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 THE ROLE OF SELF-DISCLOSURE AND DESIRABILITY OF SELF-CONTROL IN
THE PREDICTION OF TREATMENT COMPLIANCE
FOR SUBSTANCE DEPENDENT OUTPATIENTS

A DISSERTATION
PRESENTED TO THE FACULTY OF THE
CALIFORNIA SCHOOL OF PROFESSIONAL PSYCHOLOGY

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SAN DIEGO

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In Partial Fulfillment
of the Requirements for the Degree

DOCTOR OF PHILOSOPHY
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By

Mary Kaye Vizdos

1999

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 UMI Number: 9930636

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 THE ROLE OF SELF-DISCLOSURE AND DESIRABILITY OF SELF-CONTROL IN
THE PREDICTION OF TREATMENT COMPLIANCE
FOR SUBSTANCE DEPENDENT OUTPATIENTS

A DISSERTATION
PRESENTED TO THE FACULTY OF THE
CALIFORNIA SCHOOL OF PROFESSIONAL PSYCHOLOGY
SAN DIEGO

In Partial Fulfillment

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of the requirements for the degree

DOCTOR OF PHILOSOPHY
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By
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Mary Kaye Vizdos

1999
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Approved By:

Peter Briggs, Ph.D. Chairperson

) S s f z n s f j ,
Anthody Rizzo, Ph.Q^Ejjgflleaddr

Steven Bucky, Ph.D. Second Reader

Received hy:

Adele Rabin, Ph.D. Program Director

Director o f the Ph.D. Program

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 TABLE OF CONTENTS

CHAPTER PAGE

I INTRODUCTION 1
Prevalence of Substance and Alcohol Dependence 2
Alcoholics Anonymous and Narcotics Anonymous Treatment 5
Group Therapy for Alcohol and Substance Dependence 6
Theories of Self-Disclosure 7
Self-Disclosure Measures 9
The Concept of Self-Control in Recovery 9

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E REVIEW OF LITERATURE 14
Self-Disclosure 14
Self-Report Measures o f Self-Disclosure 21
Self-Control 23
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Self-Control Measures of Self-Control 31
Validity of Self-Report and Drug Use 32
Relapse During and After Treatment 35
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Predictors of Treatment Outcome 38
Substance Dependence Treatment and Outcome 40
Statement of the Problem 44
Hypotheses 46
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m METHODS AND PROCEDURES 48

Definition of Terms 48
Participants 51
Protection of Human Subj ects 59
Instrumentation 59
Description of Measures 60
Self-Disclosure Index 60
Desirability of Control Scale 62
Procedures 65
Statistical Design 66

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 IV RESULTS 69
Hypotheses Testing 69
Post-Hoc Analysis 80

DISCUSSION 83
Summary and Interpretation o f Findings 84
Theoretical and Clinical Implications 89
Methodological Implications 90
Future Research 93

REFERENCES 95

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APPENDIXES
A Consent Forms 111
B Demographic Questionnaire 120
C Desirability o f Control Scale 124

ABSTRACT
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 LIST OF TABLES

TABLE PAGE

1 Demographic Characteristics o f Sample 53

2 Demographic Characteristics Listed by Site 55
3 Previous Substance Use and Treatment 58
4 Descriptive Statistics 70
5 Pre- versus Post-Test Scores for Completers 71
6 Variables in the Equation for Treatment Completion 74
7 Variables in the Equation for Treatment Completion 75
8 Variables in the Equation for Relapse 78

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9 Variables in the Equation for Relapse 79

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 LIST OF FIGURES

FIGURE PAGE

1 Scatter Plot o f DSCS and SDI Interaction for Completers 76

2 Scatter Plot o f DSCS and SDI Interaction for Relapsers 82

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CHAPTER I

Introduction

“We admit that we are powerless over alcohol and that our lives have become

unmanageable" (Alcoholics Anonymous, 1939).

