Social Relations and Motivation for Substance Abuse Treatment among Prisoners 9781593323547, 9781593322427

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Criminal Justice Recent Scholarship

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Edited by Marilyn McShane and Frank P. Williams III

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Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

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Social Relations and Motivation for Substance Abuse Treatment among Prisoners

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Egle Narevic

LFB Scholarly Publishing LLC New York 2008 Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

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Library of Congress Cataloging-in-Publication Data Narevic, Egle, 1970Social relations and motivation for substance abuse treatment among prisoners / Egle Narevic. p. cm. -- (Criminal justice : recent scholarship) Includes bibliographical references and index. ISBN 978-1-59332-242-7 (alk. paper) 1. Prisoners--Substance use--United States--Prevention. 2. Substance abuse--United States--Prevention. 3. Criminals--Rehabilitation--United States. 4. Motivation (Psychology) I. Title. HV8836.5.N37 2008 365'.667290973--dc22 2008004170

ISBN 978-1-59332-242-7 Printed on acid-free 250-year-life paper. Manufactured in the United States of America.

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TABLE OF CONTENTS LIST OF TABLES AND FIGURES ………………

vii

ACKNOWLEDGEMENTS ……………………….

ix

Chapter 1: Introduction ……………………………

1

Chapter 2: Socialization and Substance Abuse Behavior Change Process …………….

19

Chapter 3: Empirical Research on Motivation for Treatment and Social Relations ………

55

Chapter 4: Study Approach and Measurement of Social Relations and Motivation Variables …………...............................

81

Chapter 5: Social Relations and Motivation for Substance Abuse Treatment in the Sample of Prisoners …………………

111

Chapter 6: Implications of Study Findings and Conclusion ……………………………

133

Appendix: Health Services Research Instrument (HSRI): Selected Items ……………….

161

REFERENCES …………………………………….

163

INDEX …………………………………………...

181

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LIST OF TABLES AND FIGURES Figure 1.1: Social relations effects on problem recognition and desire for help: The conceptual model ……………………

14

Table 3.1: Summary of self-report instruments measuring motivation for substance abuse treatment ……………………...

57

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Table 3.2: Summary of selected studies on motivation for substance abuse treatment ……….

64

Table 3.3: Summary of selected studies on family and peer factors in substance abuse behavior change process …………….

71

Table 4.1: Summary of control measures …………..

96

Table 4.2: Reliability coefficients and descriptive characteristics of family substance abuse, and conflict and cohesion with family and peers composites ………...

99

Table 4.3: Pearson correlations of family substance abuse, family and peer conflict and cohesion items and composite scores with Problem Recognition (PR) and Desire for Help (DH) ………………..

101

Table 4.4: Summary of social relations measures …. 104 Table 4.5: Descriptive statistics, item-total correlations, and coefficient alphas of TCU Problem Recognition and Desire for Help scales ……………………… Table 5.1: Descriptive statistics for control variables vii

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106 112

viii

List of Tables and Figures

Table 5.2: Descriptive statistics for social relations variables ……………………………..

113

Table 5.3: Pearson correlations of independent variables with Problem Recognition (PR) and Desire for Help (DH) ……... 116 Table 5.4: Hierarchical multiple regression results predicting Problem Recognition scores 121 125

Table 5.6. Final models of hierarchical multiple regression analyses predicting Problem Recognition (PR) and Desire for Help (DH) scores solely with social relations variables …………………...

128

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Table 5.5. Hierarchical multiple regression results predicting Desire for Help scores …...

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ACKNOWLEDGMENTS This book is based on study supported by Grant R01 DA11309 from the National Institute on Drug Abuse (NIDA); Carl G. Leukefeld, Principal Investigator; and by the staff and resources of the Center on Drug and Alcohol Research (CDAR) at the University of Kentucky. Opinions expressed in the book are those of the author and do not represent the position of NIDA or CDAR. I feel fortunate to have had the support and indebted for the good will I enjoyed and assistance I received from several people at the University of Kentucky. First, James Clark, Ph.D. read and proofread drafts of each chapter of this book, provided intellectually stimulating comments and conceptual advice. Dr. Clark’s thinking about treatment for mental health and substance abuse problems in criminal justice settings guided my development of ideas for this study. Next, I wish to thank Ginny Sprang, Ph.D., Annatjie Faul, Ph.D., Carl Leukefeld, Ph.D., Matthew Hiller, Ph.D., and Linda Jouridine Alexander, Ph.D. Each individual reviewed drafts of this book and provided insights that improved the finished product. I am especially grateful to Dr. Leukefeld, Professor and Director, Center on Drug and Alcohol Research and Department of Behavioral Science, for making available the data analyzed in this book, and would like to thank the Health Services Team at the Center on Dug and Alcohol Research for collecting the data, helping me learn the details, and providing stimulating and supportive environment. Special thanks to Dr. Hiller for daily support, methodological advice, and reliable friendship. Finally, I wish to thank the anonymous respondents of the study for sharing a wealth of personal information and making this project possible.

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CHAPTER 1

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Introduction

Substance abuse and addiction have impacted the criminal justice system in profound ways during the last two decades. Due to the enforcement of anti-drug laws, there was an influx of alcohol and/or drug-involved offenders into the system. In 1999, on average 79% of arrestees in U.S. tested positive for an illegal drug, had used illegal drugs recently, had histories of drug dependence or treatment, or were in need for treatment at the time of their arrest (Belenko, 2001). In a 2004 survey by the Bureau of Justice 69% of State prisoners reported regularly using drugs, while nearly a third (32%) committed their offence under the influence of drugs (Mumola & Karberg, 2006). In an effort to reduce criminal recidivism, prisons became one of the major providers of substance abuse treatment. In 2004, over a third of State prisoners (40%) had participated in treatment or other programs to address substance abuse problems since their admission to prison (Mumola & Karberg, 2006). In addition to crime-associated costs, negative health consequences of illicit drug use, such as cardiovascular complications and infectious diseases, increase the likelihood of the need for health care and pose a burden for community and criminal justice health care resources (Chitwood, McBride, French, & Comerford, 1999; Garitty, Hiller, Staton, Webster, & Leukefeld, 2002). Moreover, substance abusing offenders reentering the community may adversely affect the community’s public health due to the 1

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Social Relations and Motivation for Treatment

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increased risk for infectious diseases, including HIV, hepatitis C, and other chronic illnesses (Wexler & Fletcher, 2007). Therefore, prison-based treatment for substance abuse problems is important not only as a recidivism reduction effort, but also as a preventive public health measure. MOTIVATION AND CHANGE PROCESS OUTCOMES Substance abuse behavior change and recovery are complicated by the chronic and relapsing nature of the drug and alcohol abuse disorders (Leukefeld, Pickens, & Schuster, 1992; Leukefeld & Walker, 1998). Substance abuse treatment clients tend to have a history of multiple treatment experiences in more than one type of program prior to recovery (Leukefeld & Tims, 1988), suggesting that substance abuse behavior change is a lengthy, complex, and demanding process. Conceptualizing the change process in discrete stages – e.g. recognition of having a substance abuse problem, desire for help, readiness for entering treatment, engagement in treatment, and maintenance of outcomes – sharpens the focus on specialized intervention and evaluation strategies for each stage (Simpson, 2001). Motivational stages, specifically, problem recognition, desire for help, and treatment readiness, can mediate the outcomes of the change process. For example, low motivation may preclude change efforts altogether. Research findings indicate that motivation is a key factor in determining engagement in treatment (for overview see Simpson, 2001, 2004). Low motivation, however, is amenable to intervention, underscoring the importance of better understanding factors that affect client’s motivation for change. High attrition rates reported by all types of substance abuse treatment programs suggest that motivation for change and treatment is problematic (DiClemente, 1999). The level of motivation at the time of admission to treatment has been shown to predict dropout (Simpson &

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Introduction

3

Joe, 1993) as well as entry into post-prison aftercare (DeLeon, Melnick, Thomas, Kressel, & Wexler, 2000b). Regardless of the type of treatment, the length of time in treatment has been found to be consistently related to its effectiveness in reducing substance use and criminal behavior (Leukefeld & Tims, 1993) and maintaining behavior change for longer periods of time (Inciardi & Martin, 1997). These findings indicate that understanding factors affecting motivational stages of the substance abuse behavior change process is likely to contribute to the enhancement of engagement and retention in treatment and, subsequently, to short- and long-term treatment effects. The role of motivation for treatment in the case of criminal justice sanctions or coercion has been debated in the literature. The assumption is that external coercion might be less effective in engaging internal motivational processes, and thus less effective in facilitating a genuine behavior change. Moreover, clients with criminal justice referrals have been shown to score significantly lower in their recognition of substance abuse problems, desire for help, and treatment readiness (Farabee, Nelson, & Spence, 1993). However, the threat of criminal justice sanctions has been found to be related to treatment entry and retention in treatment for a sufficient period of time to initiate behaviorchange (Inciardi & Martin, 1993). Research findings also indicate that clients who enter treatment under coercion are more likely to comply with program requirements, to complete treatment, and to achieve more substantial behavior changes than clients with non-coercive referrals (Miller & Flaherty, 2000). These findings suggest that treatment and coercion interact, and that criminal justice settings can offer opportunities for assessing and treating drug-involved offenders, and initiating substance use behavior change (Inciardi & Martin, 1997; Leukefeld & Tims, 1993). Therefore, understanding factors affecting motivation for change in criminal justice clients is important, in order to maximize the effectiveness of clients’ participation in treatment programs.

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Social Relations and Motivation for Treatment

Motivation for substance abuse behavior change is even more complicated in the case of incarceration. The coercive nature of imprisonment might seem to preclude any voluntary decision or action, including treatment seeking. Moreover, the deprivations of imprisonment and the antisocial inmate culture, permeated with anxiety, secrecy, and alienation, create conditions that are not conducive to positive change (Toch, 1975; Wexler, 1994). Empirical findings indicate that assimilation to the inmate culture or prisonization is associated with reduced likelihood of entry into prison-based substance abuse treatment programs (Peat & Winfree, 1992). However, despite the isolation of prison environment, extra-prison contacts and relationships, as well as pre-prison socialization experiences, appear to affect inmates’ prisonization, post-release expectations, and, in turn, the likelihood of entry into re-socialization programs, such as substance abuse treatment (Lawson, Segrin, & Ward, 1996; Thomas, Peterson, & Zingraff, 1978; Zingraff, 1975). These findings suggest that study of extra-prison factors in the process of substance abuse behavior change among incarcerated individuals is warranted. Identifying and understanding factors that affect inmates’ progress through the change process prior to entering treatment might contribute to the design of effective motivational enhancement interventions, and, subsequently, such interventions might increase the likelihood of treatment engagement and the achievement of more durable substance abuse behavior change. APPROACHES TO STUDY OF MOTIVATION FOR CHANGE Over the last three decades, large scale research programs were conducted in the United Sates to evaluate the effectiveness of the national substance abuse treatment system including the Drug Abuse Reporting Program (DARP), Treatment Outcome Prospective Study (TOPS), Drug Abuse Treatment Outcome Studies (DATOS), and Improving Drug Abuse Treatment and Assessment

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Research (DATAR), for overview see Simpson (2001, 2004). Although these studies focused primarily on the effects of treatment characteristics on treatment outcomes, they also demonstrated that what patients bring into treatment (e.g. individual needs, motivation, social pressures) is no less important than aspects of the treatment program itself (Simpson, 2001). Various substance abuse behavior change process models attempt to incorporate extra-treatment elements to various extents and to describe their effects in sequential stages. The process of behavior change has been conceptualized in several stage models, with the Transtheoretical model (Prochaska, DiClemete, & Norcross, 1992) as especially influential for substance abuse research. However, its empirical validation, especially regarding pre-action or motivational stages, is not without problems (Carey, Prunine, Maisto, & Carey, 1999). The Texas Christian University (TCU) model (Simpson & Joe, 1993), empirically derived from Circumstances, Motivation, Readiness, and Suitability (CMRS) scales (DeLeon & Jainchill, 1986) and conceptually placed in the context of the Transtheoretical model, yielded a psychometrically sound motivational assessment instrument that was used in DATOS and DATAR (e.g., Joe, Simpson, & Broome, 1999). The TCU model focuses on pre-treatment stages of change, and includes scales of problem recognition, desire for help, and treatment readiness (Simpson & Joe, 1993). This model yielded a body of research that focused on motivation for treatment and readiness to change, therapeutic engagement, and the impact of these processes on treatment outcomes. The problem recognition and desire for help scales are applicable with treatment as well as non-treatment populations and, thus, allow a comparison of findings across various samples.

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Social Relations and Motivation for Treatment

Internal versus External Factors Motivation for substance abuse behavior change has been primarily conceptualized as an internal attribute of a person. The majority of the assessment instruments, including TCU scales, operationalize motivation primarily as an internal state (e.g., URICA, McConnoughy, DiClemente, Prochaska, & Velicer, 1998; SOCRATES, Miller & Tonigan, 1996; RTCQ, Rollnick, Heather, Gold, & Hall, 1992). This is despite the historical recognition of the role of external motivation in substance abuse treatment entry and retention in federal and state level civil commitment programs (Leukefeld & Tims, 1988), as well as more recent substantial proportion of criminal justice referrals in community-based treatment programs (Anglin, Prendergast, & Farabee, 1998). Research findings indicate that motivation might be an interplay of the impact of several interrelated client and environmental factors, in addition to the impact of therapeutic interventions (e.g., Broome, Knight, Knight, Hiller, & Simpson, 1997; DeLeon & Jainchill, 1986; Downey, Rosengren & Donovan, 2000). External factors, such as legal sanctions or family pressure, can facilitate progress through the behavior change process, and engage internal motivational processes necessary to maintain a stable, long-term recovery (DiClemente, 1999; Leukefeld & Tims, 1988). Nevertheless, few studies on motivation for change and substance abuse treatment explored variables from both internal and external domains and/or their interactional effects. Social Factors The research on motivation to change one’s substance abuse behavior has focused primarily on its effects on treatment engagement, retention, and outcomes (e.g., Hiller, Knight, Leukefeld, Simpson, 2002; Joe, Simpson, & Broome, 1998; Melnick, DeLeon, Thomas, Kressel, & Wexler, 2001). Considerably less attention has been paid to factors that might affect motivation for change itself. This is particularly true in regards to social factors. In their

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Introduction

7

review of research on motivation for substance abuse behavior change, DeLeon and associates (2000a) concluded that:

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The understanding of the personal and social factors, such as the influence of past and present relationships that affect the development and maintenance of motivation and the utilization of the motivational variable to facilitate treatment, and the continuing influence of motivation on the treatment process remain the challenge for future research (p.122-123). Studies on social factors in substance abuse behavior change process focus primarily on legal pressure variables that consistently emerge as significant predictors of treatment entry, retention and outcomes (e.g., Inciardi & Martin, 1993, 1997; Farabee, Prendergast, & Anglin, 1998a; for reviews see Leukefeld & Tims, 1988; Miller & Flaherty, 2000). Studies on non-legal pressures are limited and less conclusive. Findings of several studies suggested that family and job pressures can effectively influence treatment-seeking and retention (see DeLeon, Melnick, & Hawke, 2000a for review). Additionally, experiencing social pressures (such as pressure from family and friends), having more social resources (such as being married and employed), having financial resources, and being involved in larger social networks, seem to be associated with treatment entry (see Tsogia, Copello, & Oxford, 2001 for review). Thus, empirical findings document the social nature of seeking help for substance abuse. Nevertheless, variables influencing help-seeking processes might not be wholly redundant with those influencing the addictive behavior change process in general, and its motivational stages specifically (Tucker & King, 1999). Therefore, further research exploring social factors in motivational stages of change process is important.

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Social Relations and Motivation for Treatment

When non-legal social factors in substance abuse behavior change process are explored, it is often in the context of treatment process and outcomes studies. The TCU and the Center for Therapeutic Community Research (CTCR) have ongoing research programs that systematically study the contribution of motivation to treatment retention, outcomes and process in methadone maintenance and therapeutic communities (DeLeon, Melnick & Tims, 2001). CTCR included external motivation scale in their instrument (CMRS, DeLeon & Jainchill, 1986) and explored social processes within the therapeutic community programs. While TCU studies yielded some findings on the effects of social factors external to treatment programs on treatment process, including motivational variables, and treatment outcomes. Family and peer relations variables, such as the degree of family and peer deviance and the level of family dysfunction, alongside with motivation for treatment, emerge as significant predictors of treatment progress and outcomes (e.g., Broome et al., 1997; Simpson & Joe, 1993). Thus, social relations and their characteristics appear to be important factors to include when exploring social factors in the substance abuse behavior change process. Although social relations and motivation variables each have been found to predict substance abuse treatment engagement and outcomes, few attempts have been made to investigate the relationship between the two. Some evidence suggests an indirect relationship of family dysfunction and peer deviance with problem recognition, desire for help, and treatment readiness (Griffith, Knight, Joe, & Simpson, 1998). Conversely, other findings indicate that motivational variables might be mediating the relationship between social relations and treatment process variables (Broome et al., 1997). A direct relationship of higher levels of family and peer deviance and dysfunction with problem recognition, desire for help and treatment readiness was observed in adolescent and adult samples (Broome et al., 2001; Simpson & Joe, 1993, respectively).

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Introduction

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Thus, empirical findings indicate that social relations might be playing an important part in motivation for treatment and that this relationship might affect treatment process and outcomes. Limitations of Studies on Social Relations and Motivation for Substance Abuse Behavior Change A striking limitation of studies on social relations and motivational variables in substance abuse behavior change process is the almost exclusive use of treatment samples (e.g., Broome et al, 1997, 2001; Griffith et al., 1998; Simpson & Joe, 1993). This type of sample might influence results because of possible treatment effects on motivation (DeLeon et al., 2000a) and interpersonal relationships (e.g., Gibson, Sorensen, Wermuth, & Bernal, 1992; Knight, Wallace, Joe, & Logan, 2001). Therefore, it is important to test how family and peer relations affect motivation for substance abuse behavior change with non-treatment samples. An additional limitation of the aforementioned studies is that they explored family relations in general, as a composite variable (e.g., Broome et al., 1997; Griffith et al., 1998; Simpson & Joe, 1993). Although this strategy added power to the analyses by reducing the number of variables, it also might have obscured the results regarding different types of family relationships and their effects on motivation for change. It might be important to differentiate among parental, spousal, siblings and peer relations when exploring socialization effects on adult substance abuser’s motivation for change, because they might affect substance abuse behavior change process in a different pattern. In sum, empirical findings support the connection between family and peer functioning and substance abuse behavior change, but further research is needed to tap into the complex nature of these relationships, and to understand how it affects motivational stages of change.

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APPLICATION OF PRIMARY SOCIALIZATION THEORY FOR STUDY OF MOTIVATION FOR SUBSTANCE ABUSE BEHAVIOR CHANGE Prior research on social relations effects on substance abuse behavior change process was guided primarily by empirical data rather than theory (e.g., Simpson & Joe, 1993; Broome et al., 1997; for exception see Downey et al., 2000). Empirical data indicate that family and peer factors may play a role in substance abuse behavior change. Specifically, TCU studies indicated that peer deviance, peer relations problems, family dysfunction, family conflict, and family cohesion are likely to affect problem recognition, desire for help, and readiness for treatment (Broome et al, 1997, 2001; Griffith et al., 1998; Simpson & Joe, 1993). The findings were usually interpreted in the context of Prochaska and associates’ (1992) Transtheoretical model of change or problem severity hypothesis. Researchers proposed that the association of higher peer deviance and family dysfunction with higher motivational levels represent movement beyond the precontemplation stage, i.e. clients’ recognition of their substance use related problems (e.g., Griffith et al., 1998). In another study, researchers suggested that prolonged association with deviant peers might result in negative experiences, increasing problem severity and, subsequently, readiness for treatment (Broome et al., 2001). Although primary socialization theory was not applied in TCU studies, it is arguably consistent with their research findings in identifying specific social relations variables that might impact substance abuse behavior change. Primary socialization theory emphasizes the transmission of societal norms, both pro-social and deviant, within three main types of primary socialization sources: family, school/work, and peer clusters (Oetting et al., 1998b). A central premise of the theory is that the quality of the relationships, as indicated by conflict and cohesion between socializee and primary socialization sources, is a major factor in determining socialization outcomes

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Introduction

11

(Oetting, 1999). According to the theory, substance use is learned in the context of primary socialization sources; therefore, a change in primary socialization patterns is required for the behavior change to occur and be maintained (Oetting, 1999). Hence, it is important to evaluate the level of deviancy of client’s family and peers, as well as levels of conflict and cohesion a client experiences in family, school/work, and peer relationships, because these variables are likely to affect substance abuse behavior change process. These conceptual relationships are consistent with empirical findings suggesting that, along with motivational variables, family and peer deviance, conflict and cohesion can predict substance abuse treatment progress and outcomes (e.g., Broome et al., 1997, 2001; Constantini et al., 1992; Griffith et al., 1998; Simpson & Joe, 1993). Primary socialization theory can be used along with prior empirical findings to identify variables in the social domain that could be relevant to the understanding of problem recognition and desire for help. For example, problem recognition and desire for help can be conceptualized as being, in part, outcomes of socialization processes. This conceptualization is based in the understanding that social relations variables contribute to motivation for substance abuse behavior change, that social relations are part of socialization sources, which communicate norms, values, and behavioral expectations, and in the context of which behavior change processes occur. This is consistent with conceptualization of problem recognition and desire for help as including both internal processes, such as realization of dangers to one’s health and life, and external processes such as feedback from social environment (TCU scales, Simpson & Joe, 1993). Primary socialization theory is nested within learning theories of socialization (Leukefeld & Leukefeld, 1999). It includes sociological and psychological concepts of learning and socialization, as it focuses on both learning social norms and learning patterns of behavior (Gecas, 2000). The theory applies these broader concepts in its

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Social Relations and Motivation for Treatment

analysis of the etiology of substance use and criminal behavior. With its heavier emphasis on socialization processes in childhood and adolescence rather than adulthood (Oetting, 1999), the primary socialization theory represents somewhat deterministic view of socialization and human development. However, it delineates normative and deviant socialization paths that continue into adulthood, and offers insights about substance abuse behavior change process (Oetting, 1999; Oetting et al., 1998b). Primary socialization theory is a large-scale theory that describes and explains relationships among different etiological domains, such as individual, immediate environment, and broader social context, as well as their interactional effects on substance use (Oetting, 1999). Its explicit inclusion of government institutions, such as the criminal justice system, as socialization sources that influence individuals’ substance use (Leukefeld & Leukefeld, 1999; Oetting, 1999) makes it applicable for research with prison-based samples. This theory is compatible with the bio/psycho/social/spiritual practice model that has been used by substance abuse treatment practitioners (Leukefeld & Leukefeld, 1999), as well as the ecological perspective of human behavior and change widely accepted by social work practitioners (Germain, 1979; Kemp, Whittaker, & Tracy, 1997). Moreover, primary socialization theory encompasses constructs from a variety of disciplines, and has the potential to include multiple domain-specific theories (Oetting, 1999). Therefore, it can provide a basis for integration of multiple narrower concepts explored in empirical research. Primary socialization theory’s perspective of change is compatible with assertion that individual intentions and behaviors, such as substance abuse and recovery, occur in the context of social environment, and thus, successful strategies for change should be integrated within social structures, including family and other institutions (Schiling & El-Bassel, 1998). Primary socialization theory, therefore,

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Introduction

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could inform behavioral research with a focus on the interaction between individual and social-environmental level factors, as well as the integration of the disparate factors into a systemic whole. In sum, it would require a major scope study, focused on the transmission of social norms per se, to test primary socialization theory directly. However, even without such a study, primary socialization theory can inform research on motivation for substance abuse behavior change, as it can help identify the variables of interest in the study of problem recognition and desire for help, particularly among criminally involved clients. Concurrently with the empirical findings by TCU research group, primary socialization theory suggests that family and peer history of substance abuse, and quality of the relationships with these socialization sources, as indicated by reported conflict and cohesiveness are important variables to explore in the study of substance abuse behavior change process. CONCEPTUAL MODEL OF SOCIAL RELATIONS EFFECTS ON PROBLEM RECOGNITION AND DESIRE FOR HELP Empirical research findings and primary socialization theory suggest that family and peer relations are major sources of influence on one’s substance abuse behavior. The level of deviancy of these sources, as indicated by substance use history, and quality of the relationships, as indicated by conflict and cohesion, influence the effect these relationships might have on one’s behavior. The conceptual model of social relations effects on motivation for change, graphically presented in Figure 1.1 (p.12), integrates the assumptions of primary socialization theory with empirical research findings. Parental, sibling, sexual partner, and peer effects are distinguished in the model, to emphasize the possibility of unique contributions of these variables to problem recognition and desire for help.

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Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Cohesion with primary socialization sources:

Conflict with primary socialization sources:

Deviance of primary socialization sources:

Cohesion with parents Cohesion with siblings Cohesion with sex partner Cohesion with peers

Conflict with parents Conflict with siblings Conflict with sex partner Conflict with peers

Parental substance abuse Sibling substance abuse Living with substance abuser

Control variables: Sociodemographics Substance use history Health history Treatment history Criminal history

Problem Recognition and Desire for Help

Figure 1.1. Social relations effects on problem recognition and desire for help: The conceptual model.

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Introduction

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The primary variables of interest in this model are those that pertain to deviance of and conflict and cohesion with primary socialization sources. Substance abuse by parents and siblings, and living with someone who abuses substances are conceptualized as indicators of deviance of primary socialization sources. Serious problems in getting along with parents, siblings, sexual partner or spouse, and peers are included as separate variables that belong to the same broad concept of conflict with primary socialization sources. Similarly, close, enduring relationships with parents, siblings, sexual partner or spouse, and peers are conceptualized as indicators of cohesion with primary socialization sources. Personal background characteristics or control variables include socio-demographics, substance use history, health history, treatment history, and criminal history - all of which have been consistently shown to have a significant effect on substance abuse behavior change process, in general, and motivation for change, specifically (e.g., DeLeon & Jainchill, 1986; McLellan et al., 1992; Joe et al., 1998). The inclusion of individual level control variables in the model points out that the contribution of social relations factors to the explanation of problem recognition and desire for help is additional to these previously acknowledged individual level factors. Hypothesizing about the direction of the relationship between social relations and motivation variables is not straightforward. Although prior research findings and primary socialization theory point to the same variables of interest, they diverge on the direction of the influence that deviance and conflict characterizing one’s social relations might have on motivational stages of substance abuse behavior change process. According to the primary socialization theory, having deviant primary socialization sources might be expected to predict lower problem recognition and desire for help, than having normative socialization sources. Similarly, conflict with primary socialization sources is conceptualized as indicating less pro-social orientation, and, therefore, lower motivational levels. However, empirical findings indicate that family

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Social Relations and Motivation for Treatment

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and peer deviance might be associated with higher treatment readiness (Broome et al., 2001), and that family and peer relations problems might be related to higher problem recognition and desire for help (Simpson & Joe, 1993). In addition, according to the theory, cohesion with social relations might be expected to predict higher levels of problem recognition and desire for change. However, this variable has not been typically explored in studies on motivation for change, and there is a lack of significant empirical findings regarding its effects (e.g., Broome et al., 1997). Therefore, due to the inconsistency between theoretical notions and empirical findings, and lack of sufficient prior empirical data, the direction of the relationships of deviance, conflict and cohesion items with problem recognition and desire for help is not specified in the conceptual model. SUMMARY With an influx of drug-involved offenders into the criminal justice system, prisons became one of the major providers of substance abuse treatment, increasing the need to better understand factors influencing substance abuse behavior change process among inmates, especially motivational factors, in order to facilitate their participation in treatment programs. Empirical evidence suggests that motivation for change and readiness for substance abuse treatment might be a result of interplay between internal/individual and external/social factors (e.g., Broome, Knight, Knight, Hiller, & Simpson, 1997; DeLeon & Jainchill, 1986; Downey, Rosengren & Donovan, 2000). Even in the context of the isolation of prison environment, extra-prison contacts and relationships, as well as pre-prison socialization experiences, seem to affect inmates’ likelihood of entry into re-socialization programs, such as substance abuse treatment (Lawson, Segrin, & Ward, 1996; Thomas, Peterson, & Zingraff, 1978; Zingraff, 1975). However, only a few studies on motivation to change

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Introduction

17

substance abuse behavior explored variables from the social domain. Among non-legal social factors in substance abuse behavior change process, family and peer relations emerge as important predictors of treatment process and outcomes alongside with motivational variables (Broome et al., 1997; Simpson & Joe, 1993). However, few attempts have been made to investigate the relationship between social relations and motivation. Some evidence suggests that family and peer deviance, and family dysfunction are related to problem recognition, desire for help, and treatment readiness (Broome et al., 2001; Griffith et al., 1998; Simpson & Joe, 1993). The studies usually tested models based on empirical data, and findings were interpreted in the context of Transtheoretical model or problem severity hypothesis. The study described in the present book applies primary socialization theory to assist in identification of variables of interest. The theory focuses on how the characteristics of primary socialization sources, such as their deviance, and the quality of the relationships with family, school/work, and peers, as indicated by conflict and cohesion, affect the transmission of pro-social and deviant societal norms (Oetting, 1999). It suggests that successful strategies of change need to be integrated within individual’s social environment and include change in primary socialization sources. Thus, empirical findings and primary socialization theory indicate that it is important to study the impact of family and peer deviance, as well as the effects of conflict and cohesion one experiences in family and peer relations on substance abuse behavior change process. In conclusion, research on social factors in motivation for substance abuse behavior change needs to take into account the broader life experiences of the addicted person. The need for exploring primary socialization relationships, including history and characteristics of these relationships, is supported by conceptual and empirical literature. The purpose of this study, therefore, is to examine the effects that history of primary socialization relationships, such as

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family and peer deviance, conflict and cohesion, have on problem recognition and desire for help – the motivational variables of substance abuse behavior change process – in a sample of incarcerated chronic substance abusers. This study adds to the current literature by examining the unique contribution of parental, sibling, sexual partner, and peer effects to problem recognition and desire for help. In addition, the measures of social relations and motivational variables used in this study are the same or similar to ones used in prior research, increasing the comparability of findings and, thus, contributing to the building of the knowledge base.

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CHAPTER 2

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Socialization and Substance Abuse Behavior Change Process

Socialization perspective places the process of substance use behavior change, in general, and motivation for substance abuse treatment, specifically, in the context of societal continuity as well as individual development and learning through lifetime issues. The role of internal motives and external control in socialization process pertains directly to the role of internal and external motivational processes in substance abuse behavior change. In the case of imprisonment, the interplay between intraand extra-prison factors becomes part of the internal and external motivational dynamics and readiness for substance abuse treatment. DEFINITIONS OF SOCIALIZATION In the most general terms, socialization can be defined as a process through which an individual acquires the norms, values, beliefs, attitudes and communication characteristics of his or her group. (Gecas, 2000). It has been defined as a process of becoming a social being and an effective participant in society (Clausen, 1968), acquiring social and psychological identity (Wilson & Sonnad, 2001); and a 19

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process which aims to give a person knowledge, ability, and motivation to perform in social roles (Brim, 1966). Various social science disciplines and different perspectives within these disciplines highlight various aspects of socialization process. For example, anthropology is primarily interested in socialization as cultural transmission through generations. Psychology emphasizes aspects of individual development, learning patterns of behavior, and establishment of character traits, while sociology studies the learning of social norms and roles, identity development in the context of social influences, and social control issues (Gecas, 2000). The structuralfunctionalist perspective defines socialization primarily as learning of social roles. The positivist perspective is interested in the mechanics of the process in terms of stimuli-response patterns. Symbolic interactionism regards socialization mainly as self and identity formation in the context of reciprocal relations. Social constructionist theories define socialization as collective and interpretive process of reality construction (Goslin, 1969; Gecas, 2000). Theoretical perspectives define socialization differently in terms of the importance of early versus later influences on behavior and personality, individual as active versus passive participant in the socialization process, and emphasis on process versus content of the socialization experience (Goslin, 1969). The functionalist/ deterministic perspective focuses on the individual as responding to the socialization process. Alternatively, the constructivist perspective views the socializee as an active participant in the process, making conscious choices, and influencing the socialization process (Goslin, 1969; Gecas, 2000, Wilson & Sonnad, 2001). Deterministic theories maintain that individual self and personality are primarily shaped during early childhood, while constructivist theories argue for change across situations and over the lifespan. However, more contemporary socialization theories hold somewhat intermediate position maintaining that core personality develops in early socialization experiences, while other characteristics are added to self though the acquisition of

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new roles, identities and socializing experiences (Gecas, 2000). Socialization versus learning and other differentiating concepts It is important to distinguish socialization from learning processes. Learning theories define socialization as a process of learning the culture through drive, cue, stimuli, response, and reward patterns. These theories focus primarily on the individual’s learning of developmentally appropriate roles. Clausen (1968) maintains that, by definition, socialization entails learning, as contrasted with maturation or the unfolding of individual potentialities. However, not all learning is considered socialization. One position maintains that only learning that has clear implications for future role performance is relevant to socialization (Clausen, 1968). Others view the process of learning rules, norms, and behavior as socialization only to the extent to which these things become part of the way people think of themselves (Gecas, 2000). Thus, while socialization entails learning, the study of learning comprises a different field of investigation. Clausen (1968) also differentiates socialization from social control, social influence, and social conformity. Socialization as a process of transmission of social norms provides an underlying basis for, but is not equivalent to, social control. It also differs from social influence, because socialization includes unwitting influences, and does not focus on the study of modes of influence. Socialization is not the same as social conformity, because social deviance may be a consequence of socialization to deviant norms or a breakdown in a normative socialization process. Primary and secondary socialization processes One of the more important characteristics of socialization is its continuity through a lifetime. Different mechanisms of the socialization process apply in childhood and in adult socialization. The term of primary socialization usually

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refers to the early childhood experiences in the context of family, with parents acting as primary socialization agents (Gecas, 2000). Other important contexts and agents of childhood socialization are school, peer group, media, and religion (Gecas, 2000; Wilsom & Sonnad, 2001). Theories of childhood socialization are frequently situated within the developmental perspective of socialization process. Adult socialization is usually referred to as secondary, because adults bring behavioral, attitudinal, and personality predispositions to the socialization process (Goslin, 1969; Gecas, 2000). It is viewed as much more role-specific, and occurring mainly in the context of newly created family and work (Gecas, 2000). Related to role socialization is the concept of anticipatory socialization. This refers to behavior change prior to entry into the role to attune one’s behavior with social expectations and avoid role incompatibility (Yamaguchi, 1990). Relinquishing roles is as important in socialization during a life-course as learning new roles, but it is a far less understood process (Goslin, 1969). Also, a related concept, resocialization, is a more radical change in the person in the context of mental hospitals, prisons, and therapy programs; resocialization includes replacement of previous set of beliefs and values, and conceptions of the self, with a new set grounded in the socializing group’s ideology (Gecas, 2000). Internal and external socialization processes Related to the distinction between socialization in childhood as primary and socialization during adulthood as secondary is the distinction between internal motives and external control in the socialization process. In early life socialization emphasizes the external control of primary drives to facilitate normative behavior, while socialization in later life deals with secondary or learned motives generated by the internalized expectations of significant others (Brim, 1966). In other words, socialization after childhood deals more with overt behavior in specific roles, and less with influencing motivation of a fundamental kind

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or basic values (Brim, 1966). As individuals get older, an increasing proportion of their behavior may be assumed to be governed by internalized control, as the socializing group’s values become the individual’s values or at least are recognized by him or her as having legitimacy (Clausen, 1968; Goslin, 1969). In sum, one of the primary goals of the socialization process is moving from external control over one’s drives and motives towards internalized dispositions. However, some level of external control might be needed to trigger the internal one. Various theoretical perspectives converge on the importance of symbolic/cognitive processes as mediating in the interface of the individual and the social environment factors, or the internal and external processes involved in socialization (Goslin, 1969). Summary Socialization is a broad concept pertaining to a process that addresses societal continuity as well as individual development and learning through lifetime issues. Its definition varies across disciplines and theoretical perspectives, and includes the transmission of values and norms, intergenerational transmission of culture, development of individual and social identity, role learning, etc. Definitions vary in their emphasis on primary or secondary, and internal or external socialization processes. In adult socialization, internalized predispositions formed during lasting relationships with significant others become more influential than external control of primary drives. Most often, the term socialization refers to a general area of interest, not a sharply definable process (Clausen, 1968). More specific definitions come to use in specific domains of interest, such as socialization to a particular group, role or behavior.

