The Efficacy of Brief Family Based Treatment inChanging Family Members' Attitudes Toward People withAddiction and Attitudes Toward a Relative with Addiction

Item Type text; Electronic Dissertation

Authors Kolodny, Teresa Lynn

Publisher The University of Arizona.

Rights Copyright © is held by the author. Digital access to this materialis made possible by the University Libraries, University of Arizona.Further transmission, reproduction or presentation (such aspublic display or performance) of protected items is prohibitedexcept with permission of the author.

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Link to Item http://hdl.handle.net/10150/193708

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THE EFFICACY OF BRIEF FAMILY-BASED TREATMENT IN CHANGING

FAMILY MEMBERS’ ATTITUDES TOWARD PEOPLE WITH ADDICTION AND

ATTITUDES TOWARD A RELATIVE WITH ADDICTION

by

Teresa Lynn Kolodny __________________

A Dissertation Submitted to the Faculty of the

DEPARTMENT OF SPECIAL EDUCATION, REHABILITATION, AND SCHOOL

PSYCHOLOGY

In Partial Fulfillment of the Requirements For the Degree of

DOCTOR OF PHILOSOPHY

WITH A MAJOR IN REHABILITATION

In the Graduate College

THE UNIVERSITY OF ARIZONA

2009

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THE UNIVERSITY OF ARIZONA GRADUATE COLLEGE

As members of the Dissertation Committee, we certify that we have read the dissertation

prepared by Teresa Lynn Kolodny entitled The Efficacy of Brief family-based Treatment

in Changing Family Members’ Attitudes toward People with Addiction and Attitudes

toward a Relative with Addiction and recommend that it be accepted as fulfilling the

dissertation requirements for the Degree of Doctor of Philosophy.

_________________________________________________Date: October 21, 2009 Dr. Charlene Kampfe, Ph. D. __________________________________________________Date: October 21, 2009 Dr. Amos Sales, Ed. D. __________________________________________________Date: October 21, 2009 Dr. Chih-Chin Chou, Ph. D.

Final approval and acceptance of this dissertation is contingent upon the candidate’s submission of the final copies of the dissertation to the Graduate College. I hereby certify that I have read this dissertation prepared under my direction and recommend that it be accepted as fulfilling the dissertation requirement. ____________________________________________________Date: October 21, 2009 Dissertation Director: Dr. Charlene Kampfe, Ph.D.

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STATEMENT BY THE AUTHOR

This dissertation has been submitted in partial fulfillment of the requirements for an advanced degree at the University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library. Brief quotations from this dissertation are allowable without special permission, provided that accurate acknowledgement of source is made. Requests for permission for extended quotation from this manuscript in whole or in part may be granted by the head of the major department of the Dean of the Graduate College. In other instances, however, permission must be obtained from the author.

SIGNED: Teresa L Kolodny

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ACKNOWLEDGEMENTS Sincere acknowledgement is made to my dissertation committee members, Dr.

Charlene Kampfe, Ph.D., the Dissertation Chair, Dr. Amos Sales, Ed.D., and Dr. Chin

Chou, Ph.D. To them I owe a debt of gratitude for their time, patience, and

encouragement. I especially want to thank Dr. Kampfe for her strength, compassion, and

attention to detail which helped me to overcome many obstacles during this study.

Next I would like to thank Dr. Richard Morris, Ph.D. for assisting me in securing

a study site at Pima County Juvenile Court Center (PCJCC). Heartfelt appreciation goes

to the Court Director, staff, and family members at PCJCC, most notably, Dr. Beverly

Tobiason, Dr. Alvin Lewis, Paula Burns, and Pat Canterbury. I am also very appreciative

of the KARE Center staff, participants, and Director, Laurie Melrood. To all of them, I

extend my utmost appreciation for partnering with me and sharing their wisdom during

this research study.

Also, my statistician, Mark Borgstrom and my fellow doctoral students, Dr. Phil

Johnson, Cynthia Dowdall, and Dr. Lisa Degiorgio, my dear friends, Dr. Martha

Underwood and Wendy Sokol, and numerous barn buddies, Chris, Rita, Jean, and Vickie

Jo for their emotional support. Without their enthusiasm, humor, and excitement for my

study, completion would not have been possible.

Lastly, I most lovingly acknowledge my parents, Don and Rose Purcell, and dear

family members, Aaron and Amber Kolodny, Mary Kolodny, Dr. Carter Kolodny and

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Kathleen Kolodny. Their ever-present support and prayers were a life-line to me during

my graduate studies at the University of Arizona.

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DEDICATION

I dedicate this dissertation first, to my Savior, Jesus Christ. With Him, all things

are possible (even a Ph.D). Next, to my father-in-law, Dr. Stanley Kolodny, Sr., whose

belief in my abilities inspired me to follow my dreams to completion. Also, to my dear

husband, Stanley Kolodny, Jr., who listened patiently, held me when I cried, and always

said “you can do this.” And finally, to all the families who live with addiction, thank you

for sharing your story.

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TABLE OF CONTENTS

LIST OF TABLES .............................................................................................................10

LIST OF ILLUSTRATIONS .............................................................................................11

ABSTRACT .......................................................................................................................12

CHAPTER ONE: INTRODUCTION ................................................................................14

Addiction................................................................................................…..…. …14

Addiction as a Disease ...........................................................................................15

Attitudes …………………………………………………………………………16

Brief Family-based Treatment ...............................................................................22

Statement of the Problem .......................................................................................24

Significance of the Study .......................................................................................24

Research Questions ................................................................................................25

Definition of Terms................................................................................................27

CHAPTER TWO: REVIEW OF THE LITERATURE .....................................................31

Addiction Statistics and Need for Treatment .........................................................31

Family Members’ Attitudes toward Addiction ......................................................34

Brief Family-based Treatment Approaches ...........................................................35

Summary ................................................................................................................51

CHAPTER THREE: METHOD ........................................................................................54

Participants and Settings ........................................................................................54

Procedure ...............................................................................................................59

Research Design.....................................................................................................61

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Instrument ..............................................................................................................63

Piloted Study of the Attitudes Measurement: Brief Scales ....................................66

Analysis..................................................................................................................67

CHAPTER FOUR: FINDINGS .........................................................................................69

Results ....................................................................................................................70

Responsibility scale ...............................................................................................71

Negative scale ........................................................................................................73

Positive scale ..........................................................................................................76

Deservingness scale ...............................................................................................79

Entitlement scale ....................................................................................................82

Demographic Characteristics…………………………………………………….86

Summary of Findings .............................................................................................88

CHAPTER FIVE: DISCUSSION ......................................................................................90

Brief Review of the Methodology .........................................................................90

Discussion of Findings ...........................................................................................91

Limitations .............................................................................................................97

Conclusions and Recommendations ......................................................................99

APPENDIX A-1. RECRUITMENT FLYER FOR PCJCC .............................................101

APPENDIX A-1a. SUBJECT INFORMED CONSENT FORM FOR PCJCC ...............102

APPENDIX A-2. RECRUITMENT FLYER FOR KARE ..............................................103

APPENDIX A-2a. SUBJECT INFORMED CONSENT FORM FOR KARE................104

APPENDIX B-1. ATTITUDES MEASUREMENT: BRIEF SCALES (ORIGINAL) ...105

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APPENDIX B-2. ATTITUDES MEASUREMENT: BRIEF SCALES (REVISED) ....106

APPENDIX B-3. ATTITUDES MEASUREMENT: BRIEF SCALES (REVISED) .....107

APPENDIX B-4. DEMOGRAPHIC QUESTIONNAIRE ..............................................108

APPENDIX C. ATTITUDES MEASUREMENT: BRIEF SCALES (SCORING) .......109

APPENDIX D. MAC TREATMENT READINESS PROGRAM (DESCRIPTION) ....111

REFERENCES ................................................................................................................113

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LIST OF TABLES

Table 1: Analysis of Variance for the Responsibility Scale ..............................................71

Table 2: Analysis of Variance for the Negative Scale .......................................................74

Table 3: Analysis of Variance for the Positive Scale ........................................................77

Table 4: Analysis of Variance for the Deservingness Scale ..............................................80

Table 5: Analysis of Variance for the Entitlement Scale ...................................................83

Table 6: Demographic Characteristics……………………………………………………86

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LIST OF ILLUSTRATIONS

Figure 1. Means for the Responsibility Scale ....................................................................73

Figure 2. Means for the Negative Scale .............................................................................76

Figure 3. Means for the Positive Scale ..............................................................................79

Figure 4. Means for the Deservingness Scale ....................................................................82

Figure 5. Means for the Entitlement Scale.........................................................................85

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ABSTRACT

The family has been described as the center or heart of societal relationships, with

each family member playing an integral part in that relationship (Garrett & Landau, 2007;

Jay & Jay, 2000). Therefore, when a family member is affected by a disease such as

addiction, his or her predicament typically impacts other members of the family. When

this occurs, family members may seek therapy to provide solutions. One technique that

has been found to be beneficial to the entire family, by providing education about the

impact of addiction, is brief family-based treatment (FBT) (Jay & Jay; Johnson, 1998).

Brief family-based treatment teaches that as family members work together, they have a

much better chance of changing their own perceptions/attitudes about addiction, thereby

changing the outcome for the relative with addiction.

This quasi-experimental study explored the efficacy of brief family-based

treatment in changing family members’ attitudes toward people in general with addiction

and in changing family members’ attitudes toward a specific relative with addiction. The

participants were comprised of a convenience sample of two groups (i.e., treatment and

control). Participants in the treatment group (n = 19) received a brief family-based

treatment session and participants in the control group (n = 22) did not receive a brief

family-based treatment session.

This study had three phases: (a) recruiting, selecting, and determining eligibility

of family members from both groups to participate in the study, (b) applying the

intervention (i.e., brief family-based treatment) to the treatment group and collecting

data, and (c) analyzing the results. Two research questions were posed: (a) is there a

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change in family members’ attitudes toward people in general with addiction from pre-

family based treatment to post-family based treatment and (b) is there a change in family

members’ attitudes toward a specific relative with addiction from pre- family-based

treatment to post-family-based treatment? Results of this study indicated that brief

family-based treatment resulted in no significant finding with regard to changing family

members’ attitudes toward people in general with addiction and in changing attitudes

toward a specific relative with addiction. Despite these results, however, some

significance was noted in other areas. Therefore, more research into all aspects of brief

family-based treatment should be explored so that interventions can be studied for more

effectiveness.

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CHAPTER ONE

INTRODUCTION

Addiction

In 2006, approximately 30.5 million Americans aged 12 and older reported using

some type of illicit drug and an additional 54 million engaged in “heavy” drinking at least

one day out of the week, or “binge use,” within a 30 day period (SAMHSA, 2008). The

societal cost of addiction is over $300 billion and continues to rise each year. This has

resulted in one of the most severe health concerns facing America, today (SAMHSA).

Clearly, as the impact of addiction on society and families rises, so does the need to

define and better understand addiction.

Over the past few decades, the definition of addiction has been unclear, leaving

counselors and lay people with a variety of terms that are representative of the person

with an addiction (Gutman, 2006; Jay & Jay, 2000; Mumm, Olsen, & Allen, 1998; Sales,

2000; Summerall & Leshner, 2003). For example, addiction has been described as a

disease, a state of physiological or psychological dependence on an addictive substance,

where prolonged use may result in a chronic condition in which the symptoms of the

disease are likely to result in severe and damaging consequences to the person with

addiction or to family members of the person with addiction (Jay & Jay;

Gutman; Sulek, Korczak-DZiurdzik, Korbel-Pawlaws, Lyznicka, & Czarneck, 2006;

Summerall & Leshner, 2003; Wilson & Wilson, 1992). The Diagnostic and Statistical

Manual of Mental Disorders (DSM-IV TR, 2000) describes addiction as a physical

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dependence on and abuse of drugs and other miscellaneous substances. According to

Sales (2000), “addiction, alcoholism, alcohol abuse, and chemical dependency” represent

and share many of the same characteristics (p. 2). As such, the terms alcohol addiction,

alcoholism, alcohol dependence, drug addiction, and drug dependence generally suggest

some form of addiction. In a recent study completed in 2008 by the National Institute on

Drug Abuse (NIDA), researchers determined that addiction is a complicated disease that

can encompass essentially every aspect of a person’s life.

Addiction as a Disease

As a disease, addiction has typical signs and symptoms that may progress in a

certain manner, with addiction becoming the primary concern and not the result of some

other condition (Wilson & Wilson, 1992). Jellnick defined addiction in the 1950’s as a

disease, and proffered the theory that a person with addiction has a physiological

deficiency that makes him or her incapable of tolerating the addictive substance (Smith &

Miller, 2000). Furthermore, as a primary disease, rather than being a symptom of some

other disorder or dysfunction, addiction often may be the cause or may, at the very least

exacerbate, other conditions whether they are physical or emotional (Johnson, 1998). For

example, a physician is unable to treat an addict with a diseased liver until the addict is

willing to submit to treatment for his or her addiction (Johnson). Addiction, like heart

disease, cancers, and type II diabetes, is a real and complex disease (NIDA, 2008). Once

a person is addicted, his or her behavior becomes a product of the disease and, as such,

the addiction requires that the person defer to it (i.e., the addiction) rather than to his or

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her natural behavioral instincts which may tend to be less self-indulgent and more

manageable (Wilson & Wilson). A key principle of the disease model, therefore, is the

capacity to move addiction out of the realm of being a character flaw and moral issue to

that of a treatable disease (Washton & Zweben, 2006).

Attitudes

In many instances, addiction has been perceived by professionals as a moral

problem with public opinion alternating between hostility, aversion, and unconcern

toward people with addiction, on the one hand, to sympathy and consideration for their

well-being on the other hand,(Gutman, 2006). Beck, Matschinger, and Angermeyer

(2003) assert that negative perceptions and attitudes such as these have led the public to

conclude that a person with addiction is not entitled to the same type of treatment and

intervention as a person with other similar conditions.

To understand how these negative attitudes affect the outcomes of addiction, one

must first have a good definition of attitudes. Attitudes have been defined as emotionally

charged ideas that prompt a set of actions toward a certain class of individuals (Triandis,

1971). They are associated with a tendency to behave in a predictable and guarded way

toward, or in the presence of, members of a particular group (Hunt & Hunt, 2004). With

regard to attitudes, there are three common assumptions: (a) they include some kind of

judgment of someone; (b) they can be articulated through language; and (c) they are

associated with actions toward another (Eiser, 1986; McCarthy & Light, 2005). Other

terms used to describe attitudes include self-beliefs, beliefs, judgments, perceptions,

thoughts, and stigmas (Canale & Munn, 2005; Jay & Jay, 2000; Johnson, 1998). In this

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same way, family members’ attitudes toward addiction are often characterized by

thoughts of judgment, misgiving, uncertainty, and guardedness (Wilson & Wilson,1992).

For the purpose of this study, the term attitude will represent all of the above beliefs and

actions and will focus on family member’s attitudes or perceptions toward addiction.

Family members’ beliefs about addiction and their feelings toward a specific

relative with addiction often play an essential part in the psychological aspect of the

recovery process of the relative with the addiction (Jay & Jay, 2000). For example,

family members who hold a relative with addiction responsible for his or her addiction,

or who have a negative attitude toward a relative with addiction, may cause the person to

continue to use as a way of coping with his or her situation. Therefore, if recovery is to

occur, it is imperative for family members to become aware of how their thoughts and

feelings impact the relative with addiction and how vital their role is in the family

intervention process (Wilson & Wilson, 1992).

To date, there is scarce data-based research available concerning family members’

attitudes toward addiction or toward a specific relative with addiction (Smith, 2006).