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This well-known “First Step” of Alcoholics Anonymous focuses on the
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importance o f admitting the loss of self-control over drinking. Similarly, with Narcotics

Anonymous (1982), “.... We are powerless over our addiction....” This admission leads
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to the realization o f the loss of control over one's life as an alcoholic/addict, and is the

beginning o f the acceptance of addiction to alcohol/drugs. Specifically, this first step

focuses on the issue of personal self-control. The admission that every aspect of one’s
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life, when mixed with alcohol or drugs, is out-of-control, is the first necessary step taken

toward “recovery,” according to the philosophy advocated by most theorists in

Alcoholics/Narcotics Anonymous (Wallace, 1996).

Addiction appears to be a paradoxical disease. According to AA’s interpretation

o f the “disease concept,” when an alcoholic drinks even the most moderate amounts of

alcohol, his/her body sets up an “allergic reaction” to it, which somewhat paradoxically

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 drives them, to increase their consumption (Mendelson & Mello, 1992). In the

alcoholic/addict’s behavioral pattern o f excessive drinking or use, the commitment to

self-control has come to be recognized as countertherapeutic to recovery. Even though

the alcoholic/addict tries to control his or her excessive use, they do so in vain. The

delusion o f the possibility o f control over alcohol/drugs keeps the alcoholic/addict in

denial, inhibiting the chance o f recovery through sobriety.

Prevalence of Substance and Alcohol Dependence

The abuse of alcohol and drugs is one o f the major public health problems in our

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society today. Although the exact prevalence of alcohol and drug abuse is difficult to
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measure with certainty, it has been estimated that over twenty million Americans meet

the criteria for abuse or dependence (National Institute on Alcohol Abuse and
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Alcoholism, 1993). Commonly abused drugs include ethyl alcohol and illicit drugs (e.g.,

cocaine, heroin, marijuana, amphetamines, benzodiazepines, and barbiturates).

The easy access, widespread acceptance, and extensive promotion o f alcoholic

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beverages within our society make alcohol the most widely used and abused drug (United

States Department o f Health and Human Services, 1997). Universally, alcohol is the

most commonly used depressant and cause o f considerable morbidity and mortality

(DSM-IV, 1994). At some time in their lives, as many as 90% of adults in the United

States have had some experience with alcohol, and a substantial number (60% males and

30% females) have had one or more alcohol-related adverse life events (e.g., driving after

consuming too much alcohol; missing school or work due to a hangover) (DSM-IV,

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1994). National surveys since the 1960s have consistently found that alcohol is used by

over half o f all American adults, and that about 10% o f American adults have significant

problems related to the use o f alcohol (Cahalan, 1969; National Institute on Alcohol

Abuse and Alcoholism [NLAAA], 1993). Alcohol and tobacco contribute to two of the

three leading causes of preventable death in the United States (McGinnis and Foege,

1993). Alcohol abuse alone is involved in nearly 100,000 premature deaths per year

(McGinnis & Foege, 1993) and contributes to a significant share of health care costs.

Alcohol is involved in 41 percent of traffic fatalities, and is calculated as a factor in 50

percent o f homicides, 30 percent o f suicides, and 30 percent o f accidental deaths (Shute,

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1997). Chronic alcohol abuse often leads to dependence, alcohol withdrawal syndrome,
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serious medical complications (e.g., hepatitis, cirrhosis, pancreatitis, thiamin deficiency,

gastrointestinal bleeding, cardiomyopathy), and certain forms o f cancer (NLAAA, 1993).

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A possible complication for alcoholics is cirrhosis, which in 1997 was the tenth leading

cause o f death, according to the U.S. National Center for Health Statistics (1997).

Substance abuse is one o f the most prevalent mental disorders in the United
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States, affecting about 1 in nearly 20 Americans each year (Kessler et al., 1994).