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PRIMARY SOCIALIZATION THEORY OF SUBSTANCE USE One of the multiple explanations of substance use is grounded in the view that various forms of substance use are “patterns of learned behavior that are congenial to people sharing certain values and views of society and of themselves” (Clausen, 1976), i.e., that substance use is a result of socialization experiences. According to this view, group memberships and identifications are more important as explanations of substance use than personality factors or the mere availability of drugs. Thus, the function of substance use for the individual depends on both one’s personal history and the way substance use is defined in those groups that mean most to the individual, i.e., groups that are most influential in value transmission (Clausen, 1976). In primary socialization theory these groups are referred to as primary socialization sources. Primary socialization theory emphasizes social/environmental influences on substance use. Its goal is to provide an integrative framework that describes how personal characteristics and social systems interact to produce deviant behavior (Oetting & Donnenmeyer, 1998). The theory describes and explains relationships among different etiological domains, such as individual, immediate environment, and broader social contexts, as well as interactional effects of these domains on substance use (Oetting, 1999). Primary socialization theory is rooted in psychosocial theories of substance use. These theories have an advantage over disease-addiction, gateway, psychological, social and political theories of substance use in that they take into account both the characteristics of a person and the social environment (Oetting & Beauvais, 1986). The assumptions of primary socialization theory are grounded in the social learning theory (Oetting, Donnermeyer, & Deffenbacher, 1998a). Its central premise is that social behaviors and norms, pro-social as well as deviant ones, are learned through interaction with primary socialization sources,

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such as family, school, and peer clusters. Secondary socialization sources, such as extended family, community, religious institutions, associational groups, government institutions, and media, shape behavior through their influence on the primary socialization process (Oetting, 1999). According to primary socialization theory, primary socialization is not just a matter of early childhood, but occurrs throughout the life-span with primary socialization sources changing according to the developmental stage and life situation. Family is primary during preschool years; family and school are primary during grade school years; and peers achieve their highest level of influence during adolescence (Oetting, 1999). In adulthood, marriage, new family systems, new peer clusters, and work become major socialization sources. An alternative path for the young adult includes continuing or intensified association with deviant peers, such as street gangs, and subsequently higher likelihood of substance use (Oetting, 1999). In general, primary socialization theory delineates three paths to socialization. First, socialization in the context of strong, cohesive relationships with normative primary socialization sources leads to transmission of pro-social norms. Second, lack of relationships or conflict with normative primary socialization sources increases susceptibility to deviant influences. And third, strong relationships with dysfunctional or deviant primary socialization sources lead to transmission of deviant norms (Oetting, 1999). The term “relationships” is applied here to substitute for the term “bonding” originally used by Oetting and associates in describing primary socialization paths. The concept of bonding in the context of primary socialization theory is yet to be explicitly defined. Primary socialization theory applies the concept of bonding in a very broad way that includes the types of bonding such as parent-child attachment, family-child bonding, sense of belonging to and acceptance by a peer group, as well as identification with social institutions, such as school and work. The

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extent to which the immediate environment and/or larger social institutions meet the needs of the individuals and/or families depending on them determines individuals’ bonding with these environments and/or institutions. In the light of the above, it seems that using a more general term “relationships” does not reduce the explanatory value of the concept, while steering away from confusion with bonding and attachment theories that do not directly deal with primary socialization and/or substance use. Socialization and psychological predisposition to substance use Co-occurring mental health and substance abuse problems are a prevalent condition. Data from the National Comorbidity Survey indicated that 41-66% of individuals with lifetime addictive disorders also have a lifetime history of at least one other mental disorder (Kessler et al., 1996, as cited in Blanchard, 2000). In addition, the National Gains Center estimated that 5-13% of all state prisoners have co-occurring mental health and substance abuse problems (The Health Foundation of Greater Cincinnati, 2000). The main causal explanations of the relationships between the two types of conditions include the self-medication hypothesis, where the psychiatric condition is seen as primary and substance use is the person’s attempt to alleviate anxiety, depression, or stress. Alternatively, the person’s psychiatric symptomatology can be seen as caused by the substance use. Evidence indicates that these paths might vary across different psychiatric conditions as well as different substances of primary use (Blanchard, 2000). These complex interrelationships are likely to affect motivation for change of substance abuse behavior and readiness for treatment. Primary socialization theory views psychopathology as related to substance use “only when it creates problems in bonding with sources of pro-social norms or increases bonding with deviant socialization sources.” Moreover, it proposes that people who use susbstances to cope with

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emotional problems “learned through the primary socialization process, and did not start substance use simply because of their emotional problems” (Oetting, 1999, p. 972). Significant comorbidity between psychopathology and substance use is explained by the fact that many forms of psychopathology produce some deficits in the ability to relate to others, and thus lead to weakened relationships with primary socialization sources, such as family and school, increasing the likelihood of associations with deviant socialization sources, such as substance using peers (Oetting, Deffenbacher, & Donnermeyer, 1998b). Moreover, Oetting (1999) argues that the high incidence of substance use among adolescents with few emotional problems is an indicator that the socialization process, and not psychopathology, is of primary importance in substance use. A similar explanation is offered for the relationship between personal traits and substance use. According to primary socialization theory, personal characteristics and socialization interact, i.e. socialization can alter the expression of personal traits and these traits can alter the outcomes of socialization. Personal characteristics influence socialization outcomes only to the extent that they affect the relationships with primary socialization sources. In that sense their influence is secondary (Oetting, 1999). Thus, for example, it is not the tendency for sensation seeking per se, but sensation seeking in the context of being associated with other sensation seekers, that might lead to substance use (Donohew, Clayton, Skinner, & Colon, 1999; Oetting, 1999). Even though the need to engage in an exciting activity might be biologically based, activities which help to satisfy that need are learned from primary and secondary socialization sources (Donohew et al., 1999). This implies that the efforts to change substance use behavior should not only focus on changing the individual, but also on changing the socialization sources, and/or one’s choices of those sources.

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Substance use and family as primary socialization source According to primary socialization theory, family is one of the three major sources of socialization. Family is usually a source of pro-social norms if there are strong relationships between the family and the child, and if the family uses those relationships to communicate pro-social norms (Oetting & Donnermeyer, 1998). Strong relationships with a family that transmits pro-social norms increase the likelihood of strong bonds with the school, and, in turn, lead to associations with pro-social peer groups. Alternatively, weak relationships with family might lead to weak bonds with school, and increase the likelihood of associations with deviant peers. (Oetting & Donnermeyer, 1998; Oetting, 1999). Dysfunctional families, such as those with parents who are substance users or who engage in criminal activities, may directly transmit deviant norms by modeling or by teaching their children deviant behaviors (Oetting & Donnermeyer, 1998). However, primary socialization theory proposes that the most frequent path to the formation of deviant norms is not necessarily the direct transmission in the family, but occurs due to problems in relationships between parents and children, especially adolescents, which, in turn, increase the chances of associating with deviant peers who help initiate substance use (Oetting & Donnermeyer, 1998). Oetting and his associates do not distinguish between different family members or parental gender effects on transmission of norms in their formulations of primary socialization theory. However, some research findings indicate that the distinction between types of family members and their socialization effects on individual’s substance use might complement primary socialization theory. Nurco and Lerner (1999) present findings that point to the differences between mothers’ and fathers’ influences in the socialization process. They found that strong attachment to father or a surrogate father-figure during early teen age deterred addiction, possibly, due to pro-

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social norms transmission. However, attachment to mother or a surrogate mother-figure was not statistically significant predictor of later addiction, as it was almost equally very high among addicts and non-addict controls (Nurco & Lerner, 1999). Unfortunately, the effects that siblings might have on the transmission of pro-social or deviant norms within the family are not explored in more detail by Oetting and colleagues in their formulations of primary socialization theory. It is not clear conceptually whether the influence of siblings is similar to that of other family members, or whether it is similar to the influence of peers. In their cluster theory, Oetting and Beauvais (1986) list siblings as members of peer group, along with friends and acquaintances, that can provide substances and teach the young person how to use them. However, Kandel (1996) stresses one essential difference between family and peers: families are given, while, by and large, peers are chosen. Thus, in a sense, siblings could be considered as a peer group without selection effects. Several studies with adolescent samples confirm that sibling effects on one’s substance use are independent of parental effects (e.g., Brook, Whiteman, Gordon & Brook, 1990; McGue, Sharma, & Benson, 1996; Rowe & Gulley, 1992). Parent problem drinking and other family functioning variables have been found to have minimal effects on adolescent alcohol use compared to substantial sibling environmental effects (McGue et al., 1992). Moreover, having an older brother who did not use drugs was found to offset the negative effects of parental drug use risks on younger brother use (Brook et al., 1990). This effect was the strongest when combined with peers who did not use drugs (Brook et al., 1990). Emotional closeness between siblings and having mutual friends increased the likelihood of sibling influence on one’s substance use and delinquency (Rowe & Gulley, 1992). In sum, the above reviewed selected findings suggest that the familial influences on one’s substance abuse might be better

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understood when exploring parental and sibling effects separately. Substance use and peers as primary socialization source According to primary socialization theory, adolescence is the developmental stage when peers achieve their highest level of influence, and formation of norms occurs predominantly in peer clusters. Peer cluster is a smaller subset of a peer group and is characterized by strong bonds and cohesiveness of attitudes, social skills, interests and abilities among its members. It can consist of best friend dyads, small groups of close friends, or couples (Oetting & Donnermeyer, 1998). If siblings can be considered as a type of peers, then sibling pairs can be regarded as a special kind of peer cluster, within which learning of behaviors such as substance use might occur, most frequently via older sibling modeling (Needle, McCubbin, Wilson, & Reineck, 1986). In any case, adolescent substance use most often occurs in a peer context: peers not only support and model substance use, but also often provide substances (Oetting & Beauvais, 1986). The family and school are still important socialization sources as they affect peer selection process. Strong relationships between family and child, and family and school lead to the development of pro-social norms, which in turn increases the likelihood of close associations with peers who share those norms. Alternatively, when the family/child and family/school bonds are weak, primary socialization during adolescence may be dominated by peers (Oetting & Donnermeyer, 1998). However, the influence of peers can overwhelm family and school influences during this critical period of attitude formation towards substance use and deviance, sometimes even when there are good relationships with family and school (Oetting, 1999). For example, it has been found that use of alcohol and drugs by a parent increases the likelihood of an adolescent’s marijuana use when his or her friends use, but does not affect the probability of use if friends do not use (Kandel, 1973). Other studies have also

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indicated that family influences on drug use in adolescence might be mediated by or interrelated with peer socialization processes (e.g., Garnier & Stein, 2002; Mason & Windle, 2001; for review of earlier studies see Glynn, 1981). More recently, a meta-analysis suggested that, on average, peer effects on substance use was larger than the effect for parental influence among adolescents (Allen, Donohue, Griffin, Ryan, & Turner, 2003). Peer group pressure or beliefs and attitudes of intimate friends have been cited as one of the main causes for tobacco, alcohol, and other drug use among adolescents in US (Wilson & Sonnad, 2001). However, according to primary socialization theory by Oetting and associates, peer group influence does not necessarily reflect peer pressure. The dominant factor is the selection of peers with whom individual chooses to associate, with the most important and most influential ones constituting a peer cluster. Members of the peer cluster share pro- or anti-substance use beliefs and attitudes, and thus they mutually affect each other (Donohew et al., 1998; Oetting & Beauvais, 1986; Oetting & Beauvais, 1987). The emphasis of primary socialization theory on the primacy of peer group over other socialization sources in adolescence has been criticized. Whitbeck (1999) argues that the family shapes peer selection, and therefore family effects predominate over peer effects. Aseltine (1995) criticized studies such as that by Oetting and Beauvais (1987) as cross-sectional and relying upon youths’ perceptions of their friends’ behavior, both of which may exaggerate peer effects. Kandel’s (1996) critical review of research on parental and peer effects on adolescent deviance asserts that peer influences have been overstated due to inattention to the fact that families can be deviant and peers can be conforming, as well as due to inattention to indirect parent influence through peer selection. In addition, Kandel points out that while peers might be “more influential regarding deviant activities and immediate issues pertaining to lifestyles”, parents are

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“more influential regarding long term goals” (Kandel, 1996, p. 291). In sum, while there is a consensus regarding the importance of peers in shaping young persons’ attitudes and beliefs about substances as well as their actual substance use, the relative family and peer effect sizes remain controversial. Although the focus of investigations that explored family and peer factors was usually on adolescent substance use, such studies suggest a model for examining how these effects might extend into adulthood.

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Primary socialization in adulthood In adulthood, there are many and complex primary socialization patterns that can lead to either normative or deviant life-style. A young adult can form a new family, take a job, and create new associations with peers in similar life and work situations. New peer clusters and work may become major socialization sources. Or, alternatively, a young adult may remain identified with deviant a peer cluster formed during adolescence (Oetting, 1999). Among young adults, normative socialization patterns, such as getting married, having children, and holding jobs, reduce the likelihood of substance use (Kandel & Davies, 1989). On the other hand, continuous association with deviant peers such as street gang increases the likelihood of substance use (Oetting, 1999). There is also evidence that adult attachment style directly and indirectly influences frequency of use and choice of drugs among young adults (Kassel, Wardle & Roberts, 2007). Implications for substance use behavior change Oetting’s and colleagues’ formulations of primary socialization theory are mostly concerned with the etiology of substance use. However, some inferences about quitting substance use can be made. According to the primary socialization theory, behaviors are learned in the context of primary socialization sources. Thus, simply “unlearning” behaviors is not enough: some changes in primary

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socialization patterns that contributed to the deviant behavior must occur (Oetting, 1999). When an individual is not dependent on a substance, changes in primary socialization may be enough to lead to quitting the use (Oetting et al., 1998b). Examples of changes in primary socialization that can lead to decline in substance use or abstinence include graduating high school, getting married, and changing employment. Research findings point to fairly strong socialization effects of marriage on reducing or stopping the use of illicit drugs, including anticipatory socialization effects, when individuals change their drug use behavior even prior to getting married (Yamaguchi, 1990). Factors other than socialization enter into the process in cases of addiction or chronic substance use that had lead to physiological consequences. Such cases require detoxification prior to any other intervention (Oetting et al., 1998b). However, according to primary socialization theory, physical detoxification and changed attitudes about substance use are not enough. Establishment of new primary socialization sources or reinforcement of the existing relationships that support a non-substance-use lifestyle is essential to successful treatment. (Oetting et al., 1998b). Alcoholics Anonymous may serve as an example of such an approach: One of the reasons for the success of Alcoholics Anonymous may be a change in peer clusters. The treatment specifically requires other members to form bonds with new members, and the AA group itself provides a resource for establishing new peer clusters with strong sanctions against drinking. (Oetting, et al., 1998b, p. 1356) When people return to old peer clusters, substance use will very likely recur (Oetting et al., 1998b). Research findings point out that, in addition to maintaining substance abuse treatment effects, significant

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others, who may also be considered as primary socialization sources, are influential in initiating treatment and substance use behavior change. For example, pressure from a spouse or a parent was found to be associated with substance abuse treatment entry (Tsogia, Copello, Orford, 2001). Community reinforcement literature also points to the importance of significant others in substance abuse treatment entry and engagement (Meyers, Miller, Hill, & Tonigan, 1998). Moreover, Meyers and colleagues (1998) found that parents were significantly more successful in engaging an adult resistant drug user to enter treatment than were other significant others. Researchers explained their unexpected findings by stipulating that parents tend not to “divorce” their children and are less worried about possible retaliation through violence (Meyers et al, 1998). These findings are in support of primary socialization theory assumptions, and suggest that along with significant peers the family of origin remains an important socialization source that can influence individual’s substance use behavior throughout the lifespan. Critique of primary socialization theory One of the primary goals of the developers of primary socialization theory was to provide an integrative framework describing how personal, social, community, and cultural characteristics interact to produce and influence substance use and deviant behavior (Oetting & Donnenmeyer, 1998; Oetting, 1999). The theoretical model is circular, placing the individual at the center, with family, school, and peers surrounding the person as a circle. All of the outside circle components are in reciprocal relationships with an individual as well as with each other, without assigning primacy among the relationships. Unfortunately, such a general integrative framework might be less effective in specifying the relationships among the primary socialization sources as they affect an individual’s behavior and substance use. Moreover, some critics argue for a more linear model emphasizing that the effects of the

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family on school adjustment and peer associations predominate (Whitbeck, 1999). In addition, primary socialization processes in adulthood merit a more comprehensive study, as well as the impact of primary socialization processes on substance abuse behavior change. Little research has been done to test primary socialization theory. The developers of the theory reviewed prior research findings on individual-level and social-level correlates of substance use and found them generally consistent with its assumptions. Studies testing such a broad range theory that crosses over academic disciplines would be difficult, time consuming, and costly, but not impossible (Nurco & Lerner, 1999). Until such studies are conducted, the scientific validity of primary socialization theory remains inferential. Nevertheless, its conceptual insights and its hypotheses can contribute significantly to the study of etiology of deviant behavior, including substance use (Nurco & Lerner, 1999). Summary Primary socialization theory is a broad scale causative theory (Oetting, 1999; Nurco & Lerner, 1999). It combines sociological and psychological theories to enhance the thinking about causes of deviance and substance use (Oetting & Beauvais, 1986). Primary socialization theory, as formulated by Oetting and his colleagues, emphasizes the transmission of societal norms, both pro-social and deviant, within three major types of socialization sources: family, school/work, and peer clusters (Oetting et al., 1998b). A central premise of the theory is that the quality of the relationships between socializee and primary socialization sources is a major factor in determining socialization outcomes (Oetting, 1999). According to primary socialization theory, individuallevel factors, such as personality traits and psychopathology, influence development of deviance and substance use only to the extent that they affect the

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socialization process (Donohew et al., 1999). Family is usually seen as a source of pro-social norms, and the most frequent path to the formation of deviant norms is through peers (Oetting & Donnermeyer, 1998). The relative influence of family and peers, and the extent to which peer effects reflect socialization or parent mediated selection remain debated in the literature (Aseltine, 1995; Kandel, 1996). Additionally, empirical findings suggest that sibling effects on one’s substance abuse are independent of parental effects (Brooks et al., 1990; McGue et al., 1996; Rowe & Gulley, 1992). Although, the scientific validity of primary socialization theory remains to be systematically tested, it generates a number of interesting hypotheses regarding socialization effects on substance use and quitting (Nurco & Lerner, 1999). Most relevant for the present study are the implications of the theory for understanding substance abuse behavior change. Namely, the suggestion that substance use behaviors are learned in the context of primary socialization sources and, therefore, a change in primary socialization patterns is required for the behavior change to occur and be maintained (Oetting, 1999). INCARCERATION, SOCIALIZATION, AND BEHAVIOR CHANGE According to primary socialization theory, government institutions such as prisons are conceptualized as secondary socialization sources (Oetting, 1999; Leukefeld & Leukefeld, 1999). However, due to the relative isolation of prison inmates from the outside world, prison socialization that includes official institutional rules and norms, as well as inmate subculture norms and values, might be more powerful than the usually conceived indirect influence of a secondary socialization source. The prison encompasses almost all of the aspects of incarcerated individuals’ lives. Prison inmates depend on the institution for their basic needs such as food, housing, work, education, health, as well as their relational needs. Goffman (1961) suggested

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that the barrier imposed by total institutions between the inmate and the outside world and the resulting role dispossession strip the inmate of the conception of self that is provided by social arrangements in one’s home environment. One of the most prevalent forms of inmate adaptations to the prison environment is called “prizonization” (Clemmer, 1940). It includes socialization to the prison inmate subculture that adheres to such norms and values as keeping everything to oneself, doing only as much as one has to, being offensive rather than defensive, and believing that an ex-con cannot get by on the street without breaking the law (Winfree et al., 1992; Lawson et al., 1996). Thus, there is a gap between the normative expectations of inmate culture and the normative expectations of correctional authorities, which include the initiation of pro-social changes in the inmate’s attitudes, values, and behavior. The influences of both can be viewed as two conflicting processes of socialization (Thomas, 1973). Extra-prison effects on intra-prison adaptations Research on the impacts of confinement has been guided by two main models. The deprivation model emphasizes intra-institutional processes and influences (e.g., Toch, 1975). The importation model accepts the importance of intra-institutional factors, but also includes variables external to the prison context (e.g., Thomas, 1973). According to the importation model, pre-prison experiences, both criminal and non-criminal, quality and quantity of contacts with people from outside of prison, and post-prison expectations affect the degree of assimilation into the antisocial inmate culture (Thomas, 1973). The main claim is that no prison is a closed system. Inmates arrive having already been exposed to the socialization processes operative in some sector of the larger society, and they maintain contacts with these pre- and extra-prison socialization sources during their confinement (Thomas, 1973). All of these affect inmates’ post-release

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expectations and, in turn, their willingness to engage in resocialization programs, such as substance abuse treatment (Thomas, 1973; Zingraff, 1975). Research findings on extra-prison effects on personal adaptations to prison environment are equivocal. Some researchers found extra-prison contacts and positive postrelease expectations to be protective of prisonization (Thomas, 1973; Zingraff, 1975; Thomas, Petersen & Zingraff, 1978). However, more recent research found frequent contacts with persons outside of prison to predict higher levels of assimilation to prison inmate culture (Lawson et al., 1996). The inconsistency of research findings related to the direction of the effects indicates that it might not be the quantity of out-of-prison contacts, but the pro-social or deviant orientation of these extra-prison socialization sources that affects inmate’s adaptation to prison environment. For example, an increasing history of gang membership among prison inmates might be responsible for the shift in the direction of the relationships between extra-prison socialization sources and assimilation to prison inmate subculture (Peat & Winfree, 1992). Regardless of the direction of the relationships, research findings show that socialization sources prior and external to prison environment have significant effects on person’s adjustment to imprisonment and, subsequently, affect the likelihood of positive re-socialization. Implications for substance abuse behavior change As it was mentioned above, incarceration strips the inmate of familiar roles and conceptions of self. The deprivations of imprisonment may result in profound feelings of powerlessness, and related feelings of depression, anxiety, and shame (Toch, 1975). Some behavioral responses, such as retreating or exploding, might yield disciplinary sanctions that impose even more severe restrictions, thus confirming the feelings of impotence, helpless rage, and panic, and thereby initiating a self-perpetuating feedback loop (Toch, 1982). The norms and conventions of coping

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with the stresses of imprisonment include the guard-inmate chasm, exploitation of peers, insularity, dissembling and posturing, and preclude staff as well as peer support (Toch, 1975). This antisocial inmate culture, which is permeated with anxiety, secrecy, fear, and alienation, creates conditions that are not conducive to positive change (Wexler, 1994). Experiences of social disadvantage and social powerlessness can play a role in substance abuse behavior change process. Substance abuse treatment philosophies assume that substance users will have a better life when they are not using substances. However, for many substance users contemplating treatment, abstinence involves little change in many of life’s abysmal circumstances, such as social and economic disadvantages, mental health problems, family disintegration, and unemployment (Schilling & El-Bassel, 1998). This might be especially true for incarcerated substance users, as people who have no stake in society may have little reason to give up substance use (Schilling & El-Bassel, 1998). For some socially disadvantaged offenders, drug-involved activities may be the only experience of self-efficacy and social potency, for example when acting as dealers. For others, substance use may provide relief from persistent personal frustration and perceived social impotency (DeLeon et al., 2001). Even if they may express the wish to change, such individuals might not be willing to act towards change, for it might not seem attainable to them. Thus, when addiction is interwoven with social problems that span over time and across life domains, changing one’s substance use behavior becomes a complex problem. Some of the factors that motivate prison inmates to enroll in substance abuse treatment programs might include the desire to present a positive image before the parole board, boredom, and safety concerns. In addition to a constant sense of impending danger, monotony and the resulting boredom were described as major problems inmates face in prison (male inmate’s diary, Morris, 1995). In the context of the time-slowing,

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dull, sameness of prison life, participation in a prison-based substance abuse treatment program that offers more opportunities to engage in various activities might seem like a preferable way to “do time” to some drug-involved inmates. Those inmates who have a history of substance abuse treatment and know what to expect from therapeutic staff might feel less threatened by the treatment program rules. In addition, qualitative data suggests that inmates tend to regard treatment or other specialized in-prison programs, as being safer than living in the general prison population (Toch, 1975, 1996). Such a program provides an environment that is more controllable, structured, predictable and congruent than the general prison population environment. Inmates in such program environments may share similar characteristics, concerns, fears, and solutions to fears, and thus may be more predictable to each other, which in turn enhances the sense of control over the environment, as well as one’s responses to it (Toch 1996). Staff-inmate relationships surface as an important program attribute, because inmates are looking for concerned staff to help them deal with mounting situational pressures (Toch, 1996). Empirical research findings indicate that there is a negative correlation between assimilation to the inmate culture and the desire to enter in-prison substance abuse treatment program. Peat and Winfree (1992) compared the levels of prisonization among three groups of prisoners: general-population, therapeutic-community (TC) participants, and inmates eligible for TC. The inmate code adoption differentiated among the three groups, with those in general population exhibiting the highest and those in TC the lowest levels of inmate code adoption. The TC group had significantly lower levels of identification with the inmate code compared to the equally treatment oriented, prescreened and/or eligible for TC group, indicating the effect of treatment on adoption of pro-social values (Peat & Winfree, 1992; Winfree et al, 1992). Equally important is the finding that the eligible for TC

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group differed significantly from the general population which suggests that program participants already enter treatment with lower levels of socialization to the inmate subculture. Peat and Winfree’s (1992) research on prizonization did not include a motivation for treatment measure, nor did it explore extra-prison socialization effects, however, it suggests that socialization experiences affect one’s likelihood to seek substance abuse treatment. Given that problem recognition and desire for help usually precede treatment seeking (Simpson & Joe, 1993), it is likely that socialization affects these pre-treatment motivational stages of the change process as well. Summary Several socialization sources affect prison inmates. Socialization influences of correctional authorities conflict with those of inmate sub-culture (Thomas, 1973). Moreover, as isolating as prison environment can be, prison inmates still experience extra-prison socialization influences, whether they are in the form of out-of-prison contacts or pre-prison socialization experiences (Thomas, 1973). These affect inmates’ prisonization level, postrelease expectations, and, in turn, their desire to engage in re-socialization programs, such as substance abuse treatment (Lawson et al., 1996; Thomas et al., 1978; Zingraff, 1975). The deprivations of imprisonment, resulting feelings of powerlessness, and assimilation to inmate subculture, in general, are not conducive for positive behavior change. However, despite the seemingly unfavorable environment, some inmates seek in-prison substance abuse treatment. The level of socialization to the anti-social inmate culture was found to be a key variable in distinguishing treatment seekers from the non-seekers (Peat & Winfree, 1992), indicating that socialization affects pre-treatment stages of the substance abuse behavior change process.

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SUBSTANCE ABUSE BEHAVIOR CHANGE PROCESS Substance abuse behavior change and recovery from drug addiction is complicated by chronic and relapsing nature of drug and alcohol abuse disorders (Leukefeld et al., 1992; Leukefeld & Walker, 1998). Drug treatment clients tend to have a history of multiple treatment experiences in more than one type of program prior to recovery, suggesting that there are no “instant cures” (Leukefeld & Tims, 1988). Twelve-step programs, for example, define recovery as a process that sustains itself by constant awareness and that never ends (Brown, Kinlock, & Nurco, 2001). Thus, changing one’s substance abuse behavior and maintaining that change are long-term, complex, and demanding processes. Moreover, the recognition that one’s substance use is a problem, the desire to change it, and the readiness to seek help in order to achieve change involve complex motivational processes (DeLeon et al., 2001; DiClemente, 1999). Though motivation to change one’s substance use is a psychological concept measured at individual level, the process of change has a strong social dimension (Tsogia, Copello, & Orford, 2001; Brown et al., 2001; DeLeon, 2000). Stage formulations of substance abuse behavior change Three stage models of substance abuse behavior change dominate the field of research on motivation for substance abuse treatment. The Transtheoretical model (Prochaska, DiClemente, & Norcross, 1992) and the Integrated Recovery model (DeLeon, 1996) are the two stage perspectives that have guided recent research on motivation for change (DeLeon et al., 2001). The Texas Christian University (TCU) model (Simpson & Joe, 1993) is built on both of these models. It is an attempt to improve the Circumstances, Motivation, Readiness, and Suitability (CMRS) scales (DeLeon & Jainchill, 1986) – an instrument measuring motivational construct underlying the Integrated Recovery model - and to place it conceptually in the

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context of the stages of change of the Transtheoretical model (DeLeon, et al., 2001; Simpson & Joe, 1993). The Transtheoretical model According to the Transtheoretical model (Prochaska et al., 1992), the process of behavior change includes progression though the stages of precontemplation, contemplation, preparation, action, and maintenance (Prochaska et al., 1992; Prochaska & Velicer, 1997). In the precontemplation stage, there is no intention to take action towards behavior change in the foreseeable future due to lack of knowledge about the consequences of the behavior or doubt in one’s abilities to change. When precontemplators present for treatment, it is usually due to pressure form others. Resistance to recognize a problem is the hallmark of precontemplation. In the contemplation stage, there is awareness of the problem and some intent to change in the future. Weighing of pros and cons of changing occurs, but no commitment to take action has been made yet. The preparation stage is marked by intent to take action in the immediate future that is expressed by making a plan of action. The action stage entails concrete modification of behavior. While, maintenance stage means work on preventing relapse rather than application of behavior change processes (Prochaska et al., 1992; Prochaska & Velicer, 1997). “However, maintenance is a continuation, not an absence of change”, and for some, maintenance can be considered to last a lifetime (Prochaska et al., 1992, p.1104). The Transtheoretical model emphasizes that behavior change entails more than action. Complex cognitive, emotional, and social processes have to be engaged before an individual is ready to attempt action. Some of the processes of change that help individuals to progress through the stages of change include consciousness raising, emotional relief, self-reevaluation, self-liberation or empowerment, reevaluation of social environment, social empowerment or increase in social opportunities, stimulus

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control, reinforcement management, and helping relationships (Prochaska et al., 1992; Prochaska & Velicer, 1997). The efficient change depends on “doing the right things (processes) at the right time (stages)” (Prochaska et al., 1992, p. 1110). According to the Transtheoretical model, the change of substance abuse behavior does not progress in a linear fashion. Instead, it is more like a spiral process: people recycle through the stages as they relapse, each time potentially learning from their mistakes, and gradually increasing their chances of success (Prochaska et al., 1992). The Transtheoretical model yielded several operational definitions that are reviewed in the next chapter and summarized in Table 1. The Integrated Recovery model and CMRS scale The 10-stage Integrated Recovery model (DeLeon, 1996) describes the recovery process of serious substance abusers treated in a long term therapeutic community. The pretreatment stages described in the model include denial, ambivalence, extrinsic motivation, intrinsic motivation, readiness for change, and readiness for treatment. The treatment-related stages include deaddiction, abstinence, continuance, and integration and identity change (DeLeon et al., 2001). The distinction between extrinsic and intrinsic motivation in the model entails the distinction between some recognition of substance use as problematic due to external influences, and the acceptance of substance use as a central problem. The readiness for change stage includes willingness to seek change options that are not treatment related, while the readiness for treatment stage represents the acceptance of the necessity for treatment in order to achieve change (DeLeon et al., 2001). The Circumstances, Motivation, Readiness and Suitability (CMRS) scales (DeLeon & Jainchill, 1986) measure how clients perceive themselves, their circumstances and life options at the time of treatment involvement. The four factors do not imply a stage

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structure; however, they correspond closely with the last four pretreatment stages of the Integrated model. The circumstances scale measures extrinsic pressures to seek treatment (such as those coming from social relationships), the motivation scale measures intrinsic pressures or inner reasons for behavior change (such as acceptance of substance use as a problem or desire for a new lifestyle and healthier relationships), the readiness scale refers to the perceived need for help and treatment in order to achieve change, while the suitability scale measures the match between the individual and a particular treatment modality (DeLeon & Jainchill, 1986). The TCU model The Texas Christian University (TCU) model developed by Simpson and associates (Simpson & Joe, 1993) was derived from the CMRS model (DeLeon & Jainchill, 1986) and designed to capture sequential stages raging from problem recognition to acceptance of the need for change (Simpson & Joe, 1993). The TCU scales were an attempt to improve the psychometric properties of the CMRS, to place it in a broader theoretical context of the Transtheoretical model, and adapt it for use with samples other than therapeutic community clients (Simpson & Chatham, 1995; Simpson & Joe, 1993). The TCU model includes three stages in behavior change process: problem recognition, desire for help, and treatment readiness. These stages precede treatment seeking and describe progressive cognitive shift that is required for an individual to move from one behavior change stage to another (Simpson & Joe, 1993; Hiller, Knight, Leukefeld, & Simpson, 2002). Simpson and Joe (1993) argue that conceptually these stages correspond with the pre-action process of change described by Prochaska and colleagues’ (1992). The concept of problem recognition is related to movement from precontemplation to contemplation stage, for it addresses denial of problems as a barrier to change. Once problems related to substance

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abuse are acknowledged, the next critical step in the change process is to desire help in dealing with those problems. This represents a step toward what is referred to as an action stage in the Transtheoretical model. The desire for help scale is designed to assess this awareness of intrinsic need for change and interest in getting help (Joe et al., 2002). The treatment readiness scale corresponds with the action stage most closely, since it measures specific commitment to formal treatment (Simpson & Joe, 1993).