What have been reported, are limited studies or narratives of family members’ general

attitudes toward addiction and societal views of addicts and their families. Health

professionals’ attitudes toward individuals with addiction, on the other hand, have been

researched more carefully.

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Studies and Research

Alexander and Dibb (1967) conducted a study in which they compared eight

families who had a son or daughter with addiction with eight families with a son or

daughter who did not have an addiction. Several differences were found between the two

family groups. For example, in the “addict” families, fathers and mother held their son or

daughter in low esteem and thought that the son or daughter was dishonest, secretive,

disappointing, and unsuccessful (Alexander & Dibb). These findings were thought to

“validate clinical observations that societal perception in addict families serves to

perpetuate opiate addiction by undermining addicts’ self-esteem” (Alexander & Dibb, p.

17). As a result, researchers determined that there was a need for a new approach to

addiction therapy that would help change the attitudes and perceptions of family

members toward the relative with addiction (Alexander & Dibb).

Regarding research on attitudes, very limited research has been conducted that

focuses on family attitudes toward addiction. There is, however, a body of research that

centers on healthcare providers’ attitudes. The results of these studies may have some

application to family attitudes. In a qualitative study of families’ opinions about the

general attitudes of the public toward addiction (Canale & Munn, 2005), researchers

found, through interviews and focus groups comprised of family members and people

with addiction, that negative attitudes of the general public toward addiction created

barriers to access of healthcare and support for themselves and family members. Some of

the stigmas experienced by family members and addicts were feelings of “negative

judgment, long-lasting labels, disgrace, embarrassment, and shame” (Canale & Munn, p.

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13). According to Canale and Munn, negative societal views of addiction or the negative

stigma toward addiction impacts the family member and relative with addiction in areas

such as (a) being treated with less respect when seeking medical care, (b) being judged

negatively by society because of their addiction, (c) experiencing self-loathing and

internalizing the disrespect of others, and (d) continuing the cycle of addiction to avoid

dealing with the negative attitudes of others. In a different study comprised of Chinese

health professionals (Tang, Wise, Mao, & Hou, 2005), researchers found that drug abuse

was viewed as an “ugly social phenomenon”. As a result, the attitudes of Chinese

doctors were negative toward people with addiction, causing inferior treatment results

(Tang et al.). Researchers found in another study (Martinez & Parker, 2003) that nursing

students held negative attitudes toward people with addiction. According to Martinez

and Parker, student nurses were critical of addicts and perceived this population to be

weak. It was also found that nurses’ beliefs and attitudes toward addicts’ correlated with

poor quality of care. In South West Sydney, researchers studied 416 General

Practitioners’ (GP) attitudes toward patients with addiction and found that many GP’s

perceived these patients as less-rewarding, time consuming, disruptive to their practice,

and difficult to treat (Abouyanni et al., 1999). Consequently, many GP’s were reluctant

to provide care and did not want to “turn their practices into drug clinics.” In a smaller

study relating to attitudes of GP’s, Abed and Niera-Munoz (1990) found that a small

percentage of GP’s (10%) agreed with the statement: “Addicts deserve whatever

misfortune befalls them.” In a study of allied health students and physician assistant

students from one public and one private university in the United States (Baldwin et al.,

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2008), many students were unable to identify levels of drug use that were risky. Sixty

percent to seventy percent reported that they used alcohol at least on a monthly basis and

some revealed that they used legal and/or illegal drugs on occasion. The researchers

expressed concern regarding the high degree of acceptance of substance use by students

who were studying to be health professionals. The researchers further stated that they felt

that the students’ approval of the substance use may lead to permissive attitudes toward

addiction and when not properly dealt with could lead to negative outcomes for patients

and their families (Baldwin). In another study, Copello et al. (2000) examined attitudes

of 37 healthcare professionals’ (i.e., general practitioners, nurses, and health visitors)

toward family members with addiction. Researchers reported a lack of confidence and

ambivalence toward working with family members who have a relative with addiction

(Copello et al., 2000). The healthcare professionals received a brief family-based

treatment training that focused on their attitudes and confidence in working with family

members who have a relative with addiction. According to Copello, the health

professionals who received the training reported an improvement in their confidence

level and perceptions about working with family members who have a relative with

addiction in contrast to those healthcare professionals who did not receive the training.

As a result, the researchers concluded that providing brief family-based treatment training

to healthcare workers increased their confidence level and produced positive outcomes

for family members by lowering levels of stress and increasing coping skills (Copello).

Lastly, in a study using the Attitudes Measurement: Brief Scales (AMBS) created

by the National Centre for Education and Training on Addiction (NCETA, 2006) at

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Flinders University in Adelaide, Australia, researchers focused on healthcare workers’

attitudes, (i.e., stigma) surrounding addiction and how those attitudes affect quality of

care for people with addiction (Skinner, Fether, Freeman, & Roche, 2007). Results from

the study indicated that many healthcare workers who deemed a person with an addiction

as being responsible for his or her condition, held a negative view toward the person

(2006). What was incongruent, however, was that healthcare providers routinely

provided “high-quality care and treatment to individuals who hold a significant degree of

personal responsibility for other health conditions (e.g., heart disease, obesity)” (Skinner

et al., p. 164). Therefore, being responsible for the addiction may not be the only reason

healthcare workers were reluctant to provide treatment to addicts. There is some

validation that indicates that deservingness judgments are likely to influence healthcare

workers services toward persons with addiction (Skinner et al.). In the study at NCETA,

nurses were presented with two opportunities in which high and low quality health care

was provided to addicts. There were three antecedents of deservingness: (1) affective

reactions to the drug user, (2) attributions of responsibility for drug use, and (3) values

(i.e., general beliefs and attitudes) held by nurses. According to Skinner et al., the results

supported the efficacy of a “social-justice perspective in understanding the dynamics of

health-care practices regarding stigmatized conditions” (p. 165). For example, the

research supported the influence of affective responses of healthcare workers regarding

decisions about whether high or low level care is deserved. Moreover, positive affect

(i.e., sympathy, concern) predicted deservingness of high level care, while negative affect

(i.e., anger, disappointment) predicted deservingness of low level care. Furthermore, the

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judgments of addicts’ “deservingness of low (or high) quality of care” influenced the

healthcare workers own level of satisfaction with the standard of care (i.e., general

beliefs, values) (Skinner et al.).

As noted earlier, most researchers have studied attitudes of healthcare providers.

According to Smith (2006), there is still a need to study whether attitudes of family

members’ will change and the factors that may facilitate that change. One intervention,

brief family-based treatment, has demonstrated some success in this area.

Brief Family-based Treatment

Brief family-based treatment (FBT) involves a comprehensive training curriculum

that is respectful, inviting, supportive, and healing (Wilson & Wilson, 1992). Family

members share what they have experienced due to the family member’s misuse of drugs

or alcohol through newly learned communication skills, psychodrama, role play, and by

completing a strength-based family assessment (Jay & Jay, 2000). FBT therapies are

intended to change patterns of beliefs and behavior among family members (Carich &

Spilman, 2004; Miller, Meyer, & Tonigan 1999). In view of this intention, treating a

relative with addiction is considered by those who practice FBT to be a “change-oriented

process that occurs in the context of a contractual, empowering, and empathetic

relationship” (Zeig & Munion, 1990, p. 14). Thus, the goal of intervening in the family

system is to create change (Carich & Spilman). Furthermore, brief family-based

treatment can be very useful in helping family members change negative feelings and

attitudes about a relative with addiction without disrupting relationships within the family

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system (Washton & Zweben, 2006). An important component of the change-oriented

process is helping family members understand how they function and how their self-

belief (i.e., attitudes) can contribute to positive outcomes for a relative in terms of

providing supports in the recovery process using a family-based treatment model

(Vannicelli, Gingerich, & Ryback, 1983)

According to O’Farrell (1995), involving family members in the FBT process has

resulted in more positive results for the family and the addict by decreasing his or her

substance abuse and increasing interest in treatment. FBT may also help family members

to (a) have more rational attitudes toward the relative with addiction, (b) motivate the

relative with addiction to remain in treatment, and (c) recognize and address situations

that impede recovery (O’Farrell).

Additional research in the area of family involvement has also concluded that

“family members can do something to instigate change” (Miller et al. 1999, p. 695). In

an interview with therapists from Addictions Intervention Resources (A.I.R.), Dempsey

(2006) reported that the therapists believed the primary reason most relapses among

clients who are addicts occur is due to a lack of personal care and family support that is

needed to intervene and change destructive patterns of behavior. Colandro (n.d.)

maintained that it makes sense to engage parents and family members in the treatment

process to assist their relative with an addiction.

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Statement of the Problem

Recent research regarding brief family-based treatment has suggested that

working with family members of relatives with addiction can lead to positive results for

family members by offering education about the impact of addiction on the family system

(Beck et al., 2003; Jay & Jay, 2000; Johnson, 1998; Rotunda, West, & O’Farrell, 2004;

Sulek et al., 2006). Few studies, however, have been conducted that focus specifically on

examining changes in family members’ attitudes toward addiction or toward a specific

relative with addiction. To date, there is a scarcity of data regarding how FBT impacts the

opinions, self-beliefs, attitudes, and judgments of family members toward people in

general with addiction and toward a relative with addiction. Until a more conclusive

body of research exists regarding its effectiveness, practitioners, family members,

theorists, advocates, and scholars can not make definitive statements regarding the

relevance of FBT and how family member’s attitudes are affected by this intervention.

Significance of the Study

There is a developing concern today regarding the increase in addiction in our

country (Smith et al., 2006), which until recently has been seen as an individual problem

(Beck et al., 2003; Copello, Templeton, Krishnan, Orford, & Velleman, 2000; Rotunda

et al., 2004; Sulek et al., 2006). While issues related to how the family plays a role in the

addiction process have been considered, they have rarely been a component of the

treatment plan for the person with addiction (Orford, Templeton, Velleman, & Copello,

2005). Consequently, most therapies have been designed to treat addiction and have

25

focused on the individual person and not the family itself (Nelson & Sullivan, 2007).

Family-based treatment, however, teaches family members why the addictive behavior

exists, how to set consequences for behaviors, and how to focus on creating a positive

approach (i.e., change perceptions about the relative with addiction) in order to decrease

their addictive behavior (Smith, et al., 2006).

According to Smith (2006), there is a growing awareness in the therapy

community that indicates a need for more research that focuses on helping family

members to create a more positive home environment and improve their feelings, beliefs,

and perceptions (i.e., attitudes) toward addiction treatment and toward a relative with

addiction by attending a brief family-based treatment session. The purpose of the current

study is to examine whether brief family-based treatment impacts family members

attitudes toward people in general with addiction and toward a specific relative with

addiction.

Research Questions

1. Is there a change in family members’ attitudes toward people in general

with addiction from pre- family-based treatment to post-family-based treatment?

2. Is there a change in family members’ attitudes toward a specific relative

with addiction from pre- family-based treatment to post-family-based treatment?

26

Independent and Dependent Variables

1. Independent variable: FBT training; dependent variable:

perceptions/attitudes toward people in general with addiction.

2. Independent variable: FBT training; dependent variable:

perceptions/attitudes toward a specific relative with addiction.

Alternative Hypothesis

1. It is hypothesized that after brief family-based treatment, family member’s

perception of people in general with addiction will be changed in a more positive

manner.

2. It is hypothesized that after brief family-based treatment, family member’s

attitude toward a specific relative with addiction will be changed in a more positive

manner.

Null Hypothesis

1. It is hypothesized that after brief family-based treatment, there will be no

change in the family member’s perception of people in general with addiction.

2. It is hypothesized that after brief family-based treatment, there will be no

change in the family member’s attitude toward a specific relative with

addiction.

27

Definition of Terms

Addiction: a complicated disease (NIDA, 2008) that includes abuse of and physical and

mental dependence on alcohol or legal or illegal drugs; physical dependence on and

abuse of drugs and other miscellaneous substances (DSM-IV TR); and a chronic,

consistent repetition of disproportionate behavior that a person is unable or unwilling to

stop, despite its destructive consequences to the person with addiction, his or her family

members, and society (Gutman, 2006).

Anger: A feeling toward the relative with addiction that may seem like a love/hate

relationship. The person is loved, while the addiction and what it’s doing to the family I

hated. There is an inability to separate the person from the disease of addiction (Jay and

Jay, 2000).

Attitudes: Emotionally charged ideas that prompt a set of actions toward a certain class

of individuals (Triandis, 1971). Attitudes are associated with a tendency to behave in a

predictable and guarded way toward or in the presence of members of a particular group

(Hunt & Hunt, 2004). Attitudes communicate three common beliefs: (a) they include

some kind of judgment of someone; (b) they can be articulated through language; and (c)

they are associated with actions toward another (Eiser, 1986; McCarthy & Light, 2005).

Other terms used to describe attitudes include beliefs, values, opinions, self-beliefs,

judgments, perceptions, thoughts, feelings, and stigmas. Therefore, for the purpose of

this study, the term attitude will represent all of the above definitions.

Binge use: Five or more drinks on the same occasion, at the same time and within a few

hours of each other within a 30 day period (NIDA, 2008).

28

Contractual, empowering, and empathetic relationship: The capacity to recognize or

understand another's state of mind or emotion in a way that shows respect, rapport,

joining, compassion, cooperation, flexibility, safety, goal orientation, and multi-level

communication. Contractually, this framework provides a guide for the practitioner to

conduct the treatment in a way that is goal oriented and focused on intervening in the

family system to create change (Carich et al., 2004).

Current use: At least one drink in the past 30 days, this includes binge and heavy

drinking.

Differentiation: The ability of each family member to preserve his or her own identity,

while still remaining connected to the family system.

Disease of addiction: Refers to addiction as a complicated disease that can encompass

essentially every aspect of a person’s life that has typical signs and symptoms that may

progress in a certain manner (Wilson & Wilson, 1992). The person with addiction has a

disease that has a physiological deficiency that makes him or her incapable of tolerating

the addictive substance (Smith & Miller, 2000).

Drink: A can or bottle of beer, a glass of wine or wine cooler, a shot of liquor, or a mixed

drink with liquor in it.

Family: The foundation of social relationships among all cultures (Garrett et al., 2007).

Family Member: Traditional close relatives such as a mothers, fathers, spouses, siblings,

and extended family members such as grandparents, aunts, uncles, cousins, partners, and

family friends and loved ones known as significant others

29

Family-based treatment (FBT) (also referred to as brief family-based treatment,

family systems model, family systems intervention, and couple and family therapy):

A branch of psycho-education that works with families and couples in intimate

relationships to encourage change and development. Changes in terms of the systems of

interaction between family members emphasize that family relationships are an important

factor in psychological health.

Heavy drinking: Five or more drinks on the same occasion occurring on five or more

days within a 30 day period.

Homeostasis: A state that occurs when the family members seek to maintain a healthy

balance. Families tend to resist change, consequently, the family therapist can use the

concept of homeostasis to explain why a certain family symptom has surfaced at a given

time, why a specific member has become the identified patient, and what is likely to

happen when the family begins to change.

Identified patient (IP): Generally, the family member who has an addiction or who is

presented as the main symptom-bearer in the family. However, individuals referred for

family systems treatment are often incorrectly labeled "patients" when, in fact, their

symptoms are manifestations of family, not individual, dysfunction or pathology.

Recovery: A complicated, painful process of extreme transformation that is never easy

and rarely effortless for anyone involved (Brown, 1997).

Relative with addiction/loved one with addiction: A person within the family who is

identified as having an addiction to either a legal or illegal drug, or alcohol.

30

Significant other/friend: Extended family members such as grandparents, aunts, uncles,

cousins, and partners as well as individuals, known as significant others, who are not

considered to be typical family members.