Between 1 and 3 million Americans are estimated to be regular users o f cocaine. Cocaine

can substantially increase the risk of sudden death from cerebral hemorrhage, seizures,

arrhythmia, myocardial infarction, or respiratory arrest. Regular intranasal administration

o f cocaine can potentially result in sinus disease and nasal sepal perforation; respiratory

complications may occur in those individuals who smoke cocaine. The use o f cocaine

intravenously is a risk factor for the acquired immunodeficiency syndrome (AIDS) and

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several other medical complications. The use of cocaine by pregnant women may

increase the risks o f premature labor, placental abruption, intrapartum fetal distress, and

neonatal complications. Cocaine dependence produces behavioral effects such as

decreased motivation, psychomotor retardation, irregular sleep patterns, and additional

symptoms of depression (National Mental Health Association, 1998). An estimated

500,000 Americans are addicted to heroin, and more than 2 million use the drug

occasionally. Mortality rates among heroin addicts is high (about 10 per 1000 annually)

due to overdose, suicide, violence, and medical complications such as infectious hepatitis,

bacterial endocarditis, and pulmonary emboli. Infants bom to women using drugs are

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possibly at risk for long-term psychological and behavioral effects. As with intravenous
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cocaine, intravenous heroin use is a significant risk factor for developing AIDS. The

transmission of the human immunodeficiency virus (HIV) through contaminated needles

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accounts for about 25% o f all AIDS cases (NMHA, 1998). Over 10 million Americans

smoke marijuana regularly. In addition, marijuana smoke may contain more carcinogens

and tar than tobacco smoke, and consequently, increase the risk o f pulmonary disease in
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chronic smokers of cannabis. As with all substance dependence, marijuana use produces

behavioral effects such as decreased motivation, psychomotor retardation, irregular sleep

patterns, and additional symptoms of depression (NMHA, 1998).

Misuse of drugs and alcohol costs the United States substantially—$100 billion a

year in quantifiable costs, in addition to the untold emotional pain (Shute, 1997).

Problems with alcohol and drugs represent the highest contributor to health problems and

medical hospitalization in the United States (Atkinson & Shuckit, 1981; Chen, Scheier, &

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Kandel, 1996). Social consequences of alcohol and other drug dependence include

divorce, unemployment, and poverty. An estimated 27 million American children are at

risk for abnormal psychosocial development due to the abuse o f alcohol by their parents

or caretakers (NLAAA, 1993).

Alcoholics Anonymous and Narcotics Anonymous Treatment

Nearly 1 million Americans enter formal substance abuse treatment every year

(NLAAA, 1993). Alcohol and drug treatment often starts with its most drastic remedy:

lifetime abstinence, 12-Step meetings and until recently, residential treatment in

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substance-abuse clinics. Traditional treatment options available in the United States
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function primarily within the structure of “ 12-Step” Recovery model (Wallace, 1996),

which is based on the principles and practices o f Alcoholics Anonymous (AA) and
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Narcotics Anonymous (NA). The primary philosophy o f AA is that alcoholism

(addiction) is a disease of both the mind and the body -- not a moral weakness -- and that

alcoholics (addicts) must abstain completely from alcohol (drugs) in order to cope with
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their disease. A spiritual self-help group founded in 1935, AA’s aim was to enable and

encourage alcoholics to help each other understand their addiction through spiritual

renewal and the 12 steps.

However, analyzing the effectiveness o f AA or the 12-steps is difficult due to the

nature of the organization, which does not keep membership records and does not

generally participate in research. Approximately 3.5 million Americans attend AA or

other “12-Step” self-help groups annually (Room, 1993) and numbers are reported to be

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doubling every 10 years (Robertson, 1988). Surveys of substance abuse treatment

providers indicate that 88% cite AA as a major component o f treatment and 82% use it as

a form o f aftercare (Toumier, 1978). However, there have been virtually no systematic

attempts to identify the change mechanisms described in the 12-step approach (e.g.,

Robertson, 1988). Alcohol and drug treatment research is moving gradually toward a

more scientific, empirically based approach to effective treatment. The foundations o f

change necessary for successful treatment outcome and recovery need to be empirically

tested, in order to determine the most effective forms of treatment.

Specifically for this study, the concept of giving up self-control over one’s life

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and the role o f self-disclosure within treatment were investigated as potential predictor
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variables for treatment completion and relapse during treatment.
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Group Therapy for Alcohol and Substance Dependence

One of the therapeutic settings, which can lead the alcoholic/addict to a better

understanding o f their addiction, is group therapy (Toumier, 1978). Group therapy is

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essential for the process o f change necessary for successful treatment. In the group

therapy setting, in which self-disclosure and the futility o f self-control are examined,

recovery is best achieved.

