Emotional factors involved in substance abuse in a sample of rehabilitation clients.

Substance abuse among rehabilitation clients who had other (not substance abuse) primary disabilities has received considerable attention in recent years (Buss & Cramer, 1989; Greer, Roberts, & Jenkins, 1990; Hienemann, Goranson, Ginsberg, & Schnoll, 1989; Moore, Greer, & Li, 1994). For example, Buss and Cramer (1989) reported that 40 to 50 percent of persons with disabilities indicated moderate to heavy drinking. Hienemann et al. (1989) found that 39 percent of their spinal cord injured sample were intoxicated at the time of injury and reported an average of 2.5 alcohol-related incidents six months following injury. Greer (1986) reviewed research on the incidence of alcohol and drug abuse among people for whom substance abuse was not the primary disability. For some disability groups (e.g., amputees, clients with spinal cord injuries, and psychiatric patients), abuse was dramatically higher than for the general population.

Until recently, such writings have focussed primarily on the incidence of substance abuse problems. Little has been published on mediating factors associated with such problems. Moore et al. (1994) investigated attitudes associated with alcohol abuse. They found positive relationships between problematic drinking and attitudes toward entitlement and risk-taking behaviors. Thus, rehabilitation clients who drank excessively were more prone to see themselves as deserving breaks and represented themselves as high risk takers.

Sociological factors associated with drug abuse by persons with disabilities were reviewed by Alston, Harley, and Lenhoff (1995). Those authors proposed that predisposing factors such as isolation are operative in the dynamics of disability and drugs much as they are in youth, delinquency, and drugs. Phrases such as "compensation for guilt," "ease the pain," "excessive frustration," "choosing an escape," "oppressed minority," "relief from oppression," "placatory behaviors," "hostile encounters," "stressful demands," "feelings of helplessness," "stigmatized and dependent," and "isolation and loneliness" are found in literature that seeks rationale for substance abuse and leads toward intervention strategies.

Emotional factors associated with adjustment to disability have been discussed by Vash (1981), Deloach and Greer (1981), Marshak and Seligman (1993), and Ferguson, Dodds, Craig, Flannigan, and Yates (1994). Much of such discussion centers around anxiety, anger, and depression. For example, Ferguson et al. (1994) found anxiety and depression impacted feelings of self-worth. Although rehabilitation personnel may view anger outbursts as an indicator of hostility, Marshak and Seligman (1993) discussed the need for rehabilitation personnel to allow clients to express anger more freely. Such outbursts may be attempts to compensate for a perceived loss of control over their lives. Anxiety, according to Deloach and Greer (1981), is a result of the uncertainty of the individual in coming to terms with disability and the future. Both Deloach and Greer (1981) and Vash (1981) saw the use of alcohol as one way to deal with anxiety. Marshak and Seligman (1993) stated that depression is another stage or phase of adjustment to disability. Depression includes feelings of worthlessness, self blame, and suicidal thoughts. In addition to potential relationships of anxiety, anger, and depression to substance abuse, a measure of bizarre thoughts was included in the present research. Little is written regarding bizarre thoughts in relation to substance abuse or adjustment to disability, except in relation to psychiatric conditions per se.

Most of the prior work reported in the literature either has involved the study of incidence of abuse or has been theoretical as opposed to empirical. The present study was undertaken as a preliminary investigation of emotional factors associated with substance abuse among persons with disabilities. The purpose was to identify emotional factors related to alcohol abuse and/or drug abuse for this population. Investigation of mediating factors is required to provide potential in-roads for treatment and prevention. If links between emotional factors and substance abuse are identified, the legendary recalcitrance of drug and alcohol abuse might be more profitably approached by reducing maladaptive emotional responses.

Method

Sample

The sample consisted of 2,837 consumers (clients) of vocational rehabilitation services who were administered the Preliminary Diagnostic Questionnaire by rehabilitation counselors in 30 different states. Collection of the data was part of certification of examiners by the West Virginia Rehabilitation Research and Training Center (Moriarty, Walls, & McLaughlin, 1987). These rehabilitation counselors were learning to use the instrument as a functional assessment tool in the vocational rehabilitation process. The counselors were at liberty to select the consumers (clients) they would test. The resulting data provided a diverse sample of rehabilitation clients well suited to studying potential links between emotion and substance abuse for individuals with disabilities.