Treatment goals: An assessment of the individual/family to gather a family history,

training to provide the individual/family with tools to understand addiction, and an

aftercare plan designed to help the family and individual set and achieve goals set forth in

therapy (Jay et al., 2000).

31

CHAPTER TWO

REVIEW OF THE LITERATURE

Chapter Two provides an overview of the published literature with regard to the

following aspects of addiction and treatment: (a) addiction statistics and the need for

treatment, (b) attitudes toward and beliefs about addiction, and (c) family-based treatment

approaches.

Addiction Statistics and Need for Treatment

In a study conducted by the National Survey on Drug Use and Health (NSDUH,

2007), researchers found that the rate of drug use among youth aged 12 to 29 grew

slightly from 8.1% in 2005 to 8.3% of the population in 2006. The researchers also found

that more than half of youth in America (125 million) aged 12 to 29, reported drinking on

occasion; whereas 6.9% (17 million) aged 12 to 29, reported drinking heavily in 2006.

For example, the following statistics illustrated the percentage of alcohol used by youth;

12 and 13 year olds (3.9%); 14 and 15 year olds (16%); 16 and 17 year olds (29%); 18 to

20 year olds (51%); 21 to 25 year olds (68%); and 26 to 29 year olds (63.5%).

In another study completed by SAMSHA (2006), it was estimated that 30.5 million

people, aged 12 and older, were dependent on, or addicted to either drugs or alcohol.

The societal cost of addiction, according to the SAMHSA report, is over $300 billion per

year, continues to rise each year, and has resulted in one of the most severe health

concerns facing America, today. The results of a survey completed in 2007 for The

32

National Survey on Drug Use and Health National, entitled Illicit Drug or Alcohol Use

Treatment and Treatment Need, provide additional support for the need for treatment:

1. In 2007, 23.2 million persons aged 12 or older needed treatment for an

illicit drug or alcohol use problem (9.4 percent of the persons aged 12 or older). Of these,

2.4 million (1.0 percent of persons aged 12 or older and 10.4 percent of those who needed

treatment) received treatment at a specialty facility. Thus, 20.8 million persons (8.4

percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol

use problem but did not receive treatment at a specialty substance abuse facility in the

past year. These estimates are similar to the estimates for 2006 and for 2002.

2. Of the 2.4 million people aged 12 or older who received specialty

substance use treatment in 2007, approximately 1,000,000 persons received treatment for

alcohol use only, 750,000 persons received treatment for illicit drug use only, and

650,000 persons received treatment for both alcohol and illicit drug use. These estimates

are similar to the estimates for 2006 and for 2002.

3. In 2007, among persons who received their last or current substance use

treatment at a specialty facility in the past year, 53.3 percent reported using their "own

savings or earnings" as a source of payment for their most recent specialty treatment,

34.9 percent reported using private health insurance, 26.3 percent reported using public

assistance other than Medicaid, 19.7 percent reported using Medicare, 19.6 percent

reported using funds from family members, and 18.2 percent reported using Medicaid.

None of these estimates changed significantly between 2006 and 2007 and between 2002

33

and 2007, except that the 53.3 percent reported using their "own savings or earnings" as a

source of payment in 2007 was higher than the 42.1 percent reported in 2006. (Note that

persons could report more than one source of payment.)

4. Of the 20.8 million persons in 2007 who were classified as needing

substance use treatment but not receiving treatment at a specialty facility in the past year,

1.3 million persons (6.4 percent) reported that they perceived a need for treatment for

their illicit drug or alcohol use problem. Of these 1.3 million persons who felt they

needed treatment but did not receive treatment in 2007, 380,000 (28.5 percent) reported

that they made an effort to get treatment, and 955,000 (71.5 percent) reported making no

effort to get treatment (p. 80).

While researchers in the United States have concluded that substance abuse

declined slightly among adolescents, there are still 2.1 million youth in the United States,

aged 12 to 17 (8.3 % of the population) in need of treatment for illegal drug use

(SAMHSA, 2005). According to the researchers, youth who engage in substance abuse

(and especially minority youth) are found to be responsible for negative behaviors such

as criminal activities. According to the National Mental Health Association, in 2000

there were one million youth within the justice center being charged with criminal

behavior associated with drug use in the United States and many were repeat offenders.

What is clear, therefore, is that substance abuse exacerbates and prolongs criminal

behavior (Young, Dembo, & Henderson, 2007). For example, substance misuse in itself

binds one to illegal behavior (i.e., purchasing and possessing illegal substances). In

addition, youth who engage in these activities are more likely to be predisposed to

34

criminal behavior as they look for opportunities to obtain money to buy more drugs

(Chassin, Knight, Vargas-Chanes, Losoya, & Naranjo, 2009). In looking for treatment

outcomes, Stanton (2004) suggests that youth with substance disorders are generally very

close to their parents or people who raised them and as a result, parents may be

significant candidates from which to seek help.

Family Members’ Attitudes toward Addiction

The tragedy surrounding addiction is evident (Stanton et al., 1979). Especially

since addiction sets the stage for the profusion of other problems, such as criminal

activity, incarceration, emotional highs and lows, instability within the family, separation

from family, and an increase in negative attitudes about addiction and the relative with

addiction (English, 2000; Jay & Jay, 2000; Johnson, 1998). Family members who have a

relative with addiction respond not only to the addiction process, but also to their

perceptions (i.e., attitudes) associated with addiction (Bradshaw, 1996). These attitudes

include, but are not limited to, belief that the relative with addiction is personally

responsible for his/her condition, thoughts that the person with addiction does not deserve

respect, disappointment in the relative with addiction, anger toward the relative with

addiction, negative opinions about the relative with addiction, and belief by others that

the relative with addiction may not deserve the same level of medical care as individuals

who are not addicted (Bradshaw).

35

Consequently, family systems where addiction is present generally operate in

chaos, resulting in a confused state with regard to family members’ beliefs toward the

relative who is using (Suleck et al., 2006). Many of these same families remain in a

holding pattern with very little change in family attitudes or behavior while the relative

with addiction continues to use (Steinglass, 1980). Some family members, however,

wish to address the issue of addiction and support their relative. Many of these family

members search for guidance by attending a brief family-based treatment session to

address attitudinal and perception change (Cottrell et al., 2002).

Brief Family-based Treatment Approaches

Treatment for addiction is conducted in many different ways using a variety of

therapeutic approaches (NIDA, 2008). No single treatment is effective for every

individual. Because addiction is generally a chronic condition, typified by reuse and

relapse, it is often necessary for multiple treatment interventions. Consequently, the

parameters of treatment are as varied as the therapeutic techniques used (Sexton &

Alexander, 2002). Family-based treatment is one therapeutic intervention technique that

addresses the ways in which each family member plays a part in the family as a whole

(Bradshaw, 1996). The term, family-based treatment, depicts a variety of family

interactions (Cottrell & Boston, 2002) and has been found to be effective in the treatment

approaches for a variety of disorders (Sexton & Alexander). Furthermore, several studies

have rated brief family-based treatment approaches for adolescent substance abuse as the

36

treatment of choice (Stanton & Shadish, 1997; Williams & Chang, 2000). For the

purpose of this study, the focus will be on addiction and family-based treatment.

Because addiction is a disease of the family, every relative with addiction directly

impacts at least five to eight other family members. Family-based treatment, therefore, is

not about the relative with addiction, but about family members and how they choose to

view or react to the relative with addiction (Jay & Jay, 2000). The principle of FBT is to

engage the members of a specific or extended family in training that will provide

education and encourage them to adjust their self-beliefs, opinions, and perceptions (i.e.,

attitudes) in a positive manner toward people in general with addiction, and toward a

specific relative with addiction (Carich et al. 2004; Stanton, 1979; Vannicelli et al.,

1983).

FBT uses an approach that distinctly focuses on shifting the interactions between

or among family members and seeks to improve the functioning of the family system

(Gurman et al., 1986). The theory of FBT suggests that the family is the patient and

views the relative with addiction as the sign of “family psychopathology” (Bradshaw,

1996). The goal of family-based treatment, therefore, is to help family members

understand their relative’s addiction and adjust their attitudes toward the relative with

addiction and toward addiction in general. The objective of FBT is to provide short-term

treatment with the focus on intense restructuring of family functioning and greater

discernment of the problem (Steinglass, 2008). The intent, according to Cottrell and

Boston (2002), is to evaluate family members in terms of their perceptions about

addiction, focusing on training them about addiction while attempting to shift their

37

attitudes toward addiction and the specific relative with addiction in a more positive and

well-informed direction.

Family-based treatment is considered to be a valuable counseling tool for

therapists for two reasons: (a) there is increased evidence that what was once thought of

as an individual problem (i.e., substance abuse, depression, eating disorders) can be

successfully treated with FBT (Gurman et al., 1986), and (b) FBT has demonstrated

successes with families from diverse cultural backgrounds and as a consequence has

become the treatment of choice for adolescents with substance abuse and behavior

disorders (Sexton et al., 2002).

Researchers suggests that family-based treatment training programs help identify

and change attitudes and perceptions about addiction and a relative with addiction

(Cottrell et al., 2002; 2001; English, 2000; Jay & Jay, 2000; Johnson, 1998; McLendon,

McLendon, & Petr, 2005). Key points (e.g., definitions, goals, and outcomes) of family-

based treatment models are reported by various researchers (Bergin & Garfield, 1994;

Cannon & Levy, 2008; Cottrell & Boston; Connors et al.; English; O’Farrell et al.; Jay &

Jay; McLendon et al.; Miller et al.; Santisteban et al., 2003; Sexton & Alexander, 1999;

Sexton & Alexander, 2000; Sexton & Alexander 2002; Smith et al. 2006; Vetere, 2001)

and core definitions and goals of the different types of FBT are presented by researchers

or scholars (Cannon & Levy; English; Jay & Jay; Johnson; Liddle et al.; McLendon et al.;

O’Farrell et al.; Sexton & Alexander, 2000). Mixed results were found by two

researchers. Connor et al. and Miller et al. found family-based treatment to be

confrontational in nature, thereby limiting the efficacy of the intervention with 70% of

38

family members failing to complete therapy. Conversely, other researchers found

positive family/client outcomes due to family involvement, therapist involvement, the

family members’ change in attitudes toward addiction and a relative with addiction, and

the development of more effective communication and problem solving with intervention

training (Bergin & Garfield; Cannon & Levy; Liddle et al.; McLendon et al.; Santisteban

et al.; Sexton & Alexander, 2000). Following are some recognized brief family-based

treatment models that have shown promise in working with the family unit and relative

with addiction.

Brief Strategic Family Therapy

Brief Strategic Family Therapy (BSFT) was developed at the Spanish Family

Guidance Center in the Center for Family Studies, University of Miami in 1975 and has

been conducted at these centers since that time. The Center for Family Studies has been

described as the Nation’s oldest and most prominent center for development and testing

of minority family therapy interventions for prevention and treatment of adolescent

substance abuse and related behavior problems (Santisteban et al., 2003). Therapy

consists of as few as one brief session to 4 to 20 weekly, 1-hour sessions with family

members that focus on changing the environment of the adolescent in the family who has

an addiction while also identifying patterns of family interactions and attitudes toward

addiction that are associated with the adolescent’s addictive behavior (Cannon & Levy,

2008). Assessments and interviews are conducted with family members to determine

concerns about addictive behavior and the desire for abstinence and positive aftercare

39

follow-ups when the relative returns home. A therapist meets with the family with whom

the child with addiction lives to review and recommend attainable aftercare treatment

goals (O’Farrell et al., 2008).

BSFT is based on three basic sets of guidelines; first, the assumption that the

family members are interdependent of one another and therefore what impacts one family

member, often impacts another; second, patterns of behavior that exist in the family

influence the stability and balance of the family; and third, because the homeostasis of

the family is disrupted by addictive behavior, it is vital to plan therapy designed to

change patterns of interactions, ways of thinking (i.e., attitudes), and behavior within the

family unit (NIDA, 2005). The goals of BSFT are two-fold and include eradicating or

decreasing the adolescent’s addiction and changing the attitudes, perceptions, and

interactions of family members that are associated with the addiction. Therefore, to

ensure that these goals are accomplished, the family therapist must “join, diagnose, and

restructure families” (Cannon et al., 2008, p. 201). Involvement with the family is also

critical, and must be open and supportive from the beginning and focused on working

together to accomplish therapeutic goals. A literature review of BSFT conducted by

Cannon et al. assessed the treatment and engagement of Hispanic youth who were found

to have an addiction. Researchers reviewed fifteen records found in the ProQuest Social

Science Journal (1996-2006, p. 199) as well 96 records retrieved from an internet search

of key words such as “youth, substance abuse, and Latino or Hispanic.” They concluded

that BSFT was more successful because it was geared toward family involvement that

focused on changing family behavior patterns (i.e., beliefs, judgments, attitudes) toward

40

addiction, more so than traditional group therapy for youth with early stages of addiction

(Cannon et al.). As a result, BSFT was recommended for Hispanic families who had

children with addiction, in particular, because of the highly sensitive understanding

relating to a variety of cultural issues (Santisteban, et al.). In a study completed by

Santisteban et al., while working with Hispanic families, the researchers found that most

adolescent problem-behaviors were linked to dysfunctional family dynamics, unclear

family boundaries, improper family relationships, and the belief that the youth with

addiction were the cause of the families’ problems. For that reason, therapists worked

closely with family members to address dynamics, such as setting appropriate

boundaries, assigning leadership in the family, understanding how the addiction impacts

the family (i.e., perceptions of the problem of addiction), and utilizing conflict resolution.

Multidimensional Family Therapy

Multidimensional Family Therapy (MDFT) is a family-based treatment model

that was developed for adolescents with addiction and behavior problems. The MDFT

intervention has evolved over the last 17 years within a federally funded research

program designed to develop and evaluate family-based intervention for addiction

treatment for adolescents. This approach has been recognized as one of a new generation

of comprehensive, adaptable, “theoretically-derived and empirically-supported adolescent

drug abuse treatments” (Liddle, Dakof, Turner, Henderson, & Greenbaum, 2008). There

are several different therapeutic approaches of MDFT, such as home-based, residential,

office-based, and brief-intensive out-patient. Sessions vary from one to three times per

41

week over a course of 4-6 months based on the severity of the addiction and the needs of

the family and youth. What are most notable about MDFT are the four domains used by

therapists that are critical in all of the approaches. The first domain deals with the

adolescent and teaches youth how to engage in treatment by (a) using effective

communication with families, (b) acquiring coping skills that lead to emotional stability

and more effective problem-solving abilities, (c) improving social capabilities and school

or vocational performance skills, and (d) learning alternative behavior that steer clear of

addiction. The second domain is the parent domain which engages parents in therapy by

(a) increasing their emotional presence with the adolescent; (b) improving parenting

skills, especially in the areas of supervising, clarifying and deciding consequences for

behavior; and (c) addressing their “psychosocial functioning apart from their role and

responsibility as a parent” (p. 1663) (Liddle et al., 2008). The third domain deals with

interactions and focuses on (a) decreasing family conflict, (b) improving relationships, (c)

communicating more effectively, and (d) learning successful ways to problem-solve. The

fourth domain centers on extra-familial issues that foster family competencies in

numerous social systems to include school, work, courts, and leisure/entertainment. With

regard to improving parenting skills, the MDFT perspective asserts that symptom

reduction and improvement of normal social functioning in adolescents with addiction

occurs when the family system is the objective for the therapy/intervention. Furthermore,

certain behaviors, and ways of thinking (i.e., attitudes) known to be related to the

problem addiction are replaced by new behaviors and perceptions that are linked with

family functioning (Liddle et al., 2002).

