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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
Perceived Quality of Life: Adult Latino Males Post Treatment
Copyright © 2017
Ana Paulina Steffer
All rights reserved
QUALITY OF LIFE IN LATINOS POST TREATMENT 3
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
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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.
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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.
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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
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Perceived Quality of Life: Adult Latino Males Post Treatment
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).
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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
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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
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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
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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,
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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.
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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
QUALITY OF LIFE IN LATINOS POST TREATMENT 14
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
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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
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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
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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
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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.
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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.
QUALITY OF LIFE IN LATINOS POST TREATMENT 20
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).
QUALITY OF LIFE IN LATINOS POST TREATMENT 21
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
QUALITY OF LIFE IN LATINOS POST TREATMENT 22
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.
QUALITY OF LIFE IN LATINOS POST TREATMENT 23
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,
QUALITY OF LIFE IN LATINOS POST TREATMENT 24
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
QUALITY OF LIFE IN LATINOS POST TREATMENT 25
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
QUALITY OF LIFE IN LATINOS POST TREATMENT 26
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
QUALITY OF LIFE IN LATINOS POST TREATMENT 27
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
QUALITY OF LIFE IN LATINOS POST TREATMENT 28
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,
QUALITY OF LIFE IN LATINOS POST TREATMENT 29
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
QUALITY OF LIFE IN LATINOS POST TREATMENT 30
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
QUALITY OF LIFE IN LATINOS POST TREATMENT 31
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.
QUALITY OF LIFE IN LATINOS POST TREATMENT 32
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).
QUALITY OF LIFE IN LATINOS POST TREATMENT 33
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
QUALITY OF LIFE IN LATINOS POST TREATMENT 34
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
QUALITY OF LIFE IN LATINOS POST TREATMENT 35
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
QUALITY OF LIFE IN LATINOS POST TREATMENT 36
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.
QUALITY OF LIFE IN LATINOS POST TREATMENT 37
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