Substance Use & Misuse, 50:32–39, 2015 C 2015 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.957770
ORIGINAL ARTICLE
Evaluation of a Self-help Group for Parents of Substance Addicted Offspring: A Mixed Methods Approach Ioanna Passa1 and Theodoros Giovazolias2 1
Faculty of Early Childhood Education, University of Athens, Athens, Greece; 2 Department of Psychology, University of Crete, Rethymno, Greece noted the existence of intense parental disagreements that create chaotic and unstable family environments (Sullivan & Farrell, 2002).
The effectiveness of the self-help method for parents of substance addicted offsprings, using a mixed-methods approach was assessed in two samples (n = 92 and n = 6) of parents attending self-help groups in a therapy center for dependent individuals in Athens, Greece. The data were analyzed using one-way ANOVA as well as Interpretative Phenomenological Analysis (IPA). Results indicate that the self-help method contributes to the decrease of anxiety, the adoption of effective coping strategies, and the improvement of family dynamics. Study limitations and implications for clinical practice are discussed.
Effects of Psychotropic Substance Use on the Dependent Individual’s Family
Previous research has suggested that the symptoms of dependence disrupt family functions in all levels of their organizational life because dependence overturns the balance of two major system properties, namely, morphostasis, and morphogenesis. More specifically, researchers have emphasized that the symptom gradually invades the regulatory system and outweighs the tendency toward growth. The symptom, then, becomes the central organizing principle around which family life is structured (Steinglass, Bennett, Wolin, & Reiss, 1987). Parents experience high-chronic stress and complex stressful situations that often cause them poor physical health and symptoms of psychological difficulties (Copello, Velleman, & Templeton, 2005). Oreo & Ozgul (2007) studied parents of dependent individuals and found that they presented low psychological wellbeing and poor physical wellness because of increased sadness and enduring anxiety. Gruber & Floyd-Taylor (2006) added that in many cases, parents have developed ineffective strategies for countering the dependence, i.e., denial, avoiding conflict with the user, inertness, and tolerance. Barnard (2007) also confirmed the erroneous strategies developed by parents, i.e. limiting the problem within the family environment without resorting to outside help, finally adapting the family life to the demands of the dependence (e.g., providing shelter, offering money, etc.)
Keywords self-help groups, parents, mixed-method, systemic approach, drug dependence
The relevant literature supports the idea that substance dependent individuals’ families form “closed” systems that do not respond to any demands for change and are characterized by stereotypical responses (Stanton & Todd, 1982). Their members are emotionally distant, and they relate to one another in negative ways, i.e., resentment, criticism, and unsolved conflicts expressed in primitive ways and resolved by triangulation. Relationships among family members appear to be pathological in nature, with undifferentiated relationships between the dependent children and the mother, who appears to be emotionally over-involved, and with the father being emotionally and physically absent, violent, or easily manipulated by the mother (Levin, 1998). One can observe a lack of cohesion, yet hidden or obvious cross-generational coalitions are present that overturn the family’s hierarchical organization and separate parents. The boundaries among family members are often unclear, almost nonexistent, or they are highly rigid. Their communication is very poor, owing to a lack of dialogue, of true and direct rapport, and of free expression of emotions. Moreover, scholars have
The Self-Help Method
The term “self-help” refers to the process of individuals’ self-action and assumption of personal responsibility in order to face their problems within a framework of
Address correspondence to Theodoros Giovazolias, Department of Psychology, University of Crete, Rethymno, Greece; E-mail: [email protected].
