.
13. I generally know how others feel.

14. I let others know I understand what they mean.

87

15. I understand other people.

(5) strongly agree

(4) agree

(3) are neutral or undecided
(2) disagree

(1) strongly disagree

16. I am relaxed and comfortable when speaking.

17. I listen to what people say to me.

18. I like to be close and personal with people.

19. I generally know what type of behavior is

appropriate in any given situation.

20. I usually do not make unusual demands on my

friends.

21. I am an effective conversationalist.

22. I am supportive of others.

23. I do not mind meeting strangers.

24. I can easily put myself in another person’s

shoes.

25. I pay attention to the conversation.

26. I am generally relaxed when conversing with

a new acquaintance.
27. I am interested in what others have to say.

28. I don’t follow the conversation very well.

29. I enjoy social gatherings where I meet new

people.

30. I am a likable person.

31. I am flexible.

88

Q1

(5) strongly agree

(4) agree

(3) are neutral or undecided
(2) disagree

(1) strongly disagree

32. I am not afraid to speak with people in
authority.

33. People can come to me with their
problems.

34. I generally say the right thing at the right
time.

35. I like to use my voice and body expressively to
communicate.

36. I am sensitive to others’ needs of the
moment.

89

APPENDIX C

Problem Solving Inventory

90

ID#
Problem Solving Inventory

People respond to personal problems in different ways. The statements on this inventory
deal with how people react to personal difficulties and problems in their day-to-day life.
The term “problems” refers to personal problems that everyone experiences at times,
such as depression, inability to get along with friends, choosing a vocation, or deciding
whether to get a divorce. Please respond to the items as honestly as possible so as to most
accurately portray how you handle such personal problems. Your responses should reflect
what you actually do to solve problems, not how you thing you should solve them. When
you read an item, ask yourself: Do I ever behave this way? Please answer every item.

Read each statement and indicate the extent to which you agree or disagree with
that statement as it relates to your personal relationships.

(1) strongly agree

(2) moderately agree
(3) slightly agree

(4) slightly disagree

(5) moderately disagree
(6) strongly disagree

1. When a solution to a problem has failed, I do not examine why it didn’t work.

2. When I am confronted with a complex problem, I don’t take the time to develop a
strategy for collecting information that will help define the nature of the problem.

3. When my first efforts to solve a problem fail, I become uneasy about my ability to
handle the situation.

4. After I solve a problem, I do not analyze what went right and what went wrong.

5. I am usually able to think of creative and effective alternatives to my problems.

6. After following a course of action to solve a problem, I compare the actual
outcome with the one I had anticipated.

7. When I have a problem, I think of as many possible ways to handle it as I can
until I can’t come up with any more ideas.

91

10.

ll.

12.

l3.

14.

15.

16.

17.

18.

19.

20.

21.

(1) strongly agree

(2) moderately agree
(3) slightly agree

(4) slightly disagree

(5) moderately disagree
(6) strongly disagree

When confronted with a problem, I consistently examine my feelings to find out
what is going on in a problem situation.

When confused about a problem, I don’t clarify vague ideas or feelings by
thinking of them in concrete terms.

I have the ability to solve most problems even though initially no solution is
immediately apparent.

Many of the problems I face are too complex for me to solve.
When solving a problem, I make decision that I am happy with later.

When confronted with a problem, I tend to do the first thing that I can think of to
solve it.

Sometimes I do not stop and take time to deal with my problems, but just kind of
muddle ahead.

When considering solutions to a problem, I do not take the time to assess the
potential success of each alternative.

When confronted with a problem, I stop and think about it before deciding on a
next step.

I generally act on the first idea that comes to mind in solving a problem.

When making a decision, I compare alternatives and weigh the consequences of
one against the other.

When I make plans to solve a problem, I am almost certain that I can make them
work.

I try to predict the result of a particular course of action.

When I try to think of possible solutions to a problem, I do not come up with very
many alternatives.

92

’31

 

 

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

(1) strongly agree

(2) moderately agree
(3) slightly agree

(4) slightly disagree

(5) moderately disagree
(6) strongly disagree

When trying to solve a problem, one strategy I Often use is to think of past
problems that have been similar.

