THE EFFECTS OF PERCEIVED COERCION AND EMPOWERMENT ON MOTIVATIONAL PROCESSES FOR ADULTS ORDERED TO ATTEND SUBSTANCE ABUSE TREATMENT: A MIXED METHODS ANALYSIS by Tiffany Jo Merrill A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Educational Psychology The University of Utah August 2013 Copyright © Tiffany Jo Merrill 2013 All Rights Reserved The University of Utah Graduate School STATEMENT OF DISSERTATION APPROVAL The dissertation of Tiffany Jo Merrill has been approved by the following supervisory committee members: Susan L. Morrow , Chair 5/2/2013 Date Approved Jason Burrow-Sanchez , Member 5/2/2013 Date Approved Kirsten Butcher , Member 5/2/2013 Date Approved Lynne Durrant , Member 5/2/2013 Date Approved Kelly J. Lundberg , Member 5/2/2013 Date Approved and by Elaine Clark , Chair of the Department of Educational Psychology and by Donna M. White, Interim Dean of The Graduate School. ABSTRACT Substance abuse treatment agencies increasingly work with clients who are mandated to treatment by the criminal justice system. This trend has necessitated a better understanding of the impact of clients’ subjective perceptions of coercion on motivation for treatment and recovery. The present study utilized a mixed methods approach to understand the impact of both perceived coercion and empowerment on motivational processes for adults ordered by the criminal justice system to attend substance abuse treatment. Data were collected from 98 adults ordered to undergo assessment and treatment for substance abuse problems as the result of a drug-related offense. It was hypothesized that perceived coercion and empowerment would be negatively correlated. While these variables were negatively correlated, they value of the correlation was not significant. It was also hypothesized that perceived coercion and empowerment would predict motivational processes, including motivational readiness-to-change levels and whether or not motivation was internalized. Multiple and logistic regression analyses indicated that, as hypothesized, perceived coercion was a significant predictor of these processes: Higher perceived coercion predicted lower motivation levels and noninternalized motivation. Contrary to this hypothesis, however, empowerment was not a significant predictor of motivational processes. A grounded theory analysis of 11 participant interviews (from the original sample of 98 participants) resulted in the emergence of 6 themes that further developed the relationship among perceived coercion, empowerment, and motivation. The grounded theory model provided good validation of the statistical findings, suggesting that when participants spoke of feeling coerced into treatment, they spoke of a negative impact on motivation. However, the majority of interviewees, regardless of their feelings about the court order, had high expectations for treatment and anticipated addressing mental health issues and other “tools” of treatment. In further support of the statistical findings, interview participants also had a difficult time describing empowerment as impacting motivation. Instead, many participants suggested that as they worked toward recovery, which reflected a foundation of motivation, they often felt more empowered as a result. iv Dedicated to Nancy and Marty Merrill, Dylan Esson, and the memory of Bob and Mary Walker. TABLE OF CONTENTS ABSTRACT ....................................................................................................................... iii LIST OF TABLES ........................................................................................................... viii LIST OF FIGURES ........................................................................................................... ix Chapter 1. INTRODUCTION .......................................................................................................1 Literature Review.................................................................................................................3 2. METHOD ..................................................................................................................39 Mixed Methods Rationale ..................................................................................................40 Paradigm ............................................................................................................................41 Research Design.................................................................................................................44 Institutional Review Board Approval ................................................................................45 Participants and Recruitment .............................................................................................46 Sources of Data and Data Collection .................................................................................53 Data Analysis .....................................................................................................................66 Researcher as Instrument ...................................................................................................72 Ethical Considerations .......................................................................................................75 3. RESULTS ..................................................................................................................77 Research Questions 1 and 2: Statistical Analysis ..............................................................78 Research Question 3: Grounded Theory Analysis .............................................................87 Integration of Results .......................................................................................................135 4. DISCUSSION ..........................................................................................................144 Summary and Discussion of Major Findings...................................................................146 Limitations and Implications for Research ......................................................................160 Strengths ..........................................................................................................................164 Implications for Clinical Work and Social Justice ..........................................................165 Conclusion .......................................................................................................................167 Appendices A. RECRUITMENT FLIER ....................................................................................169 B. IRB INFORMED CONSENT DOCUMENT ......................................................170 C. DEMOGRAPHIC QUESTIONNAIRE ..............................................................174 D. DRUG USE INDEX ...........................................................................................175 E. UNIVERSITY OF RHODE ISLAND CHANGE ASSESSMENT (URICA) .....177 F. AUDIT TRAIL ...................................................................................................181 REFERENCES ................................................................................................................182 vii LIST OF TABLES Table Page 1. Stages of Change (SOC) and Associated Tasks and Goals .....................................6 2. Processes of Change (POC): Cognitive/Experiential and Behavioral .....................8 3. Participant Demographics: Race and Ethnicity, Religious Affiliation, and Sexual Orientation ............................................................................................................50 4. Demographic Information for Interviewed Participants ........................................52 5. Descriptive Statistics for IVs and DVs ..................................................................80 6. Descriptive Statistics for Stage of Change and Regulation Type ..........................80 7. Intercorrelations Between Perceived Coercion, Empowerment, Motivation, and Demographic/Use History Variables .....................................................................83 8. Hierarchical Regression Model Summary .............................................................85 9. Hierarchical Regression: Coefficients for Models 1-3 ..........................................85 10. Logistic Regression Predicting Likelihood of Internalized Motivation ................86 11. Scores on Survey Data for Interviewed Participants ...........................................140 LIST OF FIGURES Figure Page 1. ‘Most Problematic Drug’ as a Percentage of the Sample ........................................51 2. Conceptual Model of Themes ...............................................................................131 3. Integration of Conceptual Model and Statistical Findings ...................................142 CHAPTER 1 INTRODUCTION Understanding motivational processes among clients in treatment for substance abuse has proved elusive for researchers and clinicians alike. As a growing proportion of those in treatment for drug and alcohol problems arrive at treatment through mandates from the criminal justice system, motivation for changing substance abuse and/or dependence problems is an especially salient issue. California’s 2000 Substance Abuse and Crime Prevention Act, which mandates nonviolent drug offenders into substance abuse treatment as an alternative to incarceration, has provided a model for