42

In a study assessing adolescent addiction for problem-severity and frequent use,

MDFT was found to reduce the rate of drug use both during treatment and in the 6-month

follow-up. In addition, MDFT was found to decrease the severity of drug use, thereby

indicating that Multidimensional Family Therapy was a more effective intervention for

youth than other therapy models that did not include the family (Liddle et al., 2008).

Functional Family Therapy

Functional Family Therapy (FFT) is an intervention strategy supported by 30

years of clinical research. FFT examines the practice of youth with addiction or antisocial

behavior problems and has been applied to a wide range of youth and their families in

various multi-ethnic, multicultural contexts and with pre-adolescents and adolescents

diagnosed with conduct disorders, violent acting out and substance abuse (Sexton &

Alexander, 2000). The primary focus of Family Functional Therapy is on family

intervention and positive and negative behaviors (i.e., family belief systems and

strengths) and how those behaviors influence family and individual functioning.

According to Sexton and Alexander, FFT provides family members with a motivation for

changing their perspective (i.e., attitudes, viewpoints), by helping families build on their

strengths in ways that cultivate self-determination and detail specific goals for

improvement within the family system.

FFT is a “multi-systemic and multi-leveled” family system intervention that

focuses on three major components (a) the treatment system, (b) the family and

individual functioning, and (c) the therapist (Sexton & Alexander, 2000). FFT, like most

43

brief family-based treatment incorporates family strengths and aspirations to improve

their circumstances as a starting point. At the point of clinical engagement, “FFT

includes a systematic and multiphase-intervention map” (Sexton et al., p. 2) titled Phase

Task Analysis, which provides the basis for clinical decision-making. This map provides

a format that portrays FFT to have a flexible structure for the intervention process by

identifying treatment modalities that have a high probability of success and assisting

counselor’s with options for presenting strategies for each family therapy session. It is

also culturally sensitive and responsive to youth, their families, and their communities

(Sexton et al., 2000). The primary focus of Functional Family Therapy (FFT) is on the

family. The objective of the intervention is to reproduce a mirror image of the positive

and negative behaviors that cause and are caused by various relational systems operating

within the family.

FFT was designed in 1969 to meet the needs of a growing population of youth

who were involved in violent crimes and drug addiction (Alexander & Parsons, 1973).

The developers argued that successful treatment of youth with addiction required

therapists who were aware of culturally diverse families, and who were also

knowledgeable to work with them, especially as it related to the families resistance to

treatment. As a result, over the past 30 years, FFT counselors have recognized that

helping families identify strengths and build self-respect are keys to improving family

functioning (Sexton & Alexander, 2002). What is more, FFT developers have noted the

need to evolve as the needs of the families have changed. For example, in the late

1990’s, Functional Family Therapy advanced the phases of intervention by developing a

44

systemic approach (Sexton & Alexander, 1999) to training and systematic execution with

the addition of an all-inclusive system of individual, process, and outcomes assessment

using a computer-based component that monitors and traces clients using a device called

the Functional Family Therapy – Clinical Services System (FFT-CSS). The FFT-CSS

helps therapists identify and implement intervention goals aimed at creating change in a

way that promotes accountability through technique and outcome evaluation. As a result,

FFT has grown into an intervention model that includes systematic training, monitoring

of techniques, and assessment of outcomes that are all directed at improving the delivery

of intervention services to families in communities where juvenile addiction rates are

high (Sexton & Alexander, 2000).

Functional Family Therapy is a brief, short-term, “family-based prevention and

intervention” process that has shown efficacy in a number of difficult situations dealing

with youth between the ages of 11 and 18 who were underserved and at risk along with

their families (Sexton & Alexander, 2000). In most cases, clients are seen 8 to 12 times

for a total of 30 direct session hours over a three month period of time.

There are three intervention phases in FFT: (a) engagement and motivation, (b)

changing the negative behavior of the adolescent, and (c) generalization. The phases are

inter- and intra-dependent of one another; each have specific goals and assessment

objectives to be incorporated in therapy to change family beliefs and attitudes from

dysfunctional perceptions toward the expectation that change is possible. FFT is family-

centered, therefore, the goals are to (a) improve and build an alliance with the family and

counselor, (b) generate respect for individuals and family members, (c) change

45

maladaptive behavior while decreasing despotic negativity within families, (d) assess at

each phase how negative behaviors impact the family and relationships, and (e)

generalize the positive family changes from within the community to work

collaboratively and to create valuable alliances and support networks.

Family Functional Therapy is one of the brief family-based treatment modalities

for adolescent addiction and other behavior issues. The results of more than 30 years of

data-based research propose that following FFT guidelines may reduce addiction,

juvenile crime, violence and other delinquency problems (Sexton & Alexander, 2000).

Distinct to FFT is how the intervention focuses on family interactions from a cultural

perspective. From 1973 to the present, published data have reflected the positive

outcomes of FFT. For example, data have shown that when compared to standard

adolescent and family treatment interventions as well as alternative treatment approaches,

FFT is highly successful (Sexton & Alexander). Both randomized trials and non-

randomized comparison group studies have revealed that FFT significantly reduces

negative addictive behavior by increasing family functioning as described above.

Structural Family Therapy

Structural Family Therapy (SFT) is a method of family therapy that is linked to

the work of Salvador Minuchin; however, many other clinicians in the family therapy

arena have contributed ideas and concepts (Vetere, 2001). The emphasis is on building

family strengths by working together and learning practical ways to solve problems.

Contracts are written and agreed upon with family members. SFT is time limited, relying

46

primarily on quick and concise feedback regarding specific problems within the family

system. Many of the ideas are similar to other brief family-based treatments, such as

family roles and rules, triangulation of conflict, subsystems and boundaries,

collaborations, and stability and change. What is unique about SFT, however, is how the

therapist focuses on the organizational characteristics of the family unit and family

dynamics and the hidden and exposed rules that effect interpersonal choices and

interactions in the family (Vetere, 2001). Encouraging family members to investigate

problems and discover alternative responses to situations in the safety of the therapeutic

setting is central to SFT. Structured Family Therapy is based on the theory of action

preceding understanding, using reframing to think beyond the negative problematic

behaviors and current conflicts to see how each member’s choices affect the family

structure and relationships within the family system. The intervention is supported in

three areas: (a) challenging the behavior that is problematic, (b) challenging the family

structure, and (c) challenging the family belief system (i.e., attitudes, perceptions)

(Vetere, 2001)

A primary goal of SFT is to encourage family members to interact with one

another (i.e., communicate), problem solve together, and rethink their decisions within

the family that are considered to be dysfunctional so as to change the structure of the

family system. An essential strategy of SFT involves having the therapist enter or join

with the family system as a catalyst for positive change (Vetere, 2001). This is

accomplished when the therapist “engages the family through interactive activities”

(English, 2000, p. 194). Patterns of family behaviors, rules, roles, subsystems, conflicts,

47

collaborations, and boundaries emerge and can then be evaluated for change. According

to English, change occurs as the therapist collects information and begins to recognize

family dynamics and family structure. Slowly the therapist begins to understand the

family’s “perceived reality.” The goal, therefore, is to confront the family members’

perceived reality and to shift perceptions and self-beliefs (i.e., attitudes) from the primary

“symptom bearer” to the entire family system. Therefore, in order for therapy to be

functional, the therapist must form a new system with the family group (Vetere, 2001).

By doing so, the therapist “joins” with the family by understanding each family member,

being careful not to become biased. In addition, the therapist must also adjust to the

needs of family members. This is accomplished by accommodating family members,

which includes (a) providing support and feedback for areas where family interactions are

working and offering guidance in areas that require a change in structure, (b) carefully

assessing how the family interacts, and (c) relating to the family’s culture and range of

effect through role modeling and mirroring (Vetere). SFT posits that change is a fragile

process, too little intervention by the therapist will result in continuance of the status quo

and too much intervention will result in fear of confrontation and blaming causing a

premature ending of therapy by family members (Vetere).

With regard to the efficacy of SFT, researchers in the United Kingdom report the

use of controlled and uncontrolled group comparison designs and single case design

comparing the relative importance of SFT (Bergin & Garfield, 1994). The overall

findings from the data from the meta-analysis revealed that FST showed significant

results when working with the following problems: (a) marital conflict, (b) women with

48

depression, (c) adult and adolescent addiction, and (d) child and adolescent conduct

disorder (Vetere). According to Minuchin (1998), SFT focuses on family

communications by preserving the value of the family system. What is of importance to

the study of SFT, according to Vetere, is that “structural family therapy continues to

evolve in response to challenges mounted from within and out with the systemic field,

and as part of integrative practice and multisystemic approaches, with practitioners ever

mindful of the need for regular feedback from family members themselves” (p. 133).

Family-Directed Structural Therapy

Family-Directed Structural Therapy (FDST) is based upon the traditional

concepts of family therapy found in Structured Family Therapy ( McLendon et al., 2005).

The FDST model is comprised of an easy to administer assessment tool that adult family

members complete. The assessment is time-limited, making it easy to measure. Designed

to empower the family, FDST employs a process that is a goal-oriented, and uses a time

limited approach that helps families identify strengths and enhance family functioning

while also addressing areas of problematic behavior. FDST also teaches intra- and

interdependence that may be used by the family, both inside and outside the clinical

setting. FDST focuses on family strengths and on lessening family conflict in a time-

limited manner. McLendon et al. (2005) described the following assessment process:

The initial assessment generally requires one 90 minute session and then seven to

nine sessions to assist the family in incorporating the process and vocabulary of

FDST into their daily lives. These seven to nine sessions occur as family needs

49

dictate, although experience has shown that sessions occurring at six weeks, three

months, and six months post-intake can help to reinforce FDST concepts, assist

families to assess any new areas of concern, and apply the FDST framework

accordingly. (p. 327).

With FDST, the core concepts which are “commitment, credibility,

empowerment, control of self, and consistency” serve as the foundation of family

functioning (Mclendon, 2005, p. 328). Commitment, according to McLendon, is to see

things through to completion, regardless of personal differences and conflicts. Credibility

is giving one’s word and demonstrating the capability to follow through, and

empowerment is having a confidence that personal thoughts and views are valued and

regarded, thereby believing that a person can inspire change. Control of self is making a

personal effort to change negative opinions (i.e., attitudes, beliefs) in a way that results in

less conflict within the family and more positive relationships, and finally, consistency is

behaving and communicating in an appropriate manner, thereby creating a sense of

wellbeing within the family. These core issues are used in association with the constructs

of roles, boundaries, external stressors, and the framework of communications to help

families identify strengths and discover problematic areas.

The function of roles in FDST are related to husband/wife (partner), wife/husband

(partner), parent, father, mother, individual, and child and are similar to roles in

Structured Family Therapy (Minuchin, 1974). Each family member plays an exclusive

role with one other family member (e.g., mother to child is different than father to child).

Boundaries are differentiated by the different roles played by family members and

50

between the family as a whole (McLendon et al., 2005). In FDST the boundaries are

based on family roles, not between subsystems in the family. External stressors are those

stressful events that occur from outside of the family structure. The impact from these

stressors may be positive (e.g., going on vacation, getting a promotion at work, or going

to a movie with the family) to negative stressors (e.g., losing a job, dealing with a family

member with drug addiction, or having health problems). Lastly, the framework of

communications consists of how family members express how they feel, using “I” and

“you” messages, engaging in conversation and the dynamics and rules that are followed,

or problem-solving techniques, such as taking personal responsibility for one’s actions

(McLendon et al.).

Family-Directed Structural Therapy uses an assessment tool to help families

understand the core issues and how the concepts of FDST are defined and easily

implemented by the family. By using a scoring system, families are able to rate

themselves in various areas. For example, a mother might rate her level of commitment to

her husband as well as her belief about his commitment to her. Family members also rate

themselves and other family members with regard to roles they play and roles they see

other family members play (McLendon et al., 2005). External stressors are also rated by

family members from each personal perception rather negative or positive. Once the

assessment is complete, the therapist uses the results to help families set goals by

evaluating their core issues and addressing areas of strength and areas that are

problematic.

51

Over the past 12 years, FDST has been presented to over 450 families from

diverse ethnic backgrounds; however, little data are available with regard to efficacy.

Currently FDST is being evaluated at a major university (McLendon et al., 2005). Two

types of family interactions are being studied, (i.e., one group of families is receiving

standard counseling services only, and the other family group is receiving Family-

Directed Structural Therapy). Both family groups are being studied at specified dates

after base-line to determine if there are changes to family functioning, what those

changes are, and if the changes are maintained over time. With regard to limitations,

McClendon emphasizes that the use of FDST is contraindicated in families where there is

“active domestic violence or threat of harm to self” (p. 335). In situations such as this it

is important to provide some sort of crisis intervention as well as FDST.

Summary

Addiction is a complicated disease that can encompass essentially every aspect of

a person’s life, including social and economic status, family, work, and community

interactions (NIDA, 2008). Fortunately, there is some information to support the

effectiveness of family-based treatment with regard to addiction (Cottrell & Boston,

2002). Brief family-based treatment is time-limited, relying primarily on quick and

concise feedback regarding specific problems within the family system. Counseling

supports may begin and end in a one day session or in one week (i.e., five days) of daily

sessions or one day a week for up to twenty weekly sessions (Cannon & Levy, 2008;

McLendon et al., 2005; Sexton & Alexander, 2000). In the brief family-based treatment

52

sessions, all members of the family as well as the therapist play a role. The therapist

seeks to analyze the process of family interactions and communication style, and family

members share through various modalities of communication (e.g. role playing and list

work) the symptoms or problems that brought them into treatment. A 25-year study was

conducted by the Hazelden Foundation, with addicts, family members, and treatment

interventions (Jay & Jay, 2000). It was determined that treatment must begin with people

who are knowledgeable of the disease of addiction and people who are knowledgeable of

and connected to the person with the addiction (Jay & Jay, 2000). For that reason, it has

been deemed vital to have an effective training model with clear goals that involve family

members of people with addiction in the treatment process (Meyers et al., 2002).

The goal of brief family-based treatment is to help family members understand

their relative’s addiction and to understand how each family member plays a role in the

addiction process. The objective of FBT is to provide brief, short-term treatment with the

focus on intense restructuring of family functioning and greater discernment of the

problem (Steinglass, 2008). The intent, according to Cottrell and Boston (2002), is to

evaluate family members in terms of their perceptions about addiction, focusing on

training them about addiction while attempting to shift their attitudes toward addiction

and the specific relative with addiction in a more positive and well-informed direction. It

is for this reason that professionals in the field of addiction have over the past decade

developed a different framework for FBT which is presented in a manner that is

respectful, caring, and conveys unconditional love and acceptance toward the person with

addiction. Consequently, family members work together in a therapeutic teaching

53

environment that is designed to encourage open communication about their feelings

toward a specific relative with addiction (Johnson, 1998). Additionally, intervening with

family members using FBT facilitates change (Garrett & Landau, 2007) by identifying

family strengths, working from this core to help family members address the problems of

addiction through education and counseling with an end toward changing family

member’s self-beliefs and perceptions toward addiction in a more positive direction

(Bradshaw, 1996; Gurman et al. 1986; Johnson, 1998).

Family has become a primary focus in the family-based treatment model for

addiction, and as a result, FBT has gained approval and acceptance over the past few

decades (Meyers et al., 2002). Furthermore, despite FBT’s popularity with many

therapists not all modalities of FBT have been evaluated using well-designed studies,

(Cottrell & Boston, 2002). For example, even though family-based treatment has been

utilized for many years, only Functional Family Therapy has been studied extensively

(Sexton & Alexander, 2000). FBT has, however, shown efficacy in the treatment of

substance misuse and behavior disorders on a smaller scale. One measure of efficacy that

has not been studied in depth is the change in the family member’s attitudes toward

addiction and their attitudes toward a relative with an addiction.

