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Running head: QUALITY OF LIFE IN LATINOS POST TREATMENT 1

Perceived Quality of Life: Adult Latino Males Post Treatment

A Literature Review

Presented to

The Faculty of the Adler Graduate School

____________________

In Partial Fulfillment of the Requirement for

the Degree of Master of Arts in

Adlerian Counseling and Psychotherapy

____________________

By

Ana Paulina Steffer, MA, LADC

____________________

Chair: Ruth Buelow, DMFT

Reader: Rachelle Reinisch, DMFT

____________________

December, 2017

QUALITY OF LIFE IN LATINOS POST TREATMENT 2


Copyright © 2017

Ana Paulina Steffer

All rights reserved


Abstract

It is widely understood that when people struggle with substance use, it has an impact on many

aspects of life. Many clients receive an ultimatum from family or are mandated by the justice

system to attend treatment. As a result, when people begin treatment for a substance use

disorder, the perception is an automatic diminished quality of life (QOL). The purpose of this

work is to explore the application of a culturally sensitive chemical dependency (CD) treatment

program in relation to the efficacy of program outcomes. The QOL perceptions in adult Latino

clients is explored. Archival survey data is examined to determine QOL perceptions after adult

Latino clients successfully completed a culturally inclusive CD outpatient treatment program in

their native language at Pangea Care in St. Paul, Minnesota. In addition to QOL, an Adlerian

overview will be applied to CD treatment and QOL perceptions. Survey data findings and

recommendations for future research are presented.

Keywords: substance use treatment, quality of life, Individual Psychology, Latino

treatment programs


Acknowledgement

I want to thank and acknowledge my chair on this project, Ruth Buelow, DMFT and my reader,

Rachelle Reinisch, DMFT, who not only supported me with this project, but were also great

models during my years at Adler Graduate School. I want to thank my supervisor at Pangea

Care, Melanie Heu, LICSW, LADC, who was an advocate for this research study and the use of

archival data at Pangea Care.


Dedication

I dedicate this study to my parents and spouse, who supported me in many different ways during

my graduate program at Adler Graduate School and in my personal journey.


Table of Contents

Quality of Life Research ................................................................................................................. 9

Chemical Dependency Treatment Methods .................................................................................. 10

Quality of Life and the Impact on Chemical Dependency Treatment .......................................... 11

Quality of Life and Substance Use ............................................................................................ 13

Motivation, Recovery, and Quality of Life ............................................................................... 15

Substance Use and Latino Populations in the United States ......................................................... 16

Immigration, Multicultural, and Historical Influences ................................................................. 19

Culture within a Population....................................................................................................... 21

Adlerian Foundations and Addiction ............................................................................................ 25

Encouragement .......................................................................................................................... 26

Adlerian Individual Psychology and Addiction ........................................................................ 27

Adlerian Life Tasks ................................................................................................................... 28

The love task. ......................................................................................................................... 28

The work task ........................................................................................................................ 29

The community or social task ................................................................................................ 29

Summary ....................................................................................................................................... 29

Method .......................................................................................................................................... 30

Data ............................................................................................................................................... 30

Results ........................................................................................................................................... 32

Discussion ..................................................................................................................................... 34

Conclusion .................................................................................................................................... 36

References ..................................................................................................................................... 37



It is widely reported and understood that substance use in the US is reaching epidemic

proportions (Lyons, 2016). Lyons stated substance abuse or chemical dependency (CD)

problems affect many areas in a person’s life, including perceptions regarding one’s overall

quality of life (QOL). For some people, perceived QOL often depends on a momentary value

system. For example, an individual’s hierarchy of needs might change depending on what is

valued at the moment rather than grounded in longer term values. If substance use assumes the

top position in that momentary hierarchy of needs, then the individual’s life might suffer

undesirable consequences (Lyons, 2016); however, when an individual seeks treatment, there is

often a realization that this momentary hierarchy might be skewed. Prior to presenting for

treatment, the client may have experienced undesirable consequences such as: interpersonal

problems, involvement with the criminal justice system, job problems, and receive family or

relationship ultimatums. In other instances, the client may have been court ordered into

treatment. Nonetheless, by the time an individual reaches treatment, the perception of his or her

QOL is most often low (Lincoln et al., 2006; Taspinar, Taspinar, Aksoy & Afsar, 2014; Xiao, Wu,

Luo, & Wei, 2010).

One of the aims of substance use treatment is to improve QOL by encouraging the client

to rethink previous behavior and values hierarchy (Laudet, 2011). Moreover, when a client

successfully completes a treatment program, that person should have gained healthy coping skills

to manage life struggles. Laudet suggested the individual should no longer need to lean on

substance use as an ineffective task management tool. Through detoxification, encouragement,

and learning healthy coping skills in a holistic manner, perceptions of QOL will improve as a

person achieves positive changes in the impacted areas of his or her life (Laudet, 2011).


The focus of this research project is to study how adult male Latino clients perceive their QOL at

admission to, and successful discharge from, a CD treatment program. Through this literature

review and research project, QOL will be examined using archival data gathered over a two-year

period on Latino male clients, 18 years of age or greater, after successful completion of a CD

outpatient treatment program.

The literature reviewed for this project confirmed that there has been little investigation

on Latino populations, and limited research existed that examined the relationship between the

Latino culture, chemical dependency treatment, and QOL; however, within the reviewed studies

there was a correlation between an improvement in QOL after treating an addiction, especially

with individuals that had a substance use disorder and a co-occurring mental health disorder

(Colpaert, DeMaeyer, Broekaert, & Vanderplasschen, 2013).

Literature reviewed for this project revealed that CD treatment provided in the client’s

native language, and from a culturally sensitive framework, increased positive results regarding

perceived QOL (De Maeyer et al. 2011; Du Plessis, 2012; Guerrero, Marsh, Khachikian, Amaro,

Vega, 2013). Moreover, research suggests that addiction in immigrant populations may be the

direct result of poor acculturation, and treatment models must include culturally sensitive

treatment interventions. Immigrants adapting to US culture are affected by numerous factors,

which could increase the possibility of substance use or mental health disorders in immigrant

populations (Guerrero et al., 2013).