32
SELF-HELP METHOD IN SUBSTANCE ABUSE TREATMENT
collectiveness and solidarity. A self-help group is supportive and educational, and it aims at individual change. Change is effected through the application of different ideologies that address a specific situation without any specialized professional therapeutic methods and procedures (De Leon, 2004). Currently, a large number of self-help groups address almost any type of psychological problem. However, although scholars have theoretically described the selfhelp model (e.g., Benshoff & Janikowski, 2000; Kirby, 2004), still none to our knowledge have paid attention to evaluating its effectiveness on parents of drug- and alcohol-dependent individuals. After an extensive literature search, we could not trace any published studies regarding the effectiveness of the self-help method on issues such as parents’ general well-being as well as their efficacy in dealing with dependent children. This research scarcity can be explained by the fact that evaluation studies have concentrated mainly on self-help groups that use the 12-step approach for dependent individuals, leaving aside the groups that do not base their function on this method and address the environment of the dependent individual instead (Humphreys et al., 2004). However, studies that measure the influence of selfhelp groups on parents of children with other types of difficulties report positive results (e.g., Yuen & Toumbourou, 2011). Specifically, a study by Solomon, Pistrang, and Barker (2001) involving 56 parents of handicapped children demonstrated that parents were able to reduce feelings of insecurity, shame, fear, and loneliness, while at the same time they were informed about the problem and the available sources of help. Furthermore, a study by Chien, Norman, and Thompson (2004) of 24 parents of children with schizophrenia demonstrated that parents were able to reduce negative feelings of guilt and sorrow, better manage the burden of caring for the afflicted member, and improve their family functioning. Aims of the Study
Based on the literature review presented above, our purpose for the present study was to assess the effectiveness of a self-help group for parents of dependent individuals, as well as to examine participants’ perceptions of the group’s function and of the particular benefits they gained through their involvement in it. The methodology employed was a mixed-methods approach. Methodologists noted that by combining quantitative and qualitative research, studies can maximize the strengths of each approach, develop more complete and complementary understandings, increase the validity of results, and/or examine contextualized understandings, multilevel perspectives, and cultural influences (Creswell & Plano Clark, 2011). The research hypotheses of the quantitative study were the following: The participation in self-help groups would (a) affect the stress levels experienced by parents of dependent individuals, (b) affect the levels of cohesion and the adaptability of the family, as experienced by parents,
33
(c) affect parents’ psychological well-being, and (d) improve strategies parents use to manage stressful situations related to their children’s dependence. The qualitative study questions were the following: (a) How are the functional boundaries defined in families of dependent individuals who undergo a therapeutic procedure? (b) How do parents define functional communication (e.g. sincerity)? (c) What is the meaning of the selfhelp group to the family’s capacity for feedback? and (d) How does the self-help affect the family’s organization? To better understand the findings, we will present the two studies (quantitative, qualitative) separately. METHODS Quantitative Study
Sample The sample consisted of dependent individuals’ parents who had received help through the self-help method and who had participated in the therapeutic program of the Therapy Centre for Dependent Individuals (KETHEA), the largest institution for the treatment, rehabilitation, and social reintegration of dependent individuals in Greece. Parents’-dependent children participated in the morning nonresidential intervention program, aiming to identify and address the psychosocial factors that contribute to addiction, without the use of pharmaceutical substances or substitutes. We initially approached 120 individuals (parents). The final study sample consisted of 92 parents (76.7% response rate) with a mean age of 57.95 years (54 women, 38 men). The majority of the participants (79.3%) were married, whereas 10.9% were widowers, 5.4% were divorced, and 4.3% were separated. The majority of the participants had completed a high school education (50%), whereas 25% had completed only a primary education, 22.8% had a higher education, and 2.2% had completed postgraduate studies. Procedure We completed the data collection without any problems and protected the participants’ rights. Prior to both the administration of the questionnaires and the interviews, all participants provided signed consent forms, and they were informed that they could withdraw from the study at any time. The researchers informed the prospective participants of study’s purpose, mentioning that it concerned their experience in the self-help groups to that point as well as their interactions with the dependent child and their family members. There was no payment or other incentive to participate in this study. After the collection of the questionnaires, the researchers encoded and analyzed the data using the SPSS (Statistical Package for Social Sciences, 19.0, University of Crete). The study was approved both by the University of Athens Ethics Committee and by the KETHEA Ethics Committee. Measures For the measurement of anxiety, we used Spielberger’s State and Trait Anxiety Inventory (STAI)
34
I. PASSA AND T. GIOVAZOLIAS