Given enough time and effort, I believe I can solve most problems that confront
me.

 

When faced with a novel situation, I have confidence that I can handle problems
that arise.

Even though I work on a problem, sometimes I feel like I’m groping or wandering
and not getting down to the real issue.

I make snap judgments and later regret them.
I trust my ability to solve new and difficult problems.
I use a systematic method to compare alternatives and make decisions.

When thinking of ways to handle a problem, I seldom combine ideas from various
alternatives to anive at a workable solution.

When faced with a problem, I seldom assess the external forces that may be
contributing to the problem.

When confronted with a problem, I usually first survey the situation to determine
the relevant information.

There are times when I become so emotionally charged that I can no longer see
the alternatives for solving a particular problem.

After making a decision, the actual outcome is usually similar to what I had
anticipated.

When confronted with a problem, I am unsure of whether I can handle the
situation.

When I become aware of a problem, one of the first things I do is try to find out
exactly what the problem is.

93

APPENDIX D

Multidimensional Intimate Coping Questionnaire - Modified

94

 

")3

ID#
Multidimensional Intimate Coping Questionnaire - Modified

INSTRUCTIONS: People can experience stress in many areas Of their life. Listed below
are some of the ways that people can respond and deal with difficult ore stressful events
in their intimate relationships. This questionnaire asks you to indicate what you generally
do and feel when you experience stressful experiences in your intimate relationships.
Obviously, different stressful experiences can bring out different responses, but we are
interested in what you USUALLY do when your relationships is under a great deal of
stress. Whenever possible, answer the questions with your current partner in mind. If you
are not dating or married to anyone, answer the questions with your most recent partner
in mind. If you have never had an intimate relationship, answer in terms of what you
think your responses would most likely be.

Respond to each of the following statement by writing the letter that corresponds to the
appropriate answer on the blank provided. Please try to respond to each item separately
fiom every other item. Choose your answers thoughtfully, and make your answers as
truthful FOR YOU as you can. Please answer every item. There are no “right” or
“wrong” responses, so choose the most accurate answer for YOU — not what you think
“most people” would say or do.

Indicate how often you tend to do each of these things when dealing with stressful
experiences in your intimate relationship. Use the following scale.

When I experience stress in my intimate relationship:
A = I never do this
B = I rarely do this
C =1 sometimes do this
D = I gflgg do this
E = I usually do this

1. I am responding to the following items based on:

(A) My current intimate relationship

(B) A past intimate relationship

(C) An imagined close relationship
2. I try to grow as a person as a result of the stressful experience.
3. I concentrate my efforts on doing something about it.

4. I try to get advice from someone about what to do.

5. I get used to the idea that it happened.

95

A = I never do this

B = I rarely do this

C = I sometimes do this
D =1 o_ftgr_r_ do this

E = I usually do this

6. I get upset and let my emotions out.

7. I admit to myself that I can’t deal with it, and quit trying.

8. I force myself to wait for the right time to do something.

9. I reassure myself that I can cope with the situation.

10.

11.

12.

13.

14.

15.

l6.

17.

18.

19.

20.

21.

22.

23.

24.

25

I start feeling that I am a failure. __

I try to see it in a different light, to make it seem more positive. __
I take additional action to try to get rid of the problem. __

I talk to someone to find out more about the situation. __

I accept that this has happened and that it can’t be changed. __

I get upset, and am really aware of it.

I just give up trying to reach a desirable resolution.

I make sure not to make matters worse by acting too soon.

I provide myself with reassurance that I can cope with the situation.

I start feeling depressed and blue. __

I look for something good in what is happening. _

I take direct action to get around the problem. __

I talk to someone who could do something concrete about the problem.
I accept the reality of the fact that it happened. __

I let my feelings out.

I give up the attempt to get what I want.

96

’3‘

 

A = I never do this

B = I rarely do this

C =1 sometimes do this

D = I offing do this

E =1 usually do this
26. I restrain myself from doing anything too quickly.