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CHAPTER THREE

METHOD

Participants and Setting

This quasi-experimental study included a convenience sample of 41 participants

who were family members of persons with addiction. Nineteen participants (i.e.,

treatment group) were family members who had a relative with addiction who were

involved in brief family-based treatment (FBT) training at Pima County Juvenile Court

Center (PCJCC) in Tucson, Arizona; and twenty-two participants (i.e., control group)

were family members who had a relative with addiction who were involved in the KARE

Center, a local family support agency in Tucson, Arizona.

Description of Treatment Program

The treatment group received brief family-based treatment. Only those family

members who were 18 years and older and who had a relative with addiction were

eligible to participate. Eligibility and recruitment was based on confidential information

provided by counselors at the Pima County Juvenile Court Center (PCJCC) (see

Appendix A-1).

The Pima County Juvenile Court Center is located in South Tucson, Arizona and

was created to serve delinquent youth who have problems with criminal behavior and

substance abuse. PCJCC staff assist youth remanded to the program to (a) grow up to

become law-abiding adults, (b) find safe, permanent and nurturing homes, and (c) help

55

families in need gain access to the support and services they need to overcome the

problems that bring them into the court system (PCJCC, 2009).

“The mission of the Pima County Juvenile Court is to promote the interest and

safety of the community, promote the rehabilitation of children and families, facilitate the

protection of children who are abused and neglected, and facilitate the provision of

services to children and families involved with the court, all in accordance with the due

process of law. The Juvenile Court works actively with and provides leadership to the

community, public and private agencies to promote justice, education, and the prevention

of delinquency and abuse” (PCJCC, 2009).

The Pima County Juvenile Court Center has a Make a Change (MAC) program that

focuses on treatment readiness for family members’ who have an adolescent (youth) with

addiction. The program has a 20 bed detention center that was originally designed to

meet the needs of males between the ages of 15-17. Recently, however, an option to

include females and juveniles younger than 15 was added in a separate section.

Youth, whose family members participate in the MAC program, are detained in

the residential detention facility at the court center for 3 to 14 days. While the youth are

in detention, family members participate in a brief family-based, multi-family educational

treatment readiness session. The program components include: (a) increasing the family

member’s knowledge about the effects of substance abuse and challenging the family

member’s belief system (i.e., attitudes, perceptions) about addiction, (b) improving the

family member’s communication skills, (c) illustrating the importance of parental

supervision and support of the adolescent with addiction, and (d) offering community

56

support to family members who have an adolescent with addiction (PCJCC, 2009).

Family members meet with a structured family therapist one evening, on the first or third

Wednesday of the month for approximately two hours. The goal of the MAC program is

to help family members who have a relative with addiction to (a) understand the

addiction process, (b) identify warning signs of addiction, (c) develop positive

relationships with the youth with addiction, (d) examine their personal lifestyle and

perceptions to see what examples or judgments they may be setting for youth, and (e)

work together, in concert with other family members, to show healthy unity to youth. (A

detailed description of the treatment protocol/outline is provided in Appendix D).

Description of Therapeutic Support Program

The control group did not receive a family-based treatment session. Only those

family members who were 18 years and older and who had a relative with addiction were

eligible to participate. Eligibility and recruitment was based on confidential information

provided by the Director and counselors at the KARE Center (see Appendix A-2).

The KARE Center is a service-oriented facility where family members (i.e.,

traditional close relatives such as a mothers, fathers, sons, daughters, spouses, siblings,

and extended family members such as grandparents, aunts, uncles, nephews, nieces,

cousins, partners, and family friends and loved ones) receive out-patient family services

in the form of general and substance abuse support meetings. For example, family

members who are in need of supportive services meet on Tuesday mornings with staff to

57

discuss various concerns (e.g., substance abuse) that are related to their specific relative

(Melrood, 2008).

The KARE Center is located in Southern Arizona. The KARE campus offers the

following services to people caring for children who are born to others: (a) legal advice

about guardianship and adoption, (b) advocacy for caregivers with children in school, (c)

assistance with filling out benefits applications, (d) support groups for families raising

children of others, and (e) senior support services such as assessing financial and medical

needs for caregivers over 60 years of age. Many of the family members who receive

services from the KARE Center are supporting a person in the family who has an

addiction. The KARE Center does not offer a residential program for addiction. The

KARE Center does however, offer support services for family members who have a

relative with addiction. KARE members’ relatives with addiction are often incarcerated

for criminal behavior related to addiction and do not receive the same treatment as the

relatives with addiction at traditional treatment centers (Melrood, 2008).

Recruitment of the Treatment Group

The treatment group was found to be eligible for this study if they were age 18

years or older and had a relative who was in detention at the PCJCC. Upon arrival at

PCJCC and before the FBT session, family members read a flyer with details about the

study (see Appendix A-1).

On Wednesday evening, before the brief family-based session began, family

members met with the principle investigator (PI). The PI explained that the purpose of

58

the study was to examine family members’ perceptions toward people with addiction and

toward a specific relative with addiction (pre- and post-FBT). Family members were

advised that they would be asked to complete two pre-test and two post-test

questionnaires that had been developed to evaluate (a) perceptions toward people with

addiction and (b) perceptions toward a specific relative with addiction. Both

questionnaires were administered to family members by the PI. The pre-test

questionnaire and a demographic survey were administered before the FBT session and

the post-test questionnaires were administered after the FBT session on the same day.

Family members were informed that there was no obligation to participate in this study

and that they were free to withdraw at any time without affecting their participation or

their relative’s participation at the Pima County Juvenile Court Center. A copy of their

right to privacy and participation was signed by them and the PI prior to data collection

and before FBT class began (See Appendix A-1a).

Recruitment of the Control Group

The control group was found to be eligible for this study if they were age 18 years

or older, and members of The KARE Center. Family members in the control group read a

flyer on the day that they arrived for a support meeting at KARE (see Appendix A-2).

Upon arriving at the KARE Center on Tuesday morning for the support meeting,

family members met with the PI. The PI explained that the purpose of the study was to

examine family members’ perceptions of people with addiction and of a specific relative

with addiction. Family members were advised that they would be asked to complete two

59

pre-test and two post-test questionnaires that had been developed to evaluate (a)

perceptions about people with addiction and (b) perceptions about a specific relative with

addiction. Both questionnaires were administered to family members by the PI. The pre-

test questionnaire and a demographics questionnaire were administered on Tuesday

morning at a scheduled weekly support group meeting and the post-test questionnaires

were administered on the same day, following the Tuesday morning support group

meeting. Family members were advised that there was no obligation to participate in this

study and that they were free to withdraw at any time without affecting their participation

or their relative’s participation at the KARE Center. A copy of their right to privacy and

participation was signed by the family members and the PI on Tuesday morning, before

administering the pre-test (See Appendix A-2a).

Procedure

Pre-test questionnaires and post-test questionnaires were administered to the

treatment group and control group. A demographic questionnaire was administered to

both groups at the same time that the pre-test questionnaires were administered. The

demographic questionnaires included questions regarding general information about

participants in each group (i.e., the experimental group and the control group). The

treatment group received family-based treatment and completed two post-test

questionnaires immediately after the session. The control group did not receive FBT, but

they completed two post-test questionnaires immediately after their regular meeting at

KARE. Every effort was made to ensure that both groups were similar (i.e., recruitment

60

of participants, explanation of the study, administration of the pre-test/post-test

questionnaires, and family members of a relative with addiction) (see Appendix C).

Step one. Before family members were selected, the PI met with therapists at

PCJCC to discuss the research protocol, review the participant eligibility requirements

(i.e., age 18 or older, familymembers who have a relative with addiction, and are

involved with PCJCC), and to determine the family members who were eligible to

participate in the study. Similarly, the PI met with staff at the KARE Center to discuss

the research protocol, review the eligibility requirements (i.e., age 18 or older, family

members who have a relative with addiction, and are attending some type of support

group at the KARE Center due to a relative with addiction), and to determine the family

members who were eligible to participate in the study.

Step two. The PI met with the families at PCJCC before beginning the FBT

sessions and at The KARE Center on Tuesday morning, before the weekly support group

to discuss protocol, timelines, procedures and confidentiality, and to obtain signatures on

consent forms according to IRB requirements.

Step three. At the beginning of the FBT session, and immediately after meeting

with the PI, the family members at PCJCC completed one demographic questionnaire and

two pre-test questionnaires that were administered prior to the FBT class. Likewise, on

Tuesday morning, after meeting with the PI, family members from The KARE Center

61

completed one demographic questionnaire and two pre-test questionnaires that were

administered before their weekly support group. The instructions included a request for

the family members to provide a memorable identification number at the top left hand

side of each questionnaire. Example: 0315 (birth month and day) TIL (first three letters

of pet/place/etc…).

Step four. Family members from PCJCC completed two post-test questionnaires

that were administered after the FBT session and family members from The KARE

Center completed two post-test questionnaires that were administered following their

regular support group meeting. The instructions included a request for family members

to provide the same memorable identifier that they used on each questionnaire.

Research Design

The effects of FBT on participants’ (i.e., family members) perceptions of and

beliefs about people in general with addiction and a relative with addiction were explored

in this study. Participants in this study were chosen from a convenience sample rather

than at random, therefore, this was a quasi-experimental design. This quasi-

experimental design involved collecting data from a convenience group (i.e., treatment

group) who received FBT and collecting data from a convenience group (i.e., control

group) that did not receive FBT. A Quasi-experimental design typically imposes an

intervention such as the FBT, on a group of participants in the interest of observing the

response and measuring a cause and effect relationship between participant responses

62

(pre-test and post-test). In this study, the participants were a convenience sample and

either received brief family-based treatment, or did not. The goal was to measure whether

family members changed their perceptions (i.e., attitudes) toward people in general with

addiction and toward a specific relative with addiction pre- and post- FBT (i.e., the

intervention).

The control group in this study augmented the integrity of the experiment by

isolating the attitudes of family members in order to come to a conclusion about changes

in perceptions (i.e., attitudes) from pre-test questionnaire to post-test questionnaire. The

control group design used participants who were similar to the experimental group but

who were not subjected to the intervention process and compared them with the

experimental group (who were subjected to the intervention process) to test a causal

hypothesis (Leedy, 1993). Every attempt was made to ensure that the control and

experimental groups were identical in all relevant ways (i.e., recruitment, explanation of

the study, administration of the pre-test/post-test questionnaire, and family members of a

relative with addiction) except that the experimental group received FBT (i.e., the causal

agent) and the control group did not receive the intervention. Therefore, if the suspected

causal agent (i.e., FBT) was actually a causal factor of some event (i.e.,

perception/attitudes change), then that event should have manifested itself more

significantly in the experimental than in the control group. For example, if “C” causes

“E”, when we introduce “C” into the experimental group but not into the control group,

we should find “E” occurring in the experimental group at a significantly greater rate than

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in the control group. Significance is measured by relation to chance: if an event is not

likely due to chance, then its occurrence is significant (Leedy).

Instruments

The instruments that were used to measure family members’ general perceptions

toward addiction and their perceptions toward a specific relative with an addiction were

based on the Attitudes Measurement: Brief Scales (AMBS). The original AMBS was

developed by the National Centre for Education and Training on Addiction, Flinders

University, Adelaide, Australia (NCETA, 2006) (see Appendix B for the original). The

original AMBS utilized a 5-point, 9-item Likert-type scale. Number 7 on the scales was

inadvertently omitted on the original AMBS (NCETA). The 9-item scales were designed

to assess health care workers attitudes and beliefs regarding their judgments about people

with addictions and their deservingness of treatment. Examples of responses on the

scales range from: 1 = not at all responsible to 5 = very responsible; 1 = not at all angry

to 5 = very angry; 1 = not at all disappointed to 5 = very disappointed; and 1 = not at all

concerned to 5 = very concerned.

Key elements in the original instrument include five scales: (a) Responsibility, (b)

Negative Affect, (c) Positive Affect, (d) Deservingness, and (e) Entitlement. The

questions associated with each scale are located in Appendix C. According to the

researchers at NCETA (2006), three major beliefs influence judgments or attitudes: (a)

responsibility for an outcome (i.e., if a person studies hard for a test and makes a good

grade, it’s understood that he or she is deserving of the good grade), (b) relationship

64

between a person’s behavior and an outcome (i.e., positive behavior leads to a person

receiving a reward for his or her behavior and negative behavior leads to the person

receiving a penalty for his or her behavior), and (c) attitudes toward the person (i.e.,

positive feelings towards the person often leads to them being in receipt of more

sympathy and concern and deservingness of treatment, whereas negative attitudes toward

the person is likely to result in them being the recipients of disapproval and anger,

thereby resulting in poorer quality of care).

The AMBS, according to the NCETA research team, were primarily designed for

educators and trainers who address alcohol or drug related issues in their training courses.

The scales are used to assess attitudes and beliefs related of healthcare workers, but can

be adapted for use with other populations in the field of addiction (NCETA, 2006).

For the current study, the following revisions were made: one AMBS

questionnaire, as revised for the current study (i.e., General Perceptions toward People

with Addiction), included the eight questions that were specific to perceptions toward

people in general with addiction (see Appendix B-2). This instrument focused on family

member’s attitudes/perceptions toward people in general with addiction. The word

“attitudes” was changed to “perceptions” because there was a concern by committee

members’ that the word attitudes would influence family members’ responses in a

negative way. The questions on B-2 were also revised and renumbered for accuracy and

the instructions to the participants were revised to ask them to respond to items based on

their perceptions toward people in general with addiction.

65

A second revised AMBS questionnaire (i.e., Perceptions toward a Specific

Relative with Addiction) was revised for the current study and included eight questions

that focused on perceptions of family members toward a specific relative with addiction.

As previously stated, the word “attitudes” was changed to “perceptions.” Items were

renumbered for accuracy and instructions to participants were revised so as to focus on

perceptions toward a specific relative with addiction (see Appendix B-3).

The questionnaires were color-coded for clarity (i.e., to identify that they are two

separate instruments). For example, the pre-test/post-test questionnaire used to examine

family members’ perceptions toward people in general with addiction (AMBS: General

Perceptions toward People with Addiction) were color-coded in light blue and the pre-

test/post-test questionnaires used to examine family member’s perceptions toward a

relative with addiction (AMBS: Perceptions toward a Specific Relative with Addiction)

were color-coded in light grey. To learn more about the participants in this study, family

members were asked to complete a demographic questionnaire that focused on several

personal characteristics, such as, the age and gender of the relative with addiction, and

the income, ethnicity, and gender of the family member/participant (see Appendix B-4).

All questionnaires included a participant identification code on the left hand corner of the

page. For Spanish speaking/reading participants, the AMBS was translated to a paper

pre-test/post-test questionnaire by a certified Spanish translator.

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Scoring the AMBS

The AMBS is scored for five scales: Responsibility, Negative Affect, Positive

Affect, Deservingness, and Entitlement. For an explanation of how the AMBS was

originally scored see Appendix C-1. For the purpose of this study the Responsibility

scale on the AMBS was calculated in a different way than the original. On the

Responsibility scale in the original AMBS, item one is reverse scored. In this current

study, however, the first item on the Responsibility scale was not reverse scored because

the wording did not seem clear. In particular, the first question asked the respondent to

circle to what extent challenges in ones life were likely to be responsible for people or a

relative’s addiction. The respondent had five choices ranging from (1) not responsible at

all to (5) very responsible. If the respondent chose (1) not responsible at all, it would be

reverse scored, thereby indicating that the person was (5) very responsible for his or her

addiction. Although the question was confusing, and even though it was not reverse

scored, a positive correlation was found after running an SPSS analysis. This

indicated that respondents most likely saw challenges as personal, which correlated with

item number two on the responsibility scale. The remaining four scales, (i.e., Negative,

Positive, Deservingness, and Entitlement) were all scored according to the original

AMBS.