The sample consisted of 58.7% males and 41.3% females. There were 78.5% White, 21.0% Black, and 0.5% other races. There were 19.7% under the age of 21, 62.2% between 21 and 40, 17.8% between 41 and 60, and 0.3% older than 60. In terms of disabilities, 1.6% of the sample had visual impairments, 2.9% had hearing impairments, 27.0% had orthopedic impairments, 1.8% had amputations, 42.4% had mental impairments, and 24.4% had other impairments.

Instrument

The Preliminary Diagnostic Questionnaire (PDQ) was developed by Moriarty in 1981 (Moriarty, Walls, & McLaughlin, 1987). It was designed as a screening in-take instrument to be used by vocational rehabilitation counselors in identifying strengths and weaknesses of clients in planning their programs. Specifically, the PDQ was designed to assess cognitive factors, psychomotor skills, motivation factors, and emotional functioning (Moriarty, Walls, & McLaughlin, 1988).

Moriarty, Minton, and Spann (1981) stated that the Emotional Functioning scale of the PDQ includes 20 items and assesses four factors. These are anxiety (e.g., "I feel so tense I can't think straight"), anger (e.g., "I get mad"), depression (e.g., "I feel my life is worthless"), and bizarre thoughts (e.g., "I hear voice that other people don't hear"). Each of these items was scored on a 1 to 4 scale (always to never). In addition, consumers responded to "I have a problem with drinking" and "I have a problem with drugs," each on a I to 4 scale (always to never). Reliability of the Emotional Functioning scale was reported as r=0.86 for internal consistency (coefficient alpha) and r=0.91 for stability (test-retest over a 30 day interval). Validity of the content was based on the analysis of critical incidents in which rehabilitation clients who had been placed on a job failed due to emotional difficulties (Moriarty, Walls, & McLaughlin, 1986). When these critical incidents were analyzed, anxiety, depression, aggression/anger, and bizarre behavior were the four types of emotional problems identified. An initial pool of 35 items representing these concepts was reduced to the final 20 items using standard scale-development techniques (e.g., inter-item correlations, item to total correlations, ease of understanding, domain sampling). The 20-item emotional functioning scale was shown to significantly differentiate between those having a mental-illness disability and those having other types of disabilities.

Procedure

The database of vocational rehabilitation consumers (clients) screened via the PDQ instrument was accessed. Subsets of the database were created to allow valid comparisons of like-sized groups and to determine demographic composition in relation to the target variables. Demographic variables included gender, race, age, and disability category. Substance abuse variables were alcohol use and drug use. Emotional functioning variables were anxiety, anger, depression, and bizarre thoughts, as measured by the PDQ.

Results

The primary purpose of this investigation was to determine whether consumers reporting substance abuse could be distinguished from consumers not reporting substance abuse on emotional functioning variables. The numbers of consumers responding to the alcohol and drug items are presented in Table 1. On the alcohol abuse item, 503 consumers (17.7% of the sample) reported having a problem with drinking "always, often, or sometimes." On the item related to drug abuse, 259 consumers (9.1% of the sample) reported having a problem with drugs "always, often, or sometimes."

Table 1

Consumers' Responses to the Alcohol and Drug Items(a)

Item      Response       Code      N    % of Sample
Alcohol   Always          1       131        4.6
          Often           2        71        2.5
          Sometimes       3       301       10.6
          Never           4     2,334       82.3

Drugs     Always          1        77        2.7
          Often           2        36        1.3
          Sometimes       3       146        5.1
          Never           4     2,578       90.9

(a) Participants' responses to "I have a problem with drinking" and "I have a problem with drugs."