27. I bolster my self-confidence by telling myself that I can deal with the
problem.

28. I start feeling anxious, tense, and unsettled.

29. I learn something from the stressful experience. __

30. I do what has to be done, one step at a time. _

31. I ask people who have had similar experiences what they did. __
32. I learn to live with it.

33. I feel a lot of emotional distress, and I find myself expressing those feelings
a lot.

34. I reduce the amount of effort I’m putting into solving the problem.
35. I hold off doing anything about it until the situation permits.
36. I keep my self-esteem up by saying positive things to myself.

37. I find I can’t concentrate on my work or other interests.

97

APPENDIX E

Informed Consent Forms

98

Experimental Group

The Impact of a Relationship Skills Training Program on the Communication and
Problem Solving Abilities of Individuals in a Male Residential Substance Abuse
Treatment Program

The purpose of this letter is to ask for your participation in a study being conducted by
researchers at Michigan State University entitled The Impact of a Relationship Skills
Training Program on the Communication and Problem Solving Abilities of Individuals in
a Male Residential Substance Abuse Treatment Program. The purpose of this study is to
determine the effectiveness of a 3-week training program on your ability to use problem
solving and communicating skills along with general coping skills in your personal
relationships. It is believed that the project will assist in enhancing the knowledge of the
skills possessed and needed by those in a substance abuse treatment program to form and
maintain personal relationships.

If you are willing to participate in this study, you will go through a 3-week group training
program in which relationship coping skills, communication skills, and problem solving
skills will be presented and taught. You will be in a group with 9-11 other individuals.
You will participate in 2 groups per week, 2 hours per session for three weeks for a total
of 6 group sessions. Before beginning the group, researchers will obtain brief
demographic information (age, race, etc.) from you and have you answer three surveys
related to how you currently use communication skills, problem solving skills, and
general coping skills in your personal relationships. You will complete these same three
questionnaires after the group is completed. Your privacy will be protected to the
maximum extent allowable by law. The following precautions will be taken to protect
your confidentiality: No individual names or other identifying information will be used in
any reports or publications that may result from this study, and your name will not be
connected to any of your answers.

Your participation in the study would be greatly appreciated. However, your
participation in this study is voluntary; you may refuse to participate, refuse to answer
certain questions, or discontinue your participation at any time without penalty. If you
have any questions concerning this study, please contact: John Kosciulek, Ph.D.
(ikosciul@msu.edu or 517-353-9443) at 458 Erickson Hall, East Lansing, MI 48824 or
Kristin Humphrey, M.S., L.P.C. (coxkrisl@msu.edu or 517-712-0043) at 401C Erickson
Hall, East Lansing, MI 48824. If you have questions about your rights as a participant,
contact the chairperson of the University Committee on Research Involving Human
Subjects (Dr. Peter Vasilenko at 517-355-2180, email: ucrihs@msu.edu), or by writing:
Committee on Human Research, 202 Olds Hall, East Lansing, MI 48824-1046.

I voluntarily agree to participate in the study.

Signed

 

Date

 

99

Control Group

The Impact of a Relationship Skills Training Program on the Communication and
Problem Solving Abilities of Individuals in a Male Residential Substance Abuse
Treatment Program

The purpose of this letter is to ask for your participation in a study being conducted by
researchers at Michigan State University entitled The Impact of a Relationship Skills
Training Program on the Communication and Problem Solving Abilities of Individuals in
a Male Residential Substance Abuse Treatment Program. The purpose of this study is to
determine the effectiveness of a 3-week training program on an individual’s ability to use
problem solving and communicating skills along with general coping skills in personal
relationships. It is believed that the project will assist in enhancing the knowledge of the
skills possessed and needed by those in a substance abuse treatment program to form and
maintain personal relationships.