Due to the limited information specific to the Latino population and culturally

appropriate CD treatment, it is hoped the findings of this study can help clinicians understand the

importance of cultural considerations when providing CD and mental health treatment to Latino

males. When cultural considerations are made, including treatment offered in the native


language of the client, it is speculated that treatment outcomes will have a positive impact on the

client’s perception of QOL (Laudet, 2011). It is further hoped that this research project could

help Latino males receiving treatment and increase awareness of the importance of culturally-

sensitive treatment services provided in the client’s native language. Additionally, consideration

of cultural values could potentially prevent relapse and decrease the recidivism rate (De Maeyer

et al., 2011; Laudet, 2011).

An overview regarding QOL research, current substance use treatment approaches, a

brief overview of Alfred Adler’s Individual Psychology as it relates to substance use treatment,

and research findings regarding QOL perceptions of adult Latino males after successful

completion of substance use treatment will be presented in this paper. Also, a summary of

potential interventions and outcomes is provided in this project.

Quality of Life Research

Quality of Life (QOL) research is a global, multidisciplinary movement dedicated to the

study of the impact of QOL perceptions on health, mental health, and other fields, such as

economics (Barcaccia et al., 2013; Nussbaum & Sen, 1993; Oppezzo et al., 2016). Barcaccia et

al. stated QOL is subjective and multidimensional and encompasses positive and negative

features of an individual’s life. Quality of life is a dynamic phenomenon that responds to life

events such as a job loss, illness, or other upheaval that can quickly and dramatically change

one's definition of QOL. Quality of life is difficult to measure, but in matters of life and death,

physicians consider a patient’s perception of QOL when they make medical treatment decisions

(Barcaccia et al., 2013).

While QOL has been studied for over 20 years, a clear definition of QOL does not exist

(Barcaccia et al., 2013). In a meta-analytical review of the research, there are several common


factors among the definitions of QOL. Those common factors include: subjective satisfaction of

life, multidimensional factors of life circumstances, cultural factors, the absence of disease, the

factual interpretation of the situation, and the level of acceptance. The subjective nature of QOL

is foundational to this research, and a holistic mind-body approach is necessary to achieve a

greater understanding of the power of QOL to influence human behavior (Barcaccia et al., 2013;

Nussbaum & Sen, 1993).

Chemical Dependency Treatment Methods

Substance or chemical use, including the consumption of alcohol, is influenced by social,

physiological, and psychological factors (Patrick, Wightman, Schoeni & Schulenberg, 2012). It

is widely understood that overuse of any substance over time can result in addiction. Addiction

is routinely assessed and often results in chemical dependency (CD) treatment in order to achieve

recovery. While differing definitions of recovery exist, Gerstein and Lewin (1990) described CD

recovery as an individual’s ability to interact in a healthy manner within the community whether

or not he or she achieves full abstinence. The main goals of CD treatment include: substance use

reduction, psychological support, crime reduction, vocational and educational support, rebuilding

employment, restoring health, and improving family support (Gerstein & Lewin, 1990).

It is commonly understood that individuals enter into CD treatment because of family

pressure or as mandated by probation or parole. The purpose of mandatory participation in a CD

treatment program is to avoid additional negative circumstances related to chemical use,

potential criminal activity, or to avoid incarceration (Rittner & Dozier, 2000). Mandated

treatment often results in client reluctance or ambivalence to treatment, which may exacerbate

the difficulty some individuals experience in demanding treatment work. Rittner and Dozier

stated reduced participation in CD treatment leads to increased ineffectiveness of treatment and


other factors such as: poor implementation of treatment or methods, complicated environments,

and bad candidates for treatment.

Gerstein and Lewin (1990) identified five primary levels of CD treatment: detoxification,

CD inpatient programs, therapeutic communities, methadone maintenance, and outpatient

treatment including 12-step programs. Additionally, Gerstein and Lewin found program success

rates varied depending on contributing factors such as:

• services offered in a timely and appropriate manner,

• improving the level of services,

• early intervention,

• improved services for criminal justice populations,

• detoxification fully covered by health care plans, and

• focus on the treatment performance, care, and standards of admission to create

appropriate coverage.

As part of this increased focus on program success, the need to provide culturally

sensitive services must be addressed (Steinka-Fry, Tanner-Smith, Dakof, & Henderson, 2017;

Sue & Sue, 2012). Programs that include a focus on cultural sensitivity and QOL factors

appeared to have greater success rates than programs that did not specifically focus on all factors

as components of treatment (Steinka-Fry et al., 2017).

Quality of Life and the Impact on Chemical Dependency Treatment

As stated previously, it is difficult to measure quality of life due to the subjective

experiences from person to person (Barcaccia et al., 2013). Furthermore, circumstantial factors

have an impact on QOL suggesting a perceived state rather than a matter of reality. For instance,


an individual’s perception of good or bad may be quite different for someone else; therefore, the

impact of subjective factors in regard to QOL must be explored.

As stated in the overview of current chemical dependency treatment, when someone

struggles with chemical use, this struggle has an impact on many areas of that person’s life,

especially when seeking treatment (Barcaccia et al., 2013; Laudet, 2011; Patrick et al., 2012).

Regardless of the reason for starting a treatment program, many individuals experience an

unsatisfying event or general perception of life (Laudet, 2011). For example, if an individual

willingly enters CD treatment, that individual is generally motivated to change because

something has gone wrong in an important area of his or her life (Steinka-Fry et al., 2017).

Similarly, if someone has been mandated to a treatment program, either because of an ultimatum

from a loved one, work, or criminal justice system, more than likely, that person is experiencing

dissatisfaction in one or more areas of life. As a result, these factors suggest that measuring

changes in quality of life after completing a chemical dependency program may be helpful. That

is, the person that received services would be the best judge regarding the success of the

program, the possibility for future relapse, and the prognosis for recidivism.