(Vagg, Spielberger, & O’Hearn, 1980). STAI consists of 40 questions. The first 20 questions reflect the anxiety generated by a specific situation (state) (X-1), and the remaining 20 refer to anxiety that is a more integral part of the personality (trait) (X-2). In the present study, the reliability coefficient was found to be a = .90 for the state dimension, a = .85 for the trait dimension and α = 0.93 for the total score. The Family Adaptability and Cohesion Evaluation Scale—FACES III (Olson, 1991) assesses the cohesion and the family’s adaptability-flexibility. The FACES III consists of 20 questions that respondents answer twice—initially, in reference to the way the family functions in the “here and now” (actual form) and also in reference to the way they would like it to function (ideal functioning). In the present study, the internal consistency was a = 0.78 for adaptability, and for cohesion it was a = .71 for the family’s actual form (Olson, 1991; 2000). To measure psychological well-being, we utilized Diener’s (2000) Psychological Well-being scale—PWB. PWB consists of eight questions that measure the individual’s social and psychological well-being. In the present study, Cronbach’s α coefficient was .76. Finally, we used the Folkman & Lazarus (1988) Ways of Coping Questionnaire– WAYS to examine the strategies adopted by parents to deal with stressful events. The scale includes the following five factors/strategies: (1) positive approach with two dimensions: positive reappraisal and intentional problem solving; (2) seeking social support; (3) wishful thinking with two dimensions: wishful thinking and seeking of divine intervention; (4) avoidance/escape with two dimensions: quitting and denial; and (5) confrontational solution of the problem. The Cronbach’s α for the total scale was .85. The values of the reliability coefficient (Cronbach’s α) for all variables were higher than .68, except those for the FACES III and for the two dimensions of the ideal family functioning, which were .57. Thus, we decided to remove this particular dimension from all further analyses, following George & Mallery’s (2003) suggestion that measures of approximately .70 are acceptable and that those below .60 do not have acceptable reliability. Data Analysis We first allocated the ninety-two parents into three independent groups. The three groups were of similar size, and their construction was based on the duration of the intervention through the method of self-help: Group 1 refers to parents who at the time of the study were participating in the self-help group for a short term (up to 11 months); Group 2, medium-term (from 12 to 22 months); and Group 3, long-term (more than 23 months). The GPOWER application confirmed that we were close to the optimum sample size, given a large effect size (.40), a significance level of .05, a power level of .95, and three groups of the factor variable (duration of self-help) (Faul, Erdfelder, Buchner, & Lang, 2009). Using one-way ANOVA, we examined significant statistical differences between the means of the dependent variables (anxiety level-state and trait, level of parents’ psychological well-
being, strategies of dealing with anxiety-producing situations, cohesion, and adaptability of the family in its actual form) for the three groups of parents. Before we proceeded with the analysis, we addressed incomplete or incorrect question values using the Bayesian method (Vaus, 2002). The power for the one-way ANOVA was found to be .94. RESULTS
One-way ANOVA demonstrated statistically significant differences between the means of the three groups for some of the dependent variables. More specifically, the STAI’s results showed that the self-help intervention in the three groups of parents had an effect only in state anxiety (X-2) [F(2.89) = 10.775, p .05)]. On the trait anxiety STAI(X-2) subscale, the findings demonstrated a decreasing trend in the groups, with Group 1 having a higher score than Groups 2 and 3 [Mean Difference (1-2) = 7.115, p
ORIGINAL ARTICLE
Evaluation of a Self-help Group for Parents of Substance Addicted Offspring: A Mixed Methods Approach Ioanna Passa1 and Theodoros Giovazolias2 1
Faculty of Early Childhood Education, University of Athens, Athens, Greece; 2 Department of Psychology, University of Crete, Rethymno, Greece noted the existence of intense parental disagreements that create chaotic and unstable family environments (Sullivan & Farrell, 2002).
The effectiveness of the self-help method for parents of substance addicted offsprings, using a mixed-methods approach was assessed in two samples (n = 92 and n = 6) of parents attending self-help groups in a therapy center for dependent individuals in Athens, Greece. The data were analyzed using one-way ANOVA as well as Interpretative Phenomenological Analysis (IPA). Results indicate that the self-help method contributes to the decrease of anxiety, the adoption of effective coping strategies, and the improvement of family dynamics. Study limitations and implications for clinical practice are discussed.
Effects of Psychotropic Substance Use on the Dependent Individual’s Family
Previous research has suggested that the symptoms of dependence disrupt family functions in all levels of their organizational life because dependence overturns the balance of two major system properties, namely, morphostasis, and morphogenesis. More specifically, researchers have emphasized that the symptom gradually invades the regulatory system and outweighs the tendency toward growth. The symptom, then, becomes the central organizing principle around which family life is structured (Steinglass, Bennett, Wolin, & Reiss, 1987). Parents experience high-chronic stress and complex stressful situations that often cause them poor physical health and symptoms of psychological difficulties (Copello, Velleman, & Templeton, 2005). Oreo & Ozgul (2007) studied parents of dependent individuals and found that they presented low psychological wellbeing and poor physical wellness because of increased sadness and enduring anxiety. Gruber & Floyd-Taylor (2006) added that in many cases, parents have developed ineffective strategies for countering the dependence, i.e., denial, avoiding conflict with the user, inertness, and tolerance. Barnard (2007) also confirmed the erroneous strategies developed by parents, i.e. limiting the problem within the family environment without resorting to outside help, finally adapting the family life to the demands of the dependence (e.g., providing shelter, offering money, etc.)