Piloted Study of the AMBS

To better understand whether the two revised instruments (i.e., AMBS: General

Attitudes toward People with Addiction and AMBS: General Perceptions toward a

67

Specific Relative with Addiction) would measure what is intended for this study and

whether the demographic questionnaire was adequate for this study, a pilot test was

conducted by the PI with 10 participants who had a relative or significant other with

addiction. The following was learned from the pilot test. There was a need for clearer

instructions for completing the pre/post test (i.e., change the wording to direct the

participant to “circle the number that best fits his or her perceptions). In the original

AMBS, item number 7 was omitted; for the current study, items on the AMBS were

numbered accurately. There was a broad range of responses; however, most responses

were more positive than negative. This broad range is an indication that the AMBS

appears to allow for differing responses regarding attitudes toward people in general with

addiction and attitudes toward a specific relative with addiction. A broad range indicates

that the AMBS is more likely to achieve variance which is important for use with the

ANOVA (Johnson & Christensen, 2004). There was also a need to develop an identifier

for the individual participants that would be used from pre-tests to post-tests. The

following identifiers were suggested, birth month and day, plus the first three letters of a

pets’ name (e.g., 0130taz). Lastly it was learned that there was a need to insert other

categories in the demographics to include, niece, nephew, and combine friend and

significant other into one category.

Analysis

The data were analyzed to determine if family members’ (a) perceptions toward

people in general with addiction changed from pre-test to post-test and perceptions

68

toward a specific relative with addiction changed from pre-test to post-test (for the family

members in the treatment group at Pima County Juvenile Court Center) and (b)

perceptions toward people in general with addiction and a relative with addiction changed

for family members in the control group (who did not receive FBT) at The KARE Center

from pre-test to post-test.

A three-way Analysis of Variance (ANOVA) was used to compare the three

effects in the study (see Chapter 4, Results). The ANOVA tests differences in means (for

groups or variables) for statistical significance (Johnson & Christenson, 2004). This is

accomplished by partitioning the total variance into the components that are due to true

random error and the components that are due to differences between means. These latter

variance components are then tested for statistical significance. If not significant (i.e., no

change occurs due to the treatment), the null hypothesis is retained. If a change occurs

due to the treatment, however, the alternative hypothesis is accepted (Statsoft, 2008). For

analysis in this study, the p-value was set at .05 for significance.

Dependent and independent variables: the variables that were measured (e.g.,

perceptions toward people in general with addiction and a specific relative with

addiction) were the dependent variables. The variable that was manipulated or controlled

(e.g., FBT) was the independent variables.

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CHAPTER FOUR

FINDINGS

The current research is an investigation of the efficacy of brief family-based

treatment in changing family members’ attitudes toward people in general with addiction

and attitudes toward a specific relative with addiction after a brief family-based treatment

session. As noted in chapter one, family members’ beliefs about addiction and their

feelings toward a specific relative with addiction often play an essential part in the

psychological aspect of the recovery process of the relative with the addiction. The

purpose of the current study was to examine whether brief family-based treatment

impacts family members’ attitudes toward people with addiction in general and toward a

specific relative with addiction. The following research questions were addressed in this

study:

RQ1: Is there a change in family members’ attitudes toward people in general

with addiction from pre-family-based treatment to post-family-based treatment?

RQ2: Is there a change in family members’ attitudes toward a specific relative

with addiction from pre-family-based treatment to post-family-based treatment?

Two groups were surveyed (i.e., treatment, control). One group (treatment)

received a brief two hour family-based treatment session and one group (control) did not

receive a brief family-based treatment session. Family members in this study, from both

groups, completed a demographic survey and two Attitudes Measurement Brief Scales

(AMBS) pre-test questionnaires and two (AMBS) post-test questionnaires (i.e.,

70

perceptions toward people in general with addiction and perceptions toward a specific

relative with addiction). The treatment group completed the demographic survey and

pre-test questionnaires before a brief family-based session and the post-test

questionnaires immediately after the brief family-based session. The control group

completed the demographic test and pre-test questionnaires before a support group

meeting and the post-test questionnaires immediately after the support meeting. The

results of the pre and post tests were calculated using SPSS (Incorporated, #17) and are

described below.

Results

Three-way analyses of variance (ANOVA) were conducted to address three

factors. Factor A, was to measure treatment vs. control group; Factor B, was to measure

pre-tests vs. post-tests for each instrument; and Factor C, was to measure attitudes

regarding people in general versus relatives with addiction. The five scales in the AMBS

(i.e., Responsibility, Negative, Positive, Deservingness, and Entitlement) were used to

determine whether family members’ attitudes toward people (in general) with addiction

changed from pre-test questionnaire to post-test questionnaire, and whether family

members’ attitudes toward a specific relative with addiction changed from pre-test

questionnaire to post-test questionnaire. As stated earlier, two groups were surveyed, the

treatment group (n = 19) received a brief two hour family-based treatment session and the

control group (n = 22) did not receive a brief family-based treatment session. The results

71

of the ANOVA for the five scales are listed in Tables 1-5 and the means for each of the

five scales are illustrated in Figures 1-5.

Responsibility Scale

Two questions on the Responsibility scale measured the extent to which

respondents hold people or a relative responsible for his or her addiction. The ANOVA

results for the Responsibility scale are reported in Table 1, where TX represents the

Treatment group, CG represents the Control Group, People represents people in general

with addiction, and Relative represents a specific relative with addiction.

Table 1

Analysis of Variance for the Responsibility Scale

Source df F Parial η p

Between subjects

TX vs. CG (A) 1 0.367 .01 .55 S within-group error 39 (3.398)

Within subjects

Pre vs. Post (B) 1 1.452 .04 .24

A X B 1 1.198 .03 .28

A X B within-group error 39 (0.433)

People vs. Relative (C) 1 0.023 .00 .88

A X C 1 2.318 .06 .14

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Table 1 (continued)

Analysis of Variance for the Responsibility Scale

Source df F Parial η p

Within subjects

A X C within-group error 39 (0.542)

B X C 1 0.110 .00 .74

A X B X C 1 0.433 .01 .51

A X B X C within-group error 39 (0.264)

Results displayed on Table 1 reveal that the three-way ANOVA interaction

(AXBXC) was not significant. The scores between Pre and Post tests of the

Responsibility Scale did not change after a brief two hour family-based treatment session.

There was also no TX vs. CG, and Pre-test vs. Post-test (AXB) or TX vs. CG, and People

vs. Relative (AXC) interaction, therefore no significant effects or interactions for the

Responsibility scale were found. The findings revealed that the perceptions of the

treatment group and control group did not change from pre-test to post-test (i.e., brief

family-based treatment) with regard to holding people or a relative responsible for his or

her addiction. Thus, the null hypothesis was retained.

Figure 1 represents means for the Responsibility scale. The mean results are

reported on the bottom line of the bar graph and the line segments at the top represent the

confidence interval parameters.

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Figure 1. Responsibility Scale Means

Negative Scale

The Negative scale has two questions that measures the degree to which

respondents experience anger or disappointment toward people or a relative with

addiction. A higher score represents more anger and disappointment toward someone

with addiction. ANOVA results for the Negative scale are reported in Table 2.

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Table 2

Analysis of Variance for the Negative Scale

Source df F Parial η p

Between subjects

TX vs. CG (A) 1 0.00 .01 .99 S within-group error 39 (2.302)

Within subjects

Pre vs. Post (B) 1 0.39 .01 .53

A X B 1 0.05 .00 .83

A X B within-group error 39 (0.367)

People vs. Relative (C) 1 15.95 .29 .00

A X C 1 0.09 .00 .77

Table 2 (continued).

A X C within-group error 39 (0.646)

B X C 1 0.074 .00 .79

A X B X C 1 0.656 .02 .42

A X B X C within-group error 39 (0.220)

______________________________________________________________________________________

Results displayed on Table 2 reveal that the three-way ANOVA interaction

(AXBXC) was not significant. The scores between Pre and Post tests of the attitudes

Negative Scale did not change after a brief two hour family-based treatment session.

Similarly, there was also no significant AXB interaction, thereby resulting in no

75

significance difference between the TX vs. CG and no significant AXC interaction

between the TX vs. CG and People vs. Relative after a brief family-based treatment

session was introduced to the treatment group. Significance was found, however, on the

Negative scale (factor C) with regard to family members’ attitudes toward people with

addiction compared with family members’ attitudes toward a relative with addiction (i.e.,

People vs. Relatives). An F value of (F (1, 39) = 15.95, p < .001) was observed. Both

the treatment group and the control group had significantly more negative attitudes (i.e.,

angrier and more disappointment) toward a specific relative with addiction than toward

people in general with addiction.

The means for the Negative scale are reported in Figure 2. The mean results are

reported on the bottom line of the graph and the line segments at the top represent the

confidence interval parameters.

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Figure 2. Negative Scale Means

Positive Scale

The Positive scale has two questions that examine the intensity to which

respondents convey concern or sympathy toward people or a relative with addiction.

ANOVA results for the Positive scale are reported in Table 3.

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Table 3

Analysis of Variance for the Positive Scale

Source df F Parial η p

Between subjects

TX vs. CG (A) 1 4.02 .09 .05 S within-group error 39 (2.568)

Within subjects

Pre vs. Post (B) 1 0.22 .01 .66

A X B 1 0.03 .00 .87

A X B within-group error 39 (0.326)

People vs. Relative (C) 1 31.67 .45 .00

A X C 1 5.80 .13 .02

A X C within-group error 39 (0.319)

B X C 1 0.342 .01 .56

A X B X C 1 0.016 .00 .90

A X B X C within-group error 39 (0.224)

Results displayed on Table 3 reveal that the three-way ANOVA interaction

(AXBXC) was not significant. The scores between Pre and Post tests of the Positive

Scale did not change after a brief two hour family-based treatment session. Therefore the

null hypothesis was retained. Significance was found (i.e., F value of (F (1, 39) = 5.80,

78

p = .021) on the Positive scale with regard to the TX vs. CG and People vs. Relative

interaction (AXC), demonstrating that both the control group and treatment group were

less concerned and sympathetic toward people in general with addiction than for a

specific relative with addiction. Another main effect that was significant was the People

vs. Relatives interaction. An F value of (F (1, 39) = 31.67, p < .01) was found, indicating

that family members in the treatment group had more sympathy and concern (overall) for

a specific relative with addiction than did the control group. The reason for this response

is uncertain and may be due to the differences in demographic characteristics between the

treatment and control group. Further explanation about demographic

characteristics/differences will be discussed in Chapter 5 in the differences between

groups and limitations sections.

The means for the Positive scale are illustrated in Figure 3. The mean results are

reported on the bottom line of the graph and the line segments at the top represent the

confidence interval parameters.

79

Figure 3. Positive Scale Means

Deservingness Scale

One question on the Deservingness scale examines the extent to which

respondents believe that people or a relative with addiction are worthy of the same type

of medical treatment as people who are not addicted to drugs. ANOVA results for the

Deservingness Scale are reported on Table 4.

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Table 4

Analysis of Variance for the Deservingness Scale

Source df F Parial η p

Between subjects

TX vs. CG (A) 1 7.88 .17 .01 S within-group error 39 (3.984)

Within subjects

Pre vs. Post (B) 1 0.22 .01 .64

A X B 1 0.35 .00 .85

A X B within-group error 39 (0.261)

People vs. Relative (C) 1 2.98 .07 .09

A X C 1 0.78 .02 .38

A X C within-group error 39 (0.264)

B X C 1 0.435 .01 .51

A X B X C 1 0.069 .00 .80

A X B X C within-group error 39 (0.133)

Results displayed on Table 4 reveal that the three-way ANOVA interaction

(AXBXC) was not significant. The scores between Pre and Post tests of the

Deservingness Scale did not change after a brief two hour family-based treatment

session. Therefore the null hypothesis was retained. Similarly, there was also no

significance found in the AXB or AXC interactions. Main effects (TX vs. CG), however,

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were found to be significant with an F value of (F (1, 39) = 7.88, p = .01). The responses

of the treatment group were significantly higher than the control group. This indicated

that participants in the treatment group believed that people (i.e., people in general with

addiction) and a relative (i.e., specific relative with addiction) were more deserving of

treament for addiction than did the family members in the control group. This finding,

however, may have confines due to the varied demographic characteristics of the

treatment group and control group and will be discussed further in Chapter 5 in the

differences between groups and limitations sections.

The means for the Deservingness scale are illustrated in Figure 4. The mean

results are reported on the bottom line of the graph and the line segments at the top

represent the confidence interval parameters.

82

Figure 4. Deservingness Scale Means

Entitlement Scale

One question on the Entitlement scale examines the extent to which respondents

deem that people or a relative with addiction should be permitted to have the same type

of medical treatment as people who are not addicted to drugs. ANOVA results for the

Entitlement scale are reported in Table 5.

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Table 5

Analysis of Variance for the Entitlement Scale

Source df F Parial η p

Between subjects TX vs. CG (A) 1 8.44 .18 .01 S within-group error 38 (4.449)

Within subjects

Pre vs. Post (B) 1 0.37 .01 .55

A X B 1 0.37 .01 .55

A X B within-group error 38 (0.245)

People vs. Relative (C) 1 1.78 .05 .19

A X C 1 0.51 .01 .48

A X C within-group error 38 (0.236)

B X C 1 4.80 .11 .35

A X B X C 1 1.022 .03 .32

A X B X C within-group error 38 (0.079)

Results displayed on Table 5 reveal that the three-way ANOVA interaction

(AXBXC) was not significant. The scores between Pre and Post tests of the Entitlement

Scale did not change after a brief two hour family-based treatment session. Therefore the

null hypothesis was retained. Similarly, there was also no significance found in the AXB

or AXC interactions. Main effects, however, were found to be significant regarding TX

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vs. CG, with an F value of (F (1, 38) = 8.44, p = .01). The treatment group was

significantly higher than the control group with regard to beliefs that people in general

with addiction and a specific relative with addiction should be permitted to have the same

type of medical treatment as people/relatives who are not addicted to drugs. This effect

may be similar to the results found on the Deservingness scale since the definition is very

similar. Furthermore, as stated previously regarding the Negative, Positive, and

Deservingness scales, this deduction may be due to demographic characteristics and will

be discussed in further detail in Chapter 5 in the differences between groups and

limitations sections.

The means for the Entitlement scale are illustrated in Figure 5. The mean results

are reported on the bottom line of the graph and the line segments at the top represent the

confidence interval parameters.

85

Figure 5. Entitlement Scale Means

Demographic Characteristics

As noted in Chapter 3, this study used a convenience sample comprised of one

treatment group (n = 19) and one control group (n = 22). Demographic characteristics of

both groups are listed in Table 6.