More recently, researchers have been interested in the impact of QOL factors as they

relate to substance use (Broekart et al., 2017; Colpaert, DeMaeyer, Broekart, &

Vanderplasschen, 2013). While the area of focus, the measures utilized, and the outcomes varied

in all research studies, researchers agreed limited research exists on the importance of

considering QOL and QOL factors such as general health, mental health, financial status,

relational status, and substance use in relation to QOL.


Quality of Life and Substance Use

Colpaert et al. (2013) focused on QOL as it related to co-occurring disorders in

residential treatment. Colpaert et al. applied a mixed methods approach to research and utilized

quantitative data collected from the European Addiction Severity Index (EuropASI), the Mini-

International Neuropsychiatric Interview, and the Assessment of Personality Disorders self-

report questionnaire. The quantitative research data was gathered through the use of surveys

intended to measure perceived QOL. Colpaert et al. designed the qualitative portion of the

research with the intent to examine the difficulties experienced by each individual in treatment as

it related to perceived QOL. Colpaert et al. utilized focus groups to identify general themes

regarding difficulties of CD treatment and specific interviews to highlight the individual

differences of each participant. Colpaert et al. stated when study participants struggled with

substance abuse concerns, they had a tendency to exhibit difficulties in personal life including

health, occupation, mental health, and relationships.

Colpaert et al. (2013) reviewed prior research on CD treatment and QOL and noticed

little available research to establish effective treatment for dual substance use (i.e., both alcohol

and illicit drug use). Colpaert et al. noticed greater improvement in QOL with participants who

abused both alcohol and illicit drugs compared to participants who abused alcohol. In addition,

when participants abused only alcohol, they were less inclined to fully participate in treatment

activities. Colpaert et al. reported a diminished perception of QOL related to the severity of use,

comorbidity with other substance use, and dual diagnoses associated with mental health illness.

For example, a reduced QOL perception was evident when people suffered from CD concerns

along with a comorbid psychiatric disorder when compared to those that struggled with an

addiction diagnosis. In addition, the severity of the addiction was a determining factor for a


reduced perceived QOL; however, the choice of substance or polysubstance abuse was not a

determining factor for a lower perceived QOL (Colpaert et al., 2013).

Previous to Colpaert et al.’s (2013) findings, De Maeyer et al. (2011) conducted

qualitative research regarding methadone dependent individuals and QOL. Through face-to-face

interviews, De Maeyer et al. aimed to examine individuals diagnosed with opioid dependence

who participated in methadone treatment during a five-year trial. De Maeyer et al. utilized the

following survey tools with 159 participants in an interview format to measure QOL: Lancashire

Quality of Life Profile, the Brief Symptom Inventory, and the Addiction Severity Index. This

research was conducted in Belgium between 1997-2002 (De Maeyer et al., 2011).

The goal of De Maeyer et al.’s (2011) research was to explore CD treatment and QOL

from a qualitative perspective in order to gather the consumer’s point a view. De Maeyer et al.

pointed out that the majority of research prior to this study was quantitative in nature. Through

qualitative measurements of QOL and subjective interviews, the researchers identified a strong

correlation between health, mental health, and the effect of perceived QOL in study participants.

De Maeyer et al. (2011) believed that health and mental health should be included when

measuring QOL; however, overall health and mental health should not be the only determining

factors. Furthermore, the aim was to attend to the significant length of time after treatment to

assess maintenance and growth of QOL as it appears that QOL improvements are more

noticeable after maintenance and the passing of time (De Maeyer et al., 2011).

Five to 10 years after the start of methadone treatment, De Maeyer et al. (2011) observed

higher QOL scores than they did immediately post treatment. De Maeyer et al. noted high QOL

scores in participants who mastered the following areas of life: positive self-esteem, safety, and

satisfactory relationship quality. In addition, low QOL satisfaction was reported in regard to


finances and rated low in participants who had not mastered QOL in the other areas. Other

significant factors that contributed to the low QOL group included: a poor living situation,

negative self-esteem, and lack of general fulfillment. Participants with the inability to change a

living situation demonstrated higher psychological distress. On the other hand, when

participants had structure in daily life and at least one supportive friend, it had a positive impact

on QOL (De Maeyer et al., 2011).

Motivation, Recovery, and Quality of Life

Chen (2010) grappled with the idea of motivation and suffering in recovery from addition

and focused on the meaning of suffering and, specifically, how suffering plays a role in chemical

dependency recovery. Chen explored the meaning of suffering and differing theories including:

Buddhism, existentialism, and 12-step recovery programs. Chen’s research highlighted how

people find recovery and meaning in life through surrender after coping with pain through the

use of chemicals.

Chen (2010) explored how many different theorists defined suffering and the basis of

suffering. For example, Schopenhauer (1958) described suffering as the physical reaction to

distress. Schopenhauer (1958) suggested suffering was an emotional reaction to distress, and

Williams (1969) stated suffering was part of a creative process. According to Chen (2010), Van

Hooft stated suffering was similar to the agony of unmet goals.

Chen (2010) stressed the controversial nature of suffering as it relates spirituality. For

instance, Chen found that suffering was usually observed in terms of meaning, in relationship to

a Higher Power, and through the lens of one’s sense of values. Chen stated the Buddhists

perceived suffering as a relationship between the meaning of life and a mystical experience. In

terms of attachment and the craving of substances, Buddhists explained how through


responsibility and choice a person is able to surrender to pain to seek motivation for treatment

because it was the pain that led the person to the consumption of substances. In existential

philosophy, suffering relates to the meaning of life (Chen, 2010). Chen explained that Nietzsche

and Frankl defined suffering as means for change; however, despair was unnecessary suffering,

and this type of suffering has no purpose in life.

The 12-step program philosophy resonates with existential and Buddhist theories as both

have a similar perspective on suffering and the relationship of suffering with the meaning of life

(Chen, 2010). Chen described substance use as a temporary means to cope with suffering, which

later increases suffering by secondary consequences and leads to motivation for change and

treatment.