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Process of change and motivation Stages of change and motivation Motivation for substance abuse treatment has been defined as a dynamic process rather than a static condition (Miller, 1985). Therefore it is frequently explored in the context of the process of change stages (e.g. DeLeon et al., 2001) or even equated with the pretreatment stages of the process of change (DiClemente, 1999; Simpson & Joe, 1993). In the context of substance abuse treatment, motivation has been defined as a “multidimensional construct referring to cognitions and perceptions of the individual’s need for and readiness to change” (DeLeon et al., 2001, p. 162). In addition to motivation for treatment, researchers begun to concentrate on the problem of motivation in relapse prevention and maintenance of behavior change (DiClemente, 1999). Some of the stages of change in the Transtheoretical model (Prochaska et al., 1992) primarily describe motivational processes, such as accepting one’s substance use as a problem in contemplation stage, or recognizing that one needs help in order to achieve change in preparation stage. In the Integrated Recovery model (DeLeon, 1996) extrinsic and intrinsic motivation constitute two separate pre-treatment stages of recovery process. The two subsequent stages in the model – readiness for change and readiness for treatment – represent motivational continuum as well. In the TCU

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model (Simpson & Joe, 1993), problem recognition, desire for help, and readiness for treatment are conceptualized as three stages of motivation. Thus, it seems that the concepts of motivation and pre-treatment stages of change are frequently used interchangeably. However, motivational factors alone do not directly result in change (DeLeon at al., 2001). These factors move an individual to engage in activities that lead to change and recovery. Thus, it seems that motivational processes underlie the stages of change, but nevertheless, motivation is a separate construct from stage formulations (DeLeon et al., 2001). Some other important dimensions of the motivational construct include internal and external motivational processes (DeLeon et al., 2001; DiClemente, 1999), and self-concept or identity-related motivational issues (Downey, Rosengren, & Donovan, 2000). Internal and external motivational processes The internal and external motivational factors signify intentional versus imposed change (DiClemente, 1999). Intrinsic motivators for change arise from within and can be broadly classified into negative and positive. Negative motivators are more frequently addressed in the research literature and include perceived negative consequences of substance use and getting tired of the drug-abuse lifestyle, including the realization of being addicted and subsequent negative self-perceptions, health fears, need to reduce chaotic lifestyle, and “hitting bottom” emotionally (DeLeon et al., 2001). Positive internal motivators include desire for better relationships, more fulfilling lifestyle, extent of commitment to abstinence, and future orientation (DeLeon et al., 2001). External motivational factors can be generally defined as an outside pressure or coercion to change and/or enter/remain in treatment. These include legal, family and employment pressures. Legal pressures, such as threat of incarceration or conditions for parole, have been more fully addressed in the research literature than the latter two

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(DeLeon et al., 2001). The threat of criminal justice sanctions has been found to increase the likelihood of treatment entry and retention, and in turn, to increase the likelihood of positive outcomes (Inciardi & Martin, 1993, 1997; Miller & Flaherty, 2000). Moreover, empirical evidence suggests that clients under legal coercion do at least as well as voluntary clients in substance abuse treatment (Farabee, Prendergrast, & Anglin, 1998). However, external legal pressures or mandates to enter substance abuse treatment should be distinguished from “perceived coercion”, because not all legally mandated clients perceive that they are being coerced to treatment, while some self-referred clients report perceived external pressure to enter treatment (Prendergrast, Farabee, Cartier, & Henkin, 2002). The latter might be especially true for voluntary in-prison substance abuse treatment programs. Entering treatment in the context of the generally coercive prison environment may entail perceived pressure even when it is voluntary, due to the perceived lack of alternatives. External legal pressure and internal motivational factors have been found to be independent predictors of treatment retention (Knight, Hiller, Broome, & Simpson, 2000). However, both types of motivational processes seem to be necessary for stable recovery (DeLeon et al., 2001; DiClemente, 1999; Leukefeld & Tims, 1988). The adjudicated client’s motivation to enter and to remain in treatment is a result of an interaction between external and internal motivational factors. While external pressure may influence a person to enter and even stay in treatment, in order to maintain a stable, long-term recovery, it is necessary for externally imposed motivational processes to engage the internal ones (DiClemente, 1999; Leukefeld & Tims, 1988). Socialization can play a role in both internal and external motivational processes. Socialization sources contribute to external motivational factors by communicating norms for the appropriate behavior,

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expectations of an individual to comply with these norms, and sanctions for the non-compliance. Socialization influences internal motivation through the processes of value transmission and internalization. Thus, a person with mostly pro-social primary socialization sources is likely to have internalized pro-social norms and values, and, in case of his or her behavior deviating from those norms, is likely to experience sanctions and pressure to change. Alternatively, a person with mostly deviant primary socialization sources, such as substance using and/or criminally involved family and peers, is more likely to have his or her deviant behavior reinforced.

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Self-concept and identity-related motivational issues The role of socialization in motivational processes of change is also evident when motivation is formulated as driven by conceptions of self and internalized values. The Transtheoretical Stages of Change and the Integrative Recovery models underscore the complexity of the change process and emphasize that treatment is only a part of the recovery process. Both models call attention to the integration of the achieved changes into a lifestyle. The Integrative Recovery model takes this one step further than change maintenance by including self-perceived change in personal and social identity (DeLeon, 1996). The link between personal identity and motivation for change has been also demonstrated by research other than that related to the stage formulations of change. Downey and colleagues (2000) found motivation driven by selfconcept issues, such as wanting to like self better, wanting to feel in control of life, and wanting one’s behavior to reflect ideal self-standards, to be predictive of abstinence. Moreover, in Downey and colleagues’ (2000) sample, the average scores on identity-related motivation for abstinence were higher than were the comparable scores for motivation arising from social, health and legal concerns. The authors offered a conceptual explanation in the context of cognitive dissonance, self-discrepancy and identity

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theories (Downey et al., 2000). Specifically, they postulated that internal confrontation among core values, self-concepts, and behavior can motivate behavior change (Downey et al., 2000). The conceptualization of motivation as related to self and identity resonates with motivational interviewing approach at the core of which is the understanding of change as process of valuing, choosing and deciding, rather than counter-conditioning and skill training (Miller, 1996). Miller (1998) suggests that addictive behavior changes are fundamentally motivational and involve shifts in complex cognitive appraisals. For example, behavior change can be triggered by a discrepancy between feedback of the current status and a goal or standard with which it is compared. Or, in other words, behavior change can be initiated by the shifts in meaning attributed to a particular behavior when it collides with higher-level values and conceptions of self (Miller, 1998). The conceptualizations of motivation as identity related, and behavior change as stemming from internal confrontations between core values and actual behavior, are congruent with primary socialization theory. According to primary socialization theory, internalized norms and values communicated by primary socialization sources become part of person’s identity and affect his or her behavior, including substance use behavior (0etting, 1999). Furthermore, perceptions of what significant socialization sources expect of one’s behavior, as well as perceived expectations of specific role behavior, might affect a change in behavior (e.g., anticipatory socialization effects) (Yamaguchi, 1990). Substance abuse behavior change process and socialization The understanding of substance abuse behavior change as a process that can span the entire lifetime, the appreciation of social factors and external motivational influences on behavior change process, and the conceptualization of

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behavior change as stemming from internal confrontations between the core values one was socialized to and one’s actual behavior, indicate that socialization might be playing a significant part not only in the initiation and continuation of substance use, but also in substance use behavior change and recovery. Some of the change processes described in the Transtheoretical model (Prochaska et al., 1992), such as learning to substitute problem behaviors with socially acceptable alternatives, being in an environment that rewards and reinforces positive changes, and having trusting relationships, occur in the context of socialization sources. Socialization dimension is important in substance abuse treatment. In mutual help programs, for example, it is a fellowship of people working towards a shared goal of achieving and maintaining abstinence, and supporting each other’s recovery or coping methods (Brown et al., 2001). In therapeutic communities, the emphasis is on socialization or re-socialization to the “values of right living”, which include commitment to positive social values, such as work ethics, social productivity and communal responsibility, and positive personal values, such as honesty, self-reliance, and responsibility to oneself and significant others (DeLeon, 2000; Pearson & Lipton, 1999). The therapeutic relationships, including peer relationships between clients, appear to be the most important component of treatment (Broome et al., 1997). The effects of family dysfunction and peer deviance on substance abuse treatment outcomes have been documented by empirical research. The degree of peer deviance, particularly substance use among peer group, has been found to be associated with poorer treatment outcomes (Goehl, Nunes, Quitkin, & Hilton, 1993; Knight & Simpson, 1996). The quality of family relationships is also considered an important predictor of treatment outcome (Broome et al., 1997). Supportive family functioning, particularly in the form of cohesiveness, predicts better treatment outcomes (Constantini, Wermuth, Sorensen, &

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Lyons, 1992). Conversely, interpersonal conflict among family members is associated with poorer treatment outcomes, such as continued substance use and illegal activity (Knight & Simpson, 1996). According to primary socialization theory, family dysfunction and conflict, as well as peer deviance interfere with pro-social norms transmission (Oetting, 1999). Thus, it is this breakdown in the pro-social norms transmission and continuous exposure to deviant norms that might be affecting treatment outcomes. The role of socialization processes in the pre-treatment stages of change has been explored to a lesser extent. Recognition of one’s substance abuse as a problem and desire to change are conceptualized to include both internal processes, such as realization of dangers to one’s health and life, and external processes, such as feedback from social environment (TCU scales, Simpson & Joe, 1993). Some level of external pressure might be needed to engage internal motivational processes (DiClemente, 1999). However, socialization does not amount to just external pressure. Socialization also includes such basic processes as internalization of values and attitude formation. Thus, a substance user with deviant and/or substance using socialization sources might be less likely to recognize substance use as a problem and desire to change his or her behavior, because of less likelihood to receive a feedback triggering and enhancing problem recognition and desire for help from such sources as family, and/or because of selection of social ties that correspond to his or her values and attitudes about substance use. The quality of the relationships with primary socialization sources is a key factor in their ability to transmit pro-social norms (Oetting, 1999). Thus, having family and peer relationships permeated with conflict might diminish the influence these social relations have on one’s recognition of substance abuse as a problem and desire to change it. On the other hand, according to the “hitting bottom” hypothesis (Bell et al., 1998), conflict with one’s

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social environment indicates problem severity, which, in turn, is associated with motivation for change (Broome et al., 1997; Simpson & Joe, 1993). Moreover, perceptions of family conflict might play various roles in change process. For example, if conflict consists of family members confronting the client constructively about substance use, it might facilitate positive change (Broome et al., 1997). Therefore, in order to be able to hypothesize about the direction of the relationship between conflict with social relations and motivation for change, differentiation between “negative” and “positive” conflict is needed (Broome et al., 1997). Similarly, close and cohesive relationships with primary socialization sources might have various effects on the change process. Cohesiveness with pro-social primary socialization sources might facilitate problem recognition and desire for help, while cohesiveness with deviant and/or substance abusing primary socialization sources is less likely to bring awareness of substance abuse as a problem and, thus, unlikely to facilitate desire for help. In sum, it is difficult to predict the direction of the effects of conflict and/or cohesiveness with primary socialization sources on problem recognition and desire for help. The extent to which primary socialization sources are pro-social or deviant might interact with the effect that conflict and cohesiveness characterizing the relationships with these sources have on substance abuse behavior change process. Summary The change of one’s substance use behavior is a long-term process involving complex cognitive, emotional and social issues before an action is attempted. The process of change has been conceptualized in several stage models. The TCU model (Simpson & Joe, 1993), empirically derived from CMRS scales (DeLeon & Jainchill, 1986) and conceptually placed in the context of Transtheoretical model (Prochaska et al., 1992), yielded the constructs of problem recognition

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and desire for help – the two motivational variables at the basis of the study described in the subsequent chapters of this book. In substance abuse literature, pre-treatment stages, such as problem recognition and desire for help, are referred to as motivational stages of the process of change, and the concepts of motivation and pre-treatment stages are often used interchangeably. Relevant to the understanding of socialization effects on motivational processes is distinction between internal and external motivation, as well as relationship between self-concept and motivation. Socialization sources can affect substance use behavior change process as they communicate norms and behavioral expectations, as well as sanctions for the non-compliance. Internal confrontations between core values internalized in the process of socialization and resulting conceptions of self can also motivate behavior change. Socialization effects on substance abuse treatment process and outcomes have been documented more extensively than socialization effects on motivational processes of change. Family cohesiveness, interpersonal conflict, and degree of peer deviance have been shown to affect the likelihood of relapse and recidivism after treatment (Costantini et al., 1992; Goehl et al., 1993; Knight & Simpson, 1996). The effects of these factors on pre-treatment motivational stages of change, such as problem recognition and desire for change, need further exploration. It is difficult to predict the direction of the relationships between socialization and motivational variables. For example, family conflict might be related to a respondent’s substance abuse and indicate problem severity rather than family dysfunction. Additionally, the degree of deviance of primary socialization sources might affect the levels of conflict and cohesiveness with these sources and, subsequently, the effects of conflict and cohesiveness on problem recognition and desire for help. Moreover, family and peer socialization effects among incarcerated individuals might be further complicated by imprisonment.

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CHAPTER 3

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Empirical Research on Motivation for Treatment and Social Relations

Studies on problem recognition and desire for help are situated within a larger body of research on motivation for substance abuse treatment. Although the concepts of problem recognition and desire for change do not capture the whole motivational construct, studies on motivation explore a broad range of variables that are relevant for the study of problem recognition and desire for help. Several terms are being used interchangeably in the substance abuse literature. These include motivation for change, motivational readiness, and readiness for change (e.g., DiClemente, 1999). In the context of stage models, motivation is seen as part of the process of behavior change, hence there are the terms of motivational processes and motivational stages. In addition, treatment readiness related but separate motivational concept from readiness for change – is another relevant term, for it is seen as part of the motivational continuum. To preserve the integrity of the cited work, the following review adheres to the terms used in the original. When appropriate, specific terms of problem recognition and desire for help were used, even when referred to as motivation in the original work. When referring to problem recognition, desire for help and/or 55

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treatment readiness in general, a term of motivational scales was used. In summarizing statements referring to several studies with different terminology a general term of motivation for change and/or treatment was used. The conceptualizations of motivation for change distinguish between cognitions and perceptions concerning substance use related problems and behavioral elements of motivation such as seeking treatment (Carey et al., 1999). Problem recognition, cognitive appraisal, and attitudes toward treatment have been consistently found to be correlated with treatment entry, indicating that treatment entry might be a behavioral continuum of internal motivation for change (Tsogia et al., 2001). Therefore, in order to identify most of the relevant factors affecting motivation for treatment, when appropriate, the following review also referred to studies that explored factors related to treatment entry. Specific attention was given to the correlates of TCU Motivation Scales, since this instrument was used in the present study. MEASUREMENT OF SUBSTANCE ABUSE BEHAVIOR CHANGE PROCESS Carey and colleagues critically reviewed eight most frequently used self-report instruments assessing readiness to change substance abuse (Carey et al., 1999). These and one additional instrument are summarized in Table 3.1. Four of these instruments: 1) University of Rhode Island Change Assessment (URICA, McConnaughy et al., 1989), 2) Readiness to Change Questionnaire (RTCQ, Rollnick et al., 1992), 3) Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES, Miller & Tonigan, 1996), and 4) Texas Christian University (TCU) Motivational Assessment Scales (Simpson & Joe, 1993) – are theoretically based on the Transtheoretical Model (Prochaska et al., 1992) and focused primarily on internal motivational constructs. Four of the instruments: 1) Circumstances, Motivation, Readiness, and Suitability (CMRS) scale (DeLeon & Jainchill, 1986), 2) Recovery

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Stages of Change Readiness and Treatment Eagerness Scale, SOCRATES (Miller & Tonigan, 1996) Circumstances, Motivation, Readiness, and Suitability, CMRS (DeLeon & Jainchill, 1986) Texas Christian University (TCU) Motivational Assessment Scales (Simpson & Joe, 1993) (based on CMRS)

Instrument University of Rhode Island Change Assessment Scale, URICA (McConnaughy et al., 1989) Readiness of Change Questionnaire, RTCQ (Rollnick et al., 1992) Recognition Taking Steps Ambivalence Circumstances Motivation Readiness Suitability Problem recognition Desire for help Treatment readiness

Transtheoretical Model Not apparent

Post hoc adaptation of Transtheoretical Model

Transtheoretical Model

Subscales/Stages Precontemplation Contemplation Action Maintenance Precontemplation Contemplation Action

Theory Transtheoretical Model

Internal motivation Internal motivation

Internal & external motivation for TC Internal motivation; limited items on external

Medical patients

Alcohol treatment clients

Drug abusers in community-based and prison-based therapeutic communities (TC) Community-based long-term residential, outpatient drug free, and methadone maintenance treatment clients. Probationers and prison-based treatment clients.

Focus Internal motivation

Samples studied Varied, e.g. psychotherapy clients, smokers, and drug and alcohol treatment clients

Table 3.1. Summary of self-report instruments measuring motivation for substance abuse treatment.

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Selfdetermination theory Post-hoc adaptation of Trans-theoretical Model Cognitive dissonance, selfdiscrepancy, and identity theories

Treatment Motivation Questionnaire, TMQ (Ryan et al., 1995)

Contemplation Ladder (Biener & Abrams, 1991)

Subscales/Stages Resistance to treatment Resistance to continuing care Biomedical problems Psychosocial support Internal motivation External motivation Help seeking Confidence in treatment No subscales: single rating on continuous scale

Internal & external motivation Internal motivation

Drug and alcohol treatment clients

Workplace smokers, smoking cessation program participants, and female medical patients. Smokers, substance users, individuals seeking publicsector addiction treatment

Internal & external motivation

Focus Internal & external motivation

Samples studied Drug and alcohol treatment clients, and pregnant and postpartum substance abusers

Social influence Reasons for Quitting (RFQ) Self-concept questionnaire (Curry, et al., Health concerns 1990, revised by McBride et Legal issues al., 1994, and Downey et al., 2000). Note. The data on instruments, with the exception of RFQ, was derived primarily from Carey et al., 1999.

Theory Not apparent

Instrument Recovery Attitude and Treatment Evaluator, RAATE (Smith et al., 1995)

Table 3.1 (continued). Summary of self-report instruments measuring motivation for substance abuse treatment.

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Empirical Research on Motivation and Social Relations 59 Attitude and Treatment Evaluator (RAATE, Smith, Hoffman, & Nederhoed, 1995), 3) Treatment Motivation Questionnaire (TMQ, Ryan, Plant, & O’Malley, 1995) and 4) Reasons for Quitting (RFQ) questionnaire (Downey et al., 2000) – include explicit external factors in addition to internal. Finally, one instrument – Contemplation Ladder (Biener & Abrams, 1991) – consists of a single continuous rating scale, rather than discrete stages, and focuses primarily on internal processes of change. Carey and colleagues concluded that the “evidence from URICA, RTCQ, and SOCRATES converges in a pattern suggesting that if a stage structure [of readiness to change] exists, relatively few stages may suffice to explain the data” (p. 258, Carey et al., 1999). Indeed, factor analyses of RTCQ and TCU scales suggest a subset of fewer hypothesized stages (precontemplation, contemplation, and action; and precontemplation/contemplation, preparation, and action, respectively). In addition, as Carey and colleagues (1999) noted, many of the measures based on the Transtheoretical Model address readiness to change rather than readiness for treatment, and were designed to test process of behavior change in general rather than that specific to substance abuse. Applying these instruments with therapeutically involved substance abusers might affect the psychometric data, as certain issues that are relevant to substance abusing individuals might not be relevant to general population and visa versa. On the other hand, it has been suggested that the applicability of scales such as CMRS and TCU, which include operationalizations of readiness for substance abuse treatment, might be more specific to certain treatment contexts, such as therapeutic community and methadone maintenance clinics (Carey et al, 1999). However, since the development of the TCU motivational scales in the context of methadone clinics, they have been tested and found to be reliable in various treatment settings, including communitybased long-term residential (alphas ranging from .71 to .81, Joe, Simpson, & Broome, 1998) as well as prison-based

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programs (alphas from .88 to .89, Hiller, Leukefeld, Staton & Kayo, 2001). In addition, separating the constructs of desire for help and readiness for a particular treatment option has both theoretical and practical value (Carey et al., 1999), especially, because it has been demonstrated that readiness for certain types of treatments varies across subpopulations of substance abusers (e.g., DeLeon et al., 2000a). It is difficult to determine whether the only partial empirical support for the Transtheoretical Model reflects problems with the measures or problems with the conceptualization of the stages of change. The stage metaphor of the change process has been criticized for applying arbitrary thresholds to constructs that probably vary along a continuum, substituting a categorical approach for a process model of human adaptation and change (Bandura, 1997). In fact, the psychometric data reviewed by Carey and others (1999) suggests that the dimensions of readiness to change can be measured reliably in a continuous manner. The authors also suggest that it might be more appropriate to view readiness to change as an integrative motivational construct rather than a linear process (Carey et al., 1999). In addition, it may be more accurate to think of motivation for change as the net result of interaction between internal and external events rather than conceptualizing it as primarily an internal state (Carey et al., 1999). Three out of four instruments that had distinct scales addressing external motivational factors demonstrated good reliability, supporting the empirical evidence that internal and external motivation may have an additive effect on seeking and remaining in treatment (Knight et al., 2000). Specifically, Psychosocial Support for Recovery scale in RAATE, and External Motivation scale in TMQ had alphas higher than .60, (Carey et al., 1999; Ryan et al., 1995), while Social Influence and Legal Issues scales in RFQ had alphas .82 and .75, respectively (Downey et al., 2001).

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Empirical Research on Motivation and Social Relations 61 As mentioned previously, current motivational assessment instruments, such as the URICA and SOCRATES, typically measure client’s cognitive attributions about their motivation to change problem behaviors. However, they do not indicate why a particular person might want to change, and thus provide limited information for clinical decision-making on how to retain an “unmotivated” individual in treatment (Marlowe, Kirby, Merikle, Festinger, & McLellan, 2001). A noted exception to this is the CMRS, which measures both readiness for change and readiness for treatment. It includes client’s perceptions of external and internal pressures to change problem behaviors, as well as readiness and suitability for treatment (DeLeon & Jainchill, 1986). This scale, however, has received only limited validation and psychometric support. Its four-factor structure has not been replicated in other samples. Repeated attempts to improve this resulted in a three-factor solution represented in TCU Motivational Scales and eliminated many of the elements of external pressure and treatment suitability (Simpson & Joe, 1993). Marlowe and colleagues (2001) suggested that CMRS might not sufficiently cover the relevant content domain of perceived pressures to enter substance abuse treatment, indicating the need for further research in this area. Their multidimensional measurement of perceived pressures on treatment entry along eight psychosocial domains (psychological, financial, social, family, medical, legal, drug, and religious) revealed greater prevalence of nonlegal sources of pressures even among legally referred clients (Marlowe et al., 1996, 2001). This indicates the need for further studies of non-legal psycho-social domains in motivation for change including diverse client populations. The external/social domain in motivation for change and readiness for treatment might be context specific, thus, complicating its operationalization. For example, clients involved with criminal justice system might experience different external pressures to change behavior than voluntary clients of community-based programs. Moreover,

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the interaction between these pressures and other factors in the process of change might also vary according to context. However, only two of the instruments reviewed above – CMRS and TCU Motivational scales – were systematically tested with both criminal justice involved clients, including prisoners, and community based samples.

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Summary The main model guiding research on substance abuse behavior change seems to be the Transtheoretical stage model. The conceptualization of the change process as a series of stages is not without problems. Empirical data points to fewer stages than those hypothesized in the model (e.g., TCU scales, Simpson & Joe, 1993). As in any categorical model, there is some arbitrariness in stage thresholds (Bandura, 1997), and it is important to take into account that the process of change can also be conceptualized and measured in a continuous manner, and is not necessarily linear (Carey et al., 1999). In addition, research findings suggest that motivation for change is not solely an internal state, but is substantially influenced by external factors (e.g., Knight et al., 2000). However, the domain of external/social influences on motivational stages of the process of change such as problem recognition, desire for help and readiness for treatment is insufficiently covered in the existing instruments. Therefore, further research identifying and exploring social correlates and predictors of motivational stages of substance abuse behavior change process is important. TCU scales seem to be appropriate for this purpose, as they focus on motivational stages of the process of change, are psychometrically sound, and have been tested with both criminal justice and community based samples.

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Empirical Research on Motivation and Social Relations 63

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SOCIAL FACTORS IN MOTIVATION FOR SUBSTANCE ABUSE BEHAVIOR CHANGE Due to the lack of studies that explored socialization or related social factors and their effects on the motivational stages of substance abuse behavior change process, studies on motivation for substance abuse treatment and readiness to change were reviewed for findings on social factors, even when social factors were not a primary focus of the study (see Table 3.2, for overview of studies). Historically, studies that explored social factors in motivation for substance abuse behavior change and treatment focused primarily on legal pressure variables that consistently emerged as significant predictors of treatment entry, retention and outcomes (e.g., Inciardi & Martin, 1993, 1997; Farabee et al., 1998; for reviews see Leukefeld & Tims, 1988; Miller & Flaherty, 2000). The research on non-legal pressures is limited and less conclusive. DeLeon and associates in their review cite several studies suggesting that family and job pressures can effectively influence treatment-seeking and retention (DeLeon et al., 2000a). Tsogia and colleagues in their review concluded that, overall, experiencing social pressure, such as pressure from family and friends, and having more social resources, such as being married and employed, having financial resources, and larger social networks, seem to be associated with treatment entry (Tsogia et al., 2001). Thus, empirical findings document the social nature of seeking help for substance abuse indicating that research on social level factors in substance abuse behavior change process is justified and fruitful. Nevertheless, variables influencing help-seeking process might not be wholly redundant with those influencing the addictive behavior change process (Tucker & King, 1999).

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Note. TC – therapeutic community. A-form – adolescent form.

Studies that used Circumstances, Motivation, Readiness, and Suitability (CMRS) scales (DeLeon & Jainchill, 1986) Authors Design & Sample Study focus Measure Correlates, covariates, and Analyses predictors of motivation DeLeon & Retrospective Community Correlations of CMRS CMRS Age (younger), race (White) and Jainchill, Correlations -based TC with demographics, 52-item marijuana use correlated with lower 1986 N~400 primary drug, & retention motivation CMRS CMRS consistently predicted Community Motivation across DeLeon et Prospective 42-item retention for cocaine and opiate primary drug groups & -based TC al., 1997 Multiple abusers. Effects of gender, age, race, prediction of retention N=1398 regressions legal status, & type of drug varried. Older age most consistently CMRS Melnick et Retrospective Community Differences between contributed to higher CMRS score, adolescents and adults on 25-item -based TC Analysis of al., 1997 followed by primary use of cocaine. A- form motivation and treatment N=2555 variance & Findings on race varied by sample. outcomes Multiple regression TC treatment process and CMR Criminal history & drug severity had a Melnick et Prospective Prisonoutcomes 18-item direct positive effect on motivationPath analysis based TC al., 2001 participation interaction N=110

Table 3.2. Summary of selected studies on motivation for substance abuse treatment.

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Note. LTR - long-term residential, ODF - outpatient drug free, OMT - outpatient methadone treatment (all community based).

Drug and Alcohol Treatment Outcome Studies (DATOS) that used Texas Christian University (TCU) Motivation Scales (Simpson & Joe, 1993):Problem recognition (PR), desire for help (DH), and treatment readiness (TR) Author Design & Sample Study focus Measures Correlates, covariates, and s Analyses predictors of motivation Joe et Prospective. LTR - 2265 Motivation, PR, TR Significant covariates with TR: age, never al., 1998 Hierarchical ODF - 1791 treatment process married, employed at intake, alcohol linear model OMT - 981 and retention dependency, weekly marijuana use, legal status (HLM) and lifetime arrests. Treatment process TR Motivation was a strong determinant of Joe et Prospective. LTR - 1362 treatment involvement and retention. Other ODF - 866 al., 1999 Linear related factors: depression, alcohol OMT - 981 structural dependence, legal pressure, and frequency of equation cocaine use; these varied by treatment modeling modality, indicating complex relationships. TR TR and rapport with counselor were the most Broome Prospective. LTR – 1141 Patient and consistent predictors of treatment involvement. program attributes HLM ODF – 718 et al., Overall, patient attributes and experiences & treatment OMT - 689 1999 demonstrated relative importance over program process attributes.

Table 3.2 (continued). Summary of selected studies on motivation for substance abuse treatment.

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Other studies that used TCU scales: Prospective. 311 Simpson methadone Principal & Joe, components, mainte1993 correlations, nance clients regression Riehman Prospective. 266 cohabiting Logistic et al., or married regressions 2000 drug users PR, DH, TR

PR, DH, TR

Intimate partners’ influence on motivation

TR

Measures

Validation of TCU scales & dropout prediction

DATOS that used TCU Motivation Scales (continued) Authors Design & Sample Study focus Analyses Knight et Prospective. LTR – Legal pressure, Regression 2194 TR, engagement al., 2000 and retention

Psychological adjustment indicators were most highly correlated with TCU scales. Other significant correlates: gender, ethnicity, self- & counselor-assessed peer, family, legal and health problems. Greater income from self- than partner-sources – increased motivation. For women, partner with treatment experience increases the odds of DH & TR, drugs using partner decreases the odds of TR. For men, Hispanic ethnicity, employment, education and criminal justice involvement were significant predictors of motivation.

Correlates, covariates, and predictors of motivation Legal pressure and TR were both independently related to retention. Motivation was strongest predictor of engagement and retention.

Table 3.2 (continued). Summary of selected studies on motivation for substance abuse treatment.

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Other studies that used TCU scales (continued): Authors Design & Sample Study focus Analyses Psychosocial Hiller et Retrospectiv 661 incarcerated problems e al., 2001 severity and Correlations chronic motivation substance & linear abusers regressions Motivation as Hiller et Prospective. 419 Correlations probationers predictor of al., 2002 in residential treatment & linear engagement treatment regressions Studies that used other instruments: Self-concept/ Prospective. 654 on Downey identity and waiting list Principal et al., motivation components, for public 2000 sector Logistic addiction regression treatment Reasons for Quitting (RFQ), SOCRATES

PR, DH, TR

PR, DH

Measures

Average scores on identity-related motivation were higher than those on social pressure, health and legal issues. Higher scores on Taking Steps (SOCRATES), cocaine use, personal networks non-supportive of use, and high perceived costs of use were associated with higher scores on identity-related motivation.

Correlates, covariates, and predictors of motivation Older age, urban origin, employment problems, drugs using spouse, mental and physical health problems predicted higher PR. In prison treatment status was an additional predictor for higher DH. Higher DH & TR scores were significant predictors of higher level of engagement (perceived involvement, progress and safety in treatment).

Table 3.2 (continued). Summary of selected studies on motivation for substance abuse treatment.

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Therapeutic relationship as function of motivation

Treatment Motivation questionnaire (TMQ)

SOCRATES short 20-item version

Measures

Correlates, covariates, and predictors of motivation Recognition scale had strongest correlations, reflecting up to 15% common variance, with alcohol consumption related problem severity, including loss of control, role maladaptation, and marital problems. Greater problem severity (ASI) was associated with higher levels of internalized motivation and interpersonal help seeking. General severity had indirect positive effect on outcomes through internalized motivation; legal problems had an effect through external. Peer deviance and family dysfunction were related to therapeutic relationships indirectly through drug-related problems.

Note. SOCRATES – Stages of Change Readiness and Treatment Eagerness Scal

Studies that used other instruments (continued): Authors Design & Sample Study focus Analyses Instrument Miller & Retrospective N=1672 assessment Tonigan, Factor outpatient 1996 analysis, Project correlations MATCH baseline Instrument 109 clients Ryan, et Prospective. assessment; & 98 Correlations, al., 1995 predictors of treatment analyses of motivation; variance, path seekers; pathways to outpatient analysis. outcomes. Peer, family 250 Prospective. Broome probationers and Structural et al., in 4-months motivational equation 1997 influences residential model on treatment program

Table 3.2 (continued). Summary of selected studies on motivation for substance abuse treatment.

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.