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Table 6 Demographic Characteristics ______________________________________________________________________________________ Demographic Treatment Group Control Group ______________________________________________________________________________________ Gender of Participant

Female

73% 95%

Male 27% 5% Age of Relative with Addiction

15

32%

16

26%

17

42%

19 – 22

9%

30 – 45

36%

46 – 63

23%

Did not answer question 32% Relationship of Participant to Relative with Addiction

Father

26% 5%

Mother

58% 14%

Grandmother

16% 14%

Spouse

14%

Sister

14%

Son

9%

Cousin

5%

Niece

5%

Did not answer question 47% 22%

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Table 6 (continued) Demographic Treatment Group Control Group

Gender of Relative with Addiction

Female

16% 27%

Male

84% 50%

Did not answer question 23% Income Range of Participants

$0 - $9,999

11% 9%

$ 10,000 - $19,999

32% 18%

$20,000 - $39,999

47% 23%

$60,000 - $79,999

14%

$80,000 and above

14%

Did not answer question 7% 22% Ethnicity of Participants

Caucasian

32% 55%

Hispanic

63% 5%

African American

5% 5%

Asian

9%

Other

Did not answer question 23%

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Table 6 (continued) Demographic Treatment Group Control Group

Age of Participants

18-28

5% 9%

29-38

26% 0

39-49

47% 9%

50-64

15% 36%

65 and above

23%

Did not answer question 5% 23% Note: Percentages do not always equal 100% due to rounding.

Summary of Findings

With regard to the two research questions posed in this study, there were no

significant differences from pre-test to post-test on any of the AMBS scales for the

treatment or control group. Therefore, the null hypothesis was retained for both specific

research questions. Significance was found however, on the Negative scale within

subjects. Both the treatment group and control group had more negative attitudes (i.e.,

more anger and more disappointment) toward a relative with addiction than toward

people in general with addiction. On the Positive scale, significance was again found

within subjects. The treatment group and control group had more positive attitudes (i.e.,

concern and sympathy) toward a specific relative with addiction than toward people in

general with addiction. The family members’ in the treatment group, however, had

significantly more concern and sympathy for a specific relative than did the control

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group, both pre-test and post-test. Regarding the Deservingness scale, family members in

the treatment group believed more so than the family members in the control group that

all people with addiction deserve (i.e., are worthy of) medical treatment whether they are

a specific relative or people in general. Finally, regarding Entitlement, the treatment

group’s responses were significantly higher than the control group’s responses with the

treatment group asserting that people with addiction and a relative with addiction should

be entitled to (i.e., guaranteed) the same medical treatment as people who are not

addicted to drugs.

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CHAPTER FIVE

DISCUSSION

This chapter provides a discussion of the results presented in Chapter 4 and

includes (a) a brief review of the methodology; (b) discussion of the findings, which

includes the differences in perceptions between people in general who have addiction

versus a specific relative with addiction, the findings regarding the differences between

the treatment and control group, and differences in demographic characteristics; (c)

limitations of this study; and (d) conclusions and recommendations.

Brief Review of the Methodology

The purpose of this study was to determine whether perceptions of family

members were changed after they participated in a brief family-based treatment session.

An attempt was made to address the practical limitations of comparable research

pertaining to attitudes/perceptions of family members toward people in general with

addiction and a specific relative with addiction with regard to brief family-based

treatment. A questionnaire format was used to obtain information regarding family

members’ attitudes toward people in general with addiction and a specific relative with

addiction. A small convenience sample of participants (n = 41) was included in this

study. Nineteen of the participants were from the treatment group and twenty-two were

from the control group.

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Discussion of Findings

The result of this current study indicated that one brief family-based treatment

session did not contribute to significant changes in attitudes or perceptions toward people

in general with addiction or toward a specific relative with addiction. Because no

significance was found with regard to the two research questions, this study did not

support the hypothesis that attitudes and perceptions would change from pre-test to post-

test using the Attitudes Measurement: Brief Scales.

With respect to the AMBS, on the Responsibility scale, no significance difference

was found between the treatment group and control group concerning responsibility for

behavior whether it was people in general with addiction or a specific relative with

addiction, on either instrument. One reason may have been the scoring of the instruments

in this study. In the original AMBS the first question on the Responsibility scale was

reverse scored; however, in this current study the first question was not reverse scored.

The first question on the Responsibility scale asks specifically whether people or a

relatives’ addiction are related to life’s challenges. A family member may answer that

the challenges in the person’s life are not likely to be responsible for his or her addiction

(i.e., low score of 1). The opposite however, would be reported (i.e., high score of 5)

when the answer is reverse-scored. Therefore, reverse scoring would indicate that

challenges in one’s life are more likely to contribute to his or her addiction.

Consequently, had the first question been reverse scored, it may have resulted in a

significant finding on this scale.

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With regard to the remaining scales, significance differences were found on the

Negative and Positive scales within subjects (People vs. Relative) and on the Positive,

Deservingness, and Entitlement scales between subjects (TX vs. CG). These findings will

be discussed in the following sections.

Differences in Perceptions between People vs. a Specific Relative

This section will include a discussion about the ANOVA results and the

differences in perceptions between people in general with addiction and a specific

relative with addiction on the Negative and Positive scales. It is interesting to note that

on the Negative scale, family members’ tended to be less angry and less disappointed

toward people in general with addiction and angrier and more disappointed toward a

specific relative with addiction for both the treatment and the control group. It is possible

that family members’ responses were due to their close relationship to their relative with

addiction and their lack of closeness to people in general with addiction. Conversely, on

the Positive scale, the opposite was found with regard to concern and sympathy. Family

members’ attitudes in both groups tended to be less sympathetic and less concerned about

people in general with addiction and more sympathetic and more concerned toward a

specific relative with addiction from pre-test to post-test. While this differs from their

response on the Negative scale, it is again most likely due to their close proximity to a

relative with addiction and their concern for his or her wellbeing.

On the two remaining scales (i.e., Deservingness and Entitlement), no

significance difference was found between people versus a relative with addiction. This

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is a potential indication that family members’ did not distinguish between a specific

relative or people in general with regard to receiving medical care. Significance was

found on the Deservingness and Entitlement scales as well as the Positive scale with

regard to differences between the treatment group and control group and will be

discussed in the next section.

Differences between the Treatment and Control Group

This section will include a discussion about the differences between the two

groups (i.e., treatment vs. control) with regard to the three scales mentioned above (i.e.,

Positive, Deservingness, and Entitlement). Also discussed in this section will be the

speculation about the demographic characteristics and how they may have influenced the

findings.

Regarding the Positive Scale, family members in the treatment group had more

concern and sympathy for people in general with addiction and significantly more

concern and sympathy for a specific relative than did the control group, at both pre-test to

post-test. One reason for these findings may be due to the differences in demographic

characteristics among the treatment and control groups. For instance, the treatment group

may have been more sympathetic and concerned because they and their relative with

addiction were younger and did not have the long-term experience with addiction that

perhaps the control group had. In addition, older family members may have lived with an

adult relative with addiction longer and therefore may have experienced more

disappointments and unmet expectations.

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Similar to the Positive scale, main effects for both the Deservingness scale and

Entitlement scale were found to be significantly different between the treatment group

and control group concerning worthiness of treatment and eligibility of treatment. Once

again, the treatment group had higher scores than the control group on these two scales,

indicating that the treatment group felt that people in general and a specific relative with

addiction were more deserving and entitled to help than did the control group. As stated

earlier, this deduction may be due to differences in demographic characteristics. For

example, members in the treatment group had lower incomes than the control group.

Perhaps members in the control group had used their resources to finance treatment

options that were not successful in the past and were now somewhat guarded toward a

specific relative’s worthiness and appropriateness of receiving more treatment. Also,

because the participants in the control group were older and had relatives with addiction

who were older, they may have had more experience overall with addiction and were not

hopeful of seeing positive results from any new therapy interventions. Therefore, they did

not see the need for more treatment.

Inconsistencies in demographics, such as the ones discussed above, most likely

affected the results of the current study. As a result, it is important to discuss in detail the

other differences that were found between the treatment and control group.

Differences in Demographic Characteristics

Several demographic characteristics were examined in this study. With regard to

gender characteristics of the participants, five participants (10%) in the treatment group

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were male and fourteen were female, while in the control group one participant was male

and sixteen were female. It was unclear whether gender had any impact on the study.

Age of the relative with addiction also was unique with 100 % of participants in

the treatment group reporting the age of their relative with addiction to be fifteen to

seventeen. Relatives in the control group, on the other hand, reported ages of relatives to

be nineteen to sixty-three with more than 50% over the age of thirty. Age of the relative

may have contributed to some inequality between both groups. For example, relatives in

the control group were older and may have been dealing with addiction problems for a

longer period of time than relatives in the treatment group who were younger. As a

result, the participants in the control group may have had less sympathy and concern

toward people and a relative with addiction due to history. Many of the treatment

groups’ relatives were younger and recently incarcerated and this may also have

contributed to the treatment group feeling more concern for their relative.

Another difference between the two groups is that the control group may have

regularly attended Tuesday support group meetings, whereas the treatment group had

only a brief two hour session. These differences in support may have influenced the

perceptions of partifcipants in each group with regard to responsibility, negative, postive,

deservingness, and entitlement toward people in general and a specific relative with

addition.

Disparity was also found between both groups with regard to the relationship of

participants/family members and their relative with addiction. In the treatment group,

family members were either a mother, father, or grandmother, whereas in the control

96

group, family members were mixed (i.e., father, mother, grandmother, spouse, son,

cousin, sister, niece). Having closer family ties with someone with addiction has been

shown to improve the outcomes for that person. In this instance, family members in the

treatment group may have had closer ties and as a result tended to be more concerned and

sympathetic and to believe that their relative was more deserving and entitled to

treatment. What was not clear, however, was why the treatment group felt that people in

general were also more deserving and entitled to treatment, than did the control group.

Income range also differed, with all participants in the treatment group reporting

incomes of $39,999 or less and the control group reporting incomes of up to $80,000 and

above. It is thought that perhaps participants in the control group also had a higher level

of education because they reported a higher income. Having more education may also

have contributed to less sympathy and concern. Perhaps the participants in the control

group had found ways to use their resources to help cope more effectively with their

situation. Regarding ethnicity, a high percentage of participants in both groups were

Caucasian (i.e., treatment group – 32% and control group – 55%). In the treatment

group, however, 63% of participants reported being Hispanic while only 5% reported

being Hispanic in the control group. Ethnicity may have caused discrepancies in the

findings due to different beliefs about addiction. Family members who grow up in

households may not have the same perceptions or attitudes toward people in general or a

specific relative with addiction problems. Finally, with regard to age of the participants,

a majority of the responders in the treatment group fell within the age ranges of twenty-

nine to forty-nine whereas a majority of the responders in the control group fell within

97

the age ranges of fifty to sixty-five and above. As noted earlier, age and experience with

addiction may have played an important role in the inconsistencies found within the

results of this study. With all of this in mind, it is very likely that these differences may

have contributed to a variety of limitations and bias within the study.

Limitations

Good experimental design involves eliminating as many of the possible

confounding variables as possible. Although the task of designing this research was

relatively logical and fairly simple, there were several potential confounding variables

that most likely contributed to limitations in the study. First, this was a convenience

sample with only a small number of participants (n = 41). Six of the twenty-five family

members in the treatment group decided not to participate in the study. Five of the

twenty-two family members in the control group did not complete the demographic

survey, stating that sharing personal information about themselves or a relative with

addiction was problematic for them and one family member in the control group did not

answer all of the survey questions. As a result, the group was not well represented and

not generalizable. Second, the recruitment process may have been distracting, leading to

unwillingness of participation. For example, one family member in the treatment group

became very upset and vocal during the recruitment process. This set a negative tone for

the other participants, resulting in four family members declining the offer to contribute

to the study. Third, there was no manualized treatment protocol for the treatment group.

Therefore, it would be difficult for a researcher to replicate this study without a step-by-

98

step guide. This is not a reflection on the program, but a weakness of the research design

because it is not possible to describe clearly the treatment that the participants received.

It should be noted, however, that no manualized format was discussed in Chapter Two.

Additionally, while brief family-based treatment at PCJCC did focus on many of the

tenets of FBT, discussed in Chapter Two, only one two hour session was offered to the

treatment group as opposed to the research that suggests numerous sessions are more

effective. Several FBT modalities discussed in Chapter Two recommended at least six or

eight-one hour sessions in succession (Bergin & Garfield, 1994; Cannon & Levy; Cottrell

& Boston, 2002; Connors et al.; English, 2000; Jay & Jay, 2000; Liddle; McLendon et al.

2005; Miller et al.1999; O’Farrell et al.1995; Santisteban et al. 2003). Consequently, this

observer may postulate that having only one brief two-hour session is not adequate time

to provide a therapeutic brief family-based session that will result in a meaningful change

in perceptions toward people in general with addiction and a specific relative with

addiction. Furthermore, because there were a number of components in the treatment

readiness session at PCJCC, changing perceptions about addiction were only briefly

discussed. Fourth, the instrument used (i.e., Attitudes Measurement: Brief Scales) was

designed for use with healthcare workers and not family members. While the AMBS was

revised for use with this study, a more-well constructed scale designed with family

members’ issues in mind would have been more practical. In addition, there were some

difficulties with the scoring of the instrument. On the original AMBS, the first question

on the Responsibility scale, which questions whether the respondent feels that people or a

relatives’ “challenges in life” are responsible for his or her addiction, is meant to be

99

reverse scored, but was not reverse scored in the current study. It is likely that scoring it

like the original would have made some difference with regard to results on the

Responsibility scale and should be strongly considered for any future studies. Finally,

the fact that it was not possible to control the demographic characteristics of participants

(i.e., age, relationship to relative with addiction, income, and age of relative with

addiction) between participants in the treatment group and the control group, were also

limiting factors (see differences in demographic characteristics).

Conclusions and Recommendations

Despite the limitations of the current research, this study has offered an analysis

of the efficacy of brief family-based treatment in changing family members’ attitudes

toward people in general with addiction and family members’ attitudes toward a specific

relative with addiction. Family members’ responses to both questionnaires revealed no

significant impact on the efficacy of attending one brief family-based treatment in

changing family members’ attitudes toward people with addiction and attitudes toward a

specific relative with addiction after a brief family-based treatment session. The most

likely reason for this was due to several limitations (i.e., small sample size, short

treatment time, lack of control of demographic characteristics, and instrument

discrepancy). Despite the results, however, some significance was noted. Therefore,

more research into all aspects of brief family-based treatment should be explored so that

interventions can be studied for more effectiveness. For example, based on these

findings, implications for future research may include, (a) comparing results to shorter vs.

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longer treatment sessions; (b) manualizing the treatment protocol and describing

precisely what the session will entail; (c) watching for selection bias by recruiting from

one site and randomly selecting participants, which will also ensure a more homogenous

sample; (d) sending out a descriptive flier in advance to ensure that participants are fully

aware of the study so that disagreements will not arise during the treatment session; (e)

running an analysis of the relationships between demographics and results and how they

are related to each of the scales to help identify why some participants’ answers are more

positive, and some are more negative; and (f) developing a more effective instrument that

focuses specifically on attitudes of family member’s toward people in general with

addiction and a specific relative with addiction.

101

APPENDIX A-1

RECRUITMENT FLYER FOR PCJCC (1 of 1)

PROJECT TITLE: THE EFFICACY OF FAMILY-BASED TREATMENT

Dear Pima County Juvenile Court Center Family Member:

You are being asked to participate in a valuable study conducted by Teresa Kolodny, Ph.D.

Candidate and the Primary Investigator (PI) for a study at the University of Arizona’s College of

Education Department of Special Education, Rehabilitation, and School Psychology.

The purpose of the study is to examine family member’s perceptions of addiction and

perceptions of a relative with addiction pre- and post- Family-Based Treatment (FBT). To

achieve results, two pre- and post-test questionnaires have been developed to evaluate (1)

perceptions of addiction and (2) perceptions of a relative with addiction. Both surveys will be

administered to family members by Teresa. By comparing the pre-test questionnaires with the

post-test questionnaires, Teresa will be able to evaluate whether family member’s perceptions of

addiction and family member’s perceptions of a relative with addiction have changed. Please

understand that you are under no obligation to participate in this study and are free to withdraw at

any time without causing bad feelings or affecting your participation or your relative’s

participation at Pima County Juvenile Court Center.