Colpaert et al. (2013), De Maeyer et al. (2011), and Chen (2010) highlighted the power of

surrendering, even for mandated clients, as part of a recovery program. This research recognized

that the beginning of CD treatment can cause initial pain, but in the long run, working through

difficult issues affecting a person’s life and substance use (or vice versa) can bring satisfaction

after time. Chemical dependency treatment can affect people in different ways, especially if a

person does not feel understood, if treatment interventions are not sensitive to culture, or if the

person is not ready to enter CD treatment.

Substance Use and Latino Populations in the United States

The Latino population has grown over the last two decades, with an 11.7% of the U.S.

population being Latino (Cervantes & Felix-Ortiz, 2004). Substance use among the Latino

population is common (Alvarez, Jason, Olson, Ferrari, & Davis, 2007). According to Alvarez et

al. (2007), “Substance abuse prevalence rates for the Latino populations generally mirror those

of the general U.S. population” (p. 115). Treatment outcomes, however, for the Latino


population are poorer than the general population. Some of the primary reasons for reduced

outcomes include: acculturation factors, immigration stressors, cultural acceptance of alcohol

use, accessibility, gender, and socioeconomic factors (Alvarez et al., 2007). Alvarez et al. found

it is harder for Latinos to seek treatment in the US because of additional factors such as: the lack

of medical accessibility, the lack of culturally sensitive services, and the lack of services

available in Spanish.

Despite the growing body of research in substance use treatment for the general

population, limited research exists regarding Latino substance use in the US (Cervantes & Felix-

Ortiz, 2004; Vega & Sribney, 2005). According to Substance Abuse and Mental Health Services

Administration (SAMHSA) data from 2015, a total of 386,000 adults (i.e., 18 years or older)

received treatment for substance use in the U.S. (SAMHSA, 2017). In addition, over 315,000

individuals seeking CD treatment were males, and of those 151,000 were of the Hispanic or

Latino population (SAMHSA, 2017).

Guerrero et al. (2013) conducted a literature review analyzing articles that discussed

substance use and treatment within Latino populations in the U.S. In 2012, Guerrero et al. stated

that according to the census bureau data, 16.8% of the U.S. population identified as Latino. This

percentage was further stratified as follows: 64% Mexican, 9% Puerto Rican, 7.6% Central

American, 5.5% South American, 3.4% Cuban, 2.8% from the Dominican Republic, and 7.7%

from other Latino countries. Guerrero et al. stated by 2010, Latinos in substance use treatment

reached 12% of the total population entering substance use treatment.

Guerrero et al. (2013) further identified that acculturation, sex roles, age of migration,

rates of unemployment, and education deficits were among the largest contributing factors to

increasing substance use rates with Latino males. Guerrero et al. identified disadvantages for


Latinos when attempting to access treatment. For example, differences in social services and

human capital, involvement in the criminal justice system at a younger age, lack of cultural

sensitivity, and language barriers.

Guerrero et al. (2013) established that co-occurring diagnoses and treatment within

Latino populations is less likely than with White populations. For instance, factors contributing

to reduced likelihood of co-occurring treatment for Latino populations include: lack of medical

insurance, lack of cultural awareness, lack of medical accessibility, lack of treatment in native

language, and other economic factors. Guerrero et al. found other problems for Latino clients.

Latino clients do not receive the help they need or are exposed to expensive treatments that do

not completely satisfy the needs. In addition, transportation deficits, or difficulty, added an

additional barrier to treatment in the Latino populations. Some clients may not have access to

transportation, a driver’s license, or other transportation services in the area to enable the

commute to treatment (Guerrero et al., 2013).

As stated earlier, limited research exists regarding substance abuse treatment and the

Latino populations; however, it is believed that evidence-based treatment, such as motivational

interviewing is helpful for the Latino populations. Motivational interviewing is helpful because

it is easily tailored to the specific needs of the client. Carroll et al. (2009) conducted a

randomized study and provided three motivational interviewing sessions and three sessions of

general counseling at a multisite treatment facility. Carroll et al. demonstrated the effectiveness

of the motivational interviewing treatment intervention in Spanish rather than simply the use of

motivational interviewing or other general counseling interventions. Carroll et al. stressed the

importance of language as a key factor in effective treatment for the Latino population.


Guerrero et al. (2013) proposed that modifying evidence-based programs to be culturally

competent programs would assist Latinos in meeting treatment goals. Guerrero et al. noticed that

the more acculturated clients received greater benefit from treatment. Guerrero et al. suggested

providing culturally competent programs created a more receptive response to treatment and

would, in fact, lead to improved treatment outcomes. Research evidence indicates that Latino

clients experience longer duration in treatment, as well as improved treatment completion rates,

when they are provided services in their own language (Guerrero et al., 2013). Moreover,

increased sensitivity to culture, and culturally appropriate aftercare options, led to reduced

recidivism rates.

Guerrero et al. (2013) noted it was hard to measure how many CD treatment programs

had been providing culturally sensitive and language based competencies because CD treatment

programs must report effectiveness rates to other regulatory bodies. Guerrero et al. reported

insufficient funding and the lack of completed research with Latino populations to compare

results. Furthermore, it was difficult to find a population willing and available for recruitment

and research to obtain adequate information (Guerrero et al., 2013).

Immigration, Multicultural, and Historical Influences

It is widely accepted that immigration is difficult for individuals and families and affects

individuals and families in various ways. Individuals and families must adapt to another place,

speak a different language, and settle into a country with cultural differences. Immigration and

migration lead to richness in diversity, but many individuals struggle with a sense of loss

(Bhugra & Becker, 2005). For example, leaving behind culture, values, customs, spiritual

expression, and support systems may leave many immigrant families feeling lost and alone. All

these factors make it extremely difficult to adapt, which could result in problematic behaviors.


These losses often have an impact on mental health functioning and an individual may try to self-

medicate through the use of substances.