In this study, the relationship between “self-disclosure” as it applies to recovery

from addiction, and “self-control” as it applies to addiction, were investigated and

examined in relationship to treatment completion and relapse during treatment.

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Theories of Self-Disclosure

The first variable that was investigated in attempting to predict outpatient

treatment completion and relapse is the subjects' level of self-disclosure within a

treatment group. Defined by Sidney Jourard (1964), self-disclosure refers to the process

o f telling another person about oneself, honestly sharing thoughts and feelings that may

be very personal and private. Jourard (1970) viewed self-disclosure as both a sign and a

cause of a healthy personality, and positive mental health. Some research findings link

self- disclosure and psychological health, suggesting that persons who disclose more are

better adjusted than persons who disclose less (Jourard, 1970; Strassberg, Anchor, Gabel,

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& Cohen, 1978).
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In an extensive review of the disclosure literature, Cozby (1973) hypothesized that

“mentally healthy” persons are characterized by higher disclosure to those close to them
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and moderate disclosure to others in their social environment. Disclosure was viewed as

a relatively stable personality characteristic, which can serve a positive function, such as

improving a relationship or promoting individual growth, but it may also be

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inappropriate, when it elicits withdrawal or rejection by others (Derlega et al., 1993).

Derlega and Chaikin (1975) stated that positive mental health is related to appropriate

disclosure, which suits the time, the occasion, and the relationship between the listener

and discloser.

Clinical and counseling psychologists as a group have expressed a great interest in

self-disclosure. Self-disclosure is an important element for seeking help from others and

is necessary for the effective use of most current forms of therapy. Virtually all forms of

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 counseling and psychotherapy emphasize the importance of self-disclosure on the part of

the clients. This may be either because disclosure is viewed as central to the

self-exploration required for successful counseling or because the primary source of some

client problems is seen as stemming from problems in disclosure (Derlega & Berg,

1987). Most forms o f psychotherapy assume that encouraging self-disclosure can reduce

emotional problems by the patient (Derlega & Berg, 1987). Self-disclosure is the basis of

“the talking cure” pioneered by Sigmund Freud, the founder o f psychoanalysis. Carl

Rogers (1958) stated that a major cause of emotional problems is concealment.

According to Rogers, self-disclosure is critical in helping individuals deal with emotional

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problems by promoting self-awareness.
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According to Irvin Yalom, self-disclosure is absolutely essential in the group

therapeutic process, and is defined as “the process of revealing oneself to others fully and
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honestly” (Yalom, 1995). Yalom states:

Too much or too little self-disclosure indicates maladaptive interpersonal

behavior. Too little self-disclosure in group therapy usually results in severely

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limited opportunity for reality testing. Often individuals dread self-disclosure, not

primarily because of shame or fear of non-acceptance but because they are heavily

conflicted in the area of control. Some individuals view self-disclosure as being

dangerous because it makes them vulnerable to the control of others.

However, when others in the group have self-disclosed and made themselves

vulnerable through self-disclosure, then they are more willing to reciprocate with

increased self-disclosure. In an environment where self-disclosure is received

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with support and acceptance, as often created by treatment groups, it tends to have

a positive effect. Self-disclosure and feedback from others are a primary means

by which treatments seek to promote change (p. 137).

One o f the first settings where alcoholics were able to express their feelings

through self-disclosure, and with mutual understanding and support, was Alcoholics

Anonymous, founded in 1935. AA was created to serve as a self-help group to assist

people who are trying to stop drinking. It has created a group process through which

millions o f alcoholics/addicts achieve sobriety.

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Self-Disclosure Measures
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In order to determine why individuals differ in the extent to which they disclose to

others researchers have relied on a number of self-disclosure measures (Chelune, 1976;

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Jourard, 1964). However, these scales have had serious problems with predictive

validity. Previous disclosure research has indicated that both gender of the target and the

familiarity of the target (friend or stranger) affect the intimacy of the speaker's disclosures
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(Annicchiarico, 1973; Brooks, 1974; Hyink, 1975; Inman, 1977; Jourard, 1961;

Rickers-Ovasiankina, 1956).