Thank you very much for volunteering; your participation is greatly appreciated.

Sincerely,

Teresa Kolodny, Ph.D. Candidate

102

APPENDIX A-1a

SUBJECT INFORMED CONSENT FORM FOR PCJCC

AUTHORIZATION

Before giving my consent by signing this form, the methods, inconveniences, risks, and

benefits have been explained to me and my questions have been answered. I may ask

questions at any time and I am free to withdraw from the project at any time without

causing bad feelings or affecting my participation or my relative’s participation at Pima

County Juvenile Court Center. If new information develops during the course of this

study which may affect my willingness to continue in this research project, it will be

given to me as it becomes available. This consent form will be filed in an area designated

by the Human Subjects Committee with access restricted by the Principal Investigator,

Teresa Kolodny, Ph.D. Candidate at (520) 370-9032 or authorized representative of the

University of Arizona’s College of Education Department of Special Education,

Rehabilitation and School Psychology. I do not give up any of my rights by signing this

form. A copy of this signed consent form will be given to me.

___________________________________ ______________________________

Subject’s Name (printed) Signature

____________________________________

Date

103

APPENDIX A-2

RECRUITMENT FLYER FOR KARE

PROJECT TITLE: THE EFFICACY OF FAMILY-BASED TREATMENT

Dear KARE Center Family Member:

You are being asked to participate in a valuable study conducted by Teresa Kolodny, Ph.D.

Candidate and the Primary Investigator (PI) for a study at the University of Arizona’s College of

Education Department of Special Education, Rehabilitation, and School Psychology.

The purpose of the study is to examine family member’s perceptions toward addiction and

family member’s perceptions toward a relative with addiction. To achieve results, two pre- and

post- test questionnaires have been developed to evaluate (1) perceptions toward addiction and

(2) perceptions toward a relative with addiction. Both questionnaires will be administered to

family members by Teresa. By comparing the pre-test questionnaires with the post-test

questionnaires, Teresa will be able to evaluate whether family member’s perceptions toward

addiction and family member’s perceptions toward a relative with addiction have changed.

Please understand that you are under no obligation to participate in this study and are free to

withdraw at any time without causing bad feelings or affecting your participation or your

relative’s participation at the KARE Center.

Thank you very much for volunteering; your participation is greatly appreciated.

Sincerely,

Teresa Kolodny, Ph.D. Candidate

104

APPENDIX A-2a

SUBJECT INFORMED CONSENT FORM FOR KARE

AUTHORIZATION

Before giving my consent by signing this form, the methods, inconveniences, risks, and

benefits have been explained to me and my questions have been answered. I may ask

questions at any time and I am free to withdraw from the project at any time without

causing bad feelings or affecting my participation or my relative’s participation at the

KARE Center. If new information develops during the course of this study which may

affect either my willingness to continue in this research project, it will be given to me as

it becomes available. This consent form will be filed in an area designated by the Human

Subjects Committee with access restricted by the Principal Investigator, Teresa Kolodny,

Ph.D. Candidate at (520) 370-9032 or authorized representative of the University of

Arizona’s College of Education Department of Special Education, Rehabilitation and

School Psychology. I do not give up any of my rights by signing this form. A copy of this

signed consent form will be given to me.

___________________________________

Subject’s Name (printed)

___________________________________ _______________________________

Signature Date

105

APPENDIX B-1 ATTITUDE MEASUREMENT: BRIEF SCALES (ORIGINAL)

ATTTITUDES TOWARD ADDICTION

These scales should be used as part of the training course evaluation. It is recommended that participants complete the scales prior to training and also on completion of training. Comparison of the pre and post training score will indicate the extent to which attitude change has been achieved. The wording of the scales can be adapted in order to measure attitudes toward specific drugs (e.g. heroin, methamphetamines, alcohol, etc…)

1. To what extent are adverse life circumstances likely to be responsible for a person’s

problematic drug use? 1 2 3 4 5

Not responsible at all moderately responsible very responsible 2. To what extent is an individual personally responsible for their problematic drug use?

1 2 3 4 5 Not responsible at all moderately responsible very responsible

3. To what extent do you feel angry towards people using drugs?

1 2 3 4 5 Not angry at all moderately angry very angry

4. To what extent do you feel disappointed towards people using drugs?

1 2 3 4 5 Not at all disappointed moderately disappointed very disappointed

5. To what extent do you feel sympathetic towards people using drugs?

1 2 3 4 5 Not at all sympathetic moderately sympathetic very sympathetic

6. To what extent do you feel concerned towards people using drugs?

1 2 3 4 5 Not at all concerned moderately concerned very concerned

7. To what extent do people who use drugs deserve the same level of medical care as

people who don’t use drugs? 1 2 3 4 5

Not at all deserving moderately deserving definitely deserving

8. To what extent are people who use drugs entitled to the same level of medical care as people who don’t use drugs? 1 2 3 4 5 Not at all entitled moderately entitled definitely entitled

106

APPENDIX B-2 ATTITUDE MEASUREMENT: BRIEF SCALES (REVISED)

Pre-test____ Post-test____ CG____ TX____ Participant ID____________

GENERAL PERCEPTIONS TOWARD PEOPLE WITH ADDICTION

Please circle the number that most closely fits your general perceptions toward addiction.

1. To what extent are the challenges in ones life likely to be responsible for his or her difficult substance abuse?

1 2 3 4 5 Not responsible at all moderately responsible very responsible

2. To what extent do you feel an individual is personally responsible for his or her

problems with substance abuse? 1 2 3 4 5 Not responsible at all moderately responsible very responsible 3. Do you feel angry toward other people’s substance abuse? 1 2 3 4 5 Not angry at all moderately angry very angry

4. Do you feel disappointed toward other people’s substance abuse?

1 2 3 4 5 Not at all disappointed moderately disappointed very disappointed

5. How sympathetic do you feel toward other people with substance abuse problems? 1 2 3 4 5 Not at all sympathetic moderately sympathetic very sympathetic

6. How concerned are you toward other people’s substance abuse?

1 2 3 4 5 Not at all concerned moderately concerned very concerned

7. Do you feel that people who use drugs deserve the same level of medical care as

people who don’t use drugs? 1 2 3 4 5 Not at all deserving moderately deserving definitely deserving

8. Do you feel that people who use drugs are entitled to the same level of medical

care as people who don’t use drugs? 1 2 3 4 5 Not at all entitled moderately entitled definitely entitled

107

APPENDIX B-3 ATTITUDE MEASUREMENT: BRIEF SCALES (REVISED)

Pre-test____ Post-test____ CG___ TX___ Participant ID____________

GENERAL PERCEPTIONS TOWARD A SPECIFIC RELATIVE WITH ADDICTION Please circle the number that most closely fits your general perceptions toward a specific relative with addiction.

1. To what extent are the challenges in your relative’s life likely to be responsible for his or her difficult substance abuse?

1 2 3 4 5 Not responsible at all moderately responsible very responsible

2. To what extent do you feel your relative is personally responsible for his or her problems with substance abuse?

1 2 3 4 5 Not responsible at all moderately responsible very responsible

3. Do you feel angry toward your specific relative’s substance abuse?

1 2 3 4 5 Not angry at all moderately angry very angry

4. Do you feel disappointed toward your specific relative’s substance abuse?

1 2 3 4 5 Not at all disappointed moderately disappointed very disappointed

5. How sympathetic do you feel toward your specific relative with substance abuse?

1 2 3 4 5 Not at all sympathetic moderately sympathetic very sympathetic

6. How concerned are you toward your specific relative who has substance abuse issues?

1 2 3 4 5 Not at all concerned moderately concerned very concerned

7. Do you feel that your specific relative who uses drugs deserves the same level of medical care as people who don’t use drugs?

1 2 3 4 5 Not at all deserving moderately deserving definitely deserving 8. Do you feel your relative who uses drugs is entitled to the same level of medical care as people who don’t use drugs? 1 2 3 4 5 Not at all entitled moderately entitled definitely entitled

108

APPENDIX B-4 DEMOGRAPHIC QUESTIONNAIRE

Pre-test____ Post-test____ CG____ TX____ Participant ID___________ Please circle or write in the best answer to each question that best fits who you are.

1. What is your gender? Female Male

2. What is the age of your relative with addiction? _______

3. What is your relationship to your specific relative with addiction? I am his or her: Mother Son Father Daughter Stepmother Spouse Stepfather Brother Legal Guardian Sister Parent/significant other Nephew Foster Parent Niece Grandmother Cousin Grandfather Step-sibling Aunt Uncle 4. Please circle the best answer: My relative with addiction is a Male Female 5. Please circle the number that best fits your annual income. $0-$9,999 $10,000 - $19,999 $20,000 - $39,000 $40,000 - $59,000 $60,000 – $79,000 $80,000 - $ 99,000 $100,000 and above 6. Please circle all of the categories that apply. I am: Caucasian Hispanic Asian African-American Native-American Other _________ 7. Please circle the answer that best fits. My age is: 18 – 28 29 – 38 39 – 49 50 – 64 65 (+)

109

APPENDIX C

ATTITUDES MEASUREMENT: BRIEF SCALES (SCORING)

The AMBS was designed by The National Center for Education and Training on

Addiction (NCETA) for use by educators and trainers who address alcohol and substance

abuse concerns in their training programs (NCETA, 2006). For several years, NCETA

staff has worked on numerous projects relating to addiction. The most recent project was

in Adelaide in September of 2006 and involved research to examine the impact of

attitudes of healthcare providers toward patients with addiction.

One of the materials included in the project was the AMBS, a short survey that

measures attitudes of healthcare workers towards individuals who use heroin,

amphetamines, tobacco, and alcohol (see Appendix B-1). Participants completed the

AMBS prior to training and also at the completion of training. Comparison of the pre-

test and post-test results indicated whether, or to what extent there was a change in

attitudes of the healthcare worker towards people with addiction.

Scoring Instructions:

The AMBS is a short 8-item scale that assesses the attitudes of healthcare workers toward

people who use drugs (NCETA, 2006). Trainees complete a pre-test questionnaire before

training and a post-test questionnaire after training. Comparison of pre and post training

scores assess the extent of attitude changes. Questions one and two on the pre/post-test

entail responsibility. The responsibility scale measures how much a trainee/healthcare

110

APPENDIX C (continued)

worker feels that a person with addiction is responsible for his or her addiction.

Responses range from 1 to 5, with 5 being the most responsible for his or her addiction.

The sum of the two questions is averaged after the first question is reverse-scored.

Questions three and four assess how negative (i.e., angry or disappointed) the trainee is

toward the person with addiction. Responses on the Negative scale range from 1 to 5,

with 5 being very angry or very disappointed. The sum of the two questions is then

averaged to determine a score. Questions five and six measures to what degree a trainee

feels positive regard (i.e., concern or sympathy) toward a person with addiction.

Responses on the Positive scale range from 1 to 5, with 5 being very concerned or

sympathetic. The sum of the two questions on the Positive scale is then averaged to

determine a score. Question seven has to do with deservingness. The Deservingness

scale measures whether a trainee believes that a person with addiction is worthy of

receiving medical treatment. Responses on the Deservingness scale range from 1 to 5,

with 5 stating that the person is very deserving. Because there is only one question,

there is no need to average the score. Question eight has to do with entitlement. The

Entitlement scale assesses whether a trainee believes that a person with addiction should

be permitted medical treatment. Responses on the Entitlement scale range from 1 to 5,

with 5 asserting that the person with addiction is definitely entitled to medical treatment.

Similar to question seven, because there is only one question on the Entitlement scale,

there is no need to average the score (Freeman, 2008).

111

APPENDIX D

MAC TREATMENT READINESS PROGRAMMING (DESCRIPTION) A detailed description of the MAC program as described by this observer: Treatment Readiness Program Components:

1. Daily treatment readiness group sessions (youth) 2. Individual treatment and readiness sessions (minimum of one session) 3. Multi-family educational session (Brief Family-based) 4. Weekly family treatment readiness session 5. Detention programming including Step Up, CBT skill building, and prosocial recreation (youth) 6. Case management for parent and community engagement transition

Youth in the MAC living unit are expected to participate in daily group and at least one individual readiness session with a master’s level trained, licensed substance abuse counselor. Family involvement is highly encouraged. A weekly multi-family educational session is offered each Saturday afternoon and brief family based sessions are offered evenings and weekends to best meet the needs of family schedules. MAC programming is focused on preparing youth and their families to engage in their outpatient substance abuse treatment programs and on-going sobriety. Treatment Readiness Groups: Treatment readiness group sessions for youth focus on motivational enhancement, cognitive behavioral skill building, relapse planning, and decision making. Youth attend daily groups. A positive peer culture is encouraged in the MAC living unit. Individual Treatment Readiness: Individual sessions for youth focus on motivational enhancement, cognitive behavioral skill building, and an assessment of the obstacles which are interfering with successful engagement in outpatient substance abuse and treatment. Multi-family Treatment Readiness Education Classes: Multi-family education classes (i.e., Brief Family-based treatment) focus on increasing knowledge about addiction, the importance of parental supervision and support of their youth with substance abuse in outpatient treatment, perceptions about addiction and increasing the knowledge on the effects of substance abuse on youth and families, and offering community resources for ongoing support of families and youth. Family Treatment Readiness: Family sessions will be encouraged and will focus on increasing parental supervision and support for their youth with substance abuse while in outpatient treatment and improving family cohesion and communication skills. Detention Programming: Daily detention programming includes Step Up, cognitive behavioral skill building, and guided prosocial recreation (i.e., sports, arts, writing, reading). Case Management: Case management will focus on engaging families, community transitional planning, and follow-up services.

112

APPENDIX D (continued)

Mental Health and Medical Service: All additional mental health and medical services will be provided by University Physicians Healthcare, Inc. (UPH). MAC Treatment Readiness Plan Youth Name: _____________________________________________________ JC#: _____________________________________________________________ DOB: ____________________________________________________________ Treatment Readiness Plan: Presenting Problem: Substance abuse and treatment readiness Objectives/Goals: 1. Increase youth readiness to engage in community-based substance abuse treatment. 2. Increase substance refusals. 3. Increase parent involvement in supporting/supervising youth in treatment (Brief Family-based). Interventions: 1. Daily educational group sessions using motivational enhancement, cognitive behavioral skills, relapse planning, and decision making. 2. Minimum of one individual session using the above skills. 3. Minimum one multi-family education session for parent/legal guardian to increase knowledge about addiction and skills on support and supervision of youth and to increase knowledge of effects of substance abuse on families and youth. 4. Minimum of one family readiness session to increase parental support and

supervision. Additional Focus: Changing family’s perceptions about addiction and youth with addiction by increasing knowledge and understanding about the addiction process, helping youth admit he/she has a problem, discussing misconceptions about acceptable use, developing cohesive/clear family relationships through contracting and setting rules, discussing friendships that are healthy and lead to sobriety, encouraging youth to engage in natural highs, work/volunteer opportunities, and getting serious about completing a GED or high school education. How to Help Yourself: 1. Look at your perceptions toward addiction and your teen with addiction, are they healthy and realistic, are they negative or positive? 2. Examine the example that you are setting for your teen? What are your opinions about substance abuse/addiction?

3. Work in concert with your other family members to show unity and understanding of substance abuse problems to your youth.

4. Plan to attend an Alanon meeting to learn about your own awareness about addiction. 5. Accompany your teen to an AA meeting to discuss views about addiction.

113

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