Within the Latino/Hispanic culture, there are many different subgroups, which also affect

the individual’s relationships and perception of what it is like to live in the U.S. Acculturation is

the assimilation of the dominant culture, and enculturation is the retention of the native culture

(Alegría et al., 2007). Both acculturation and enculturation can coexist in an individual, which is

actually believed to promote healthier overall mental health, because these individuals can adapt

within the two cultures; however, Alegría et al. stated additional research is needed to determine

how these processes affect an individual. Frequently, studies focus on minor details like

language, which do not completely define acculturation and enculturation factors (Alegría et al.,

2007).

Alegría et al. (2007) believed that many aspects could influence successful acculturation

or enculturation factors, as well as the effect on psychiatric disorders. Alegría et al. stated the

age of migration or whether or not one was born in the U.S. influenced the level of individual

acculturation. Alegría et al. defined individuals that had an immigration age of younger than six

years old as “in-US-as-child” (IUSC), and people who came to the U.S. after age six are defined

as “later-arrival immigrants” (LAI). Depending on the group, cultural identity, family

relationships, or expectations may change and affect the individual. In addition to age of

migration, other influencing factors may contribute to mental health predisposition such as,

discrimination, living in an unsafe environment, and social status (Alegría et al., 2007). For

example, factors that affect social status include: country of origin, income, employment,

education, marital status, and perceived social status. These factors also influence substance use

(Alegría et al., 2007).


Alegría et al. (2007) conducted a study and focused on the prevalence of psychiatric

disorders among Latinos living in the U.S. The purpose of the study was to learn if family

relationships, age of immigration, immigration generation, contextual factors, social status,

immigration, and acculturation and enculturation factors had an influence on the acculturation

and enculturation process. Additionally, Alegría et al. hypothesized these factors influenced the

individual’s predisposition for mental health disorders.

Alegría et al. (2007) found an increase in mental health disorders when Latino individuals

arrived in the U.S. after age 25. The burden of immigration and family conflict appeared to

correlate strongly to increased psychopathology; however, there was no difference between LAI

and IUSC participants regarding the risk for anxiety disorders. Alegría et al. reported several

factors influenced a positive adaptation to U.S. culture and included: a positive perception of

social status, integration into profitable neighborhoods, and the maintenance of family harmony.

Culture Within a Population

Tibbets and Hemmens (2010) defined subculture as a cultural group with a defining set of

values and norms. Farley (1990) described subculture as “a set of cultural characteristics shared

among a group within a society that are distinct in some ways from the larger culture within

which the group exists” (p. 102). Birdseye (2013) stated some substance use theorists expressed

agreement with the subcultural theories because treating addiction specific to culture and

subculture allows the clinician to view substance use and treatment through a social lens.

According to Birdseye, viewing substance use through a social lens is invaluable, as it considers

all the social components that have an impact on substance use and influence substance use

treatment. In contrast, some theorists disagree that the consideration of culture and subculture

factors contribute to effectiveness because it reaches the limits of the subculture and it overlooks


the other components outside of the subculture. For example, Birdseye interviewed numerous

CD supervisors and concluded that the application of subculture theory was useful because

subcultural factors increase substance use.

Due to the influence of subculture on a person’s ability to seek treatment in the U.S., it is

important to understand subculture when considering how access to care affects Latinos. Lê

Cook and Alegría (2011), Sims (2005) and Adler, Mueller, and Laufer (2007) stated many

Latinos, as well as individuals in other subgroups, enter substance use treatment because of

criminal justice involvement. Lê Cook and Alegría (2011) reported the majority of people

committing crimes are doing so while under the influence of substances.

Lê Cook and Alegría (2011) explored disparities between minorities in the U.S. including

Black and Latino individuals seeking CD treatment after being involved in criminal justice. The

Institute of Medicine (IOM) provided a definition of racial-ethnic disparities and explained how

these differences arise from the legal and health care operational systems (Lê Cook & Alegría,

2011). These differences included discrimination, prejudice, and biases. Lê Cook and Alegría

suggested the definition excluded patient preferences and clinical appropriateness.

Lê Cook and Alegría (2011) studied individuals in CD treatment over a five-year period

in order to observe the growing disparities in these populations. Lê Cook and Alegría discovered

disparities in ethnicity-race, socioeconomic status, and criminal justice involvement. Results

indicated 70% of White, Black, and Latino individuals receiving treatment in the last year had

been involved in the criminal justice system; Latino and Black individuals were more likely to be

on supervised parole than Whites; and Latino and Black individuals were more likely to develop

substance use dependence, or alcohol dependence, than White individuals.


Lê Cook and Alegría (2011) stated Medicaid coverage was identified as a discrepancy

affecting Black and Latino populations; however, a college education, being uninsured, or

having employment were not identified as a disparity in treatment. Lê Cook and Alegría

concluded that socioeconomic status, criminal justice involvement, and ethnic-racial differences

are paramount when considering CD treatment disparities and should be considered in future

studies.

Previous to LeCook and Alegría (2011), Sims (2005) reported that 47% of inmates

consumed substances prior to arrest, and 75% of all prison inmates could be considered drug-

involved offenders. Sims data provided the strong support for the identification of substance use

as a precursor to involvement with the criminal justice system.

Adler et al. (2007) suggested addiction and criminology have a biopsychological

component and stated violence may be associated with substance use and crime. The American

Psychiatric Association (APA) recognized that substance use could be associated with criminal

behavior (APA, 2013). The New York Commission on Drugs and the Courts (2000) reported

treatment of substance use disorders is necessary to diminish crime. Recognizing the association

between substance use and criminal involvement, Birdseye (2013) noted the importance of a

holistic approach to the treatment of substance use and criminology. A holistic approach would

include the social, physical health, and psychological perspective (Birdseye, 2013).

Within the criminal justice population, Lê Cook and Alegría (2011) observed individuals

who are under the influence of a substance are more likely to commit a crime. For instance, as

many as 50% of federal prisoners admitted to being under the influence of mood-altering

substances when they committed a crime. In addition, 80% of state prisoners, and 70% of

federal prisoners, reported utilizing illegal substances. Lê Cook and Alegría stated that in 2003,


36% of CD treatment admissions were mandated by the criminal justice system as an expectation

of probation, parole, or a condition for employment.