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Empirical Research on Motivation and Social Relations 69 STUDIES ON FAMILY AND PEER RELATIONS AND SUBSTANCE ABUSE BEHAVIOR CHANGE When non-legal social factors in substance abuse behavior change process are explored, it is often in the context of treatment process and outcomes studies. Family and peer relations variables seem to be the main social factors hypothesized to affect the process of change (e.g., Broome et al., 1997; Constantini et al., 1992; Simpson & Joe, 1993). The degree of family and peer deviance and the level of family dysfunction at the time of treatment entry emerge as important predictors of treatment progress and outcomes. These findings are consistent with primary socialization theory that stresses the role of family and peers as primary in individual’s substance use behavior formation and change (Oetting et al., 1998a). The characteristics of these primary socialization sources, such as deviance and substance abuse history, and the quality of the relationships with them, as indicated by the level of conflict and cohesiveness, are conceptualized as main factors influencing socialization outcomes, such as substance abuse behavior and its change (Oetting, 1999). Thus, a study of socialization effects on substance abuse behavior change process within the theoretical framework of primary socialization should include family and peer relations variables. Studies of drug users’ family system identified dysfunctional patterns of interaction, such as interpersonal conflict, poor interpersonal boundaries, and poor communication, as predominant features of these families (Kaufman, 1981; Stanton, Todd, Heard et al., 1978). The dysfunctional characteristics of relationships experienced in the family of origin are often recreated in the family of marriage (Harbin & Maziar, 1975). Research findings indicate that adult chronic drug abusers maintain frequent contacts and tend to be more involved with their families of origin than non- users, and that these relationships may affect one’s ability to engage in substance abuse treatment

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(Kaufman, 1981; Stanton et al., 1978; Vaillant, 1966). Research findings also suggest that family cohesion as well as emotional support from intimate relationship or relative predicts better treatment progress and outcomes (Constantini et al., 1992; Tucker, 1985). Conversely, family conflict is associated with poorer treatment outcomes (Knight & Simpson, 1996). Peer group is another major socialization source influencing adult person’s substance use behavior. Clients with deviant peer relations, especially with substance using peers, have been found to have greater relapse rates (e.g., Goehl et al, 1993). Even when new social networks may be formed as a result of treatment, clients who have a history of associating with deviant peers are at greater risk of relapse, as their new relationships are more likely to include substance users (Hawkins & Fraser, 1987). However, those who are able to maintain or establish new relationships that encourage recovery are better able to cope with physical and psychological effects of withdrawing from drugs (Wills, 1990). In addition, some evidence suggests that family and peer deviance and dysfunction might be related to motivation for treatment, and that some of the family and peer effects on treatment process variables might be mediated by motivation variables (Simpson & Joe, 1993; Broome et al., 1997). Thus, family and peer relations emerge as potentially significant sources of influence on persons’ motivation for change in both conceptual as well as empirical literature. Several studies focused on family and peer relations effects on substance abuse treatment process and outcomes (see Table 3.3, for overview of studies). Constantini and associates (1992) explored the effects of family cohesion and adaptability as measured by FACES II on progress in substance abuse treatment among 23 applicants to methadone maintenance program at San Francisco General Hospital. The results indicated that family functioning, lower scores on cohesion dimension in particular, predicts

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Prospective. Principal components, correlations, regression

Design & Analyses Prospective. Multiple regressions.

311 methadone maintenance clients

23 applicants to methadone maintenance program

Sample

Measures of family and peer factors Family functioning: Family Adaptability and Cohesion Scales (Faces II)

Peer criminality: arguments or fights, dealing drugs, committing crimes, gang involvement, incarceration. Peer-generated problems: encourage risk-taking that resulted social or legal trouble, make fun of the client. Availability of drugs: ease of obtaining drugs, pressure to use, using due to being in certain places. Family relation problems: ASI Peer relation problems: ASI

Study focus Relation of family functioning to problem severity Validation of TCU scales, dropout prediction

Lower family cohesion scores predicted greater severity of drug use, family and psychosocial problems (ASI)*. Self-reported peergenerated problems and peer-related availability of drugs were related to higher levels of PR. Counselor-assessed family and peer relations problems were significantly related to both: higher levels of PR and DH*.

Findings

Note. * ASI – Addiction Severity Index (McLellan et al., 1992). * PR – Problem Recognition, DH – Desire for Help.

Simpson & Joe, 1993

Constantini et al, 1992

Authors

Table 3.3. Summary of selected studies on family and peer factors in substance abuse behavior change process.

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Positive changes in family conflict and peer deviance were associated with behavioral improvements for clients. Indirect effects of peer deviance and family dysfunction on PR, DH and TR* were significant, mediated by poor psychosocial functioning.

Peer deviance/criminality Family conflict: blaming the client, disagreements and loud arguments.

Peer deviance: (see above) Family dysfunction: helped each other with problems, blamed or fussed at the client, had disagreements (combined measure of conflict and cohesion)

Change in family conflict and peer deviance during treatment Peer deviance and family dysfunction effects on treatment process

439 communitybased methadone maintenance clinic clients 303 graduates of methadone maintenance program

Prospective. Reliable change index, logistic regression. Prospective. Structural equation modeling

Knight & Simpson, 1996

Griffith et al., 1998

Note. * PR – Problem Recognition, DH – Desire for Help, TR – Treatment Readiness.

Findings

Measures of family and peer factors

Study focus

Sample

Design & Analyses

Authors

Table 3.3 (continued). Overview of selected studies on family and peer factors in substance abuse behavior change process.

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Design & Analyses Prospective. Structural equation modeling

Study focus Relationships between patient background variables, TR, and therapeutic engagement.

Sample 556 residential, 231 outpatient, and 319 short-term inpatient treatment

Measures of family and peer factors Family and peer deviance: how many of their family and friends in the year before admission had used illegal drugs, drank heavily, or been arrested (from 1 = none to 3 = many).

Note. * DATOS-A adolescents’ sample. * TR – Treatment Readiness.

Broome et al., 2001*

Authors

Family and peer deviance was significantly related to higher TR* across all treatment modalities.

Findings

Table 3.3 (continued). Overview of selected studies on family and peer factors in substance abuse behavior change process.

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greater severity of patient’s dysfunction resulting from substance use, family, and psychological problems, as measured by ASI. Although the study had several limitations, such as small sample size and multiple analyses without adjustment of the p value, it supports the relevance of family factors in substance abuse treatment (Constantini et al., 1992). Research conducted by Simpson and associates has focused on the role of motivation in treatment retention and, more recently, on treatment process issues. Simpson and Joe (1993) explored correlations of client background measures with TCU motivation scales among 311 methadone maintenance clients. Self-reported peergenerated problems and peer-related availability of drugs were related to significantly higher levels of recognition of drug problems. In addition, counselor-assessed family and peer relation problems were significantly related to higher levels of drug problem recognition and desire for help. Simpson and Joe (1993) pointed out that while motivation contributes unique variance to the prediction of treatment outcomes, it should be considered in the broader context of, and in conjunction with, several background, psychological, peer, social, and expectation variables. Subsequent TCU studies on treatment process and outcomes integrated measures of family and peer relations, including peer deviance, family conflict and cohesion, alongside with motivational assessment scales (e.g., Broome et al., 1997; Griffith et al., 1998; Knight & Simpson, 1996). Broome and associates’ (1997) study examined the effects that drug-related problems, peer deviance, and family dysfunction have on therapeutic relationships and recidivism. Data was collected from 250 probationers in a residential substance abuse treatment facility. Peer deviance was defined by three composite measures, including peer deviance, social conformity, and negative influences. Family dysfunction was defined by two composite measures of family conflict and cohesion. The researchers found that peer deviance and family

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Empirical Research on Motivation and Social Relations 75 dysfunction only affected therapeutic relationships indirectly through their association with clients’ recognition of drug related problems (Broome et al., 1997). Thus, even though the social relations variables were not significantly related to the treatment process and outcome, the findings suggest that peer deviance and family dysfunction might be related to the motivational elements, such as problem recognition, of the substance abuse behavior change process. An additional study by the TCU research group examined change in family conflict and peer deviance from intake to during treatment in a voluntary sample of 439 methadone treatment clients (Knight & Simpson, 1996). The study found that positive changes in family conflict and peer deviance were associated with behavioral improvements for clients. The researchers suggested that individual differences in the direction and degree of change may be attributed, among other factors, to the history of relationships with parents, family members, or peers over the life span, and indicated that further research is needed to examine the reciprocal nature of interpersonal relationships and substance abuse behavior change process (Knight & Simpson, 1996). Although social relations and motivation variables are often considered important predictors of substance abuse treatment engagement and outcomes, few attempts have been made to investigate the relationship between the two. An exception to this is Griffith and associates’ study, which, although explored simultaneous impact of social relations and motivation on drug treatment outcomes, also tested indirect effects of family and peer variables on motivation in a sample of 303 male and female graduates of voluntary methadone treatment program (Griffith et al., 1998). Family dysfunction, measured by mutual help, blaming and disagreement items, and peer deviance, measured by dealing drugs, positive attitude, and causing trouble items, were reliable predictors of poor psychosocial functioning, which in turn was found to be related to higher motivational levels, measured by TCU problem

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recognition, desire for help, and treatment readiness scales. An examination of the indirect effects showed that paths from perceived peer deviance to motivation and from perceived family dysfunction to motivation were significant (Griffith et al., 1998). Griffith and associates (1998) interpreted their findings in the context of the Transtheoretical model of change (Prochaska et al., 1992), and suggested that the relationship between perceived family dysfunction, peer deviance and motivation may represent clients’ progression past the precontemplation stage. That is, individuals appear to acknowledge poor social relations and their drug use problem. The researchers concluded on the importance for further studies to confirm that perceptions of peer deviance and family dysfunction are important contributing factors toward the level of motivation and participation in treatment (Griffith et al., 1998). On the first glance, Griffith and associates’ (1998) findings seem contradictory with primary socialization theory-driven assumption that family dysfunction and peer deviance can lead to lower likelihood of positive behavior change and its maintenance. The difference between perceived and actual family and peer deviance might explain this apparent contradiction. While family and peer deviance might be related to one’s likelihood to abuse substances, an awareness and acknowledgment of the deviance of one’s social environment might reflect problem recognition and, thus, play a more important role in the motivational stages of the process of change. A direct relationship between family and peer deviance and motivation for substance abuse treatment was explored with adolescent sample in a DATOS-A study of treatment engagement models, including 1,732 clients of residential, outpatient drug-free, and short-term inpatient treatment programs (Broome, Joe, & Simpson, 2001). However, the study included only one of the TCU Motivational Assessment Scales – Treatment Readiness (TR) scale. Family and peer deviance was consistently linked with

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Empirical Research on Motivation and Social Relations 77 higher TR across all treatment modalities. This finding might seem contradictory, as greater involvement with deviant friends and family was expected to be a barrier to TR (Broome, et al., 2001). The researchers suggested that exposure to deviant friends, although exciting at first, eventually can become a negative experience for the clients, leading to negative emotional and physical consequences, and subsequently to increased readiness to enter treatment (Broome, et al., 2001). One of the limitations of this study is that family and peer deviance was entered into the model as one composite variable, therefore, it remains unclear whether family and peer deviance are related to the motivation for treatment in a similar pattern. Although this study included adolescent sample, in the scarcity of studies on family and peer effects on motivation for change and treatment among adults, it can provide a model for examining how the effects of family and peer relations might extend into adulthood. The models tested in the aforementioned studies are based primarily on empirical data. The findings are usually interpreted in the context of Prochaska and associates’ (1992) Transtheoretical model of change (e.g., Griffith et al., 1998) or problem severity hypothesis (Broome et al., 2001). Primary socialization theory can be used along with prior empirical findings to identify additional variables in the social domain that might be relevant to the understanding of problem recognition and desire for help. In addition, participants in these studies were from treatment samples, and participation in treatment might affect motivation for change (DeLeon et al., 2000a) as well as one’s interpersonal relationships (e.g., Gibson, Sorensen, Wermuth, & Bernal, 1992; Knight, Wallace, Joe, & Logan, 2001). Therefore, it is important to test how family and peer relations affect motivation for substance abuse behavior change with non-treatment samples as well. Moreover, although some of the aforementioned studies included criminal justice- referred clients, none explored social relationships’ effects on motivation for change

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among incarcerated individuals. Despite the isolation of imprisonment, pre-prison socialization experiences and socialization sources external to prison, such as family and peer group, seem to affect inmates’ desire to engage in resocialization programs (Lawson et al., 1996; Zingraff, 1975; Thomas et al., 1978). Therefore, it is important to explore the effects that history of family and peer relations might have on inmates’ problem recognition and desire for help. Traditionally, studies exploring family effects on adult person’s substance abuse and treatment outcomes focus on relationships with parents or family relations in general. Studies that focus on spousal or couple relationships are usually conducted with samples of alcoholics (e.g., Moos & Moos, 1984). Sibling relations effects on one’s substance abuse behavior are usually explored with adolescent samples, where sibling relationships are viewed as a type of peer relationships (e.g., Needle et al., 1986). However, some evidence from addicts’ family structure analyses suggests that siblings are important to adult substance abuser either through their own addiction as fellow addicts, or their authoritative parental role in the family (Kaufman, 1981). Thus, it is important to include parental, spousal, siblings and peer relations when exploring socialization effects on adult substance abuser’s motivation for change, and to explore the effects of these relations separately, for they might affect substance abuse behavior change process in a different pattern. Summary Empirical evidence documents the social nature of seeking help for substance abuse problems, however, studies exploring motivation for substance abuse behavior change and non-legal social factors, in general, as well as socialization effects, specifically, are scarce. The theoretical framework of primary socialization suggests that study of socialization effects on substance abuse behavior change process should include family and peer

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Empirical Research on Motivation and Social Relations 79 relations variables, specifically - deviance, conflict and cohesion that characterize these relationships. Empirical findings support these conceptual notions. The degree of family and peer deviance and the level of family dysfunction alongside with motivation variables consistently emerge as important predictors of treatment progress and outcomes (e.g., Broome et al., 1997; Simpson & Joe, 1993) (see Table 3.3, for overview of studies). The relationships between motivation and social variables, however, have rarely been explored, and when they have been, it was in the context of treatment process and outcomes studies. Some evidence suggests indirect relationship of family dysfunction and peer deviance with problem recognition, desire for help, and treatment readiness (Griffith et al., 1998). Conversely, other findings indicate that motivational variables might be mediating the relationship between social relations and treatment process variables (Broome et al., 1997). A direct relationship of higher levels of family and peer deviance and dysfunction with problem recognition, desire for help and treatment readiness was observed in adolescent and adult samples (Broome et al., 2001; Simpson & Joe, 1993, respectively). In sum, empirical findings support the connection between family and peer functioning and substance abuse behavior change, but further research is needed to unravel the complex nature of this relationship, and to understand how it affects substance abuse behavior change process throughout the motivational stages of change. The study presented in subsequent chapters examined the effects that history of primary socialization relationships, such as family and peer deviance, conflict and cohesion, have on problem recognition and desire for help – the motivational variables of substance abuse behavior change process – in the sample of incarcerated chronic substance abusers, including inmates in general prison population, as well as those enrolled in substance abuse program. This study aimed to identify primary socialization relationships and their characteristics that correlate significantly with problem recognition and desire

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for help, and to build prediction models testing the unique contribution of primary socialization factors to the variance in problem recognition and desire for help after controlling for personal background characteristics. The present study contributes to the prior literature on social relations effects on motivation for substance abuse treatment by applying primary socialization theory to identify variables of interest and to interpret findings. In addition, prior research of family and peer effects on motivational variables was limited to treatment samples. This may affect the results due to possible treatment effects on problem recognition and desire for help, as well as interpersonal relationships. The present study contributes to the current literature by including individuals that are not enrolled in substance abuse treatment program along with those that are in treatment. Furthermore, it expands the exploration of family and peer relations factors onto the prison sample. And finally, it adds to the prior research by exploring sibling relations effects on problem recognition and desire for help, alongside with traditionally explored parental, spousal and peer effects, in a sample of adult chronic substance users.

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CHAPTER 4

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Study Approach and Measurement of Social Relations and Motivation Variables

The current study used data from a project supported by the National Institute on Dug Abuse that examined the health services utilization of drug-involved prisoners (Leukefeld et al., 1998). Retrospective and prospective health status and health services utilization data were collected. The current study used part of the retrospective data. Other retrospective project findings were published elsewhere (e.g., Garrity et al., 2002; Leukefeld et al., 2002; Narevic et al., 2006). Prospective project findings have recently become available as well (Leukefeld, Hiller, Webster, Staton, Martin, Duvall et al., 2006). STUDY DESIGN AND PROCEDURE The review of empirical literature indicated that motivational components of behavior change process, such as problem recognition (PR) and desire for help (DH), were usually explored as part of larger, prospective/longitudinal studies on treatment process and outcomes, with motivation assessed as a predictor of the latter (e.g., Joe et al., 1998; 81

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Melnick et al., 2001). Studies that examined PR and DH as dependent variables usually used cross-sectional data, with PR and DH measured at the same point in time as their predictors, i.e., the predictors were assessed retrospectively (e.g., Hiller et al., in press; Simpson & Joe, 1993). In accord with previous research, this study is a crosssectional survey, with history variables assessed at the same point in time with PR and DH. Although longitudinal studies exploring changes in PR and DH over time are warranted, especially in the light of the process definition of addictive behavior change, the research on social factors and socialization effects on PR and DH is scarce, therefore, cross-sectional survey design is appropriate. Sample Data were collected from 661 male inmates in four Kentucky State Correctional facilities: Kentucky State Reformatory (KSR) – 330 (50%), Luther Luckett Correctional Complex (LLCC) – 107 (16%), Blackburn Correctional Complex (BCC) – 59 (9%), and Eastern Kentucky Correctional Complex (EKCC) – 165 (25%). Three of these (KSR, LLCC, EKCC) were medium security prisons and one (BCC) was minimum security. Participants were selected for the study three months prior to their review by the parole board to increase the opportunity for conducting a one-year post-release interview. Participants were eligible for the study if they: (1) reported substantial substance use at least 3-5 times per week during the year prior to incarceration; (2) had incurred no violent charges such as rape or homicide; (3) had been scheduled to see the parole board within the next three months; and, (4) had an interest in participating in the study (see Hiller, et al., 2005; Webster, et al., 2005 and Leukefeld et al., 2006 for additional discussions of sampling procedures). Any inmate that met the criteria could be included in the study. Four hundred forty one (67%) of the participants in the study were from general prison population in one of the

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four institutions. While 220 (33%) study participants were residents in prison-based substance abuse treatment program – 6-months therapeutic community at the Kentucky State Reformatory (KSR) – at the time of the interview. Ninety nine percent of the sample reported prior use of alcohol, 98% marijuana use, 81% cocaine use, 59% hallucinogens use, 57% sedatives use, 47% amphetamines use, 41% opiates use, and about 96% reported use of multiple substances. The average length of reported regular use (i.e., an average of three times per week) ranged from 9 years for alcohol and marijuana, 7 years for multiple substances use, 3 years for cocaine, sedatives, amphetamines, and opiates, and about a year for hallucinogens (a more detailed sample description is provided in Ch. 5). Procedure Potential participants from the general prison population as well as prison-based substance abuse treatment program were identified on a monthly basis between January 1998 and October 1999 from lists of inmates scheduled to go before the parole board within the subsequent 3 months. All of the inmates on these lists were sent letters informing them of the purpose of the study and a time for a general eligibility screening. Group screenings were administered to determine individual eligibility, to answer questions about the study, and to obtain agreement to participate in the study. Screenings consisted of a four-page questionnaire to ascertain eligibility and interest and took approximately ten minutes to complete. A total of 2,125 general population inmates were scheduled for parole hearings during the recruitment phase of the project and each was sent a study recruitment letters. About 60% of these inmates came to a screening session and about half of these were eligible to participate. Final refusal rates among eligible prisoners for participating in the study were low (~5%), possibly due to the confidential nature of the interview and monetary compensation of $50 for participation.

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Within two weeks following the screening, eligible participants were interviewed face-to-face in a private setting within the institution by a trained interviewer. Following IRB-approved informed consent procedures, the interviewer asked each question individually and marked participant’s responses directly on the structured interview instrument. Security measures were taken to protect the interviewers, but correctional officers were not present during the interview. Enrollment in the project was voluntary, and confidentiality was strictly maintained. The interview lasted approximately two hours and covered the domains of health, health service utilization, substance use and related issues including problem recognition, desire for help and readiness for treatment, mental health, HIV risk behavior, violence, and spirituality. Major components of the structured interview included the University of Miami Health Services Research Instrument (HSRI; Chitwood, McBride, French, & Comerford, 1999), and the Addiction Severity Index (ASI; McLellan, Kushner, & Metzger et al., 1992). MEASURES OF BACKGROUND CHARACTERISTICS AND SOCIAL RELATIONS VARIABLES The independent and control variables were derived from Addiction Severity Index (ASI, McLellan et al., 1992), and the University of Miami Health Services Research Instrument (HSRI, Chitwood, McBride, French, & Comerford, 1999). Socio-demographic variables (with the exception of rural/urban place of residence), substance use, treatment history, recidivism, and socialization variables were obtained from ASI. Lifetime physical health history was obtained from HSRI. Detailed operational definitions for all independent variables follow the general description of the instruments.

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The Addiction Severity Index The Addiction Severity Index (ASI, McLellan et al., 1992) is a multidimensional diagnostic instrument designed to measure problems in seven areas commonly affected by alcohol and drug abuse: medical status, employment/support, alcohol and drug use, legal status, family/social relationships and history, and psychiatric status. The ASI has been widely used in the evaluation of substance abuse treatment and client outcomes for about 20 years. Its internal reliability within the seven problem areas were .70 and higher, and its composite scores were found to be highly correlated with the clinician severity ratings (average correlation = .88) (McGahan, Griffith, Parente, & McLellan, 1986). The ASI has demonstrated high interrater reliability, ranging from r = .74 to r = .99, and testretest reliability over a 3-day period, ranging from r = .84 to r = .95 (McLellan, et al., 1985). Test-retest reliability over 1-week and 18-day intervals also has been found good (for more detailed review see Leonard, Mulvey, Gastfriend, & Shwartz, 2000). There is evidence of satisfactory concurrent, discriminant, predictive criterion-related as well as construct validity across a range of populations (Leonard et al., 2000). It has been used with diverse client populations including homeless persons, persons with mental illness, inpatient, outpatient and methadone maintenance clients, as well as incarcerated persons. Also, it has been demonstrated that the psychometric qualities of ASI are robust to various routes of administration and various degrees of interviewer training (Leonard et al., 2000). The ASI 5th edition and its scoring manual are publicly available at: http://www.tresearch.org/resources/instruments.htm. The University of Miami Health Services Research Instrument The University of Miami Health Services Research Instrument (HSRI, Chitwood et al., 1999) assesses

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substance use history, lifetime and 12-month health history, and health service utilization. Health service topics in the HSRI include the need for health care, actual health care use, failure to receive needed care, and barriers to utilization. The HSRI has been used to examine the relationship between chronic drug use and the health care system and to assess self-reported health problems (Chitwood et al., 2001; McCoy et al., 2001). Several sections of the HSRI were part of existing instruments, such as Ryan White Health Care Utilization Supplement and the National Health Interview Survey (NHIS), with established validity and reliability. The entire HSRI was pre-tested with ethnically diverse, male and female sample of active injection drug users, other chronic drug users, and individuals who never have used cocaine or opiates (Chitwood et al., 1999). While there have been several articles published from the data obtained through the HSRI, nothing has been published on the psychometric properties of the instrument (M. Comerford, personal communication, January 7, 2005). In the current study the HSRI was used to measure one control variable - lifetime health care problems. Health history in HSRI is assessed by identifying problematic health domains rather than specific health conditions, similarly to the new 1997 redesigned NHIS (National Center for Health Statistics, 2002). Physical health history assessed by HSRI covers 13 domains (reproductive/urinary tract, respiratory, trauma/physical injury, muscle/bone, liver, circulatory, stomach/digestive, nervous system, skin, eye/ear/nose/throat, sexually transmitted diseases, dental, and other physical health problems). Behavioral health history consists of additional 3 domains: alcohol problems, drug problems, and mental health problems. Reliability analysis for the overall 16 health history items with the current sample yielded Cronbach’s alpha of .62. This relatively low reliability of a composite health problems variable is one of the limitations of this study. However, similar composite variables of health problems were used

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in additional University of Kentucky Center on Drug and Alcohol Research studies (e.g., Hiller, et al., 2005; Webster, et al., 2005), and data showed that this health status measure related to health care use measures in a similar fashion as other self-report health status measures (Garrity, Hiller, Staton, Webster, & Leukefeld, 2002). The list of all independent and control variables used in the study and their descriptive statistics are presented in Ch. 5.

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MEASUREMENT OF CONTROL VARIABLES Socio-demographic variables The literature indicates that older age is associated with higher CMRS as well as TCU motivational scores in therapeutic community, community-based residential and outpatient treatment programs, and prison-based sample (Melnick et al., 1997; DeLeon & Jainchill, 1986; Joe et al., 1998; Hiller et al., in press, respectively). Clinical and theoretical hypotheses regarding age-related changes in substance use and criminal behavior include “maturing out” of addiction without treatment and “bottoming out” to seek treatment. In general, older substance users are more likely to have experienced negative consequences of substance use and fatigue with the drug abuse lifestyle, which are likely to affect motivation for substance use behavior change (for review see DeLeon et al., 2000a). Thus, it is important to control for age when exploring other correlates and predictors of problem recognition and desire for help. Additional socio-demographic variables may also be related to motivational variables of substance abuse behavior change process. In outpatient methadone maintenance treatment, being African American was related to lower TCU Problem Recognition (PR) and Desire for Help (DH) scores, while being White was significantly positively correlated with all three TCU Motivational Scales (Simpson & Joe, 1993). Literature also

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suggests that the effects of race/ethnicity on motivation might vary across treatment modalities (DeLeon et al., 2000a). Education and marital status did not appear to be consistently related with motivation for substance abuse treatment in general, and with TCU Scales specifically (Simpson & Joe, 1993; Tsogia et al., 2001). However, having substance using spouse predicted higher PR, but not DH, scores among incarcerated substance abusers (Hiller et al., 2001). The evidence of a relationship between employment status and motivation for treatment is inconclusive. In DATOS, being employed at intake covaried significantly with TCU Treatment Readiness (TR) scale and had positive effects on retention in treatment (Joe et al., 1998). However, being employed also was found to be associated with lower PR among men with drug abuse history (Riehman et al., 2000). Age, race/ethnicity, education, marital status, and employment status were included in the current study in order to follow the standard study protocol for socio-demographics. Rural/urban place of origin has not been explored in many motivation studies. Among incarcerated chronic substance abusers, having a rural place of origin was found to predict lower PR and DH scores (Hiller, et al., in press). In another study, inmates from very rural areas were less likely than inmates from urban areas to have sought treatment. However, this effect did not remain after PR score was entered into the equation (Warner & Leukefeld, 2001). Thus, limited studies that included rural/urban place of origin indicate that rural place of origin might be related to lower motivational scores. Rural/urban place of origin was included in the current study also because of the original focus of the larger project on the effect of the rurality on health services utilization among chronic substance users. Operational definitions of socio-demographic variables: Age was used as a continuous variable - current age in years - as it appears in ASI. Race/ethnicity was used as a

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dichotomous (white/non-white) variable, because all but 17 respondents indicated being either White or African American. Education was measured continuously – years of education. Employment pattern in the three years prior to the current incarceration was dichotomized into “employed” (including full and part time, regular and irregular hours) and “not employed”. Marital status was dichotomized into “single” and “non-single” (including married and cohabiting). Rural/urban place of residence in this study was defined by mapping census tract data to the following question: “What town, county, and state do you consider your home base or permanent residence?” A cut off of less than 50,000 was used to define rural and 50,000 or more for urban home base. Although dichotomous differentiation between rural and urban is not without problems, using this contrast is helpful in beginning to understand the influence of place on substance use-related problems (Conger, 1997). The cut point of 50,000 was derived from the US Census Bureau definition of “metropolitan area”, and has been used in prior research on rural residence and substance use-related issues (Conger, 1997; Leukefeld et al, 2002; Mueser et al, 2001; Warner & Leukefeld, 2001). Substance use variables Primary substance of use and severity of use emerged from the literature as related to various motivational components of addictive behavior change process, in general (e.g., DeLeon & Jainchill, 1986; DeLeon et al, 1997; Downey et al, 2000), and problem recognition and desire for help, specifically (e.g., Joe et al, 1998). For example, the multiprogram Motivational Project found that motivational levels vary across primary substance of use groups and differentially predict retention in treatment (Melnick, 1999). Motivational scores were significantly higher for crack and cocaine abusers compared to marijuana and alcohol abusers, while opiate abusers were in the middle range (DeLeon et al., 2000a). Several studies found

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severity of substance use to be more relevant to motivation than the primary substance used (DeLeon et al., 2000a). Greater drug use severity was consistently associated with higher motivational scores that, in turn, mediated treatment outcomes among therapeutic community residents and probationers in outpatient treatment (Melnick, 1999; Simpson, Joe, & Rowan-Szal, 1997). However, in a study of incarcerated substance abusers, the amount of selfreported illicit drug use in the 6 months prior to incarceration was not found to be related to either PR or DH scores (Hiller et al., in press). The association between problem severity and motivation for behavior change is also being referred to as “hitting bottom” hypothesis (Bell et al., 1998), according to which, a certain level of problem severity is needed for a sufficient level of motivation for change and for action towards that change to occur. Thus, “hitting bottom” and socialization hypotheses can be seen as competing explanations of what affects problem recognition and desire for help the most – problem severity or socializing relationships. Therefore, it is important to control for substance use severity in order to determine whether social relations variables have additional explanatory value. In the present study alcohol and drug use severity or frequency pattern during the last year prior to incarceration was used, resulting in three variables: alcohol use severity, marijuana use severity, and narcotics use severity. The severity of use of alcohol, marijuana and other drugs (“narcotics”) was assessed separately to reflect the three major groups of primary substance of use in this sample (31% of the respondents reported alcohol, 26% marijuana, and 41% reported narcotics use as their major problem). Assessing use severity by substance group takes into account combined effect of both – severity of use and primary substance of use – variables that each separately emerged in the literature as associated with motivational scores.

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Operational definitions of substance use variables:

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Substance use severity variables were measured using ASI items. The frequency of substance use was coded as (0) ‘not used’, (1) ‘1-3 times’, (2) ‘once per month’, (3) ‘2-3 times per month’, (4) ‘once per week’, (5) ‘2-6 times per week’, (6) ‘once per day’, (7) ‘2-3 times per day’, (8) ‘4 or more times per day’. Respondents were asked which pattern best describes their use of each specific substance in the 12 months prior to incarceration. The severity of alcohol use and the severity of marijuana or cannabis use, each were measured by one item, with the score range 0-8. The severity of narcotics use score was obtained from the maximum value of use frequency across 7 drug categories: cocaine, hallucinogens, sedatives, amphetamines, heroin, other opiates and analgesics, and use of multiple substances per day (including alcohol) – score range 0-8. The three measures of the severity of substance use were used as continuous scales. Physical and mental health history Substance abuse leads to serious negative health consequences. Drug users experience a variety of acute and chronic health problems associated with the route of administration (e.g., hepatitis, skin infections, HIV), the length and frequency of drug use (e.g., pulmonary and cardiovascular complications, liver dysfunction, endocrine abnormalities, and infectious diseases), and chronic drug use-related lifestyles (e.g., nutritional deficiencies) (Chitwood et al., 1998, 1999). Self-rated health status is conceptualized as an important predictor of seeking care in the behavioral health services utilization model (Andersen and Newman, 1973), and in the revised model for drug abusing offenders (Leukefeld, Logan, Martin, Purvis, & Farabee, 1998). Therefore, it is customary to include a health problems’ measure when assessing substance userelated problem severity (e.g., ASI, McLellan et al., 1992).

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In addition, empirical evidence suggests that selfreported health problems can predict certain motivational components of addictive behavior change process. Drugrelated health problems or heightened health concerns were significantly correlated with higher DH scores among methadone maintenance clients (Simpson & Joe, 1993). Health problem severity measured by Addiction Severity Index (ASI, McLellan, et al., 1992) was significantly correlated with higher scores on the Help Seeking scale of TMQ (Ryan et al., 1995). Among prison-based program participants, physical health problems predicted higher PR and DH scores (Hiller et al., in press). Overall, the severity of health problems seems to be consistently related to higher motivational levels, indicating that it is an important variable to control for when exploring other factors in problem recognition and desire for help. Co-occurring mental health and substance abuse problems are also a prevalent condition. The hypothesized causal relationships between the two types of conditions include self-medication hypothesis, where psychiatric condition is seen as primary and drug use - as an attempt to alleviate anxiety, depression, or stress. As well as the hypothesis that psychiatric problems are caused by the drug use. Evidence indicates that these paths might vary across different psychiatric conditions as well as different substances of primary use (Blanchard, 2000). These multifaceted interrelationships are likely to affect motivation for change of substance abuse behavior (e.g., DeLeon et al., 2000a; Hiller et al., in press; Melnick, 1999; Ryan et al., 1995), however, their complexity demands a separate study. Primary socialization theory views psychopathology as related to substance use “only when it creates problems in bonding with sources of pro-social norms or increases bonding with deviant socialization sources”. Moreover, it proposes that people, who use drugs to cope with emotional problems, “learned [it] through the primary socialization process, and did not start drug use simply because of their emotional problems” (Oetting, 1999, p. 972). This suggests

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the inclusion of psychopathology factors as control rather than causal variables in the study of problem recognition and desire for help. In sum, psychiatric comorbidity is a separate area of inquiry in the substance abuse field. Assessment of the complex relationships between psychiatric problems and motivation for substance abuse treatment is beyond the scope of the current study. An attempt was made to control for the possible effect of psychiatric problems on PR and DH by including a mental health problems item in the assessment of the overall health problems.

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Operational definition of lifetime health problems variable: Lifetime health problems were measured using the HSRI that assesses health history by identifying problematic health domains rather than specific health conditions. Sixteen physical and behavioral health domains were assessed, including reproductive/urinary tract, respiratory, trauma/physical injury, muscle/bone, liver, circulatory, stomach/digestive, neurological system, skin, eye/ear/nose/throat, sexually transmitted diseases, dental, other physical health problems, alcohol and drug use problems, and mental health problems. Respondents were asked whether they ever experienced problems in a specific health domain, and were provided with the examples of the problems (see Appendix). A composite index consists of sum of the positive responses (score range 0-16). Reliability analysis yielded alpha = .62, for this specific sample of prisoners. Substance abuse treatment history Due to the chronic and relapsing nature of drug and alcohol abuse, the recovery process is usually characterized by multiple treatment attempts (Leukefeld & Tims, 1988; Tims et al., 2001). Prior substance abuse treatment experience emerged from the literature review as a significant predictor of subsequent treatment seeking and

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entry (Tsogia et al., 2001). In most studies it was linked with some success in treatment, such as certain periods of abstinence (DeLeon et al., 2000a; Tsogia et al., 2001). Moreover, general treatment history for any kind of problem increased the likelihood of entering treatment for drinking problems (Weisner, 1993). According to primary socialization theory, establishing relationship with such secondary socialization sources as health services, and perceiving that these services can meet one’s needs create an environment conducive for further positive interactions between the individual and health services (Oetting, 1999) and, thus, may influence motivation to seek help for one’s substance abuse problems. Therefore, it is important to control for treatment history when exploring socialization effects on problem recognition and desire for help.