Keywords self-help groups, parents, mixed-method, systemic approach, drug dependence
The relevant literature supports the idea that substance dependent individuals’ families form “closed” systems that do not respond to any demands for change and are characterized by stereotypical responses (Stanton & Todd, 1982). Their members are emotionally distant, and they relate to one another in negative ways, i.e., resentment, criticism, and unsolved conflicts expressed in primitive ways and resolved by triangulation. Relationships among family members appear to be pathological in nature, with undifferentiated relationships between the dependent children and the mother, who appears to be emotionally over-involved, and with the father being emotionally and physically absent, violent, or easily manipulated by the mother (Levin, 1998). One can observe a lack of cohesion, yet hidden or obvious cross-generational coalitions are present that overturn the family’s hierarchical organization and separate parents. The boundaries among family members are often unclear, almost nonexistent, or they are highly rigid. Their communication is very poor, owing to a lack of dialogue, of true and direct rapport, and of free expression of emotions. Moreover, scholars have
The Self-Help Method
The term “self-help” refers to the process of individuals’ self-action and assumption of personal responsibility in order to face their problems within a framework of
Address correspondence to Theodoros Giovazolias, Department of Psychology, University of Crete, Rethymno, Greece; E-mail: [email protected].
32
SELF-HELP METHOD IN SUBSTANCE ABUSE TREATMENT
collectiveness and solidarity. A self-help group is supportive and educational, and it aims at individual change. Change is effected through the application of different ideologies that address a specific situation without any specialized professional therapeutic methods and procedures (De Leon, 2004). Currently, a large number of self-help groups address almost any type of psychological problem. However, although scholars have theoretically described the selfhelp model (e.g., Benshoff & Janikowski, 2000; Kirby, 2004), still none to our knowledge have paid attention to evaluating its effectiveness on parents of drug- and alcohol-dependent individuals. After an extensive literature search, we could not trace any published studies regarding the effectiveness of the self-help method on issues such as parents’ general well-being as well as their efficacy in dealing with dependent children. This research scarcity can be explained by the fact that evaluation studies have concentrated mainly on self-help groups that use the 12-step approach for dependent individuals, leaving aside the groups that do not base their function on this method and address the environment of the dependent individual instead (Humphreys et al., 2004). However, studies that measure the influence of selfhelp groups on parents of children with other types of difficulties report positive results (e.g., Yuen & Toumbourou, 2011). Specifically, a study by Solomon, Pistrang, and Barker (2001) involving 56 parents of handicapped children demonstrated that parents were able to reduce feelings of insecurity, shame, fear, and loneliness, while at the same time they were informed about the problem and the available sources of help. Furthermore, a study by Chien, Norman, and Thompson (2004) of 24 parents of children with schizophrenia demonstrated that parents were able to reduce negative feelings of guilt and sorrow, better manage the burden of caring for the afflicted member, and improve their family functioning. Aims of the Study
Based on the literature review presented above, our purpose for the present study was to assess the effectiveness of a self-help group for parents of dependent individuals, as well as to examine participants’ perceptions of the group’s function and of the particular benefits they gained through their involvement in it. The methodology employed was a mixed-methods approach. Methodologists noted that by combining quantitative and qualitative research, studies can maximize the strengths of each approach, develop more complete and complementary understandings, increase the validity of results, and/or examine contextualized understandings, multilevel perspectives, and cultural influences (Creswell & Plano Clark, 2011). The research hypotheses of the quantitative study were the following: The participation in self-help groups would (a) affect the stress levels experienced by parents of dependent individuals, (b) affect the levels of cohesion and the adaptability of the family, as experienced by parents,
33
(c) affect parents’ psychological well-being, and (d) improve strategies parents use to manage stressful situations related to their children’s dependence. The qualitative study questions were the following: (a) How are the functional boundaries defined in families of dependent individuals who undergo a therapeutic procedure? (b) How do parents define functional communication (e.g. sincerity)? (c) What is the meaning of the selfhelp group to the family’s capacity for feedback? and (d) How does the self-help affect the family’s organization? To better understand the findings, we will present the two studies (quantitative, qualitative) separately. METHODS Quantitative Study