Lê Cook and Alegría (2011) noticed that within these statistics racial minorities were

more likely to become involved in the criminal justice system because of the crimes they

committed; therefore, more likely to experience mandated CD treatment. Additionally, research

shows that individuals with lower socioeconomic status and without a high school education

have a greater tendency to enter CD treatment (Lê Cook & Alegría, 2011; Patrick et al., 2012).

Lê Cook and Alegría (2011) purported the increase in treatment presentation occurred because of

the lack of preventive information and the increased availability of the substances in the

environment.

The National Survey on Drug Use and Health (NSDUH) collected substance use

treatment data for a five-year period from 2005-2009 (Lê Cook & Alegría, 2011). The collected

data was representative of three populations and reported substance dependence within the last

year. The study included 18,565 White, 2,782 Black, and 3,812 Latino adults. Disparity

variables included (a) predisposing factors, such as demographic characteristics, (b) enabling

factors, such as income and health insurance, and (c) need factors, such as level of need and

severity of symptoms. Lê Cook and Alegría reported 70% of White, Black, and Latino

individuals receiving treatment had been involved in the criminal justice system. Latino and

Black individuals were more likely to be on supervised parole and diagnosed with substance and

alcohol use or dependence than White individuals (Lê Cook & Alegría, 2011). According to Lê

Cook and Alegría, Medicaid was an identified discrepancy that affected Black and Latino

populations. Black populations were more likely to receive public programs and to be insured by


public programs than White populations and was a significant predictor of substance abuse

treatment when compared with privately insured individuals.

Adlerian Foundations and Addiction

After leaving Freud’s psychoanalytic circle, Adler started his own therapeutic approach

(Mosak & Maniacci, 1999). Adler’s approach differed from Freud. Adler’s interest focused on

treating the individual holistically. Adler noticed that an individual is more than just one part,

and he treated his patients inclusive of feelings, actions, and beliefs.

One of Adler’s key concepts is social interest (Ansbacher & Ansbacher, 1956/1964).

Social interest in German is Gemeinschaftsgefūhl, which translates as “community feeling,” as

opposed to one’s private interests or concerns (Oberst & Stewart, 2003). An individual’s style of

life is the set of subjective and personal narratives that an individual creates in order to cope with

the world. According to Ansbacher and Ansbacher (1956/1964) if a person demonstrates social

interest then the Adlerian therapist considers the demonstration a useful style of life. In contrast,

if a person does not have social interest then they are concerned only with one’s self. The

Adlerian therapist considers this style of life to be on the useless side of life (Ansbacher &

Ansbacher, 1956/1964).

Adler believed that a person could reach good mental health through the development of

social interest and the completion of life tasks (as cited in Ansbacher & Ansbacher, 1956/1964).

Many people misunderstand the purpose of Individual Psychology, which may be related to the

misconception of the name. Some people believed that Individual Psychology focused solely on

discovering the subjective meaning of the individual; however, what Adler intended by the word


Individual (in the pure German translation) was indivisible, which relates more to a holistic

concept (Ansbacher & Ansbacher, 1956/1964; Aslinia, Rasheed, & Simpson, 2011).

Adlerian therapy considers the individual within his or her environment (Mosak &

Maniacci, 1999). Adlerian therapy also purports that social interest is the individual contribution

to the whole community (Ansbacher & Ansbacher, 1956/1964). Aslinia et al. (2011) suggested

an Adlerian therapeutic approach complimented collectivist cultures. In a collectivist society,

the individual’s actions reflect and serve the community. Western culture adopts a more

individualistic framework, and the individual is concerned about the purpose of his or her actions

and remains minimally concerned with how their actions reflect the community (Aslinia et al.,

2011); therefore, an Adlerian approach to CD treatment would be both culturally sensitive and

work well within natural collectivist cultures.

With the intention of remaining in the moment, some clinicians may avoid learning more

about the client’s culture. Other clinicians want to be perceived as an expert, have expectations

for the client to acculturate, or other personal concerns. From an Adlerian perspective, it is

appropriate to know clients as they are embedded within culture (Aslinia et al., 2011).

According to Aslinia et al., Adler believed it was important to understand the client’s childhood,

because the individual’s world view is established by the age of 5 or 6 years. By understanding

the client’s family environment, culture, and family history, the clinician can understand the

influences that shaped the client’s values, thoughts, belief system, and other things that inform

the person’s style of life (Aslinia et al., 2011).

Encouragement

The Adlerian therapist’s aim is to help the client feel empowered (Mosak & Maniacci,

1999). Empowerment is achieved by helping the client find the ultimate unconscious final goal


or self-ideal. The final goal or self-ideal is determined in interactions with family members

during early childhood (Mosak & Maniacci, 1999). Encouragement is an Adlerian technique

used to support the client to find a unique contribution to the community. Encouragement builds

social interest, and improved social interest is the catalyst to mental health healing.

Aslinia et al. (2011) stated the Adlerian therapist facilitates the reorientation to a healthier

style of life. Through an Adlerian lens, one difficulty when treating client’s from a collectivist

culture is when the individual may notice his or her desires may have precedence over the

culture; however, through social interest, an Adlerian therapist may help the client reframe goals

and desires, feel validated, and improve the therapeutic alliance, which will help the client with

further exploration of the self and reorientation to a healthier behavioral path (Aslinia et al.,

2011).

Adlerian Individual Psychology and Addiction

Addiction is a biopsychosocial problem, as the individual can be affected by many

different areas, including: genetics, spirituality, relationships, and occupation (Horvath, Misra,

Epner & Cooper, 2013). The most difficult part in CD recovery is relapse, and it is believed that

if an individual fails to make changes in his or her lifestyle, it will be more difficult to avoid

relapse. Therefore, introducing Individual Psychology, including Adler’s lifestyle assessment,

into relapse prevention, could reduce the possibility of relapse. Jafari, Amadhi,

Mohammadzadeh, and Najafi (2012) believed that lifestyle components could prevent relapse by

improving resiliency, which is believed to be the ability to be flexible despite facing problems in

life.

