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A Pervasive Mental Model of Addiction Recovery and Its Implications for Sustaining Change Erin Stringfellow Washington University in St

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A Pervasive Mental Model of Addiction Recovery and Its Implications for Sustaining Change Erin Stringfellow Washington University in St Washington University in St. Louis Washington University Open Scholarship Arts & Sciences Electronic Theses and Dissertations Arts & Sciences Spring 5-15-2019 “You Have to Want It”: A Pervasive Mental Model of Addiction Recovery and Its Implications for Sustaining Change Erin Stringfellow Washington University in St. Louis Follow this and additional works at: https://openscholarship.wustl.edu/art_sci_etds Part of the Psychiatric and Mental Health Commons Recommended Citation Stringfellow, Erin, "“You Have to Want It”: A Pervasive Mental Model of Addiction Recovery and Its Implications for Sustaining Change" (2019). Arts & Sciences Electronic Theses and Dissertations. 1760. https://openscholarship.wustl.edu/art_sci_etds/1760 This Dissertation is brought to you for free and open access by the Arts & Sciences at Washington University Open Scholarship. It has been accepted for inclusion in Arts & Sciences Electronic Theses and Dissertations by an authorized administrator of Washington University Open Scholarship. For more information, please contact [email protected]. WASHINGTON UNIVERSITY IN ST. LOUIS Brown School Dissertation Examination Committee: Renee M. Cunningham-Williams, Chair Patrick Fowler Sarah Gehlert Lee Hoffer Peter S. Hovmand Carrie Pettus-Davis Bradley Stoner “You Have to Want It”: A Pervasive Mental Model of Addiction Recovery and Its Implications for Sustaining Change by Erin J. Stringfellow A dissertation presented to The Graduate School of Washington University in partial fulfillment of the requirements for the degree of Doctor of Philosophy May 2019 St. Louis, Missouri © 2019, Erin Stringfellow Table of Contents List of Figures ............................................................................................................................... iv List of Tables ................................................................................................................................. v Acknowledgments ........................................................................................................................ vi Abstract ......................................................................................................................................... ix Chapter 1: Introduction ............................................................................................................... 1 1.1 Overview of the Dissertation ................................................................................................. 1 1.2 Statement of the Problem ...................................................................................................... 2 1.3 Significance of the Study ....................................................................................................... 4 Chapter 2: Background ................................................................................................................ 5 2.1 Theoretical Framework ......................................................................................................... 5 2.2 Substantive Background ...................................................................................................... 10 2.3 Gaps in Prior Research ....................................................................................................... 33 Chapter 3: Methods .................................................................................................................... 35 3.1 Research Design .................................................................................................................. 35 3.2 Setting .................................................................................................................................. 40 3.3 Sampling and Recruitment .................................................................................................. 49 3.4 Data Collection ................................................................................................................... 51 3.5 Data Coding and Analysis ................................................................................................... 53 3.6 Simulation Model Development .......................................................................................... 56 Chapter 4: Grounded Theory Results ...................................................................................... 64 4.1 Sample ................................................................................................................................. 64 4.2 Factors Driving the Propensity to Use ............................................................................... 66 4.3 “You Have to Want It” ........................................................................................................ 70 Chapter 5: Model Simulation Results ..................................................................................... 110 5.1 Reference Modes ............................................................................................................... 110 5.2 Model-Building Steps ........................................................................................................ 121 5.3 Model Equations ............................................................................................................... 132 5.4 Baseline Model .................................................................................................................. 136 5.5 Model Experimentation ..................................................................................................... 146 ii Chapter 6: Discussion ............................................................................................................... 176 6.1 Summary ............................................................................................................................ 176 6.2 Implications for Social Work Practice and Policy ............................................................ 186 6.3 Implications for Research ................................................................................................. 193 6.4 Limitations ......................................................................................................................... 196 6.5 Future Directions .............................................................................................................. 199 6.6 Conclusion ......................................................................................................................... 201 References .................................................................................................................................. 203 Appendix .................................................................................................................................... 226 iii List of Figures Figure 2.1. Trajectories of Use Over 30 Years as Described in the Literature ............................. 18 Figure 2.2. Three “Business as Usual” Patterns of Use Over 30 Years and Desired Pattern ....... 23 Figure 3.1. Causal Loop Diagram ................................................................................................. 40 Figure 3.2. Map of 2010 Census Tracts in Franklin County, Missouri ........................................ 46 Figure 3.3. Past Year Use of Selected Drugs, Missouri, 2015-2016 ............................................ 48 Figure 3.4. Iterative Translation between Interviews, Coding, and Model .................................. 59 Figure 3.5. Difference Between a Qualitative Shift and a Numeric Difference in Trends ........... 62 Figure 4.1. Propensity Reinforcing Loop ..................................................................................... 67 Figure 4.2. Fear of Future Self ...................................................................................................... 74 Figure 4.3. Adjusting Expectations ............................................................................................... 76 Figure 4.4. Nothing to Live For and Nothing to Lose .................................................................. 79 Figure 4.5. Ambivalence about Quitting Reinforces Use ............................................................. 82 Figure 4.6. Monitoring for Evidence of Wanting It ...................................................................... 88 Figure 4.7. Loved Ones Withdrawing........................................................................................... 92 Figure 4.8. Sick and Tired Balancing Loop (Final Diagram) ..................................................... 106 Figure 5.1. Three “Business as Usual” Patterns of Use Over 30 Years and Desired Pattern ..... 112 Figure 5.2. Reference Mode for Propensity to Use .................................................................... 114 Figure 5.3. Reference Modes for Recovery Starting 15 Years After Initiation .......................... 121 Figure 5.4. Baseline Model ......................................................................................................... 139 Figure 5.5. Baseline Model with Low Initial Support Received ................................................ 140 Figure 5.6. Baseline Model with High Initial Support Received ................................................ 142 Figure 5.7. Effect of Reducing Propensity for One Month for Average Initial Support ............ 150 Figure 5.8. Independent Effects of Interventions on Propensity to Use ..................................... 162 Figure 5.9. Independent Effects Interventions
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