The Concept o f Self-Control in Recovery

The second variable that was investigated in attempting to predict outpatient

treatment completion and relapse is the subjects' level o f self-control. Jellinek (1960)

was one o f the first researchers to define the terms "loss of control" and "inability to

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abstain.” He used these concepts as defining characteristics of two different subtypes of

physically dependent alcoholics. Jellinek's description o f loss of control and inability to

abstain were of great value and remain important concepts in the area o f addiction

research and literature.

One of the theories proposed in this study, which underlies the mechanisms of

change that is necessary for recovery, is the acceptance of “powerlessness.” The

admission o f powerlessness leads to the goal o f giving up control over one’s use of

alcohol and drugs for one’s entire life. This first step is a necessary mechanism for

successful recovery. This study examined how the desirability of self-control may

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influence treatment completion and relapse during treatment for substance dependent

outpatients.
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The area of literature on self-control has long been plagued with terminological
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confusions and misconceptions. For example, the term “self-control” is often interpreted

as being synonymous with restraint, in addition to being labeled as “self-regulation” and

“self-management” (Thorensen & Mahoney, 1974). Conceptually, there are two basic
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views on the issue o f self-control: traditional “willpower” conceptions and functional

“behavioral” conceptions. “Willpower” is defined as a personality trait or psychic force

that enables the person to exhibit control over his own actions. However, this

intrapsychic conception o f self-control as being composed of willpower has not shown

itself to be a helpful concept in the experimental analysis of self-control (Thorensen &

Mahoney, 1974).

The definition o f self-control, according to Thoresen and Mahoney (1974),

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involves three important features. The first feature involves two or more alternate

behaviors. For example, the individual who chooses to quit drinking or using drugs has

the option to (1) use or (2) not use. The second feature involves the consequences of the

two alternative behaviors, which are usually conflicting. For example, the consequences

o f using may be immediately pleasurable but eventually aversive, while the consequences

of not using may be completely the opposite. The final feature is the self-regulatory

pattern, which is usually prompted and/or maintained by internal factors such as long­

term consequences.

Several key theorists, such as Tiebout (1944), Brown (1985) and Mack (1981),

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have offered conceptual frameworks based on the concept of “control” to explain what
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takes place when the alcoholic stops drinking. In the 1940’s, Harry Tiebout, M.D.,

provided the best known, and most comprehensive examination o f what happens to
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alcoholics in recovery. Tiebout (1944) saw the successful change from drinking to

abstinence as a conversion phenomenon that he defined as a "psychological event in

which there is a major change in personality manifestation.” He observed the creation of

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a positive attitude toward reality following the act of “surrendering” (Brown, 1985).

According to Brown, through surrendering, the addict can accept reality. “Reality,” as

defined by Mack, is accepting the loss of control or powerlessness over alcohol (Mack,

1981). The individual who has accepted the “reality” of his or her loss-of-control can

proceed with living in this newly acquired “reality,” thereby beginning the process of

recovery. This process is synonymous with Step One of the twelve-step program of

Alcoholics/Narcotics Anonymous. According to AA philosophy, the cornerstone of

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successful recovery is the acceptance of powerlessness over alcohol. Specifically, in Step

1 of the 12 Steps: "We admitted we are powerless over alcohol - that our lives had

become unmanageable." The admission of powerlessness is viewed as the first step in the

assumption o f responsibility and recovery. It is the false belief in control and the striving

for control that keeps the individual so resistant to recognizing his or her powerlessness

over alcohol/drugs, and perpetuates drinking in the alcoholic and drug use in the addict.

The false, irrational belief in the possibility o f controlled drinking or using drugs stands

in the way of surrendering and acceptance. The belief that control o f drinking or using

can be achieved is the fundamental confusion a substance dependent individual struggles

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with in their addiction. The need to control an “out o f control” behavior by increasing
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control, eventually propels the substance dependent individual down the path of

continued use to destruction.