Jafari et al. (2012) measured the impact of lifestyle training on relapse rates of opiate

dependent patients starting treatment. Jafari et al. conducted the study in a treatment center in


Tehran on individuals with an opioid dependence diagnosis after detoxification. Jafari et al.

implemented coping skills in an experimental group and did not introduce the skills to a control

group. In this way, the researchers would be able to examine the impact of lifestyle training on

relapse prevention. Jafari et al. demonstrated lifestyle training had a significant effect on

individuals struggling with opioid addiction. After the post-test, the researchers recognized a

significant difference regarding enhanced resiliency of individuals exposed to lifestyle training.

For instance, 83% did not relapse and 64% of those who did not receive lifestyle training

relapsed (Jafari et al., 2012). Examination of the Adlerian life tasks is part of the style of life

analysis.

Adlerian Life Tasks

Every individual lives within a social context (individual in the environment) and moves

as a coherent unit toward unique useful or useless personal goals (Ansbacher & Ansbacher,

1956/1964). Personal goals are creatively developed and chosen by the individual as he or she

interacts with the environment (Ansbacher & Ansbacher, 1956/1964; Oberst & Stewart, 2003).

The individual is understood through his or her movements used to complete or avoid life tasks.

According to Ansbacher and Ansbacher (1956/1964), Adler believed all of the events in life

could be categorized in three primary life tasks. The three life tasks include: the love task, the

work task, and the community or social task. Later, Dreikurs and Mosak (1967) would add two

additional tasks, the self task and the spiritual task.

The love task. “Adler defined love with sexual intimacy as one of the three tasks of life

that must be met by each person” (Adlerpedia, 2017, para. 1). The love task begins for children

in the intimacy of family interaction with his or her caregiver. Adler often said that the child's

first experience of cooperation occurs within the family (as cited in Ansbacher & Ansbacher,


1956/1964). As the child grows and matures, the child develops perceptions of what it means to

be a man or a woman. If the child is properly encouraged, the child will learn to meet the

challenges of forming an intimate relationship (Mosak & Maniacci, 1999). When individuals

struggle with substance abuse, frequently intimate relationships are not healthy, or the individual

has avoided the love task altogether.

The work task. The occupational life task includes profession, work matters, and school

(Mosak & Maniacci, 1999). Mosak and Maniacci stated Adler believed the work task was tied to

cooperation and community and considered work the task of survival (i.e., the ability to provide

food and shelter). Many individuals presenting for chemical dependency treatment experience

difficulties at work, and some individuals find they cannot maintain a job when they are under

the influence of alcohol and drugs. Therefore, it may be useful to review the work task and

determine what the client may be avoiding through addiction.

The community or social task. Ansbacher and Ansbacher (1956/1964) stated Adler

believed all human beings are social and all human problems are social in nature. The

community or social life task concerns itself with cooperation, contribution, and belonging

within a community (Ansbacher & Ansbacher, 1956/1964). When people struggle with chemical

dependency, many individuals find belonging in an unhealthy way through relationships with

fellow users (Ansbacher & Ansbacher, 1956/1964). A profound feeling of inferiority naturally

leaves a person feeling as if they do not belong. Once this perspective develops, it is difficult to

deal with the emotions and inner turmoil. Consideration of the social life task may be beneficial

for clinicians when they plan treatment interventions for substance abuse clients.

Summary


In this literature review, an overview of QOL research, an outline of current substance

use treatment approaches, and a brief discussion of Alfred Adler’s Individual Psychology as it

relates to substance use treatment has been discussed. The available research findings regarding

QOL perceptions of adult Latino males after successful completion of substance use treatment

follows this discussion.

Method

The purpose of the proposed study was to review CD and mental health services provided

at Pangea Care to Latino, Hmong, Karen, and English-speaking populations in their own

languages. Participants were 18 years of age or older, and lived in the state of Minnesota. At the

time of admission and discharge, every client completed a survey which included questions

about the client’s perception of QOL. For the purpose of this study, the data examined included

surveys by adult Latino males that had completed treatment and had been successfully

discharged from the CD treatment program.

All participants were part of the CD outpatient program at Pangea Care. The program

consisted of different weekly treatment requirements depending on the client’s treatment need

(level of care), which corresponded to an assessment at the beginning of treatment. Minimal

requirements for this program consisted of one weekly individual CD session and participation in

a two to three-hour group therapy session. Higher treatment levels of care varied depending on

the existence of a co-occurring mental health disorder, intensity of substance use, and potential

risk. People needing a higher level of care could have one to three additional groups per week,

as well as an individual mental health session.

Data


Archival data gathered from Pangea Care between 2014-2017 was used for this study.

The only archival data reviewed was from Latino male clients, age 18-60 years who completed

treatment and had been successfully discharged from the CD program. This information was

accessed to determine the perception of quality of life upon admission and discharge from the

program.

The self-report data was collected through interactive questioning between clients and

clinicians during the admission and discharge process. The focus was to measure lifestyle areas

affected by substance use, perception of quality of life, perceived readiness to change, and

overall satisfaction of the program. As previously mentioned the focus of this research included

collecting archival data from those clients who successfully discharged from the program.

Clients with successful discharge were the most likely to have acquired changes during the

process. The archival data utilized for the study was not accessed until Pangea Care’s chief

executive officer (CEO) granted access to the data.

This study was originally designed as a mixed method case field study. The study was

designed to include focus groups and interviews where data collected through a questionnaire

could be more fully explored with the experiences and opinions of the Latino population

attending CD treatment (Creswell, 2013). The hypothesis was: Does the perception of QOL

among Latino immigrants improve after successful completion of CD outpatient treatment? The

dependent variable was the subjective perception of quality of life in Latino clients. The

independent variable was the satisfactory completion of CD outpatient treatment. The study was

reduced to a quantitative methodology when the CD treatment program abruptly closed due to

bankruptcy.