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Operational definition of substance abuse treatment history: Substance abuse treatment history was assessed as lifetime incidents of being treated for drug or alcohol abuse, excluding incidents that were detoxification only. The measure was derived from two ASI items: “How many times in your life you have been treated for 1- alcohol abuse, 2- drug abuse? (count any type of alcohol or drug treatment, including detoxification, halfway houses, inpatient, outpatient counseling, and AA or NA if 3 or more sessions within one month period)” and “ How many of these were detox only 1- alcohol, 2- drug?”. The final individual score was derived by summing up the reported treatment incidents for alcohol and drug abuse and subtracting detox only incidents. Criminal history Criminal history or recidivism can provide an indication of the breadth and the severity of individual’s deviant behavior. During imprisonment individuals are exposed to the inmate culture and values that are in conflict with those

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of the normative society (Winfree et al., 1992; Lawson et al., 1996), and therefore, not conducive to addictive behavior change (Wexler, 1994). On the other hand, lifetime arrests and incarcerations can be indicators of problem severity and “hitting bottom”, and therefore, increase the likelihood of problem recognition and desire for help. Criminal history, beyond having a legal referral to treatment, had not received much attention in the motivation for substance abuse treatment literature. Lifetime arrests were found to covariate significantly with TR and to decrease the likelihood of retention in treatment (Joe et al., 1998). In another study, lifetime incarcerations had a direct positive effect on motivation-participation interaction, indicating that the relationship between criminal history and relapse is, at least in part, mediated by motivation (Melnick et al., 2001). Also, being recruited for the study from jail, rather than emergency room or STD clinic, was associated with higher motivation for men, indicating that, for men, the involvement with criminal justice system can be an important motivator to change their drug use (Riehman et al., 2000). Operational definition of recidivism: In the present study recidivism was measured as a number of times individual was incarcerated after a conviction as an adult. The measure was derived from ASI. Summary of all independent variables to be controlled for prior to exploring the effects of social relations variables on PR and DH is presented in Table 4.1. Descriptive statistics for all independent variables are presented in Chapter 5.

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Table 4.1. Summary of control measures. Variable

Measurement scale

Socio-demographic Age Race-ethnicity Home-base Education Employment Marital status

Years of age White / Non-white Rural / Urban Years of education Employed / Unemployed Single / Married & cohabiting

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Substance use severity/frequency 1 year prior to incarceration Alcohol Marijuana Narcotics

Range 0-8: (0) not used, (1) 1-3 times, (2) once per month, (3) 2-3 times per moth, (4) once per week, (5) 2-6 times per week, (6) once per day, (7) 2-3 times per day, (8) 4 or more times per day

Health history Lifetime health problems

Range 0-16: (0) no problems – (16) problems in 16 health domains

Treatment history For substance abuse

Number of treatment incidents (detox excluded)

Recidivism

Number of incarcerations after conviction as an adult

MEASUREMENT OF SOCIAL RELATIONS VARIABLES Variables defining primary socialization sources, such as family and peers, are of the primary interest in this study. Within the framework of primary socialization theory, the characteristics of socialization sources, such as deviance and/or substance abuse history, and the quality of the relationships with them, as indicated by the level of conflict and cohesion, are conceptualized as main factors influencing socialization outcomes, such as substance abuse behavior and its change (Oetting, 1999). According

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to the theory, primary socialization sources in adulthood include family of origin, marriage partner, workplace, and peers (Oetting, 1999). Workplace as a socialization source may not be very relevant in the sample of incarcerated men. Moreover, only data on conflict with co-workers and no data on their substance use and cohesion with them were available in this study. Therefore, this study focused on characteristics of the relationships with family members and peers. The rationale for exploring parental and sibling variables separately is discussed on p.103 of this section. Sexual partner as a socialization source substituted for the concept of marriage partner. The empirical literature supports the importance of such primary socialization sources as family and peers in the process of change. The degree of family and peer deviance and the level of family dysfunction consistently emerge as important predictors of treatment progress and outcomes alongside with motivation variables (e.g., Broome et al., 1997; Simpson & Joe, 1993) (see Table 3.3, for overview of studies). The relationships between motivation and social variables, however, have rarely been explored. Some evidence suggests indirect relationship of family dysfunction and peer deviance with problem recognition, desire for help, and treatment readiness (Griffith et al., 1998). Conversely, other findings indicate that motivational variables might be mediating the relationship between social relations and treatment process variables (Broome et al., 1997). A direct relationship of higher levels of family and peer deviance and dysfunction with problem recognition, desire for help and treatment readiness was observed in adolescent and adult samples (Broome et al., 2001; Simpson & Joe, 1993, respectively). Family and peer deviance measures reported in the literature usually included items on substance abuse and criminality (e.g., Simpson & Joe, 1993; Broome et al., 2001). Family functioning was usually defined by composites of items on family conflict and/or cohesion (e.g., Broome et al., 1997; Constantini et al., 1992; Griffith et al., 1998; Knight &

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Simpson, 1996). In addition, at least one study included separate measures of family and peer relation problems derived from ASI (Simpson & Joe, 1993). In accord with the above cited conceptual and empirical literature, composite measures of family history of substance abuse as an indicator of deviance, family and peer relations problems as indicator of conflict, and close relationships with family and peers as indicator of cohesion were created for the purpose of this study. Family deviance was measured as a composite score of 14 ASI items on serious drug and alcohol problems experienced by paternal and maternal grandparents, biological aunts and uncles, parents, and siblings. Separate composite measures were calculated for alcohol and drug abuse, reliability analyses yielded alpha of .62 for alcohol and .54 for drug abuse by family members (see Table 4.2). Conflict with family and peers was measured by 9 ASI items on having had significant periods in which a respondent experienced serious problems in getting along with mother, father, siblings, sexual partner/spouse, children, other significant family, close friends, neighbors, and co-workers (alpha = .54). Cohesion with family and peers was measured by a composite score of 6 ASI items on having had close, long lasting relationships with mother, father, siblings, sexual partner/spouse, children, friends (alpha = .39). Therefore, due to relatively low reliability coefficients of the composite measures, per item correlations with problem recognition (PR) and desire for help (DH) were explored to determine whether it would be appropriate to use separate items rather than the overall composites in prediction models (see Table 4.3). Only siblings drug and alcohol use items were consistently significantly correlated with PR and DH. Items on conflict with mother, siblings, sexual partner, and friends were significantly correlated with PR, but conflict with sexual partner was the only item correlated with DH. Close relationship with friends was the only cohesion item significantly correlated with PR and DH. The lack of significant correlations of PR and DH with

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parental substance abuse, conflict and cohesion items is surprising in the light of theory and prior research findings. In order to keep the models consistent with primary socialization theory and empirical findings on family and peer factors in motivation for substance abuse treatment, parental items were included in the study. Table 4.2. Reliability coefficients and descriptive characteristics of family substance abuse, and conflict and cohesion with family and peers composites.

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Statistics

Reliability coefficients Alpha Standardized alpha Descriptives M SD Range a

Family alcohol a abuse

Family drug a abuse

Conflic t with family and b peers

Cohesion with family and c peers

.62 .63

.54 .63

.54 .54

.39 .39

2.61 2.08 0-12

1.34 1.45 0-10

2.40 1.71 0-8

3.48 1.17 0-5

b

Note. N of cases = 643, N of variables = 12. N of cases = 646, N c of variables = 8. N of cases = 600, N of variables = 5.

The effects of siblings on motivation for change have not been explored in prior research with adult substance abusers, nor have they been outlined in the primary socialization theory formulations by Oetting (1999) and associates. However, analyses of substance abusers’ families indicate that siblings might have a unique impact on family dynamics contributing to one’s substance abuse behavior (e.g., Kaufman, 1981). It is possible that substance abuse by siblings, as well as conflict and cohesion with siblings, might affect one’s motivation for change in a different pattern than characteristics of

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relationships with parents and their substance abuse. Although sometimes compared to peers in studies with adolescents (e.g., Oetting & Beauvais, 1987), siblings cannot be safely assumed to have similar influence as peers have on one’s substance use behavior, because they are not selected as peers (Kandel, 1996). Therefore, parental, sibling and peer variables pertaining to deviance, conflict and cohesion were explored separately. Operational definitions of deviance of primary socialization sources: The level of parental deviance was defined as parental substance abuse. Parental substance abuse was measured by 4 ASI items pertaining to whether mother or father had ever experienced problems with drugs or alcohol that did or should have led to treatment. A sum of positive responses (maximum possible score = 4) was dichotomized into 0 – ‘neither of the parents ever had drug or alcohol problem’, and 1 – ‘at least one of the parents have had drug or alcohol problem’, to avoid problems associated with deviation from normal distribution. The level of siblings’ deviance was defined as siblings’ substance abuse. It was measured as a composite of 8 ASI items pertaining to whether brother 1, brother 2, sister 1 and sister 2 had ever experienced problems with drugs or alcohol that did or should have led to treatment. A sum of positive responses (maximum possible score = 8) was then dichotomized into 0 – ‘neither of the siblings ever had drug or alcohol problem’, and 1 – ‘at least one of the siblings have had drug or alcohol problem’, to avoid problems associated with deviation from normal distribution. Data on substance abuse by sexual partner and peers was not available in this study. However, given that only 18% of the sample were married, it seemed appropriate to include an item of living with someone who has alcohol and/or drug problem as an indicator of exposure to deviant primary socialization sources instead.

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Table 4.3. Pearson correlations of family substance abuse, family and peer conflict and cohesion items and composite scores with Problem Recognition (PR) and Desire for Help (DH). Social relations variables PR DH Family members with history of alcohol abuse (1-yes, 0-no): .041 .050 Maternal grandmother -.009 .009 Maternal grandfather .025 .011 Mother .050 .010 Maternal aunt -.042 -.012 Maternal uncle .002 .034 Paternal grandmother -.037 .013 Paternal grandfather -.011 .038 Father -.032 -.020 Paternal aunt .074 .111*** Paternal uncle .094* .081* Brothers (at least one=1) .116*** .140**** Sisters (at least one=1) .054 .093* Composite score Family members with history of drug abuse (1-yes, 0-no): -.006 .000 Maternal grandmother -.011 .000 Maternal grandfather -.028 -.014 Mother .000 .004 Maternal aunt -.036 .010 Maternal uncle -.055 -.044 Paternal grandmother .012 .014 Paternal grandfather .030 .035 Father -.014 -.022 Paternal aunt -.023 .019 Paternal uncle .093* .106*** Brothers (at least one=1) .105** .084* Sisters (at least one=1) .041 .068 Composite score Note. * p < .05, ** p < .01, *** p < .005, **** p < .0005 (2-tailed).

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Table 4.3 (continued). Pearson correlations of family substance abuse, family and peer conflict and cohesion items and composite scores with Problem Recognition (PR) and Desire for Help (DH). Social relations variables Problems getting along with: Mother Father Siblings Sexual partner Other significant family members Friends Neighbors Co-workers Composite score Close relationship with: Mother Father Siblings Sexual partner Friends Composite score

PR

DH

.088* -.001 .134*** .123*** .059 .111*** .072 .015 .159****

.055 -.019 .051 .091* .020 .036 .050 -.022 .073

-.011 .036 -.037 .026 -.156**** -.064

-.022 .024 .030 .046 -.138**** -.037

Note. * p < .05, ** p < .01, *** p < .005, **** p < .0005 (2-tailed).

Living with a substance abuser was measured as a combined score of two ASI items: ‘when you were not incarcerated, did you usually live with anyone who 1) had alcohol problem, 2) used non-prescribed drugs?’ (dichotomized into 0 – ‘no’ and 1 – ‘lived with someone who had at least one of the problems’). This variable pertained to family of origin (19% of the sample indicated living with parents or other family members 3 years prior to the current incarceration), sexual partner (46%), friends (3%), and any other living arrangements. Comparable data on peer substance abuse history was not available.

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Operational definitions of conflict with primary socialization sources: Conflict with parents was defined by two ASI items pertaining to whether a respondent had significant periods in which he experienced serious problems in getting along with mother or father. The composite score was dichotomized into 0 – ‘no’ and 1 – ‘had problems with at least one of the parents’. Conflict with siblings was measured by one ASI item “have you had significant periods in which you experienced serious problems getting along with brothers/sisters?” (0 – ‘no’, 1 – ‘yes’). Conflict with sexual partner was measured by one ASI item “have you had significant periods in which you experienced serious problems getting along with sexual partner/spouse?” (0 – ‘no’, 1 – ‘yes’). Conflict with peers was measured by one ASI item “have you had significant periods in which you experienced serious problems getting along with close friends?” (0 – ‘no’, 1 – ‘yes’). Operational definitions of cohesion with primary socialization sources Cohesion with parents was defined by two ASI items pertaining to whether a respondent would say that he have had close, long lasting relationship with mother or father. To ensure that mutual responsibility and closeness exists, respondents were asked whether they value the person beyond self-benefit, and whether they work to maintain the relationship. The composite score was dichotomized into 0 – ‘no’ and 1 – ‘had close relationship with at least one of the parents’. Cohesion with siblings was measured by one ASI item “have you had close, long lasting relationships with brothers/sisters?” (0 – ‘no’, 1 – ‘yes’). Cohesion with sexual partner was measured by one ASI item “have you had close, long lasting relationship with sexual partner/spouse?” (0 – ‘no’, 1 – ‘yes’). Cohesion with peers was measured by one ASI item “have you had close, long lasting relationships with friends?” (0 – ‘no’, 1 – ‘yes’).

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Summary of all social relations variables and their measurement scales is provided in Table 4.4. Descriptive statistics of social relations variables in the current study sample are presented in chapter 5.

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Table 4.4. Summary of social relations measures. Variable Deviance indicators Parental substance abuse Sibling substance abuse Living with substance abuser (includes alcohol and/or drug use) Conflict with Parents Siblings Sexual partner Peers Cohesion with Parents Siblings Sexual partner Peers

Measurement scales Dichotomous: Yes (at least one parent) / No Yes(at least one sibling) / No Yes / No Dichotomous: Yes (at least one parent) / No Yes(at least one sibling) / No Yes / No Yes / No Dichotomous: Yes (at least one parent) / No Yes(at least one sibling) / No Yes / No Yes / No

TCU MOTIVATIONAL ASSESSMENT SCALES A set of motivational scales has been developed by the Texas Christian University (TCU) Institute of Behavioral Research team in an effort to improve the CMRS scales by revising them according to the Transtheoretical Model as well as psychometric properties, and to expand their scope of use for application in outpatient treatment settings, specifically, methadone maintenance clinics (Simpson & Chatham, 1995; Simpson & Joe, 1993). The TCU scales were designed to reflect sequential stages of cognitive movement, from recognition to acceptance of the need to change, paralleling precontemplation, contemplation, and action stages in the Transtheoretical Model (Simpson & Joe, 1993).

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The TCU Motivational Assessment includes three scales: Problem Recognition (PR), Desire for Help (DH), and Treatment Readiness (TR). Only PR and DH scales were used in the present study, because TR represents specific commitments to formal treatment and, therefore, is not applicable with non-treatment sample. PR consists of nine items that examine different types of problems and external pressures attributed to drug abuse. Sample item is “Your drug use is more trouble than it’s worth”. DH includes seven items that address general interest in getting help for dealing with drug problems. Sample item is “You want to get your life straightened out” (Simpson & Joe, 1993). Each item in the two scales is rated on a 5-point Likert scale that can be based either on frequency of occurrence (never, rarely, sometimes, often, always), or on degree of agreement (strongly disagree, disagree, undecided, agree, strongly agree), with some items reverse scored. The theoretical structure and psychometric properties of the scales are maintained with both response formats (TCU, 1998). The present study used frequency of occurrence scores. The composite score for each scale is derived by calculating the mean score of all items in the scale: a sum of scores on all items is divided by the number of items. Higher values reflect higher degree of problem recognition and greater desire for help. Internal reliability estimates obtained from three samples of clients (total N=311) have been reported by Simpson and Joe (1993). Coefficient alphas for the PR scale ranged from .87 to .90, demonstrating high internal consistency. Alpha coefficients ranged from .72 to .79 for the DH scale. The test-retest reliability was tested with a sample of 44 substance abusing probationers, 8-10 days apart. The test-retest reliability coefficients were .54 for PR, and .74 for DH (Knight, Holcom, & Simpson, 1994). In addition, based upon its significant prediction of treatment engagement indicators, DH also has adequate construct validity (Joe et al., 1999; Joe et al., 2002). Confirmatory factor analyses supported single factor solutions for both scales (Simpson & Joe, 1993), although

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Table 4.5. Descriptive statistics, item-total correlations, and coefficient alphas of TCU Problem Recognition and Desire for Help scales. Scale/Items

M

SD

Problem Recognition (PR): alpha = .89 In your opinion your drug use – Was a problem for you Was more trouble than it was worth Caused problems with the law Caused problems in thinking or work Caused problems with family or friends Caused problems in finding or keeping a job Caused problems with your health Caused your life to become worse and worse Was going to cause your death Desire for Help (DH): alpha = .85 You needed help in dealing with your drug use It was urgent that you find help immediately for your drug use You were tired of the problems caused by drugs You would have given up your friends and hangouts to solve your drug problems You could have quit using drugs without R any help Your life went out of control You wanted to straighten your life out

2.02

1.11

Itemtotal r --

1.87 2.05 2.51 1.99 2.42

1.54 1.55 1.45 1.44 1.38

.67 .62 .55 .71 .65

1.62 1.40

1.59 1.42

.55 .64

2.44 1.87 1.92

1.53 1.71 1.14

.77 .67 --

1.86

1.64

.78

1.19

1.50

.73

2.06

1.65

.79

1.36

1.59

.63

2.00 2.17 2.79

1.74 1.53 1.36

.61 .44 .33

Note. N=652 for PR, N=654 for DH. Range of scores is 0–4, from R ‘never’ (0) to ‘always’ (4). Reverse scored item, i.e. the score has been reflected so that a smaller number indicates more agreement with the statement and, therefore, more desire for help.

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subsequent analyses for DH found some residual variation between the variables (Joe et al., 2002). Based on principal components analyses, DH can be considered unidimensional (Joe et al., 2002). The PR and DH scales intercorrelated at the r = .58 level (Simpson & Joe, 1993). The scores of the two scales tend to be reported separately in the literature, for they represent two distinct, though interrelated, stages in the behavior change process. Accordingly, in the present study each TCU motivational scale was treated as a separate dependent variable. In the present study PR and DH scales were used in their entirety. Internal consistency alphas for the present sample were .89 (PR) and .85 (DH). The descriptives, alpha coefficients and item-total correlations for both scales are presented in Table 4.5. The instrument was modified for the current study to word the questions in past rather than present tense, to reflect respondents’ experiences during the year prior to incarceration. DATA ANALYSIS STRATEGY In the first step of data analysis the sample was described across the set of independent variables. In the second step, bivariate relationships of the independent variables with PR and DH were explored to find the most parsimonious and relevant set of predictors. This is a customary analytic approach to screening data in the model building phase of multivariate analysis (Tabachnick & Fidell, 2000). Pearson correlations were calculated with continuously as well as categorically measured independent variables in this exploratory step prior to proceeding with regression analyses, as dichotomized variables were all coded in the scale of 0 to 1. At this step there were no a priori adjustment of the significance level, in spite of multiple comparisons, for this was an exploratory step of data analysis. At the final step, two hierarchical multiple regression models were tested. Separate analyses were run for each of the dependent variables: Problem Recognition

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(PR) and Desire for Help (DH) – with the same set of predictors. In order to have sufficient power for the analysis to detect significant effects where they exist, the general rule of thumb is to have at least 15 cases per predictor for the hierarchical models, and 45 cases per predictor for sequential regression models (Stevens, 1996). Hierarchical models are more powerful, because the order in which predictors enter the model is determined based on theory and prior research findings. This study used hierarchical regression models with blocks of predictors entering the model in predetermined order, while the variables within the block were entered simultaneously. For the sample of 661, twenty predictors result in about 33 cases per predictor. Thus, a priori power analysis indicated sufficient power to detect existing effects, given that a combination of hierarchical and sequential entries was used. Predictors already established in the literature, such as substance use severity, were entered into regression equations before the exploratory variables. Also, in order to observe some causal sequence, symptom indicators were entered before treatment history variables, and substance abuse indicators by primary socialization sources were entered before conflict and cohesion variables. Thus, sociodemographic variables entered the equation as a block in the first step to control for any variance they might account for in motivation. Substance use variables entered on the second step. Health history was entered in the third step, followed by treatment history variables in the fourth step, and criminal history in the fifth step. Substance abuse by primary socialization sources, as well as conflict and cohesion with them are the exploratory variables in this study. Because substance abuse by family members is frequently conceptualized as predisposing one for substance use and also might affect the quality of the relationships with these family members, substance abuse variables were entered first, as a block in the sixth step. Conflict and cohesion items were entered into the

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regression equation simultaneously at the seventh step, to test their unique contribution to the variance in motivation. Entering socialization variables into the regression equation as the last two blocks, rather than the first blocks, provides a more conservative test of their additional explanatory power of PR and DH after controlling for other previously identified predictors. Thus, this study did not aim to only explore whether these specific socialization factors can predict PR and DH, but whether these factors have something to add to the explanation of PR and DH by already established predictors. Study hypotheses Deviance, conflict and cohesion items were expected to add significantly to the explanation of variance in PR and DH after controlling for personal background characteristics. Substance abuse by parents, siblings and living with a substance abuser were expected to predict lower PR and DH scores, as these variables were conceptualized as indicators of deviance of primary socialization sources. Close relationships with parents, siblings, sexual partner and friends were expected to predict higher PR and DH scores, as they were conceptualized as indicators of normative, pro-social relationships that are more likely to support substance abuse behavior change. It was more difficult to hypothesize about the effects of conflict with primary socialization sources on PR and DH. From primary socialization standpoint, conflict can be seen as an indicator of less normative relationships and, thus, to be expected to predict lower PR and DH scores. On the other hand, conflict can be seen as indicator of problem severity and, thus, to be expected to predict higher PR and DH scores.

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CHAPTER 5

Social Relations and Motivation for Substance Abuse Treatment in the Sample of Prisoners

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Baseline data were collected from 661 male prisoners in four state prisons. Descriptions of sample selection and study procedures are presented in chapter 4. SAMPLE DESCRIPTION Personal background characteristics / control variables Overall sample description across the control and socialization variables is presented in Tables 5.1 and 5.2. The sample was predominantly white (53%), with 40% being from a rural residence. The average age was 31 years (SD = 8.3). Participants reported an average of 12 years of education (SD = 1.8), with 67% reporting they had either a high school diploma or a GED. Of the total sample, 18% were married and 82% were single, divorced or widowed. About 35% of the sample were unemployed, 20% had held part-time jobs, and 45% had held full-time jobs three years prior to their current incarceration. The average frequency pattern of marijuana and alcohol use a year prior to incarceration was about 2-6 times per week, with alcohol 111 Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

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use tending to be slightly more frequent. The average frequency pattern of narcotics was slightly less than once per day. Respondents reported an average of 2.4 (SD = 4.5) substance abuse treatment attempts, excluding detoxification incidents. On average, study participants reported lifetime health problems in about 5 out of 16 health domains (SD = 2.2). The average number of incarcerations as an adult was 5 (SD = 11).

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Table 5.1. Descriptive statistics for control variables. Variables Socio-demographic Age M(SD) Race: White Count(%) Non-white Count(%) Home base: Rural Count(%) Urban Count(%) Education (years) M(SD) Employment: Employed Count(%) Unemployed Count(%) Marital status: Single Count(%) Married Count(%) Substance use severity/frequency a Alcohol M(SD) a Marijuana M(SD) a Narcotics M(SD) b Lifetime health problems M(SD) Substance abuse treatment incidents M(SD) Recidivism: Lifetime incarcerations M(SD)

Descriptive statistics 31.42 (8.25) 349 (53) 312 (47) 264 (40) 391 (60) 11.58 (1.81) 428 (65) 229 (35) 543 (82) 117 (18) 5.34 (2.43) 4.94 (3.12) 5.84 (2.53) 4.95 (2.19) 2.37 (4.49) 5.02 (10.97)

Note. N varies from 661 to 644 due to missing data. a Range 0-8: (0) not used, (1) 1-3 times, (2) once per month, (3) 2-3 times per moth, (4) once per week, (5) 2-6 times per week, (6) once per day, (7) 2-3 times per day, (8) 4 or more times per day. b Range 0-16: (0) no problems, (16) problems in 16 health domains.

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Primary socialization characteristics / social relations variables Slightly more than half of the sample (52%) reported having at least one parent who experienced a substance abuse problem that led or should have led to treatment (Table 5.2). The majority of the sample (56%) reported having at least one sibling with substance abuse problem. Slightly less than half of the sample (46%) reported that when they were not incarcerated they usually lived with someone who had an alcohol and/or drug problem. Table 5.2. Descriptive statistics for social relations variables.

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Variables Deviance indicators Parental substance abuse Sibling substance abuse Living with substance abuser Conflict with Parents Siblings Sexual partner Peers Cohesion with Parents Siblings Sexual partner Peers

Yes Count (%)

No Count (%)

343 (52) 370 (56) 305 (46)

317 (48) 291 (44) 354 (54)

410 (62) 223 (34) 312 (47) 185 (28)

251 (38) 434 (66) 349 (53) 474 (72)

574 (87) 502 (78) 506 (78) 456 (71)

87 (13) 144 (22) 141 (22) 188 (29)

Note. N varies from 661 to 644 due to missing data.

The majority of the sample (62%) reported conflict, i.e. experiencing serious problems in getting along, with at least one of the parents. About one third of respondents (34%) reported conflict with siblings, 47% reported conflict with sexual partner, and 28% reported conflict with peers.

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Majority of the sample reported cohesion, i.e. close, long lasting relationships, across all of the primary socialization categories. Eighty seven percent (87%) reported cohesion with parents, 78% - with siblings and sexual partner, and 71% reported cohesion with peers.

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BIVARIATE RELATIONSHIPS WITH PROBLEM RECOGNITION AND DESIRE FOR HELP Pearson correlations of all independent variables with Problem Recognition (PR) and Desire fir Help (DH) are presented in Table 5.3. Correlations were used to explore bivariate relationships with PR and DH for continuous as well as dichotomous variables at this preliminary stage of data analyses that led to the regression models. All dichotomous variables were coded on the scale of 0 to 1; therefore, it was appropriate to use correlations. Personal background characteristics / control variables Age was significantly positively related to PR and DH (r = .2 and r = .24, respectively, p < .0005) (Table 8, p. 120). Race and home base were significantly related to DH (r = .12, p < .005, and r = -.1, p < .05, respectively), but not PR, with non-white and urban respondents expressing more desire for help. Education and employment were not significantly related to either PR or DH. Marital status was significantly related to PR and DH (r = -.1, p < .05 for both), with married respondents being more likely to score higher on both measures. Severity of alcohol use was significantly correlated with PR (r = .12, p < .005), but not DH. Severity of marijuana use was significantly correlated with both PR and DH (r = -.18 and r = -.27, respectively, p < .0005). Severity of narcotics use was also significantly related to both measures (r = .25, p < .0005 for PR and r = .1, p < .05 for DH). While more frequent use of alcohol and narcotics was related to higher PR and DH scores, for marijuana use the relationship was reversed: more frequent users tended to report lower PR and DH. Reporting more lifetime health problems was significantly related to higher

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PR and DH scores (r = .3 and r = .26, respectively, p < .0005). Having been in substance abuse treatment more times was also significantly related to higher PR and DH scores (r = .24 and r = .2, respectively, p < .0005). As was the number of lifetime incarcerations (r = .16 for PR and r = .18 for DH, p < .0005). In sum, in this sample of incarcerated male chronic substance users, being older, married, not frequent marijuana user, frequent narcotics user, having more health problems, having been in substance abuse treatment more times, and having been incarcerated more times was related to higher levels of problem recognition and desire for help. Primary socialization characteristics Parental substance abuse, i.e. having at least one parent who has experienced a substance abuse problem that led or should have led to treatment, was not significantly related to PR and DH (Table 5.3). Sibling substance abuse was significantly related to both measures (r = .17 for PR and r = .15 for DH, p < .0005), with those having at least one sibling with a substance abuse problem scoring higher on PR and DH. Living with a substance abuser prior to incarceration was significantly related with higher PR (r = .15, p < .0005), but not DH scores. Conflict with parents was not significantly related to either PR or DH. Conflict with siblings, sexual partner, and peers were all significantly related to higher PR scores (r = .13, r = .12, r = .11, respectively, p < .005). However, only conflict with sexual partner was significantly related to higher DH scores (r = .1, p < .05) as well. Among cohesion variables, only cohesion with peers was significantly related to PR and DH (r = -.16 and r = -.14, respectively, p < .0005), with those reporting close peer relationships tending to report lower PR and DH scores.

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Table 5.3. Pearson correlations of independent variables with Problem Recognition (PR) and Desire for Help (DH). Independent variables PR DH Socio-demographic .239*** Age (years) .200*** -.121** Race-ethnicity (1=white, 0=non-white) .018 -.095* Home base (1=rural, 0=urban) -.073 -.050 Education (years) -.076 .057 Employment (1=employed, 0=unemployed) .005 -.104* Marital status (single=1, 0=non-single) -.097* Substance use severity/frequency a .019 .124** Alcohol a -.181*** -.270*** Marijuana a .086* .252*** Narcotics b .258*** .299*** Lifetime health problems Treatment history .206*** .239*** Substance abuse treatment incidents c .214*** .270*** Substance abuse treatment incidents (log) Recidivism .177*** .158*** Lifetime incarcerations c .210*** .230*** Lifetime incarcerations (log) Deviance indicators .001 .037 Parental substance abuse (1=yes, 0=no) .154*** .171*** Sibling substance abuse (1=yes, 0=no) .030 .148*** Living with substance abuser (1=yes, 0=no) .019 .025 Conflict with: Parents (1=yes, 0=no) .051 .134** Siblings (1=yes, 0=no) .091* .123** Sexual partner (1=yes, 0=no) .036 .111** Peers (1=yes, 0=no) -.017 -.003 Cohesion with: Parents (1=yes, 0=no) .030 -.037 Siblings (1=yes, 0=no) .046 .026 Sexual partner (1=yes, 0=no) -.156*** -.138*** Peers (1=yes, 0=no) Note. N varies from 658 to 639 due to missing data. *p < .05, ** p < a .005, *** p < .0005. Range 0-8: (0) not used - (8) 4 or more times b per day. Range 0-16: (0) no problems, (16) problems in 16 health c domains. Logarithmic transformation of the variable to reduce skewness.

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In sum, having at least one sibling with serious substance abuse problem, experiencing conflict with sexual partner, and not having close peer relationships was related to higher levels of problem recognition and desire for help. In addition, living with substance abuser, and experiencing conflict with siblings and peers was related to higher levels of problem recognition, but not desire for help. MULTIPLE REGRESSION RESULTS Two hierarchical multiple regressions were employed to determine whether addition of information regarding deviance of primary socialization sources, and conflict and cohesion with them improves prediction of Problem Recognition (PR) and Desire for Help (DH) beyond that afforded by differences in sociodemographic characteristics, substance use history, health problems, treatment history, and recidivism – predictors established in prior research. Analyses were performed using SPSS software. Both dependent variables seem to be normally distributed (see central tendency statistics in Table 4.5), although regression analysis is robust to slight deviations from normality. Logarithmic transformations were applied to two independent variables: substance abuse treatment history and recidivism – to reduce skewness (Tabachnick & Fidell, 2000). A correlation matrix was used to explore intercorrelations between the independent variables. None of the independent variables correlated at r = .8 or higher. The largest correlation was between age and severity of marijuana use (r = -.40). Collinearity diagnostics showed no evident multicolinearity: none of the tolerances in both PR and DH models approached zero, and although the last root in both models had a condition index above 30, no dimension had more than one variance proportion greater than .50 (Tabachnick & Fidell, 2000). No multivariate outliers among the cases were identified using a p < .001 criterion for Mahalanobis distance. All standardized residuals were < 3 in PR model. One case had a

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standardized residual > 3 in DH model, but, with Cook’s distance < 1, it did not seem to be an influential data point. For both, PR and DH, the histogram and the scatterplot of standardized residuals indicated that the assumptions of normal distribution and constant variance of standardized residuals were reasonably met. For both, PR and DH, the pp plot of standardized residuals suggested that the overall set of assumptions have been met. Education, employment and marital status variables were eliminated from the list of predictors based on the lack of significant bivariate relationships with PR and DH (see Table 5.3), in order to limit the number of predictors, as they were not among the variables of primary interest in this study. In order to maintain the integrity of the theoretical model, none of the primary socialization variables were excluded from regression analyses. In sum, after some variable transformations and reduction of the number of predictors, the assumptions for multiple regression analysis appeared to be adequately met for this set of independent variables predicting PR as well as DH. Problem Recognition model The results of multiple regression predicting Problem Recognition (PR) are presented in Table 5.4. Listwise deletion of missing data was used resulting in a sample of 598. Sociodemographic variables were entered into the regression equation first. As a block, sociodemographics accounted for 5.1% of the variance in PR (adjusted R 2 = .04; F (4, 593) = 7.95; p < .0005). Only age had a significant contribution (β = .19; t = 4.79; p < .0005), older age was related to higher PR scores. On step 2, substance use severity variables were added into the regression equation resulting in a significant model, R 2 = .17; adjusted R 2 = .16; F (7, 590) = 17.56; p < .0005. As a block, substance use severity variables added 12.2% to the explanation of variance in PR, after controlling for the variance accounted by sociodemographics. The increment in R 2 was significant (F inc (3, 590) = 28.88, p < .0005).