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The recovering addict in Alcoholics Anonymous and Narcotics Anonymous is

encouraged to adopt a belief in a power greater than oneself. This supports relinquishing

the belief in the ability to achieve controlled drinking through the power of self-control or
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“willpower.” The alcoholic/addict surrenders their desire for self-control over their

substance use and their lives in order to live a life in recovery. There are some differences

o f opinion in A.A. regarding the definition of self-control. Some A.A. theorists state that

in order to successfully complete the first step, the addict must admit to the loss of control

over his/her addiction, and admit to the loss of control over all aspects of their life. Other

theorists have a more moderate position, stating the definition of loss of control is only in

regard to the area in their life that deals with their addiction. (Wallace, 1996).

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Addiction affects every aspect o f one’s life. There is the downward spiral that

destroys one’s self-image, interpersonal relationships, career, financial stability, health,

and ultimately, one’s future. Furthermore, the DSM-IV (1994) describes substance

dependence and abuse as clinically significant impairment or distress in important social,

occupational, or recreational activities. Therefore, the definition of giving up control in

this study was defined as encompassing a global concept, which was interpreted as the

stricter position cited in Wallace (1996) and the DSM-IV (1994).

This study hypothesized that people who self-disclose, as measured by the Self-

Disclosure Index, would be more likely to complete outpatient substance dependence

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treatment and have a lower rate of relapse than people who do not disclose. This study
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also utilized the concept of self-control, as measured by the Desirability o f Self-Control

Scale, as a second variable, to predict outpatient substance dependence treatment

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completion and relapse within treatment. The subjects who have acknowledged the loss

of control over their lives were expected to complete treatment, and relapse less often

than subjects with a feeling of self-control over their lives. Combined, these two
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variables were utilized to predict treatment completion and relapse during treatment.

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CHAPTER H

REVIEW OF LITERATURE

This chapter is divided into six sections. The first two sections review the

literature on the two predictor variables, self-disclosure and self-control, utilized in this

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study to predict relapse and treatment completion among substance dependent

outpatients. The third and fourth sections examine the literature on relapse and treatment
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outcome. The fifth section examines alcohol dependence and its treatment. The final

section of this chapter is the statement o f the problem and the hypotheses.
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Self-Disclosure
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The literature on self-disclosure has developed over the last forty years, beginning

in 1958 with the work of Jourard and Lasakow (Braithwaite, 1974). Self-disclosure has

been defined in various terms by several different authors. Jourard (1960) defined self­

disclosure as “the amount of personal information that one person is willing to disclose to

another” (p.428). Chelune (1976) defined self-disclosure as “the communication of

personal information about one’s self’ and “an important and broad conceptual class of

behavior which has both verbal and nonverbal components.”

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Several authors have described self-disclosure as a behavioral dimension. Cozby

(1973) in his review of literature on self-disclosure identified: “(a) breadth or amount o f

information disclosed, (b) depth or intimacy of information disclosed, and (c) duration or

amount o f time spent describing each item of information” (p. 75). Chelune (1976) in his

article on self-disclosure, discussed the importance o f the additional dimensions of

“(d) affective manner of presentation, and (e) flexibility of disclosure pattem.”(p.l5)

In 1970, Jourard and Resnick studied self-disclosure among college women. The

subjects, 80 unmarried females, were given a 40-item (self-disclosure) questionnaire,

which asked them to indicate which o f the topics that they had fully revealed to a friend,

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and which topics they would be willing to discuss with a same sex partner who is a
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stranger. Subjects who scored high were chosen to form the high disclosure group

(x=149.00), while the lower scores were assigned to the lower disclosure group
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(x=42.08). The answer sheets were scored by either an unweighted method, each item

was simply rated by the subject as follows: 0 = declined to answer; 1 = withheld some

relevant things - did not disclose fully; 2 = withheld nothing relevant - disclosed fully.
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The numerical values assigned to the ratings were summed for each subject yielding

unweighted self-disclosure scores. For weighted scores, the value of each topic was taken

into account (numerical weights assigned as indicated in the parentheses): L = low

intimacy (1); M = medium intimacy (2); H = high intimacy (3). A weighted rating for

each item was obtained by multiplying the subjects rating by the intimacy value of the

item (e.g., a highly intimate item disclosed fully yields a weighted rating of 6; a low

intimacy item disclosed fully yields a weighted rating o f 2). These weighted ratings were

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