If you are willing to participate in this study, researchers will obtain brief demographic
information (age, race, etc.) from you and have you answer three surveys related to how
you currently use communication skills, problem solving Skills, and general coping skills
in your personal relationships. You will complete these same three questionnaires three
weeks later. Next, you will go through a 3-week group training program in which
relationship coping skills, communication skills, and problem solving skills will be
presented and taught. You will be in a group with 9-11 other individuals. You will
participate in 2 groups per week, 2 hours per session for three weeks for a total of 6 group
sessions. Your privacy will be protected to the maximum extent allowable by law. The
following precautions will be taken to protect your confidentiality: No individual names
or other identifying information will be used in any reports or publications that may result
from this study, and your name will not be connected to any of your answers.

Your participation in the study would be greatly appreciated. However, your
participation in this study is voluntary; you may refuse to participate, refuse to answer
certain questions, or discontinue your participation at any time without penalty. If you
have any questions concerning this study, please contact: John Kosciulek, Ph.D.
(jkosciul@msu.edu or 517-353-9443) at 458 Erickson Hall, East Lansing, MI 48824 or
Kristin Humphrey, M.S., L.P.C. (coxkrisl@msu.edu or 517-712-0043) at 401C Erickson
Hall, East Lansing, MI 48824. If you have questions about your rights as a participant,
contact the chairperson of the University Committee on Research Involving Human
Subjects (Dr. Peter Vasilenko at 517-355-2180, email: ucrihs@msu.edu), or by writing:
Committee on Human Research, 202 Olds Hall, East Lansing, MI 48824-1046.

I voluntarily agree to participate in the study.

Signed

 

Date

 

100

APPENDIX F

Outline of Each Psychoeducational Session

101

A New Outlook on Relationships

 

Session Length: 2 hours

- . ' e an purpose e wor op
Objectrves Estabhshth goals d oral ksh
Explore male and female sex roles and their impact on relationships

Define personal goals for improving intimate relationships

Rationale Most men have had few opportunities to seriously explore and define their
sexuality and their need for intimacy. This lack of opportunity is perpetu-
ated by social and cultural beliefs that often go unchallenged. This session
seeks to increase participants’ willingness to explore new ways of thinking
about sexuality, love, and intimacy, and to work on personal goals for

 

 

 

 

 

 

 

 

 

improving relationships.

Session Procedure Time
outline Client Survey (pretest) 16 minutes
G Getting Started 10 minutes
Group Introductions and Guidelines 20 minutes
Challenging Stereotypes 20 minutes
Break 10 minutes
Improving Relationships 36 minutes
Homework: Partner Interview - 10 minutes
Total Time for Session 1 120 minutes

 

Time Out! For Men

102

Objectives

Rationale

Session
Outline

(5

Time Out! For Men

An Assertive Attitude

 

SessionLength: 2hours

Understand importance of communication in maintaining relationships

Distinguish assertiveness from awessive and passive communication

Learn how to use “I-Ststements” in communication situations

Many problems in intimate relationships are communication problems. Men
(ftenhavebeensodalisedtoappmschcommrmicationin relationshipsfroman
aggressive or controlling stems and may benefit from learning the parameters

of difl’erent communication styles, especially the assertiveness option. This

session seeks to introduce skills for efiective communication by helping partici-
pants embrace the importance of an assertive attitude in communication inter-
actionswiththeirpartners. I-Statementsarehighlightedasafoundationskill

 

 

 

 

 

 

for good communication. .
Procedure Time
Welcome and Process Homework 15 minutes
An Assertive Attitude 25 minutes
Discussion: Understanding Assertiveness 15 minutes
Break 10 minutes
Using l-Ststements 20 minutes

 

Practice: Making an [Statement

25 minutes

 

Homework: Assertiveness Logbook

10 minutes

 

Total Time for Session 2

120 minutes

 

103

Listening

Sessionhength: Zhours

 

Objectives Understand listening as a learnable skill
Explore common listening problems

Identifygoodlisteninghabitsandprscticelisteningskills

Rationale Listening is a inundation skill for all good interpersonal relationships, intimate
andotherwise.1nsddifion,theabifitymhstenisassodstedwithbothleammg.
andreasoning,a-itical issuesinbehaviorchangeandrecovery. Thissession
seekstoanphasizethatfisteningisaskfllflratcanimpmerelationshipsand
facilitate self-growth, and to provide practice toward skills building.