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Severity of marijuana and narcotics use contributed significantly to the prediction of PR (β = -.22; t = -5.09; p < .0005 and β = .32; t = 7.77; p < .0005, respectively). More frequent marijuana use was related to lower PR scores, while more frequent narcotics use was related to higher PR scores. Alcohol use was not significantly related to PR. After introducing substance use severity variables, home base emerged as significant predictor of PR (β = -.10; t = -2.34; p = .019), reporting rural home base was related to lower PR scores. On step 3 lifetime health problems were entered into the regression equation, adding 4.1% to the explanation of variance in PR (R 2 = .21; adjusted R 2 = .20; F (8, 589) = 19.94; p < .0005). The change in R 2 was significant (F inc (1, 589) = 30.42; p < .0005). Reporting problems in more health domains was related to higher PR scores (β = .22; t = 5.52; p < .0005). After the addition of health problems, contribution of age ceased being significant. On step 4 the logarithmic transformation of substance abuse treatment incidents variable was entered into the regression equation, adding 2.7% to the explanation of variance in PR (R 2 = .24; adjusted R 2 = .23; F (9, 588) = 20.62; p < .0005). The change in R 2 was significant (F inc (1, 588) = 20.72, p < .0005). Attempting treatment more times was related to higher PR scores (β = .17; t = 4.55; p < .0005). On step 5 logarithmic transformation of lifetime incarcerations / recidivism variable was entered into the regression equation, adding 1.0 % to the explanation of variance in PR (R 2 = .25; adjusted R 2 = .24; F (10, 587) = 19.55; p < .0005). The change in R 2 was significant (F inc (1, 587) = 7.78, p = .005). Being incarcerated more times was related to higher PR scores (β = .11; t = 2.79; p = .005). After the addition of recidivism, none of the sociodemographic variables remained significant. On step 6 the first block of the variables of interest – indicators of deviance of primary socialization sources – were entered into the regression equation. The model was significant, R 2 = .27; adjusted R 2 = .25; F (13, 584) = 16.40; p < .0005. As a block, indicators of deviance added

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1.8 % to the explanation of variance in PR, after controlling for the variance accounted for by sociodemographics, substance use severity, health problems, treatment history, and recidivism. The increment in R 2 was significant (F inc (3, 584) = 4.69, p = .003). Having at least one sibling with substance abuse problem and living with someone who has substance abuse problem contributed significantly to the prediction of PR (β = .09; t = 2.55; p = .011 and β = .09; t = 2.44; p = .015, respectively). Parental substance abuse did not contribute significantly to the explanation of variance in PR at this step. The indicators of conflict and cohesion with social relations were entered into the regression equation on the final step. R for regression was significantly different from zero, F (21, 576) = 10.49; p < .0005. Altogether, 28% (25% adjusted) of the variability in PR was predicted by knowing scores on the whole set of 21 independent variables. However the change in R 2 , after introducing conflict and cohesion indicators into the equation, was not significant. Neither of the individual variables in the block contributed significantly to the equation, after controlling for the variance in PR accounted by control variables and deviance of primary socialization sources. On the final step, the model yielded 7 significant predictors of PR: Lower severity of marijuana use (β = -.20; t = -4.70; p < .0005), higher severity of narcotics use (β = .24; t = 5.81; p < .0005), problems in more health domains (β = .16; t = 4.00; p < .0005), more substance abuse treatment attempts (β = .17; t = 4.26; p < .0005), more incarcerations (β = .09; t = 2.28; p < .023), having at least one sibling with significant substance abuse problem (β = .09; t = 2.30; p = .022), and usually living with someone who abuses alcohol, and/or drugs (β = .09; t = 2.35; p = .019) were related to higher problem recognition (see Table 5.4).

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Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

R2 =.21 F inc =30.42*

R2 =.17 F inc =28.88*

R2 =.05 F=7.95*

Model 3 β t 1.61 .07 -.10 -.00 -2.60* -.10 -.05 -1.35 1.85 .07 -5.02* -.21 .28 6.67* .22 5.52*

Model 2 β t 2.87* .12 .03 .71 -.10 -2.34* -.06 -1.53 .08 1.92 -.22 -5.09* .32 7.77*

Model 1 β t 4.79* .19 .05 1.21 -.08 -1.92 -.06 -1.38

F inc =20.72*

R2 =.24

Model 4 β t 1.51 .06 -.83 -.03 -2.19* -.09 -.04 -1.09 1.94 .07 -4.51* -.19 .26 6.37* .19 4.72* .17 4.55*

F inc =7.77*

R2 =.25

Model 5 β t .67 .03 -1.10 -.04 -1.91 -.08 -.98 -.04 1.74 .07 -4.53* -.19 .26 6.40* .19 4.74* .16 4.04 .11 2.79*

F inc =4.69*

R2 =.27

Model 6 β t .60 .03 -1.59 -.06 -1.82 -.07 -.70 -.03 .06 1.66 -.20 -4.71* .24 5.96* .17 4.30* .16 4.27* .09 2.21* -.02 -.45 .09 2.55* .09 2.44*

F inc =.91

Model 7 β t .53 .02 -1.50 -.06 -1.64 -.06 -.69 -.03 .05 1.43 -.20 -4.70* .24 5.81* .16 4.00* .17 4.26* .09 2.28* -.02 -.40 .09 2.30* .09 2.35* .06 .00 1.04 .04 -.49 -.02 .99 .04 1.55 .06 -.39 -.02 -.11 -.00 -1.29 -.05 2 R =.28

relations were coded dichotomously: 1=yes. F inc - F ratio for change in R2 - significance test for the unique contribution of the block of variables.

Note. N=598. * p < .05. SA - substance abuse, w SA – with substance abuser. Variables of substance abuse by and conflict and cohesion with social

Predictors Age (years) Race (1=white) Home (1=rural) Marital (single=1) Alcohol use Marijuana use Narcotics use Health problems SA treatment Recidivism Parent SA Sibling SA Live w SA Conflict/Parents Conflict/Siblings Conflict/Partner Conflict/Peers Cohesion/Parents Cohesion/Siblings Cohesion/Partner Cohesion/Peers

Table 5.4. Hierarchical multiple regression results predicting Problem Recognition scores.

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In sum, overall, the set of 21 predictors accounted for 28% of variance in PR. Control variables accounted for the largest bulk (25%) of variance in PR. The largest increase in R 2 (12%) occurred when severity of substance use variables were entered into the equation, followed by health problems (4%), substance abuse treatment incidents (3%), and substance abuse by primary socialization sources (2%). Conflict and cohesion with primary socialization sources added 1% to the explanation of variance in PR, however, the R 2 change was not significant at this step. In the final model, more severe marijuana use predicted lower PR scores, while more severe narcotics use, health problems across more health domains, more incidents of substance abuse treatment, more incarcerations, having at least one sibling with substance abuse problem, and usually living with a substance abuser predicted higher PR scores. Desire for Help model The results of multiple regression predicting Desire for Help (DH) are presented in Table 5.5. Listwise deletion of missing data was used resulting in a sample of 596. Sociodemographic variables were entered into the regression equation as a first block and accounted for 7.7% of the variance in DH (adjusted R 2 = .07; F (4, 591) = 12.37; p < .0005). Age and race emerged as significant predictors of DH (β = .22; t = 5.60; p < .0005 and β = -.10; t = -2.47; p = .014, respectively). Older age was related to higher DH scores, while identifying as White was related to lower DH scores. On step 2, substance use severity variables were added into the regression equation resulting in a significant model, R 2 = .15; adjusted R 2 = .14; F (7, 588) = 14.40; p < .0005. As a block, substance use severity variables added 6.9% to the explanation of variance in DH, after controlling for the variance accounted by sociodemographics. The increment in R 2 was significant (F inc (3, 588) = 15.86, p < .0005). Severity of marijuana and narcotics use contributed significantly to the prediction of DH (β = -.26; t = -5.95; p < .0005 and β = .19; t = 4.50; p

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< .0005, respectively). More frequent marijuana use was related to lower DH scores, while more frequent narcotics use was related to higher DH scores. Similarly to the PR model, alcohol use was not significantly related to DH. On step 3 lifetime health problems were entered into the regression equation, adding 4.2% to the explanation of variance in DH (R 2 = .19; adjusted R 2 = .18; F (8, 587) = 17.05; p < .0005). The change in R 2 was significant (F inc (1, 587) = 30.56; p < .0005). Reporting problems in more health domains was related to higher DH scores (β = .22; t = 5.53; p < .0005). Similarly to the PR model, after the addition of health problems, contribution of age ceased being significant. On step 4 logarithmic transformation of substance abuse treatment incidents variable was entered into the regression equation, adding 1.9% to the explanation of variance in DH (R 2 = .21; adjusted R 2 = .20; F (9, 586) = 17.06; p < .0005). The change in R 2 was significant (F inc (1, 586) = 14.10, p < .0005). Attempting treatment more times was related to higher DH scores (β = .15; t = 3.76; p < .0005). On step 5 logarithmic transformation of lifetime incarcerations / recidivism variable was entered into the regression equation, adding 1.0 % to the explanation of variance in DH (R 2 = .22; adjusted R 2 = .20; F (10, 585) = 16.29; p < .0005). The change in R 2 was significant (F inc (1, 585) = 7.60, p = .006). Being incarcerated more times was related to higher DH scores (β = .11; t = 2.76; p = .006). On step 6 the first block of the variables of interest – indicators of deviance of primary socialization sources – were entered into the regression equation. The model was significant, R 2 = .23; adjusted R 2 = .22; F (13, 582) = 13.57; p < .0005. As a block, indicators of deviance of primary socialization sources added 1.5 % to the explanation of variance in DH, after controlling for the variance accounted for by sociodemographics, substance use severity, health problems, treatment history, and recidivism. The increment in R 2 was significant (F inc (3, 582) = 3.73, p = .011). Having at least one sibling with substance abuse problem contributed significantly to the

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prediction of DH (β = .12; t = 3.28; p = .001). Parental substance abuse and living with substance abuser did not contribute significantly to the explanation of variance in DH at this step. The indicators of conflict and cohesion with primary socialization sources were entered into the regression equation on the final step. R for regression was significantly different from zero, F (21, 574) = 8.47; p < .0005. Altogether, 24% (21% adjusted) of the variability in DH was predicted by knowing scores on the whole set of 21 independent variables. However the change in R 2 , after introducing conflict and cohesion indicators into the equation, was not significant. Neither of the individual variables in the block contributed significantly to the equation, after controlling for the variance in DH accounted by sociodemographics, substance use severity, health and treatment history, recidivism, and deviance of primary socialization sources. On the final step, the model yielded 7 significant predictors of PR: Identifying as White (β = -.17; t = -3.96; p < .0005), lower severity of marijuana use (β = .24; t = -5.55; p < .0005), higher severity of narcotics use (β = .11; t = 2.67; p = .008), problems in more health domains (β = .19; t = 4.52; p < .0005), more substance abuse treatment attempts (β = .13; t = 3.29; p = .001), more incarcerations (β = .09; t = 2.31; p = .021), having at least one sibling with significant substance abuse problem (β = .13; t = 3.28; p = .001), were related to higher desire for help (see Table 5.5). In sum, overall, the set of 21 predictors accounted for 24% of variance in DH. Control variables accounted for the largest bulk (22%) of variance in DH. The largest increase in R 2 (7%) occurred when severity of substance use variables were entered into the equation, followed by health problems (4%), substance abuse treatment incidents (2%), and substance abuse by primary socialization sources (2%).

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Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

R2 =.19 F inc =30.56*

R2 =.15 F inc =15.86*

R2 =.08 F=12.37*

Model 3 β t 1.75 .07 -3.45* -.14 -1.66 -.07 -1.18 -.04 .56 .02 -5.91* -.26 .14 3.38* .22 5.53*

Model 2 β t 3.02* .13 -.11 -2.58* -.06 -1.42 -.05 -1.34 .03 .67 -.26 -5.95* .19 4.50*

Model 1 β t 5.60* .22 -.10 -2.47* -.06 -1.40 -.06 -1.46

F inc =14.10*

R2 =.21

Model 4 β t 1.67 .07 -4.04* -.16 -1.31 -.05 -.95 -.04 .02 .63 -.24 -5.47* .13 3.09* .20 4.84* .15 3.76*

F inc =7.60*

R2 =.22

Model 5 β t .84 .04 -4.31* -.18 -1.03 -.04 -.84 -.03 .02 .42 -.24 -5.49* .13 3.10* .20 4.86* .13 3.25* .11 2.76*

F inc =3.73*

R2 =.23

Model 6 β t .67 .03 -4.46* -.18 -.98 -.04 -.60 -.02 .02 .39 -.24 -5.51* .11 2.73* .19 4.66* .14 3.47* .10 2.36* -.01 -.33 .12 3.28* .01 .28

F inc =.37

Model 7 β t .62 .03 -3.96* -.17 -.91 -.04 -.48 -.02 .01 .37 -.24 -5.55* .11 2.67* .19 4.52* .13 3.29* .09 2.31* -.02 -.54 .13 3.28* .01 .25 .70 .03 -.28 -.01 -.21 -.01 .12 .01 .67 .03 .76 .03 .43 .02 -1.11 -.04 R2 =.24

relations were coded dichotomously: 1=yes. F inc - F ratio for change in R2 - significance test for the unique contribution of the block of variables.

Note. N=598. * p < .05. SA - substance abuse, w SA – with substance abuser. Variables of substance abuse by and conflict and cohesion with social

Predictors Age (years) Race (1=white) Home (1=rural) Marital (single=1) Alcohol use Marijuana use Narcotics use Health problems SA treatment Recidivism Parent SA Sibling SA Live w SA Conflict/Parents Conflict/Siblings Conflict/Partner Conflict/Peers Cohesion/Parents Cohesion/Siblings Cohesion/Partner Cohesion/Peers

Table 5.5. Hierarchical multiple regression results predicting Desire for Help scores.

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Conflict and cohesion with primary socialization sources added only 0.4% to the explanation of variance in DH, and the R 2 change was not significant at this step. In the final model, identifying as White and more severe marijuana use predicted lower DH scores. More severe narcotics use, health problems across more health domains, more incidents of substance abuse treatment, more incarcerations, and having at least one sibling with substance abuse problem predicted higher DH scores. Post-hoc power analyses In the case of non-significant results, it is customary to conduct post-hoc power analysis to determine whether the statistical analysis had sufficient power to detect existing effects, and what is the likelihood that false null hypothesis is being accepted. Two power analyses were conducted for each, PR and DH, regression models: evaluating 6th and 7th steps, in which exploratory predictors were entered into the regression equation. Multiple regression power analyses were conducted using PASS software. PASS approach to multiple regression power analysis is based on formulas suggested by Cohen (1988). For the 6th step of the PR model, a sample size of 598 achieves 91% power to detect an R 2 = .018 attributed to 3 independent variables: parental substance abuse, sibling substance abuse, and living with substance abuser –using an F-test with a p < .05, after adjustment for 10 control variables with an R 2 = .25. Cohen (1988) recommended adoption of the convention that power = .80. Thus, with power = .91, step 6 of the PR model seems to have had sufficient power to detect existing effects. For the 7th step of the PR model, a sample size of 598 achieves 44% power to detect an R 2 = .009 attributed to 8 independent variables - conflict and cohesion items – using an F-test with a p < .05, after adjustment for 13 variables entered in previous steps with an R 2 = .27. Thus, it seems that the last step of the PR model may have had low power to detect significant effects.

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For the 6th step of the DH model, a sample size of 596 achieves 82% power to detect an R 2 = .015 attributed to 3 independent variables: parental substance abuse, sibling substance abuse, and living with substance abuser –using an F-test with a p < .05, after adjustment for 10 control variables with an R 2 = .20. Thus, it seems that the step 6 of the DH model was likely to have had sufficient power to detect existing effects. For the last step of the DH model, a sample size of 596 achieves 18% power to detect an R 2 = .004 attributed to 8 independent variables - conflict and cohesion items – using an F-test with a p < .05, after adjustment for 13 variables entered in previous steps with an R 2 = .22. Thus, it seems that the last step of the DH model may have had low power to detect significant effects. To test whether the failure to detect significant effects might be due to the low power at the last step of the regression models, analyses were rerun without the control variables, to decrease the number of predictors and, thus, to increase power (Table 5.6). The models accounted for very small amounts of variance in the dependent variables: R 2 = .09 for PR, and R 2 = .05 for DH. Similarly to the full regression models, in the block of items on deviance of primary socialization sources, sibling substance abuse predicted higher PR and DH scores (β = .14; t = 3.51; p < .0005 and β = .17; t = 3.94; p < .0005, respectively), while living with a substance abuser predicted higher PR scores (β = .12; t = 2.96; p = .003). Differently form the full regression models, in the block of conflict and cohesion variables, cohesion with peers predicted lower PR and DH scores (β = -.13; t = -3.21; p = .001 and β = -.13; t = -3.12; p = .002, respectively) , while conflict with sexual partner was marginally significant as a predictor of higher PR scores (β = .08; t = 2.02; p = .04). Thus, it seems that the lack of significant effects at the last step of the full regression models cannot be solely attributed to the low power, as even with the reduced number of predictors the variables on conflict with primary socialization sources do not contribute significantly to the

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prediction of PR and DH, after controlling for deviance of these socialization sources. Table 5.6. Final models of hierarchical multiple regression analyses predicting Problem Recognition (PR) and Desire for Help (DH) scores solely with social relations variables.

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Predictors Deviance indicators Parental substance abuse Sibling substance abuse Living with substance abuser Conflict with: Parents Siblings Sexual partner Peers Cohesion with: Parents Siblings Sexual partner Peers

PR N = 609 β t

DH N = 607 β t

-.51 -.02 .14 3.51*** .12 2.96** -.27 -.01 .89 .04 .08 2.02* .07 1.66 .56 .02 -.19 -.01 .05 1.25 -.13 -3.21** R2 = .09

-.05 -1.22 .17 3.94*** .24 .01 .38 .02 -.57 -.03 .07 1.75 .37 .02 -.34 -.01 .96 .04 .08 1.87 -.13 -3.11** R2 = .05

Note. All variables were coded dichotomously (1=yes, 0=no). *p < .05, ** p < .005, *** p < .000

SUMMARY OF THE FINDINGS Statistical analyses were conducted to: First, describe the sample of 661 male incarcerated chronic substance abusers, including characteristics of their primary socialization relationships; second, explore bivariate relationships of independent variables with Problem Recognition (PR) and Desire for Help (DH); and, finally, build prediction models for PR and DH. Sample description (Tables 5.1 & 5.2) indicated that about half of the sample reported deviant primary socialization sources, including having at least one

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parent with substance abuse problem, at least one sibling with substance abuse problem, and usually living with a substance abuser. Majority of the sample reported conflict with at least one parent, about one third - reported conflict with siblings, slightly less than half - reported conflict with sexual partner, and less than third - reported conflict with peers. Majority of the sample reported cohesion with all four categories of primary socialization sources: parents, siblings, sexual partner, and peers. At the bivariate level (Table 5.3), being older, married, not frequent marijuana user, frequent narcotics user, having more health problems, having been in substance abuse treatment more times, and having been incarcerated more times were related to higher PR and DH scores. Examination of bivariate relationships between characteristics of primary socialization relationships and dependent variables showed that more variables were significantly related to PR than to DH. Substance abuse by siblings was significantly positively correlated with PR and DH, while living with substance abuser was significantly related to PR only. Conflict with siblings, sexual partner, and peers was significantly positively correlated with PR, while only conflict with sexual partner was significantly related to DH. Only one cohesion variable – cohesion with peers – was significantly related to PR and DH, those with close peer relations tended to score lower on both dependent variables. From the non exploratory variables, only those significantly correlated with either PR or DH were included in prediction models, to reduce the number of predictors. However, all primary socialization variables were included, in order to preserve the integrity of the theoretical model. In multiple regression analyses, the set of predictors overall accounted for 28% of variance in PR and 24% - in DH. In both models, control variables accounted for the majority of variability in dependent variables, with largest increases in R 2 following the entry of substance use severity variables. Variables measuring deviance /

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substance abuse by social relations increased R 2 significantly in both – PR and DH models, while variables measuring conflict and cohesion with social relations did not contribute significantly to the explanation of variability in PR or DH. Post-hoc power analyses indicated that, for the last block of variables, regression analyses may have lacked sufficient power to detect significant effects. However, rerunning the regression analyses without the control variables and, thus, increasing the power of the analyses, indicated that the results cannot be solely attributed to the low power. In both, PR and DH, models, less frequent marijuana use, more frequent narcotics use, problems in more health domains, more substance abuse treatment incidents, and more incarcerations emerged as significant predictors of higher problem recognition and desire for help. In both models, age ceased to be significant predictor after entering health problems into the regression equation. While race did not appear to have significant contribution in any step of the PR model, it was significant predictor in all steps of the DH model, with those who identified as White being more likely to have lower desire for help. Two variables of interest – sibling substance abuse and living with substance abuser – emerged as significant predictors of higher PR scores. Only one variable of interest – sibling substance abuse – contributed significantly to the prediction of DH. In conclusion, the hypothesis, that deviance of primary socialization sources is significantly related to problem recognition and desire for help, was partially supported by the results of this study. Two deviance variables – sibling substance abuse and living with substance abuser – were significant predictors of PR, while one – sibling substance abuse – was significant predictor of DH. However, the direction of the relationship was contrary to the hypothesized: Substance abuse by siblings and living with someone who has substance abuse problem predicted higher, not lower, PR and DH scores. Although at the bivariate level several indicators of conflict and cohesion

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with primary socialization sources were significantly related to PR and/or DH, the hypotheses that these variables predict PR and/or DH could not be reliably supported at the multivariate level. The results are interpreted and discussed in the context of theory and prior research findings in the next chapter.

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CHAPTER 6

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Implications of Study Findings and Conclusion

The purpose of the present study was three-fold. First, it described the primary socialization relationships and their characteristics, including family and peer deviance, conflict and cohesion in a sample of incarcerated chronic substance abusers. Second, it examined whether these social relations variables were related to problem recognition and desire for help – the motivational variables of substance abuse behavior change process. And, finally, it tested whether social relations variables added to the explanation of problem recognition and desire for help beyond predictors already established in the empirical literature. DESCRIPTION OF SOCIAL RELATIONS CHARACTERISTICS The findings of this study suggest that the majority of 661 incarcerated men with chronic substance abuse problem had relationship history with some type of deviant primary socialization source. About half of the sample reported having at least one parent with substance abuse problem (52%), at least one sibling with substance abuse problem (56%), and usually living with a substance abuser when not incarcerated (46%, Table 5.2). These results are not surprising in the context of DATOS-A findings, where 133

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family drug abuse ranged from 68% for residential treatment clients to 87% for short-term inpatient treatment clients (Broome et al., 2001). In addition, these results are consistent with the literature on trans-generational patterns and family transmission of drug abuse. Empirical findings indicate that substance abuse by parents significantly increases one’s risk for having a substance abuse disorder (e.g., Hoffman & Cerbone, 2002; Merikangas, Stolar, Stevens, et al., 1998). These risks appear to cumulate in the case of substance abuse by siblings (e.g., Bierut, Dinwiddie, Begleiter, et al., 1998; Compton, Cottler, Ridenour, Ben-Abdallah, & Spitznagel, 2002). Also, these findings are consistent with primary socialization theory that focuses on environmental influences in the etiology of substance use (Oetting, 1999). In the present study, however, family history of substance abuse and living with a substance abuser are of interest as indicators of history of relationships with deviant primary socialization sources that might affect one’s problem recognition and desire for help. The findings of the present study indicate that the majority of the respondents experienced conflict with at least one parent (62%) for a significant period of time in their lifetime, about one third experienced conflict with siblings (34%), slightly less than half (47%) - with sexual partner, and less than third (28%) - with peers. Also, the results indicate that incarcerated substance abusers perceive their pre-prison social relationships as close. The majority of the respondents reported cohesion with parents (87%), siblings (78%), sexual partner (78%), and peers (71%). These findings seem to be consistent with numerous reports that substance abusers maintain close contact with their family members (e.g., Kaufman, 1981; Stanton et al., 1978; Vaillant, 1966). The present study’s findings on conflict and cohesion with parents, siblings, sexual partner, and peers are difficult to compare with other studies that did not report percentages and/or used aggregate measures of conflict and cohesion. However, it seems that substantial

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rates of family conflict and cohesion were found in prior research as well. No comparable data on peers was reported in the literature. For example, in the study of probationers in a residential treatment program, the mean score for family conflict was 1.9 within the possible range of 3, and the mean score for family cohesion (reflected so that lower scores represent more cohesion) was 1.2 within the possible range of 4 (Broome et al., 1997). In sum, in the present study, incarcerated men with chronic substance abuse problems reported substantial percentages of substance abuse by primary socialization sources, as well as conflict and cohesion with parents, siblings, sexual partner, and peers. These rates seem to be consistent with prior research findings, especially those regarding family relations.

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BIVARIATE CORRELATIONS WITH PROBLEM RECOGNITION AND DESIRE FOR HELP Control variables The findings on bivariate relationships between control and motivational variables suggest that those with higher problem recognition (PR) and desire for help (DH) scores tend to be older, use marijuana less frequently, use narcotics more frequently, have more health problems, have more substance abuse treatment attempts, and have more incarceration incidents (Table 5.3). In addition, identifying as having a non-white racial/ethnic background and urban home-base is related to higher DH, while higher severity of alcohol use is related to higher PR scores. The finding that the severity of marijuana use relates to PR and DH in a different direction than the severity of alcohol and narcotics use supports the decision to measure the use severity for the three types of substances separately. With the exception of some demographic variables, the aforementioned results are largely consistent with Simpson and Joe (1993) findings on client background

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characteristics and their relationships with TCU Motivation Scales. They found that severity of drug use, criminality, and health problems were significantly positively related to PR and/or DH (Simpson & Joe, 1993). This indicates that in the sample of the present study the control variables relate to the motivational variables in a similar fashion reported by prior research. Primary socialization characteristics An examination of bivariate relationships between characteristics of primary socialization relations and motivational variables shows that sibling substance abuse, living with substance abuser, conflict with siblings, sexual partner and peers, and cohesion with peers are significantly related to PR. Only three of those items – sibling substance abuse, conflict with sexual partner, and cohesion with peers – are significantly related to DH (Table 5.3). All of the aforementioned variables, with the exception of cohesion with peers, are positively related to the motivational scales. Cohesion with peers, on the other hand, is related to lower PR and DH scores. The present study results regarding conflict with siblings, sexual partner, and peers seem to be consistent with Simpson and Joe (1993) study findings that peer generated problems, peer-related availability of drugs, and family and peer relation problems are related to higher PR and/or DH. On the other hand, the findings that sibling substance abuse, living with substance abuser, and conflict with siblings, sexual partner, and peers are related to higher motivational levels seem to be contrary to the primary socialization theory-driven hypothesis that deviance of and conflict with primary socialization sources might result in lower PR and DH scores. One possible explanation to this is that while actual deviance of primary socialization sources might contribute to one’s substance use, the perceptions of deviance in one’s social environment play a more important role when the process of change is concerned, especially its motivational stages. The role of client perceptions in recovery process

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has been recently illustrated in a study of predictors of reincarceration, with clients who had more positive evaluations of self-change being significantly less likely to be reincarcerated at a 3-year follow-up (DeLeon, Melnick, Cao, & Wexler, 2006). In regards to perceptions of social relations and their effects on motivation for substance abuse treatment, Griffith and associates (1998) suggested that the relationship between perceived family dysfunction, peer deviance and motivation may represent clients’ progression past the precontemplation stage. That is, individuals with higher motivational levels appear to acknowledge poor social relations. Another interpretation of these findings might be that the measures of deviance of and conflict with social relations used in the present study assessed problem severity rather than socialization characteristics. Exposure to deviant social relationships may lead to negative emotional and physical consequences, and subsequently to increased readiness for change (Broome et al., 2001). In addition, perceptions of conflict may play different roles in the process of change. If conflict consists of family members and/or peers confronting the individual about his or her substance use, then the conflict might facilitate positive change (Broome et al., 1997). Thus, without differentiation between “positive” and “negative” conflict, which was not possible in the present study, the statistical relationship between conflict with social relations and motivational variables is obscured. Similarly, the finding that cohesion with peers is related to lower PR and DH scores is difficult to interpret without a context on the extent of substance abuse/deviance in one’s peer environment. According to the primary socialization theory, one of the paths to transmission of deviant norms is through close relationships with deviant socialization sources (Oetting, 1999). Thus, close relationships with substance abusing peers might preclude problem recognition and desire for help, especially if these relationships are perceived as satisfactory for one’s emotional needs. Unfortunately, data on peer substance

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abuse was not available in this study. Therefore, it was not possible to test the effect of the interaction between peer deviance and cohesion with peers on the motivational variables. The finding that parental items in deviance, conflict and cohesion categories do not significantly correlate with PR and DH is surprising. Numerous studies indicate that adult drug users maintain frequent contacts with their parents (e.g., Stanton et al., 1978; Vaillant, 1966), that parents may be involved in drug users addiction dynamics (e.g., Kaufman, 1981; for review see Harbin & Maziar, 1975), and that family members, including parents, may influence the process of change of substance use behaviors, including treatment entry (for review see Tsogia et al., 2001) and treatment process and outcomes (e.g., Constantini et al., 1992; Knight & Simpson, 1996). Thus, it was expected that substance abuse by, and conflict and cohesion with parents would be related to the motivational variables as well. On the other hand, primary socialization theory suggests that, in adulthood, family of procreation and/or peer cluster gain primacy over the family of orientation (Oetting, 1999). Hence, the relationship between motivation for change and deviance, conflict and cohesion characterizing the relationships with sexual partner and peers, but not with parents. The finding that sibling deviance and conflict with siblings are significantly related to PR and/or DH might indicate that influence by siblings is more similar to that of peers and sexual partner, than that of parents. Thus, it is important to understand how the primacy of various socializing relationships changes over time, and which social relationships may be most likely to influence substance abuse behavior change process during different life stages. It is also possible that the failure to detect statistically significant relationships between motivational variables and parental deviance and conflict and cohesion with parents is due to the limitations of measurement and study design. The measures of deviance of and conflict and

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cohesion with primary socialization sources were lifetime measures, not specific to any period of time and not sensitive to change over time. Such measurement might not be able to detect a relationship between variables that tend to change over time as a result of different circumstances. For example, the parental deviance item can indicate a parent that experienced a significant substance abuse problem at some point in his or her life, but we don’t know when this parent had substance abuse problem, and whether he or she is currently in recovery. Having a parent with a past substance abuse problem who maintains successful recovery, might affect one’s problem recognition and desire for help differently than having a parent with a current substance abuse problem. Also, one may have experienced significant periods of time in life when one had serious problems getting along with one or both parents; however, if those problems were resolved, they may be unrelated to the present levels of PR and DH. Also, the measures did not distinguish between those respondents who have living parents and those who have not. Thus, future research should attempt to capture the change in primary socialization relationships, and how it relates to the motivational processes of substance abuse behavior change. Finally, the results of bivariate correlations indicate that different though overlapping sets of variables might be related to PR and DH. This seems to be consistent with the conceptualization of PR and DH as two distinct motivational stages of substance abuse behavior change process, representing progressive movement through stages described in the Transtheoretical model, from precontemplation to contemplation of change, towards an action stage based on the recognition of problem severity, awareness of the need for change, and interest in getting help (Simpson & Joe, 1993). As a person progresses from one stage of change towards another, different processes of change take place, the needs of the person change, and, thus, different personal background variables might become or cease to be influential (Prochaska et al., 1992).