Sample The sample consisted of dependent individuals’ parents who had received help through the self-help method and who had participated in the therapeutic program of the Therapy Centre for Dependent Individuals (KETHEA), the largest institution for the treatment, rehabilitation, and social reintegration of dependent individuals in Greece. Parents’-dependent children participated in the morning nonresidential intervention program, aiming to identify and address the psychosocial factors that contribute to addiction, without the use of pharmaceutical substances or substitutes. We initially approached 120 individuals (parents). The final study sample consisted of 92 parents (76.7% response rate) with a mean age of 57.95 years (54 women, 38 men). The majority of the participants (79.3%) were married, whereas 10.9% were widowers, 5.4% were divorced, and 4.3% were separated. The majority of the participants had completed a high school education (50%), whereas 25% had completed only a primary education, 22.8% had a higher education, and 2.2% had completed postgraduate studies. Procedure We completed the data collection without any problems and protected the participants’ rights. Prior to both the administration of the questionnaires and the interviews, all participants provided signed consent forms, and they were informed that they could withdraw from the study at any time. The researchers informed the prospective participants of study’s purpose, mentioning that it concerned their experience in the self-help groups to that point as well as their interactions with the dependent child and their family members. There was no payment or other incentive to participate in this study. After the collection of the questionnaires, the researchers encoded and analyzed the data using the SPSS (Statistical Package for Social Sciences, 19.0, University of Crete). The study was approved both by the University of Athens Ethics Committee and by the KETHEA Ethics Committee. Measures For the measurement of anxiety, we used Spielberger’s State and Trait Anxiety Inventory (STAI)
34
I. PASSA AND T. GIOVAZOLIAS
(Vagg, Spielberger, & O’Hearn, 1980). STAI consists of 40 questions. The first 20 questions reflect the anxiety generated by a specific situation (state) (X-1), and the remaining 20 refer to anxiety that is a more integral part of the personality (trait) (X-2). In the present study, the reliability coefficient was found to be a = .90 for the state dimension, a = .85 for the trait dimension and α = 0.93 for the total score. The Family Adaptability and Cohesion Evaluation Scale—FACES III (Olson, 1991) assesses the cohesion and the family’s adaptability-flexibility. The FACES III consists of 20 questions that respondents answer twice—initially, in reference to the way the family functions in the “here and now” (actual form) and also in reference to the way they would like it to function (ideal functioning). In the present study, the internal consistency was a = 0.78 for adaptability, and for cohesion it was a = .71 for the family’s actual form (Olson, 1991; 2000). To measure psychological well-being, we utilized Diener’s (2000) Psychological Well-being scale—PWB. PWB consists of eight questions that measure the individual’s social and psychological well-being. In the present study, Cronbach’s α coefficient was .76. Finally, we used the Folkman & Lazarus (1988) Ways of Coping Questionnaire– WAYS to examine the strategies adopted by parents to deal with stressful events. The scale includes the following five factors/strategies: (1) positive approach with two dimensions: positive reappraisal and intentional problem solving; (2) seeking social support; (3) wishful thinking with two dimensions: wishful thinking and seeking of divine intervention; (4) avoidance/escape with two dimensions: quitting and denial; and (5) confrontational solution of the problem. The Cronbach’s α for the total scale was .85. The values of the reliability coefficient (Cronbach’s α) for all variables were higher than .68, except those for the FACES III and for the two dimensions of the ideal family functioning, which were .57. Thus, we decided to remove this particular dimension from all further analyses, following George & Mallery’s (2003) suggestion that measures of approximately .70 are acceptable and that those below .60 do not have acceptable reliability. Data Analysis We first allocated the ninety-two parents into three independent groups. The three groups were of similar size, and their construction was based on the duration of the intervention through the method of self-help: Group 1 refers to parents who at the time of the study were participating in the self-help group for a short term (up to 11 months); Group 2, medium-term (from 12 to 22 months); and Group 3, long-term (more than 23 months). The GPOWER application confirmed that we were close to the optimum sample size, given a large effect size (.40), a significance level of .05, a power level of .95, and three groups of the factor variable (duration of self-help) (Faul, Erdfelder, Buchner, & Lang, 2009). Using one-way ANOVA, we examined significant statistical differences between the means of the dependent variables (anxiety level-state and trait, level of parents’ psychological well-
being, strategies of dealing with anxiety-producing situations, cohesion, and adaptability of the family in its actual form) for the three groups of parents. Before we proceeded with the analysis, we addressed incomplete or incorrect question values using the Bayesian method (Vaus, 2002). The power for the one-way ANOVA was found to be .94. RESULTS
One-way ANOVA demonstrated statistically significant differences between the means of the three groups for some of the dependent variables. More specifically, the STAI’s results showed that the self-help intervention in the three groups of parents had an effect only in state anxiety (X-2) [F(2.89) = 10.775, p .05)]. On the trait anxiety STAI(X-2) subscale, the findings demonstrated a decreasing trend in the groups, with Group 1 having a higher score than Groups 2 and 3 [Mean Difference (1-2) = 7.115, p