 

 

 

 

 

 

 

 

Session Wm ' Time
outhne Welcome and Process Homework 10 minutes ’
<5 Exercise: Focused Listening 30 minutes
Listening Skills 26 minutes
Break 10 minutes
Practice: Listening Skills 35 minutes
Homework: Listening to Each Other 10 minutes
Total 'lime for Session 3 120 minutes

 

Time Out! For Men

104

Objectives

Rationale

Session
Outline

CD

Time Out! For Men

Talk It Over .
Part 1: Feelings and Needs
SessionLength: 2 hours

Expknefeelingsandhowfeelmpareexpreasedinrelstionships
Understand the maize offeelings and fieeling states

1earnhowtouseanaseertion“firrmula’toexpressfeelingsandneedsand
negotiatesolutions

Idenfifyingandmanagingfeeflngsinintimaterelatkmshipsisacommoncom-
munication issue. Accepting and expressing feelings in constructive ways is
titenchallengingfiarmen. Whenemotiimsariseincommunicstionsituations,
menofienatiempttocontrolormhfimisewhattheysrefieeling,resultingin
roadblocks and impasees. This session seeks to hdp men identify and accept
feelingsasnormalandbetterunderstandhowinappropriatemsnagementof
feelingsresultsincommnnicationbreakdowns. AnassertionfirrmulaCl‘aIcht
Over) is introduced as a framework for practicing openness and self-expression
inintirnaterelationships.

 

 

 

 

 

 

 

 

 

Procedure Time

Welcome and Process Homework 10 minutes
Feelings and Communication 25 minutes
Discussion: Accepting Feelings 16 minutes
Break 10 minutes
Talk It Over Formula 26 minutes
Practice: Using the Formula 25 minutes
Homework: Talk It Over Practice 10 minutes
Total Time for Session 4 120 minutes

 

105

Objectives

Rationale

Session
Outline

(5

Time Out! For Men

Talk It Over
Part 2: Resolving Conflict

Sessionlength: Zhours

Understandcommonissuesinvolvedinparherconflicts
Identify rules for ‘Tair fights” and negotiation
Discussandpracticeaconflictresdutionmodel

fireabflitytoresolverelatkmshipcmflkssinawaythatimmintimacy
ratherthanweakensitisanimportantskill. Unsettledorrearrringconflict
aestesemotionaltmmoilinrelatiomhipsthatcanworkagsinetrecovery. This'
sessionseekstointroduce menteamodelfiorconflictreeolution, emphasizing

solutionsrathertiianblsme. 'Iheimportanceof‘fightingfaifandactiveprob-
lemsolvingishighlightedandasserfivenessskillsarereviewed.

 

 

 

 

 

 

 

 

Procedure Time

Welcome and Process Homework 10 minutes
Conflict in Relationships 25 minutes
Conflict Remlution Skills 25 minutes
Break . 10 minutes
Exercise: Conflict Case Studies 40 minutes
Homework: Fighting Fair 10 minutes
Total Time for Session 5 120 minutes

 

106

Making Relationships Work

SessionLength: Zhours

 

Objectives Explore techniques fi)!‘ enhancing self-esteem
Review skills for improving communication in relationships

Identify solutions to common relationship problems

Rationale Aheahhysmseofself-esteemisimportantinmsintainingcbseintimate
relationships. 'l‘hissessionseekstoinaeasepsrticipants’awarenessofthe
importance of self-esteem and to introduce afirmstions as a positive self-help
technique. In addition, the session prorn'dm closure for the workshop by review-
ingrelationshipskillsanddisaissingtheapplicstiondthoeeskins.

 

Session procedure Time

 

 

 

 

 

 

 

 

Outline Welcome and Process Homework 10 minutes
<5 Self-Esteem and Afirmations 20 minutes
Review: Communication and Relationships 15 minutes

Break 10 minutes

Handling Problems in Relationships 25 minutes

Workshop Closure 10 minutes

Graduation and aient Survey (posttest) 30 minutes

Total Time for Session 8 120 minutes

 

Time Out] For Men

107

. v V .—

   

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