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In sum, the examination of bivariate relationships between characteristics of primary socialization relations and motivational variables yields more significant correlates for PR than for DH. The results of correlational analyses cannot lead to causal explanations; however, it seems that the findings of this study are consistent with conclusions drawn by other researchers that self-reported substance abuse by one’s social relations might be more likely to represent problem recognition and problem severity rather than deviant socialization (Broome et al., 2001; Griffith et al., 1998). On the other hand, the finding that parental substance abuse, and conflict and cohesion with parents did not significantly correlate with PR and DH, might actually be consistent with primary socialization theory and reflect the shift of primacy from the family of orientation towards the family of procreation in adulthood. And finally, the interpretation of findings on conflict and cohesion with primary socialization sources is limited by the lack of data on the types of conflict and the extent of substance abuse in one’s peer environment. PREDICTION OF PROBLEM RECOGNITION AND DESIRE FOR HELP Multiple regression analyses were conducted to test whether socialization variables add significantly to the explanation of problem recognition and desire for help beyond the contribution of sociodemographic, substance use, health, treatment, and criminal history variables. The set of predictors overall accounts for 28% of variance in PR and 24% in DH. These effect sizes are rather small, however, R 2 s smaller than .25 are commonly reported in the substance abuse research literature (e.g., Constantini et al., 1992; Hiller et al., in press). In both – PR and DH models, the control variables account for the majority of variability in dependent variables, with largest increases in R 2 following the entry of substance use severity variables. Age ceases to be a significant predictor of PR and DH after entering health problems into the equations. Variables

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measuring deviance/substance abuse by primary socialization sources increase R 2 significantly in both – PR and DH models, with sibling substance abuse predicting higher PR and DH scores, and living with substance abuser predicting higher PR scores. Variables measuring conflict and cohesion with primary socialization sources do not contribute significantly to the explanation of variability in PR and DH (Table 5.4, & Table 5.5). Thus, although significantly related to the DH and/or PR at the bivariate level, conflict with siblings, sexual partner and peers, and cohesion with peers do not appear to add significantly to the explanation of PR and DH after controlling for other personal background variables. Rerunning the analyses without the control variables indicates that these results cannot be confidently attributed to the low power (Table 5.6), especially, in the case of conflict with primary socialization sources. After controlling for deviance of primary socialization sources, information about conflict with these social relations does not seem to add significantly to the prediction of PR and DH. The same cannot be concluded with confidence regarding cohesion with peers, which emerged as a significant predictor of PR and DH in the truncated multiple regression models. Data on peer substance abuse was not available in this study; therefore, it is unclear whether cohesion with peers would predict PR and DH after controlling for peer deviance. Overall, however, it seems likely that information on deviance/substance abuse by primary socialization sources is more relevant to the understanding of one’s problem recognition and desire for help, than the information on conflict and cohesion with these social relations. The interpretation of findings that substance abuse by siblings and living with substance abuser predict higher, rather then lower, DH and/or PR scores is similar to that already discussed in the section on bivariate correlations. It is possible that the recognition of deviance in one’s social environment contributes to the overall recognition of

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problems related to one’s drug abuse and, subsequently, to the desire for help (Griffith et al., 1998). A related explanation is that prolonged exposure to deviant social relationships may lead to negative emotional and physical consequences, and subsequently to increased motivation for change (Broome et al., 2001). In addition, to understand the effect of substance abuse by primary socialization relations on one’s motivation for change, a more thorough assessment of substance abuse by these relations is needed, including their current substance use status, length of their substance abuse history, treatment and recovery history, and severity of their substance abuse-related problems. For example, it is interesting whether a history of treatment attempts and/or substantial periods of recovery by a significant social relation would increase one’s motivation for change. It is interesting to note that substance abuse by siblings is the only significant predictor among primary socialization variables that emerged in both, PR and DH, models. Sibling relationships have not been given much attention in the substance abuse literature on adults, including the primary socialization theory. Research findings on risks for substance use by adolescents and young adults indicate that environmental effects of having a sibling with substance abuse problem increase the risk above that associated with parental substance abuse (e.g., Brook et al., 1990; McGue et al., 1996; Rowe & Gulley, 1992). However, it is not clear conceptually whether the influence of siblings is similar to that of other family members, or that of peers. On one hand, siblings are seen as members of peer group that share friends and acquaintances, provide drugs and teach drug use (Oetting & Beauvais, 1986). On the other hand, one essential difference between family and peers is stressed: families, including siblings, are given, while, by and large, peers are chosen (Kandel, 1996). Thus, in a sense, siblings can be seen as peers that were not selected. If this is correct, then it could be that siblings are less likely to be selected out

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when a comparison with them, as kind of peer reference group, becomes less favorable to one’s self image, and thus might affect change in one’s substance abuse behavior. The findings of the current study suggest that among incarcerated adult male substance users having a sibling with substance abuse problem, the risk factor for substance use in adolescence and early adulthood, might also be a factor related to higher problem recognition and desire for help in adulthood. Different processes might be involved in this relationship between substance abuse by siblings and motivation for change. Witnessing a sibling “hit bottom” might facilitate the recognition of one’s own substance abuse problems, and increase desire for help. On the other hand, having a sibling who is intimately familiar with the drug abuse lifestyle, yet seeks and values change, and is recovery-oriented, might increase one’s motivation for change. In addition, a person that has siblings with a current or past substance abuse problem might feel more similar to others in his social environment, and thus perceive more overall support, as well as support for substance abuse behavior change, than someone who is sort of a “black sheep” in the family. Whether one is an older or a younger sibling might make a difference as well (Brook et al., 1990). More research with adult samples is needed to understand these issues. Further studies need to explore the extent of siblings’ involvement in adult substance abusers addiction dynamics and the process of change, how the birth order of siblings affects these dynamics, and how their influence differs from that of other significant social relations in substance abuser’s environment. In sum, primary socialization variables have a small effect on the prediction of PR and DH in the sample of incarcerated male substance abusers. Only substance abuse of primary socialization sources contributes significantly, while conflict and cohesion variables have no significant effect on motivational variables. The emergence of substance abuse by siblings as a significant predictor of higher PR and DH raises questions about the influence of siblings versus that of other family members and peers. It

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is possible that siblings have been an overlooked resource in substance abuse treatment for adults. LIMITATIONS OF THE STUDY One of the limitations of this study is that it was not specifically designed to explore socialization effects on problem recognition and desire for help. This study is a secondary analysis of data collected in a larger research project focused on health services utilization among incarcerated chronic substance abusers. As a result, the measures of social relations have several limitations. According to the primary socialization theory, deviance of, and conflict and cohesion with primary socialization sources such as family of orientation and family of procreation as well as peers affect one’s substance abuse behavior and its change (Oetting, 1999). Variables that emerge from empirical research as likely to affect problem recognition and desire for help include peer deviance, peer relations problems, family dysfunction, family conflict, and family cohesion (Broome et al., 1997, 2001; Griffith et al., 1998; Simpson & Joe, 1993). In addition, siblings’ effects on one’s substance abuse behavior were demonstrated in studies with samples of adolescents (e.g., Brook et al., 1990; McGue et al., 1996; Rowe & Gulley, 1992). Therefore, following the assumptions of primary socialization theory and prior research findings, the model should include parental, sibling, sexual partner, and peers item in each of the three blocks of variables characterizing primary socialization sources, namely, deviance, conflict and cohesion (Figure 1.1). However, the block on deviance of primary socialization sources is incomplete, due to the lack of sufficient data on substance abuse by sexual partner and peers. While an item on living with a substance abuser could somewhat substitute for the lack of data on a sexual partner, no comparable data on peers is available in this study. This limits the interpretation of the results regarding cohesion with peers, as it remains unclear whether it is

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cohesion with peers in general or cohesion with deviant peers that is related to lower PR and DH. In addition, differentiation between “positive” and “negative” conflict, such as information on whether the conflict is related to one’s substance use, may illuminate the findings on bivariate relationships between conflict with primary socialization sources and higher PR and/or DH (Broome et al., 1997). Additional limitations that should be noted for the current study include 1) self-reported data, 2) a crosssectional research design, and 3) a non-probability sample. Self-reported data are subject to problems associated with memory recall, limitations in differentiating between actual and perceived deviance, conflict and cohesion, and limitations in knowing how truthful participants were in their responses. Nevertheless, it is clear that the participants in the health services study provided a great deal of personal information on their health status, substance use, criminality, HIV-risk behaviors, as well as their social relationships (reported elsewhere, e.g.: Leukefeld, Staton, Hiller, Logan, Warner, Shaw et al., 2002; Leukefeld et al., 2002; Webster et al., 2005). While the cross-sectional design of the study provides useful and relevant information about pre-prison relationships and their bivariate correlations with and predictive value for problem recognition and desire for help of the prisoners, it does not allow direct examination of causal or time-sensitive relationships between these variables. Thus, for example, it is difficult to say whether reported deviance of primary socialization sources is among the causes of higher motivation for change, or an artifact of problem recognition (Broome et al., 1997). Similarly, it is unclear whether the lack of parental effects on motivational variables is due to possible decrease in parental influence in adulthood (Oetting, 1999). Finally, the current study used a purposive sampling design rather than randomly selecting inmates on a probability basis from the prison population. This sampling

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approach was taken because of constraints imposed by prison authorities. Purposive sample limits the generalizability of findings to other samples with similar characteristics (Kazdin, 1998), in this case, criminallyinvolved, male, chronic substance abusers. Even with limited generalizability, these data are important because they focus on offenders who are fairly typical of those in the larger Mid-Western region of the U.S. correctional system. In addition, the findings of the present study are fairly consistent with the findings of prior research conducted primarily with samples of substance abusers in the community (Broome et al., 2001; Griffith et al., 1998; Simpson & Joe, 1993). Moreover, given the findings that criminal justice- and non-criminal justice-involved substance abusers do not differ significantly in their demographic and psychosocial profiles (Farabee & Nelson, 1993; Hubbard, Collins, Rachal & Cavanaugh, 1988), the findings of the present study can be cautiously generalized to chronic substance abusers in the community. In conclusion, the findings of this study add to the scarce data on the effects of specific social relationships on substance abusers’ problem recognition and desire for help, motivational variables consistently linked with treatment process and outcomes. IMPLICATIONS OF THE STUDY Implications for research Social factors and motivation for substance abuse behavior change have been explored primarily in the context of treatment process and outcome studies. The relationships between social and motivational variables are usually not in the primary focus of studies. As a result, the interpretation of these findings is frequently limited by conceptual and measurement issues. However, the findings of the present study, along with prior empirical findings, indicate that additional research on social level factors in motivation for

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substance abuse behavior change is warranted. Therefore, further studies need to be designed specifically to test the relationships between social factors and motivational variables. Systematic approach to a such study requires integration of theoretical assumptions and empirical findings into a heuristic model to guide variable selection and interpretation of findings. The present study built on primary socialization theory assumptions that deviance of socialization sources, including family and peers, and quality of the relationships with socialization sources, as indicated by cohesion and conflict, are major factors in determining socialization outcomes, such as substance abuse and behavior change (Oetting & Donnermeyer, 1998; Oetting, 1999). These theoretical assumptions along with prior empirical findings, particularly by the TCU research group that found family and peer relations variables to affect PR and DH (Broome et al., 1997; Griffith et al., 1998; Simpson & Joe, 1993), guided the selection of variables of interest for this study. The results are somewhat disappointing, as only two social relations variables have significant effects on motivational variables in multivariate models. Nevertheless, the findings of this study and the discussion of its limitations can lead to several suggestions for further research. Additional variables from social domain need to be explored to find better fitting models for PR and DH. To better understand the effects of conflict on motivation for substance abuse behavior change, further studies should attempt to differentiate between positive and negative conflict, i.e., conflict related to constructive confrontation about one’s substance use versus relationships permeated with abuse and conflict (Broome et al., 1997). In addition, interaction between cohesion with and substance abuse by social relations and its effect on motivational variables needs to be tested, particularly regarding peers, in order to shed some light on significant correlation between higher cohesion with peers and lower PR and DH scores found in the present study. While cohesion with non-using social

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relation might increase motivation for change, cohesion with substance abusing social relations might indicate that the current situation is comfortable for the person. The differentiation between types of conflict and cohesion can help to test whether conflict and cohesion with social relations add significantly to the explanation of PR and DH beyond the effects of substance abuse by social relations. More time-sensitive information needs to be included in the measures of conflict with social relations, such as: when was the period of serious conflict, recently, months or years ago; has it been resolved in some way; does the client presently have active relationship with person/s involved in the conflict; and whether the client thinks that this period of significant conflict affected the way he or she understands his/her current substance abuse situation and desire to change it. Time context can help differentiation between the effects of severity of problems with the immediate social environment and the effects of primary socialization variables on motivation for change. Also, more information about substance abuse by social relations needs to be collected, including current use, length of use, treatment and recovery history. These additional data can help understand the effect of history of substance abuse by social relations on PR and DH, by differentiating between the effects of treatment and recovery history and the effects of current problem severity experienced by social relations, rather than focusing solely on the presence or absence of a substance abuse history. Furthermore, more studies with adult samples of substance abusers need to include data on siblings, as the results of the present study indicate that sibling substance abuse history, and the quality of the relationships with them might affect one’s motivation for change and substance abuse treatment. It is not clear how sibling effects on one’s PR and DH differ from the effects of other family members and peers. Siblings can be fellow addicts as well as authoritarian, parental figures (Kaufman, 1981). Information about birth order of siblings might shed some

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light on the relationship between sibling substance abuse and one’s motivation for change, as older siblings might be more likely to influence younger siblings’ drug use by their own use or non-use (Brook et al., 1990). And, as it was discussed above, more detailed assessments of sibling substance abuse history are needed to better understand its effect on respondents’ PR and DH. Although in this study an attempt was made to control for mental health problems as part of the health history composite, it is possible that the exclusion of mental health problem severity measure affected the results. The severity of mental health problems is likely to affect substance use behavior and motivation for change (e.g., DeLeon et al., 2000a; Hiller et al., in press; Melnick, 1999; Ryan et al., 1995). Also, evidence suggests that psychosocial functioning might be mediating the relationships between social and motivational variables (Griffith et al., 1998). Given the high prevalence of substance abuse and psychiatric co-morbidity, it is important to explore how it affects the relationships between social and motivational variables in a specifically designed study, especially after confirming which social relations variables consistently predict motivation for change. Such study might allow testing the assumption of primary socialization theory that socialization is primary to psychopathology as a causal factor in substance abuse. In addition, the effects of social relations on problem recognition and desire for help need to be explored with diverse samples, including women and non-correctional populations. And finally, causal rather than correlational effects of social relations on motivation for substance abuse behavior change need to be explored in prospective, longitudinal studies in which social relations variables would be measured prior in time to motivation variables. Path analyses and other structural modeling techniques, when sufficient sample sizes are available, can also indicate causal relationships.

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Implications for practice Conceptualizing substance abuse behavior change process in discrete stages sharpens the focus on specialized intervention and evaluation strategies for each stage (Simpson, 2001). The present study focuses on motivational stages of the change process, and, therefore, its implications are primarily for the interventions in pretreatment stages. Motivational variables, such as problem recognition, and desire for help, can mediate substance abuse treatment outcomes and low motivation may preclude change efforts altogether. Research findings indicate that motivation is a key factor in determining engagement and retention in treatment (for overview see Simpson, 2001, 2004). Therefore, understanding factors affecting motivational stages of substance abuse behavior change process is likely to contribute to the enhancement of treatment engagement and retention and, subsequently, short- and long-term treatment effects. The findings of the present study indicate that substance abuse by and conflict with siblings, sexual partner and peers, cohesion with peers, and living with a substance abuser are related to inmates’ problem recognition and desire for help. Moreover, the results show that having sibling/s with a history of substance abuse and usually living with a substance abuser has a small but significant effect on inmates’ desire for help and/or problem recognition, even after taking into account their substance use, health, treatment, and criminal history. These findings are consistent with understanding motivation to change substance abuse behavior as interplay of individual and environmental characteristics, rather than internal attribute of a person, and bring to focus the need for interventions that go beyond the individual level, and for evaluation of client’s social environment and resources. Individual intentions and behaviors, such as substance abuse, motivation for change, and recovery, occur in the context of social environment and, thus, the successful

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strategies of change should be integrated within social structures, including family and other institutions (Schilling & El-Bassel, 1998). The need for treatment strategies to focus on building and maintaining supportive networks for clients to use during and after treatment, and the need for mobilizing family and social network to engage adult substance abusers in treatment or self-help have been pointed out by several researchers (e.g., Griffith et al., 1998; Landau et al., 2000; Meyers et al., 1998; Soyez, DeLeon, Broekaert & Rosseel, 2006). The present study contributes to this literature by examining the specific effects of relationships with parents, siblings, sexual partner, and peers on motivational variables of the process of change. The majority of methods for utilizing family and/or other social network members in the engagement effort, such as Berenson’s (1976) model for working with most motivated family members, a “unilateral family therapy” (Thomas et al., 1987; Barber & Gilbertson, 1997), community reinforcement training (CRT) and family training (CRAFT) (Meyers et al., 1998), and brief motivational counseling (Miller & Rollnick, 1991) focus primarily on a spouse or a live-in partner to get substance abuser into treatment or self-help program. Other methods, such as a more confrontational Johnson intervention (Johnson, 1986), and relational intervention sequence for engagement (ARISE) (Landau et al., 2000), utilize larger social networks toward treatment engagement. The findings of the present study indicate that siblings and persons who usually share a living arrangement with clients might be of particular importance for problem recognition and desire for help in the sample of primarily single (82%) incarcerated male substance abusers. Most of the aforementioned intervention methods stress the importance of involvement of a non-using and supportive of drug-free lifestyle significant other in treatment engagement efforts. The findings of the present study indicate, however, that having a sibling with

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substance abuse history and usually living with a substance abuser are related to higher levels of problem recognition and desire for help. It is possible that while non-users might feel alienated by the addict’s substance abuse, a sibling or a live-in partner with substance abuse experience might be in a position to offer support during the change process. However, it is also known that substance abusing social network can be detrimental to the recovery process (Goehl et al., 1993; Hawkins & Fraser, 1987). Therefore, it is important to carefully assess whether these social relations are supportive of recovery lifestyle, rather than affecting one’s problem recognition due to their own problem severity. Further research of these variables and deeper understanding of their possible role in treatment engagement is needed. However, in the current state of knowledge, these findings indicate that it might be important to include more specific assessment questions about substance abuse by siblings and person/s usually sharing a living arrangement with a client. These questions could include information on current substance use by siblings and person/s usually living with a client, their treatment history, and client’s current relationships with them. Such assessments can be used as part of motivational interviewing to increase problem recognition and desire for help, regardless of whether they can lead to the establishment of a social environment supportive of substance abuse behavior change process. Specifically for correctional populations with extensive substance abuse histories, assessments of social relationships might be important for planning inmates’ reentry into the community, particularly, for sustaining client’s motivation to enter aftercare. One of the recent National Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) initiatives, for example, focuses on the development of assessment tools to track changes in motivation, engagement, behavioral and social functions of offenders reentering the community, and the use of these performance indicators to effectively plan aftercare services (Wexler & Fletcher, 2007). Data also indicate that

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inmates who completed in-prison substance abuse treatment followed by community-based aftercare are less likely to be reincarcerated (NIDA, 2005; Re-Entry Policy Council, 2004). However, often, incarcerated substance abusers either do not enter treatment when they are released or soon drop out. One of the CJ-DAT Studies focuses on the effects of transitional case management (TCM) on increasing participation in community-based treatment for substance abuse problems following prisonbased treatment (Wexler & Fletcher, 2007). TCM uses strengths-based case management model, which builds on individual’s accomplishments, pro-social abilities and goals, and supportive networks. Assessing inmate’s social resources at intake and working towards maintaining and/or rebuilding significant supportive relationships in the community, might help mobilize those resources to engage the released inmate in the aftercare program and, thus, ensure the continuity of care necessary for positive outcomes. Informal social support networks, when used in conjunction with formal treatment, can be a valuable part of recovery strategy (Sorensen & Gibson, 1983). This is especially important because individuals may be more likely to maintain personal relationships with family members and peers in recovery after their release, rather than developing mandatory relationships with formal support agencies. Case managers should work with clients to identify the relationships that are most beneficial to their problem recognition and desire for help and attempt to engage these significant others in their reentry planning as early as possible, when appropriate. Although generalization of this study’s findings to nonincarcerated populations is limited, some implications for practice with substance abusers in the community can be inferred. There is no apparent reason to believe that social relationships with siblings, sexual partner, and peers might have a different influence on problem recognition and desire for help among substance abusers in the community when compared with incarcerated substance abusers. In

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fact, it is likely that substance abusers in the community are more in touch with their families and other significant social relations than those who are incarcerated and, therefore are more likely to be exposed to the influences of these social relations (Brochu, Gyon, & Desjardins, 1999). The magnitude of the effects of social relations on motivation among clients in the community who are criminal justice involved and those who are not might be different, because clients with criminal justice involvement tend to score lower in their problem recognition and desire for help (Farabee & Nelson, 1993). This indicates that for these clients external motivation stemming from legal sanctions might be more relevant than motivation stemming from other sources, at least in the beginning stages of the behavior change process. Nevertheless, in the challenge to motivate chronic substance abusers to enter and remain in treatment, assessment and possible involvement of social relations can be a valuable resource in the case on non-criminal justice clients, and an important addition to legal sanctions in the case of criminal justice involved clients. Implications for policy With over three quarters of inmates in state prisons characterized as “drug-involved” (Bureau of Justice Statistics, Mumola, 1999), and with corrections system accounting for about half of all entries into addiction treatment programs in US (NSSTATS, 2002, as cited in McLellan, 2003), motivation for change, in clinical terms, or amenability to treatment, in judicial terms, become important issues in policy decisions about treatment resources allocation within prisons (McLellan, 2003). The highest potential for positive treatment outcomes such as recidivism reduction and, thus, public safety is a primary goal of these policy decisions (Wexler, 2003). Criminal justice and community treatment agencies have implemented many approaches across multiple settings to address the problems of criminally-involved substance

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abusers (Wexler & Fletcher, 2007). There is a need to better understand how to maximize the cooperation between community-based and prison-based treatment services in order to ensure the continuity of care for chronic substance abusers reentering the community. The issue of motivation and readiness for change among correctional populations reaches over the boundaries of in-prison treatment into aftercare programs that lately gained greater attention. Recent studies show that effective substance abuse treatment for inmates and, thus, a strategy to ensure public safety, need to include aftercare (see Wexler, 2003 for overview), and that greater motivation for change increases the likelihood of entering aftercare (DeLeon et al., 2000b). However, it is difficult to sustain the effects of individual motivation for change in the context of fragmented systems of community care, stigma of criminal justice involvement, and long waiting lists for limited publicly funded treatment opportunities that contribute to the discontinuity of services from prison into the community (Wexler, 2003). Emerging re-entry courts modeled after widely accepted drug courts hold promise for integration of corrections-based programming with community-based services. For example, Kentucky Reentry Court pilot program model combined 6-months of in-prison substance abuse treatment with at least 1 year of treatment in an established Drug Court program upon return to the community. Program participants showed high levels of compliance with treatment expectations, including attendance of counseling sessions, drug negative urine tests, no new criminal charges, and active employment (Hiller, Narevic, Leukefeld, & Webster, 2001). Nevertheless, the program was discontinued due to the lack of availability of federal funding. This example highlights the importance of federal level policies for program initiatives at the state level and, subsequently, the availability of aftercare treatment options for inmates reentering local communities.

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The focus of the present study is not on correctional substance abuse treatment policy, but some general implications can be inferred. The review of conceptual issues and selected findings of this study points to the potential influence of extra-prison social relations on inmates’ recognition of their substance abuse as a problem and their desire for help. The programmatic implications of these findings for aftercare planning were discussed in more detail above, in the section on implications for practice. However, for any programmatic approach to be implemented effectively, broad-based, systemic action is needed (Gregrich, 2003). The collaboration between correctional authorities and community health care system is an essential prerequisite to ensure continuity of substance abuse services for re-entering inmates. The Community Action approach that was one of the forces that facilitated acceptance of correctional substance abuse treatment (Wexler, 2003) can be employed in facilitating the collaboration between corrections and community health care systems on designing accessible and effective aftercare programs. The Community Action approach actively encourages partnerships among researchers, practitioners, policy makers and stakeholders in both – correctional and community services systems, as well as clients and their families. Such process facilitates identification of barriers to continuity of services, information exchange, development of consensus, and program model appropriate for local conditions (Wexler, 2003). And, most importantly, it engages the community in the reentry process. SUMMARY AND CONCLUSION Social relations and motivation variables are often regarded important determinants of substance abuse behavior change process (e.g., DeLeon et al., 2000b; Simpson & Joe, 1993; Tsogia et al., 2001). Few attempts, however, have been made to investigate the relationships between them. Scarce empirical studies suggest that family and peer relations

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might be playing an important part in motivation for treatment and that this relationship might affect treatment process and outcomes (Broome et al., 1997, 2001; Griffith et al., 1998; Simpson & Joe, 1993). In the present study, primary socialization theory of drug use and criminal behavior (Oetting, 1999; Oetting & Donnermeyer, 1998) informed the organization of empirically derived social relations variables into a conceptual model and the selection of additional variables of interest. The purpose of this study was to explore how characteristics of primary socialization, including deviance of, and conflict and cohesion with parents, siblings, sexual partner, and peers, are related to problem recognition (PR) and desire for help (DH) – motivational components of substance abuse behavior change process – among incarcerated substance abusers. TCU Motivational Scales and ASI were used to measure motivation and social relations variables in the sample of 661 incarcerated men with chronic substance abuse problems. About half of the sample reported deviant socialization sources. Majority reported conflict with some and cohesion with all socialization sources. Sibling substance abuse, living with substance abuser, conflict with siblings, sexual partner, and peers, and cohesion with peers were significantly correlated with DH and/or PR. In the multiple linear regression models, deviance of primary socialization sources had a small but significant effect on PR and DH, after controlling for sociodemographic characteristics, and substance use, health, treatment, and criminal histories. Sibling substance abuse and living with substance abuser significantly predicted higher PR, and sibling substance abuse predicted higher DH scores. Additional analyses confirmed that after controlling for deviance of socialization sources, information about conflict with these social relations might not add significantly to the prediction of PR and DH. The same conclusion was not possible regarding cohesion due to limitations in measurement.

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In general, the results of this study were consistent with prior empirical findings, indicating that family and peer deviance, and family and peer relation problems are related to higher PR and DH scores (Broome et al., 2001; Griffith et al., 1998; Simpson & Joe, 1993). Further research is needed to understand the direction of causality in this relationship, as it might represent heightened awareness of family and peer deviance and relations problems by respondents who progressed past the precontemplation stage of the behavior change process (Griffith et al., 1998), as well as it might indicate that the exposure to deviant and problem-ridden social relationships lead to increased readiness for change (Broome et al., 2001). In order to better understand the effect of social relations with substance abuse history on one’s motivation for change, more information on substance abuse by these social relations needs to be collected in further research, including their current use status, as well as treatment and recovery history. In addition, the results of this study highlighted the importance of sibling relationships among adult substance users. Siblings have been underrepresented in substance abuse literature on adults, including literature on methods for utilizing family and other social relations in the efforts of engaging substance abuser in treatment (e.g., Meyers et al., 1998; Miller & Rollnick, 1991). Although the results of the present study are far from implying any causal relationship between sibling substance abuse and one’s motivation for treatment, they do indicate that it is important to assess for more information on siblings, their substance abuse history and current status, particularly with incarcerated populations as part of reentry planning. Assessment is the first step in determining what interventions are needed. Criminally-involved substance abusers often have multiple and complex problems, such as mental disorders, employment and housing difficulties, and problems with social relations, especially those supportive of recovery life style. Moreover, drug-related life style

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leads to serious negative health consequences, including exposure to HIV, hepatitis C, and other chronic illnesses (e.g., Chitwood et al., 1998, 1999). Therefore, engaging offenders in prison-based treatment for substance abuse problems followed by community-based aftercare program upon reentry may have the potential to reduce the risks to community public health and to alleviate prison-based health care burden, in case of reincarceration (Wexler & Fletcher, 2007). Given such serious social consequences of substance abuse by individuals, substance abuse needs to be regarded as a social problem with implications for public health, community safety, education system, criminal justice system, and family functioning, to name just a few. Therefore, successful strategies for change should be integrated within these social systems and structures (Schilling & El-Bassel, 1998). One of the basic tenets of the present book is that the process of acquiring substance abuse behavior has significant social component, and, therefore, the process of changing individual’s substance abuse behavior is also inevitably affected by these social influences and requires a thorough assessment of not only individual’s strengths, but also of the strengths of one’s social relations and social systems. The results of the present study suggest that such an assessment needs to be unbiased, as an apparent weakness in one’s social relations, such as substance abuse history, may also be strength and contribute to one’s problem recognition and desire for help in complex ways. In conclusion, the present study added to the scarce literature on social relations and motivation for substance abuse behavior change. Its contribution included examining parental, sibling, sexual partner, and peers items separately, to explore the unique effects that substance abuse by and conflict and cohesion with these social relations have on problem recognition and desire for help. This approach proved to be partially fruitful and highlighted previously underrepresented sibling relationships as potentially

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important for incarcerated male substance abusers’ motivation to change their behavior and seek help for their substance abuse problems.

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APPENDIX

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HEALTH SERVICES RESEARCH INSTRUMENT (HSRI): SELECTED ITEMS Items used to create the lifetime health problems variable: Answer key: 0 – No, 1 – Yes Have you ever (even if no treatment was sought) experienced 1- male problems such as prostate problems, urinary tract infections, or cancer of the testicles? 2- respiratory system or breathing problems such as TB, bronchitis, pneumonia, emphysema, asthma, hay fever, shortness of breath or wheezing? 3- a physical injury or accident such as broken bones, head injury, concussion, gunshot or knife wounds, sports injuries, or sexual assault? 4- muscle or bone problems such as arthritis, constant back pain, paralysis, permanent stiffness, or foot problems? 5- liver related problems such as hepatitis, yellow jaundice, cirrhosis, or diabetes? 6- heart, blood, or circulatory problems such as high or low blood pressure, endocarditis, irregular heart beat, angina, heart attack, stroke, blood disease, or tingling or numbness in the hands or feet? (Interviewer note: endocarditis is an inflammation of the membrane that lines the interior of the heart; angina is attacks of suffocating pain in the chest area.) 7- stomach or digestive problems such as ulcers, colitis, nausea, vomiting, or persistent diarrhea? 8- nervous system problems such as migraine headaches, epilepsy, seizures? 9- skin problems such as abscesses, cellulites, skin ulcers, skin cancer, rashes or infections? (Interviewer note: cellulites is a spreading inflammation of the skin connective tissue.) 161

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10- eye, ear, nose, or throat problems such as persistent sore throat, ear infections, deviated septum? 11- syphilis, gonorrhea, chlamydia, or other sexually transmitted diseases other than HIV/AIDS? 12- dental problems such as cavities, infected teeth, gum disease? 13- alcohol problems such as overdose or delirium tremens? 14- other drug problems such as addiction, overdose, or detoxification? 15- Nervous or mental health problems such as nerves, stress, anxiety, depression, manic depression? (This question targets more than just a slight episode of being stressed out or nervous. If the subject indicates this is the type of episode he is referring to, i.e. “yeah, I get stressed sometimes”, probe further to determine if these episodes lasted for long periods of time or lead to symptoms or problems such as loss of appetite, inability to sleep, sleeping too much, etc.) 16- any other health problems that I have not already asked you about for which you received care or felt you needed care?

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REFERENCES Alaszewski, A., & Harrison, L. (1992). Alcohol and social work: A literature review. British Journal of Social Work, 22, 331-343. Allen, M., Donohue, W. A., Griffin, A., Ryan, D., Mitchell Turner, M. M. (2003). Comparing the influence of parents and peers on the choice to use drugs. Criminal Justice and Behavior, 30(2), 163186. Andersen, R., & Newman, J. F. (1973). Societal and individual determinants of medical care utilization in the United States. Milbank Memorial Fund Quarterly 51, 95-124. Anglin, M. D., Prendergast, M., & Farabee, D. (1998). The effectiveness of coerced treatment for drug-abusing offenders. Paper presented at the Office of National Drug Control Policy’s Conference of Scholars and Policy Makers, Washington, DC. Retrieved September 27, 2005, from http://www.ncjrs.org/ondcppubs/treat/consensus/anglin.pdf Aseltine, R. H. (1995). A reconsideration of parental and peer influences on adolescent deviance. Journal of Health and Social Behavior, 36(2), 103-121. Bandura, A. (1997). Editorial: The anatomy of stages of change. American Journal of Health Promotion, 12(1), 8-10. Barber, J. G, & Gilbertson, R. (1997). Unilateral interventions for women living with heavy drinkers. Social Work, 42(1), 69-78. Belenko, S. (2001). The promises and challenges of drug courts. Offender Substance Abuse Report, 1(3), 33-48. Bell, D. C., Montoya, I. D., Richard, A. J., & Dayton, C. A. (1998). The motivation for drug abuse treatment: Testing cognitive and 12-step theories. American Journal of Drug and Alcohol Abuse, 24(4), 551-571. Berenson, D. (1976). Alcohol and the family system. In P. Guerin (Ed.), Family therapy: Theory and practice. NY: Gardner Press. Biener, L., & Abrams, D. B. (1991). The contemplation ladder: Validation of a measure of readiness to consider smoking cessation. Health Psychology, 10, 360-365. Bierut, L. J., Dinwiddie, S. H., Begleiter, H., Crowe, R. R., Hesselbrock, V., Nurnberger, J., Porjesz, B., Schuckit, M. A., & Reich, T. (1998). Familial transmission of substance dependence:

163 Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

164

References

Alcohol, marijuana, cocaine, and habitual smoking: A report from the collaborative e study on the genetics of alcoholism. Archives of General Psychiatry, 55(11), 982-988. Blanchard, J. J. (Ed.)(2000). The co-occurrence of substance use in other mental disorders. Clinical Psychology Review, 20(2), the whole issue. Brim, O. G. Jr. (1966). Socialization through the life cycle. In O. G. Jr. Brim, Socialization after childhood: Two essays (pp. 3-49). New York: John Wiley & Sons, Inc. Brochu, S., Guyon, L., & Desjardins, L. (1999). Comparative profiles of addicted populations in rehabilitation and correctional services. Journal of Substance Abuse Treatment, 16(2), 173-182. Brook, J. S., Whiteman, M., Gordon, A. S., & Brook, D. W. (1990). The role of older brothers in younger brothers’ drug use viewed in the context of parent and peer influences. Journal of Genetic Psychology, 151(1), 59-75. Broome, K. M., Joe, G. W., & Simpson, D. D. (2001). Engagement models for adolescents in DATOS-A. Journal of Adolescent Research, 16(6), 608-623. Broome, K. M., Knight, D. K., Knight, K., Hiller, M. L., & Simpson, D. D. (1997). Peer, family and motivational influences on drug treatment process and recidivism for probationers. Journal of Clinical Psychology, 53(4), 387-397. Broome, K. M., Simpson, D. D., & Joe, G. W. (1999). Patient and program attributes related to treatment process indicators in DATOS. Drug and Alcohol Dependence, 57, 217-135. Brown, B. S., Kinlock, T., W., & Nurco, D., N. Self-help initiatives to reduce the risk of relapse. In F. M. Tims, C. G. Leukefeld & J. J. Platt (eds.), Relapse and recovery in addictions (pp. 253-275). New Haven, CT: Yale University Press. Carey, K. B., Purnine, D. M., Maisto, S. A., Carey, M. P. (1999). Assessing readiness to change substance abuse: A critical review of instruments. Clinical Psychology: Science and Practice, 6(3), 245-266. Chitwood, D. C., McBride, D. C., French, M. T., & Comerford, M. (1999). Health care need and utilization: A preliminary comparison of injection drug users, other illicit drug users, and nonusers. Substance Use and Misuse, 34, 727-746.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

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References

165

Chitwood, D. D., McBride, D. C., Metch, L. R., Comerford, M., & McCoy, C. B. (1998). A comparison of the need for health care and use of health care by injection-drug users, other chronic drug users, and nondrug users. American Behavioral Scientist, 41(8), 1107-1122. Chitwood, D. D., Sanchez, J., Comerford M., & McCoy, C. B. (2001). Primary preventive health care among injection drug users, other sustained drug users, and non-users. Substance Use and Misuse, 36(6-7), 807-824. Clemmer, D. (1940). The prison community. Boston: Christopher. Clausen, J. A. (1968). Introduction. In J. A. Clausen (Ed.), Socialization and society (pp. 3-17). Boston, MA: Little, Brown and Company. Clausen, J. A. (1976). Drug use as a social problem. In R. K. Mertnon & R. Nisbet (Eds.), Contemporary social problems (4th ed., pp. 144-167). New York: Harcourt Brace Jovanovich, Inc. Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence ErlbaumAssociates. Compton, W. M., Cottler, L. B., Ridenour, T., Ben-Abdallah, A., & Spitznagel, E. L. (2002). The specificity of family history of alcohol and drug abuse in cocaine abusers. American Journal on Addictions, 11, 85-95. Conger, R. D. (1997). The Special Nature of Rural America. Rural Substance Abuse: State of Knowledge and Issues (pp. 38-52). NIDA Research Monograph 168. Rockville, MD: US Department of Health and Human Services, NIH. Constantini, M., F., Wermuth, L., Sorensen, J. L., & Lyons, J. S. (1992). Family functioning as a predictor of progress in substance abuse treatment. Journal of Substance Abuse Treatment, 9, 331335. Curry, S., Wagner, E. H., & Grothaus, L. C. (1990). Intrinsic and extrinsic motivation for smoking cessation. Journal of Consulting and Clinical Psychology, 58, 310-316. DeLeon, G. (1996). Integrative recovery: A stage paradigm. Substance Abuse, 17(1), 51-63. DeLeon, G. (1998). Commentary: Reconsidering the self-selection factor in addiction treatment research. Psychology of Addictive Behaviors, 12(1), 71-77.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