Using the historically collected surveys, clients were asked to rate QOL using the

following five options: (1) very poor – my life is miserable, (2) pretty rough, but some days are

okay, (3) so-so – my life is okay, but it could be better, (4) things are going pretty well for the

most part, and (5) my life is great, everything is going my way. This survey was created by

supervising staff at Pangea Care since the beginning of the program with the intention to

evaluate perceived change of QOL; however, the information had never been reviewed and

analyzed prior to this research.

Results

After examining the archival data, only 32 subjects met the criteria for the study. These

subjects were Latino males between 18-60 years old and had successfully completed the CD

program at Pangea Care. One of the participants had to be discarded, as his admission

questionnaire was not found in the archives. As a result, the study included 31 subjects. The

collected research data was accessed through Pangea Care’s archives. In this case, clients were

not considered vulnerable because they had already satisfactorily terminated treatment and had

been previously informed through the treatment’s informed consent that the information from the

surveys may be utilized for research purposes. All participants signed Pangea Care’s informed

consent form as it was a requirement for admission to the treatment program.

Within the admission responses (see Figure 1), 3% of the participants rated the perception

of QOL as a two (i.e., pretty rough, but some days are okay), 48% of participants chose number

three (i.e., so-so, my like is okay, but it could be better), 42% participants chose number four

(i.e., things are going pretty well for the most part), and finally, 7% of participants chose number

five (i.e., my life is great everything is going my way).


Figure 1. Perception of quality of life upon admission on Latino clients at Pangea Care.

Within the discharge responses (see Figure 2), 19% of participants answered three (i.e.,

so-so my life is ok, but it could be better), 65% of participants chose number four (i.e., things are

going pretty well for the most part), and 16% of participants chose number five (i.e., my life is

great, everything is going my way).

Figure 2. Perception of quality of life upon discharge on Latino clients at Pangea Care.

The data suggests that the perception of QOL among Latino immigrants improved after

satisfactory completion of CD outpatient treatment as 84% of the participants rated quality of life

Legend

Legend


as a four or five. Additionally, 49% of the total Latino male population evaluated QOL as a four

or a five. The admission mean was 3.5, and the discharge mean was 3.9 (see Figure 3). The

admission and discharge mode was four.

Figure 3. Perception of quality of life upon admission and discharge on Latino clients at

Pangea Care.

Discussion

Threats to the validity of this study included previously identified limitations.

Limitations of this study included: a small sample size, the lack of ability to have a longitudinal

study, and the participant sample is from one treatment center within one state. The inability to

interview participants to obtain additional insight regarding the answers on the initial

questionnaire was another extremely limiting factor. Other main threats to validity include

internal validity factors such as history, maturity, regression, mortality, and testing.

Because the CD treatment program closed, it is difficult to know if the participants

changed because of treatment, or if other components of the journey through Pangea Care may

have influenced QOL perceptions. It is also unknown if other life factors had an impact on

impulse maturity or regression and the perception of QOL. The original intention of the study

was to add focus groups in order to expand the understanding of the reasons for the answers

Legend


upon admission and discharge participants; however, this was not possible as Pangea Care

claimed bankruptcy and had to close its doors on June 2017.

This study could have benefitted from a longitudinal exploration, where the participant’s

perception of QOL could have been assessed at 6 months or 1-year post program completion.

Unfortunately, it was not possible to perform a longitudinal study on this population because the

clinic closed, and the information was accessed through archival records.

Other limitations of this study include regular uncontrollable threats to internal validity.

For example, during testing, it is difficult to know if participants based responses on personal

thoughts or on what was expected of them. For instance, participants may want to please the

interviewer or assure treatment discharge.

Other external threats to validity may include the fact that this study was focused on one

treatment facility, males only, in just one state, and the results were time bound to a certain

period, which limit the ability of a researcher to generalize to the entire Latino population of

individuals exposed to CD treatment in U.S.

This study included participants from different outpatient levels of care, and participants

were treated by different practitioners with different styles and approaches. Different styles may

have an impact on the conditions for every participant. These factors are difficult to manipulate

and could affect not only the validity but also the reliability of the study.

Considering these factors, it is proposed that in order to focus on accuracy of findings

regarding the perception of QOL on Latino populations upon admission and discharge from a

CD treatment program, a focus group could be used to expand the rationale and insight for the

participant answers. These focus groups could explore how each person’s life tasks and lifestyle

have been affected upon admission and discharge. Becoming more intentional about the


interventions used with each participant could increase understanding regarding the interventions

and if they had an impact on the efficiency of the participant’s program. After considering this

proposal, and applying these steps, it would be ideal to consider following participants as part of

a longitudinal study in order to review the perception of QOL, life tasks, and life tasks over the

long-term.

Conclusion

Participants representing the Latino adult male population in the U.S. perceived an

improved QOL upon discharge from the Pangea Care CD treatment program. This information

could help clinicians or criminal justice practitioners working with this population realize that

CD outpatient treatment could be helpful if treatment is offered in a culturally sensitive manner

and with the language barrier removed. The study at Pangea Care’s Spanish CD program could

be helpful for someone who is considering this information for the benefit of clients. Pangea

Care’s Spanish outpatient CD program included: a program in the client’s language,

individualized treatment goals, groups, and available mental health options.

Unfortunately, this study had to be limited to quantitative review of archival data, as the

clinic closed before the focus groups started. Focus groups could have provided support for, and

expand the information found, in this research. Focus groups could provide the opportunity to

better understand the reasoning behind the participant’s answers by including specific

information on how the person’s lifestyle was affected by chemical use and chemical

dependency treatment. Additional studies could help narrow the population by considering

interventions and approaches utilized by clinicians in order to better understand which are more

sensitive and favorable for this population. A longitudinal application of this study could

provide the researcher an opportunity to expand on the validity of treatment over time.


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