166

References

DeLeon, G. (2000). The therapeutic community: Theory, model, and method. New York: Springer Publishing. DeLeon, G., & Jainchill, N. (1986). Circumstance, motivation, readiness and suitability as correlates of treatment tenure. Journal of Psychoactive Drugs, 18(3), 203-208. De Leon, G., Melnick, G., Cao, Y., & Wexler, H. (2006). Recoveryoriented perceptions of reincarceration. Journal of Substance Abuse Treatment, 31, 87-94. De Leon, G., Melnick, G., & Hawke, J. (2000a). The motivationreadiness factor in drug treatment: Implications for research and policy. Advances in Medical Sociology, 7, 103-129. De Leon, G., Melnick, G., Kressel, D. (1997). Motivation and readiness for therapeutic community treatment among cocaine and other drug abusers. American Journal of Drug and Alcohol Abuse, 23(2), 169-189. De Leon, G., Melnick, G., Thomas, G., Kressel, D., & Wexler, H. K. (2000b). Motivation for treatment in a prison-based therapeutic community. American Journal of Drug and Alcohol Abuse, 26(1), 33-46. DeLeon, G., Melnick, G., & Tims, F. M. (2001). The role of motivation and readiness in treatment and recovery. In F. M. Tims, C. G. Leukefeld and J. J. Platt (eds.), Relapse and recovery in addictions. New Haven: Yale University Press. DiClemente, C. C. (1999). Motivation for change: Implications for substance abuse treatment. Psychological Science, 10(3), 209-213. Donohew, L., Clayton, R. R., Skinner, W. F., & Colon, S. (1999). Peer networks and sensation seeking: Some implications for primary socialization theory. Substance Use and Misuse, 34(7), 1013-1023. Downey. L., Rosengren, D. B., & Donovan, D. M. (2000). To thine own self be true: Self-concept and motivation for abstinence among substance abusers. Addictive Behaviors, 25(5), 743-757. Einstein, S., & Wolfson, E. (1970). Alcoholism curricula: How professionals are trained. International Journal of the Addictions, 5, 295-312. Farabee, D., Leukefeld, C. G., & Hays, L. (1998). Accessing drug abuse treatment: Perceptions of out-of-patient injectors. Journal of Drug Issues, 28, 381-394.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

References

167

Farabee, D., & Nelson, R. (1993). Psychosocial profiles of criminal justice- and non criminal justice-referred substance abusers in treatment. Criminal Justice and Behavior, 20(4), 336-347. Farabee, D., Prendergast, M. L., & Anglin, M. D. (1998). The effectiveness of coerced treatment for drug-abusing offenders. Federal Probation, 62, 3-10. Finney, J. W., & Moos, R. H. (1995). Entering treatment for alcohol abuse: A stress and coping model. Addiction, 90, 1223-1240. Garnier, H. E., & Stein, J. A. (2002). An 18-year model of family and peer effects on adolescent drug use and delinquency. Journal of Youth and Adolescence, 31(1), 45-56. Garrity, T. E., Hiller, M. L., Staton, M., Webster, J. M., & Leukefeld, C. G. (2002). Factors predicting illness and health services use among male Kentucky prisoners with a history of drug abuse. The Prison Journal, 82(3), 295-313. Gecas, V. (2000). Socialization. In E. F. Borgatta & R. J. V. Montgomery (Eds.), Encyclopedia of sociology(Vol. 4, pp. 28552864). New York: Macmillan Reference. Germain, C. B. (Ed.) (1979). Social work practice: People and environments. New York: Free Press. Gibson, D. R., Sorensen, J. L., Wermuth, L., & Bernal, G. (1992). Families are helped by drug treatment. The International Journal of the Addictions, 27(8), 961-978. Glynn, T. J. (1981). From family to peer: A review of transitions of influence among drug-using youth. Journal of Youth and Adolescence, 10(5), 363-383. Goehl, l., Nunes, E., Quitkin, F., & Hilton, I. (1993). Social networks and methadone treatment outcome: The costs and benefits of social ties. American Journal of Drug and Alcohol Abuse, 19, 251-262. Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. Chicago, Il: Aldine Publishing Company. Goslin, D. A. (1969). Introduction. In D. A. Goslin (Ed.), A handbook of socialization theory and research (pp. 1-25). Chicago, Il: Rand McNally College Publishing Company. Gregrich, R. J. (2003). A note to researchers: Communicating science to policy makers and practitioners. Journal of Substance Abuse Treatment, 25, 233-237.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

168

References

Griffith, J. D., Knight, D. K., Joe, G. W., & Simpson, D. D. (1998). Implications of family and peer relations for treatment engagement and follow-up outcomes: An integrative model. Psychology of addictive behaviors, 12(2), 113-126. Hall, M. N., Amodeo, M., Shaffer, H. J., & Vander Bilt, J. (2000). Social workers employed in substance abuse treatment agencies: A training needs assessment. Social Work, 45(2), 141-155. Harbin, H. T., & Maziar, H. M. (1975). The families of drug abusers: A literature review. Family Process, 14, 411-431. Hawkins, J. D., & Fraser, M. W. (1987). The social networks of drug abusers before and after treatment. International Journal of the Addictions, 22, 343-355. The Health Foundation of Greater Cincinnati. (2000). Mental illness and substance abuse in the criminal justice system. Cincinnati, OH: The Health Foundation of Greater Cincinnati. Hiller, M., L., Knight, K., Leukefeld, C., Simpson, D. D. (2002). Motivation as predictor of therapeutic engagement in mandated residential substance abuse treatment. Criminal Justice and Behavior, 29(1), 56-75. Hiller, M., L., Knight, K., Simpson, D. D. (1996). An assessment of comorbid psychological problems in a residential criminal justice drug treatment program. Psychology of Addictive Behaviors, 10(3), 181-189. Hiller, M. L., Leukefeld, C., Staton, M., & Kayo, R. (2001). Problem severity and treatment motivation among substance abusers. Paper presented at the annual meeting of College on Problems of Drug Dependence, June 2001, Phoenix, AZ. Hiller, M. L., Narevic, E., Leukefeld, C., & Webster, J. M. (2001). Kentucky Reentry Courts: Evaluation of the pilot programs (University of Kentucky Center on Drug and Alcohol Research). Retrieved September 19, 2005, from the State Justice Institute: http://www.kycourts.net/AOC/DrugCourt/KYReentryFinalReport/ %20_final_pdf Hiller, M. L., Narevic, E., Webster, J. M., Rosen, P., Staton, M., Leukefeld, C., Garrity, T. F., & Kayo, R. (in press). Problem severity and motivation for treatment in incarcerated substance abusers. Substance Use and Misuse. Hiller, M. L., Webster, J. M, Garrity, T. F., Leukefeld, C. G., Narevic, E., Staton, M. (2005). Prisoners with substance abuse and mental

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

References

169

health problems: Health and health services use. The American Journal of Drug and Alcohol Abuse, 31(1), 1-20. Hoffmann, J. P., & Cerbone, F. G. (2002). Parental substance use disorder and the risk of adolescent drug abuse: An event history analysis. Drug and Alcohol Dependency, 66, 255-264. Hubbard, R. L., Collins, J. J., Rachal, J. V., & Cavanaugh, E. R. (1988). The criminal justice client in drug abuse treatment. In C. G. Leukefeld & F. M. Tims (Eds.), Compulsory treatment of drug abuse: Research and clinical practice (pp. 57-80). NIDA Research Monograph 86. Washington, DC: U.S. Government Printing Office. Inciardi, J. A., & Martin, S. S. (1993). Drug abuse treatment in criminal justice settings. Journal of Drug Issues, 23(1), 1-6. Inciardi, J. A., & Martin, S. S. (1997). An effective model of prisonbased treatment for drug-involved offenders. Journal of Drug Issues, 27(2), 261-278. Joe, G. W., Broome, K. M., Rowan-Szal, G. A., & Simpson, D. D. (2002). Journal of Substance Abuse Treatment, 22, 183-196. Joe, G. W., Simpson, D. D., & Broome, K. M. (1998). Effects of readiness for drug abuse treatment on client retention and assessment of process. Addiction, 93, 1177-1190. Joe, G. W., Simpson, D. D., & Broome, K. M. (1999). Retention and engagement models for different treatment modalities in DATOS. Drug and Alcohol Dependence, 57, 113-125. Johnson, V. E. (1986). Intervention – how to help someone who doesn’t want help. Minneapolis, MA: Johnson Institute Books. Kagle, J. D. (1987). Secondary prevention of substance abuse. Social Work, 32, 446-448. Kandel, D. (1973). Adolescent marihuana use: Role of parents and peers. Science, 181, 1067-1070. Kandel, D. (1996). The parental and peer contexts of adolescent deviance: An algebra of interpersonal influences. Journal of Drug Issues, 26(2), 289-315. Kandel, D., & Davies, V. H. (1989). Cessation of illicit drug use in young adulthood. Archives of General Psychiatry, 46, 109-116. Kassel, J. D., Wardle, M., Roberts, J. E. (2007). Adult attachment security and college student substance use. Addictive Behaviors, 32(6), 1164-1176.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

170

References

Kaufman, E. (1981). Family structures of narcotic addicts. The International Journal of the Addictions, 16(2), 273-282. Kazdin, A. (1998). Research design in clinical psychology (3rd ed.). MA, Needham Heights: Allyn & Bacon. Kemp, S. P., Whittaker, J. K., & Tracy, E. M. (1997). Personenvironment practice: The social ecology of interpersonal helping. New York: Aldine de Gruyter. Knight, D., & Simpson, D. D. (1996). Influences of family and friends on client progress during drug abuse treatment. Journal of Substance Abuse, 8(4), 417-429. Knight, D. K., Wallace, G. L., Joe, G. W., & Logan, S. M. (2001). Change in Psychosocial functioning and social relations among women in residential substance abuse treatment. Journal of Substance Abuse, 13, 533-547. Knight, K., Hiller, M. L., Broome, K. M., & Simpson, D.D. (2000). Legal pressure, treatment readiness, and engagement in long-term residential programs. Journal of Offender Rehabilitation, 31, 101115. Knight, K., Holcom, M., & Simpson, D.D. (1994, January). TCU Psychosocial Functioning and Motivation Scales: Manual on psychometric properties. Retrieved April 22, 2002, from http://www.ibr.tcu.edu/pubs/datacoll/kk6-srf-95.pdf Landau, J., Garrett, J., Shea, R. R., Stanton, M. D., Brinkman-Sull, D., &, Baciewicz, G. (2000). Strength in numbers: The ARISE method for mobilizing family and network to engage substance abusers in treatment. American Journal of Drug and Alcohol Abuse, 26(3), 379-398. Lawson, D. P., Segrin, C., & Ward, T. D. (1996). The relationship between prisonization and social skills among prison inmates. The Prison Journal, 76(3), 293-309. Leonard, C., Mulvey, K., Gastfriend, D. R., & Shwartz, M. (2000). The Addiction Severity Index: A field study of internal consistency and validity. Journal of Substance Abuse Treatment, 18, 129-135. Leukefeld, C. G., Hiller, M. L., Webster, J. M., Staton Tindall, M., Martin, S. S., Duvall, J., Tolbert, V., & Garrity, T. F. (2006). A prospective examination of high-cost health services utilization among drug using prisoners re-entering the community. Journal of Behavioral Health Services & Research, 73-85.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

References

171

Leukefeld, C. G., & Leukefeld, S. (1999). Primary socialization theory, and bio/psycho/social/spiritual practice model for substance use. Substance Use and Misuse, 34(7), 983-991. Leukefeld, C. G., Logan, T. K., Martin, S. S., Purvis, R. T., & Farabee, D. (1998). A health services use framework for drug-abusing offenders. American Behavioral Scientist, 41(8), 1123-1135. Leukefeld, C. G., Narevic, E., Hiller, M. L., Staton, M., Logan, T. K., Gillespie, W., Webster,J. M., Garrity, T. F., & Purvis, R. (2002). Alcohol and drug use among rural and urban incarcerated substance abusers. International Journal of Offender Therapy and Comparative Criminology, 46(6), 715-728. Leukefeld, C., Pickens, R. W., & Schuster, C. R. (1992). Recommendations for improving drug treatment. The International Journal of Addictions, 27(10), 1223-1239. Leukefeld, C., Staton, M., Hiller, M., Logan T. K., Warner, B., Shaw, K., Purvis, R. (2002). A descriptive profile of health problems, health services utilization, and HIV serostatus among incarcerated male drug abusers. Journal of Behavioral Health Services and Research, 29(2), 167-175. Leukefeld, C. G., & Tims, F. M. (Eds.) (1988). Compulsory treatment for drug abuse: Clinical practice and research. NIDA Research Monograph 86. Washington, DC: U.S. Government Printing Office. Leukefeld, C. G., & Tims, F. M. (1993). Drug abuse treatment in prisons and jails. Journal of Substance Abuse Treatment, 10, 7784. Leukefeld, C. G., & Walker, R. (1998). Substance use disorders. In J. B. W. Williams & K. Ell (eds.), Advances in mental health research: Implications for practice. Washington, DC: NASW Press. Marlowe, D. B., Kirby, K. C., Bonieskie, L. M., Glass, D. J., Dodds, L. D., Husband, S. D., et al. (1996). Assessment of coercive and noncoercive pressures to enter drug abuse treatment. Drug and Alcohol Dependence, 42, 77-84. Marlowe, D. B., Kirby, K. C., Merikle, E. P., Festinger, D. S., & McLellan, A. T. (2001). Multidimensional assessment of perceived treatment-entry pressures among substance abusers. Psychology of Addictive Behaviors, 15(2), 97-108.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

172

References

Mason, W. A., & Windle, M. (2001). Family, religious, school and peer influences on adolescent alcohol use: A longitudinal study. Journal of Study on Alcohol, 62, 44-53. McBride, C. M., Curry, S. J., Stephens, R. S., Wells, E. A., Roffman, R. A., & Hawkins, J. D. (1994). Intrinsic and extrinsic motivation for change in cigarette smokers, marijuana smokers, and cocaine users. Psychology of Addictive Behaviors, 8, 243-250. McConnaughy, E. A., DiClemente, C. C., Prochaska, J. O., & Velicer, W. F. (1989). Stages of change in psychotherapy: A follow-up report. Psychotherapy, 26, 494-503. McCoy, C. B., Metsch, L. R., Chitwood, D. D., & Miles, C. (2001). Drug use and barriers to use of health care services. Substance Use and Misuse, 36(6-7), 789-806. McGahan, P. L., Griffith, J. A., Parente, R., McLellan, A. T. (1986). Addiction Severity Index: Composite scores manual. Philadelphia, PA: University of Pennsylvania Veterans Administration Center for Studies of Addiction, Treatment Research Institute. McGue, M., Sharma, A., & Benson, P. (1996). Parent and sibling influences on adolescent alcohol use and misuse: Evidence from a U.S. adoption cohort. Journal of Studies of Alcohol, 57, 8-18. McLellan, A. T. (2003). Crime and punishment and treatment: Latest findings in the treatment of drug-related offenders. Journal of Substance Abuse Treatment, 25, 187-188. McLellan, A. T., Kushner, H., Metzger, D., Peters, R. H., Smith, I., Grissom, G. Pettinati, H., & Argeriou, M. (1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9, 119-213. McLellan, A. T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F., & Barr, H., & O’Brien, C. (1985). New data from the Addiction Severity Index: Reliability and validity in three centers. The Journal of Mental and Nervous Disease, 173, 412-423. Melnick, G. (1999). Assessing treatment readiness in special populations. In Final Report of Project Activities. Rockville, MD: National Institute of Drug Abuse. Melnick, G., DeLeon G.,Hawke, J., Jainchill, N., & Kressel, D. (1997). Motivation and readiness for therapeutic community treatment among adolescents and adult substance abusers. American Journal of Drug and Alcohol Abuse, 23(4), 485-506.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

References

173

Melnick, G., DeLeon G., Thomas, G., Kressel, D., & Wexler, H. K. (2001). Treatment process in prison therapeutic communities: Motivation, participation, and outcome. American Journal of Drug and Alcohol Abuse, 27(4), 633-650. Merikangas, K. R., Stolar, M., Stevens, D. E., Goulet, J., Preisig, M. A., Fenton, B., Zhang, H., O’Malley, S. S., & Rounsaville, B. J. (1998). Familial transmission of substance use disorders. Archives of General Psychiatry, 55, 973-979. Meyers, R. J., Miller, W. R., Hill, D. E., & Tonigan, J. S. (1998). Community reinforcement and family training (CRAFT): Engaging unmotivated drug users in treatment. Journal of Substance Abuse, 10(3), 291-308. Miller, N. S., & Flaherty, J. A. (2000). Effectiveness of coerced addiction treatment (alternative consequences): A review of the clinical research. Journal of Substance Abuse Treatment, 18, 9-16. Miller, W. R. (1985). Motivation for treatment: A review, the special emphasis on alcoholism. Psychological Bulletin, 98, 84-107. Miller, W. R. (1996). Motivational interviewing: Research, practice, and puzzles. Addictive Behaviors, 21(6), 835-842. Miller, W. R. (1998). Why do people change addictive behavior? The 1996 H. David Archibald lecture. Addiction, 91(2), 163-172. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. NY: Guilford Press. Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers’ motivation for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors, 10(2), 81-89. Moos, R. H., & Moos, B. S. (1984). The process of recovery from alcoholism: III. Comparing functioning in families of alcoholics and matched control families. Journal of Studies on Alcohol, 45(2), 111-118. Morris, N. (1995). The contemporary prison: 1965-present. In N. Morris & D. J. Rothman (eds.), The Oxford history of the prison. New York: Oxford University Press. Mueser, K. T., Essock, S. M., Drake, R. E., Wolfe, R. S., & Frisman, L. (2001). Rural and urban differences in patients with dual diagnosis. Schizophrenia Research, 48, 93-107.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

174

References

Mumola, C. J. (1999). Substance abuse and treatment, State and Federal prisoners, 1997. Bureau of Justice Statistics: Special Report (NCJ 172871). Retrieved November 17, 2007, from U.S. Department of Justice: Office of Justice Programs: http://www.ojp.usdoj.gov/bjs/ Mumola, C. J., & Karberg, J. C. (2006, October; revised 2007, January). Drug use and dependence, State and Federal prisoners, 2004. Bureau of Justice Statistics: Special Report (NCJ 213530). Retrieved October 16, 2007, from U.S. Department of Justice: Office of Justice Programs: http://www.ojp.usdoj.gov/bjs/ Narevic, E., Garrity, T. F., Schoenberg, N. E., Hiller, M. L., Leukefeld, C. G., & Staton, M. (2006). Unmet service needs and barriers to health care among incarcerated substance users. Substance Use and Misuse, 41, 1077-1094. National Center for Health Statistics (NCHS), National Health Interview Survey (NHIS) (2002, June 07). Health Measures in the New 1997 Redesigned National Health Interview Survey. Retrieved May 18, 2003, from http://www.cdc.gov/nchs/about/major/nhis/hisdesgn.htm National Institute on Drug Abuse (NIDA) (2005, March 8). Drug addiction treatment methods. Retrieved May 18, 2005, from NIDA Infofacts: http://www.nida.nih.gov/infofacts/treatmeth.html Needle, R., McCubbin, H., Wilson, M., & Reineck, R. (1986). Interpersonal influences in adolescent drug use: The role of older siblings, parents, and peers. International Journal of the Addictions, 21, 739-766. Nurco, D. N., & Lerner, M. (1999). A complementary perspective to primary socialization theory. Substance Use and Misuse, 34(7), 993-1003. Oetting, E. R. (1999). Primary socialization theory. Developmental stages, spirituality, government institutions, sensation seeking, and theoretical implications. V. Substance Use and Misuse, 34(7), 947982. Oetting, E. R., & Beauvais, F. (1986). Peer cluster theory: Drugs and adolescent. Journal of Counseling and Development, 65, 17-22. Oetting, E. R., & Beauvais, F. (1987). Peer cluster theory, socialization characteristics, and adolescent drug use: A path analysis. Journal of Consulting and Clinical Psychology, 34, 205-213.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

References

175

Oetting, E. R., & Donnermeyer, J. F. (1998). Primary socialization theory. The etiology of drug use and deviance. I. Substance Use and Misuse, 33(4), 995-1026. Oetting, E. R., Deffenbacher, J. L, & Donnermeyer, J. F. (1998b). Primary socialization theory. The role played by personal traits in the etiology of drug use and deviance. II. Substance Use and Misuse, 33(6), 1337-1366. Oetting, E. R., Donnermeyer, J. F., & Deffenbacher (1998a). Primary socialization theory. The influence of the community on drug use and deviance. III. Substance Use and Misuse, 33(8), 1629-1665. Pearson, F. S., & Lipton, D. S. (1999). A meta-analytic review of the effectiveness of corrections-based treatments for drug abuse. The Prison Journal, 79(4), 384-410. Peat, B. J., & Winfree, L. T. (1992). Reducing the intra-institutional effects of “prisonization”: A study of therapeutic community for drug-using inmates. Criminal Justice and Behavior, 19(2), 206225. Peleg-Oren, N., Rahav, G., & Teichman, M. (2002). Social work and the treatment of substance abuse in Israel. Journal of Social Work Practice in the Addictions, 2(3/4), 85-96. Peyton, S., Chaddick, J., & Gorsuch, R. (1980). Willingness to treat alcoholics: A study of graduate social work students. Journal of Studies on Alcohol, 41, 935-940. Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114. Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38-48. Re-Entry Policy Council (2004). Report of the re-entry policy council: Charting the safe and successful return of prisoners to the community. Retrieved on May 04, 2005, from http://www.reentrypolicy.org Riehman, K. S., Hser, Y. I., Zeller, M. (2000). Gender differences in how intimate partners influence drug treatment motivation. Journal of Drug Issues, 30(4), 823-838. Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a short “readiness to change” questionnaire for use in brief,

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

176

References

opportunistic interventions among excessive drinkers. British Journal of Addiction, 87, 743-754. Rowe, D. C., & Gulley, B. L. (1992). Sibling effects on substance use and delinquency. Criminology, 30(2), 217-233. Ryan, R. M., Plant, R. W., & O’Malley, S. (1995). Initial motivation for alcohol treatment: Relations with patient characteristics, treatment involvement, and dropout. Addictive Behaviors, 20, 279297. Schilling, R. F., & El-Bassel, N. (1998). Substance abuse interventions. In J. B. W. Williams & K. Ell (eds.), Advances in mental health research: Implications for practice. Washington, DC: NASW Press. Schlesinger, S. E., & Barg, M .D. (1986). Substance misuse training in nursing, psychiatry, and social work. International Journal of the Addictions, 21, 595-604. Simpson, D. D. (2001). Modeling treatment process and outcomes. Addiction, 96, 207-211. Simpson, D. D. (2004). A conceptual framework fro drug treatment process and outcomes. Journal of Substance Abuse Treatment, 27, 99-121. Simpson, D. D., & Chatham, L. R. (1995). TCU/DATAR Form manual: Improving Drug Abuse Treatment, Assessment, and Research (DATAR) project. Fort Worth, TX: Texas Christian University, Institute of Behavioral Research. Simpson, D. D., & Joe, G. W. (1993). Motivation as a predictor of early dropout from drug abuse treatment. Psychotherapy, 30(2), 357-368. Simpson, D. D., Joe, G. W., & Rowan-Szal (1997). Drug abuse treatment retention and process effects on follow-up outcomes. Drug and Alcohol Dependence, 47, 227-235. Smith, M. B., Hoffman, N. G., & Nederhoed, R. (1995). The development and reliability of the RAATE-CE. Journal of Substance Abuse, 4, 355-363. Sorensen, J., & Gibson, D. (1983). Community network approach to drug abuse treatment. Bulletin of the Society of Psychologists and Addictive Behaviors, 2(2), 99-102. Soyez, V., DeLeon, G., Broekaert, E., & Rosseel, Y. (2006). The impact of a social network intervention on retention on Belgian

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

References

177

therapeutic communities: a quasi-experimental study. Addiction,101,1027-1034. Stanton, M. D., Todd, T. C., Heard, D. B., Kirschner, S., Kleiman, J. I., Mowatt, D. T. et al. (1978). Heroin addiction as a family phenomenon: A new conceptual model. American Journal of Drug and Alcohol Abuse, 5(2), 125-150. Stevens, J. (1996). Applied multivariate statistics for the social sciences (3rd ed.). Mahwah, NJ: Lawrence Erlbaum Associates, Inc., Publishers. Tabachnick, B. G., & Fidell, L. S. (2000). Using multivariate statistics (4th ed.). Needham Heights, MA: Allyn & Bacon. Texas Christian University (TCU), Institute of Behavioral Research. (1998, July). Items in TCU Treatment Motivation Scales: Scoring guide. Retrieved April 22, 2002, from http://www.ibr.tcu.edu/pubs/datacoll/Forms/Srf-cd-mot-95.PDF Thomas, C. W. (1973). Prisonization or resocialization? A study of external factors associated with the impact of imprisonment. Journal of Research in Crime and Delinquency, 10, 13-21. Thomas, C. W., Peterson, D. M., & Zingraff, R. M. (1978). Structural and psychological correlates of prisonization. Criminology, 16, 383-393. Thomas, E. J., Santa, C. A., Bronson, D., et al. (1987). Unilateral family therapy with the spouses of alcoholics. Journal of Social Services Research, 10, 145-162. Tims, F. M., Leukefeld, C. G., & Platt, J. J. (2001). Relapse and recovery. In F. M. Tims, C. G. Leukefeld & J. J. Platt (eds.), Relapse and recovery in addictions (pp. 3-18). New Haven, CT: Yale University Press. Toch, H. (1975). Men in crisis: Human breakdowns in prison. Chicago, IL: Aldine Publishing Company. Toch, H. (1982). Studying and reducing stress. In R. Johnson & H. Toch (eds.), The pains of imprisonment. Beverly Hills, CA: Sage Publications. Toch, H. (1996). Living in prison: The ecology of survival, (2nd ed.). Washington, DC: American Psychological Association. Tsogia D., Copello, A. & Orford, J. (2001). Entering treatment for substance misuse: A review of the literature. Journal of Mental Health, 10(5), 481-499.

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

Copyright © 2008. LFB Scholarly Publishing LLC. All rights reserved.

178

References

Tucker, M. B. (1985). Coping and drug use among heroin-addicted women and men. In S. Shiffman & T. A. Wills (Eds.), Coping and substance use (pp. 147-170). Orlando, FL: Academic Press. Tucker, J. A., & King, M. P. (1999). Resolving alcohol and drug problems: influences on addictive behavior change and helpseeking. In J. A. Tucker, D. M. Donovan & G. A. Marlatt (Eds.), Changing addictive behavior: Bridging clinical and public health strategies (pp.97-126). New York: Guilford Press. Vaillant, G. (1966). A 12-year follow-up of New York narcotic addicts. Archives of General Psychiatry, 15, 599-609. Warner, B. D., & Leukefeld, C. G. (2001). Rural-urban differences in substance use and treatment utilization among prisoners. American Journal of Drug and Alcohol Abuse, 27(2), 265-280. Webster, J. M., Leukefeld, C. G., Staton, M., Hiller, M. L., Garrity, T. F., & Narevic, E. (2005). Lifetime health services use by male drug-abusing offenders. The Prison Journal, 85(1), 50-64. Wexler, H. K. (1994). Progress in prison substance abuse treatment: A five-year report. Journal of Drug Issues, 24(1/2), 349-361. Wexler, H. K. (2003). The promise of prison-based treatment for dually diagnosed inmates. Journal of Substance Abuse Treatment. 25, 223-231. Wexler, H. K., & Fletcher, B. W. (2007). National Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) overview. The Prison Journal, 87(1), 9-24. Whitbeck, L. B. (1999). Primary socialization theory: It all begins with the family. Substance Use and Misuse, 34(7), 1025-1032. Wills, T. A. (1990). Multiple networks and substance use. Journal of Social and Clinical Psychology, 9, 78-90. Wilson, J., & Sonnad, S (2001). Socialization. In The Corsini encyclopedia of psychology and behavioral science (Vol. 3, pp. 1578-1580). New York: Wiley. Winfree, L. T., Mays, G. L., Crowley, J. E., & Peat, B. J. (1992). Drug history and prisonization: Toward understanding variations in inmate institutional adaptations. International Journal of Offender Therapy and Comparative Criminology, 38(4), 281-296. Yamaguchi, K. (1990). Drug use and its social covariates from the period of adolescence to young adulthood: Some implications from longitudinal studies. In M. Galanter (Ed.), Recent developments in alcoholism: Combined alcohol and other drug

Narevic, Egle. Social Relations and Motivation for Substance Abuse Treatment among Prisoners, LFB Scholarly

References

179

dependence: The syndrome, social deviancy, biological issues, clinical issues (Vol 8). New York: Plenum Press. Young, D. (2002). Impact of perceived legal pressure on retention in drug treatment. Criminal Justice and Behavior, 29(1), 27-55.

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Zingraff, M. T. (1975). Prisonization as an inhibitor of effective resocialization. Criminology, 13, 366-388

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INDEX Community reinforcement and family training (CRAFT), 151 Community reinforcement training (CRT), 151 Conflict with parents, 103, 115, 128-129 Conflict with peers, 103, 128129 Conflict with primary socialization sources, 14, 98-99, 103, 128-129, 136137, 141, 145, 148 Conflict with sexual partner, 103, 128-129 Conflict with siblings, 103, 115, 128-129 Constructivist perspective, 20 Contemplation Ladder, 58-59 Co-occurring mental health and substance abuse problems, 26, 92 Desire for help, 5, 8, 13-16, 45, 57, 66-67, 74, 76-80, 101-102, 104-107, 122126, 140-144 Deviance of primary socialization sources, 14, 100, 119-120, 123-124, 130, 136, 141, 144-145 Drug Abuse Reporting Program (DARP), 4 Drug Abuse Treatment and Assessment Research (DATAR), 5

Addiction Severity Index (ASI), 68, 71, 74, 84-85, 157 Adult socialization, 32 Aftercare, 3, 152-153, 155156, 159 Alcohol use severity, 90-91 Alcoholics Anonymous (AA), 33, 94 Brief motivational counseling, 151 Center for Therapeutic Community Research (CTCR), 8 Center on Drug and Alcohol Research (CDAR) at the University of Kentucky, ix Circumstances, Motivation, Readiness and Suitability (CMRS) scale, 5, 8, 42, 44-45, 53, 56-57, 59, 6162, 64, 87, 104 Cohesion with parents, 103, 128-129 Cohesion with peers, 103, 128129, 136, 141 Cohesion with primary socialization sources, 14, 30, 69, 98-99, 103, 120122, 124-126, 130-131, 139-141, 144, 148 Cohesion with siblings, 103, 128-129 Community Action approach, 156

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182 Drug and Alcohol Treatment Outcome Studies (DATOS), 4-5, 65-66, 73, 76, 88, 133 Ecological perspective, 12 Engagement in treatment, 6-8, 75-76, 150-151 External motivation, 6-8, 4749, 57-58 Family as primary socialization source see primary socialization source Health Services Research Instrument (HSRI), 84-87, 93 Hitting bottom hypothesis, 47, 53, 90 Incarceration, 4, 36-41, 82-83, 94-95 Integrated Recovery model, 42, 44, 46 Internal motivation, 6-8, 4749, 56-58 Johnson intervention, 151 Kentucky State Correctional facilities, 82 Learning theory, 21, 24 Marijuana use severity, 90 Motivation: and treatment outcomes, 2-4; and socialization, 50-53; and incarceration, 38-41 Motivational interviewing, 50, 152 Narcotics use severity, 90 National Criminal Justice Drug Abuse Treatment Studies (CJ-DATS), 152

Index Negative conflict, 147 Peer deviance, 51-52, 68-76, 97, 133, 137-138, 141, 144 Peer group, 22, 25, 28-31, 51, 70, 78, 142 Primary socialization theory, 10-13, 24-36 Primary socialization source: family as, 28-30; peers as, 30-32 Primary substance of use, 89, 90 Prisonization, 4, 37-41 Problem recognition, 5, 14, 4547, 105-107, 118-122, 140-144 Problem severity, 89-92, 95, 137 Readiness to Change Questionnaire (RTCQ), 6, 56-57, 59 Reasons for Quitting (RFQ) questionnaire, 58-60, 67 Recidivism, 94-96 Recovery Attitude and Treatment Evaluator (RAATE), 58-60 Re-entry court, 155 Relational intervention sequence for engagement (ARISE), 151 Retention in treatment, 6-8, 48, 63, 74, 150 Secondary socialization, 2122, 25, 36 Self-concept, 49-50, 58, 67 Self-efficacy, 39 Severity of use, 89-91

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Index

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Sibling relations, 78, 142-143 Social control, 20-21 Social factors, 7-8, 16-17, 63, 69 Social network, 7, 63, 70, 151152 Socialization: definitions of, 19-23, and incarceration, 36-37 Stage models of substance abuse behavior change, 42-46 Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), 6, 56-57, 59, 61, 67-68 Strengths-based case management, 153 Substance abuse treatment, 9394

183 Texas Christian University (TCU) Motivational Assessment Scales, 5, 4547, 56, 65-67, 104-107 Therapeutic community, 40, 51, 57, 64, 83 Transitional case management (TCM), 153 Transtheoretical model, 5, 4244, 51, 76-77, 139 Treatment Motivation Questionnaire (TMQ), 5860, 68, 92 Treatment Outcome Prospective Study (TOPS), 4 Treatment readiness, 45, 57, 65-67, 105 University of Rhode Island Change Assessment (URICA), 6, 56-57, 59, 61

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