To gain balanced comparison in terms of both degree and &umber, random samples were drawn, via a computer algorithm, from the consumers responding "never" to analyze against those who responded "always." Thus, the independent variable for alcohol abuse included 131 abusers (drinking always a problem) versus 129 nonabusers (drinking never a problem). The results of these one-way analyses of variance and the means are reported in Table 2. Consumers for whom drinking was always a problem expressed significantly more anxiety (p [is less than] .01) and anger (p [is less than] .01) than did those for whom drinking was never a problem. These two groups did not differ when either depression (p [is greater than] .05) or bizarre thoughts (p [is greater than] .05) was the dependent variable.

Table 2 Comparisons of Alcohol and Drug Abusers versus
Nonabusers (Independent Variable) on Anxiety, Anger, Depression,
and Bizarre Thoughts (Dependent Variables)

Independent Variables                  Dependent Variables

                                       Anxiety     Anger

Alcohol
 F value                               13.20        14.37
 Significance                          p<.01        p<.01
 Abusers Mean (n=131)(a)               14.2(b)      16.0
 Nonabusers Mean(n=129)(a)             15.3(b)      17.0

Drugs
 F value                                8.97        17.07
 Significance                          p<.01        p<.01
 Abusers Mean(n=78)(a)                 13.9(b)      15.5
 Nonabusers Mean (n=77)(a)             15.1(b)      16.9

                                     Depression    Bizarre Thoughts

Alcohol
 F value                                0.09         1.53
 Significance                            NS           NS
 Abusers Mean (n=131)(a)               15.8          14.6
 Nonabusers Mean(n=129)(a)             15.8          14.3

Drugs
 F value                                0.03          0.00
 Significance                            NS           NS
 Abusers Mean(n=78)(a)                  15.5          14.4
 Nonabusers Mean (n=77)(a)              15.6          14.4

(a) The numbers of consumers varied slightly in the different analyses. (b) Smaller means indicate greater problems (reverse scoring) for all dependent variables.

In the second set of four analyses of variance, the independent variable for drug abuse was composed of 78 abusers (drugs always a problem) versus 77 nonabusers (drugs never a problem). The two groups were compared on the measures of anxiety, anger, depression, and bizarre thoughts. Results of the analyses of variance and the means appear in Table 2. Clients who acknowledged problems with drugs were more anxious (p [is less than] .01) and angry (p [is less than] .01 than clients without drug problems. As with the alcohol abusers, those for whom drugs were always a problem did not differ significantly from consumers for whom drugs were never a problem on the variables of depression (p [is greater than] .05) and bizarre thoughts (p [is greater than] .05).

Thus, the measures of anxiety and anger were demonstrated to differentiate between those for whom substance abuse was always a problem versus never a problem. Calculation of internal consistency (coefficient alpha) yielded high levels of reliability for both anxiety and anger. These reliability coefficients (alpha) were r=0.74 for anxiety, r=0.78 for anger, r=0.67 for depression, and r=0.61 for bizarre thoughts. Reliability of the overall Emotional Functioning scale was calculated to be r=0.86. The n was approximately 2,900 consumers for each of these reliability coefficients.

Discussion

The objective of this investigation was to explore intervening emotional factors involved in substance abuse by consumers with disabilities. It was found that consumers who acknowledge abusing alcohol or drugs also tend to be angrier and more anxious than nonabusers. It would appear that anger and anxiety are mediating factors in abuse of alcohol or drugs for this sample. Replication of these results is warranted for the following reasons. First, substance abuse patterns appear to have changed since the 1980s when the counselors assessed these individuals with disabilities. Second, more extensive measures of substance use/abuse as well as measures of emotional functioning would be desirable. Third, replication studies could compare and contrast results for (a) consumers of rehabilitation services who do not abuse substance) (b) consumers whose primary disability is not substance dependence, and (c) consumers whose primary disabling condition is substance dependence. On the basis of the results of this investigation, it appears appropriate to develop intervention strategies that incorporate activities for anger management and techniques to reduce anxiety.

Anxiety is characterized by varying degrees of fear or worry about things to come. It can be a vague uneasiness, worry about a specific upcoming event, or intolerable phobia. The disquieting anxiety associated with the stress, isolation, and learned helplessness of disability may contribute to abuse of alcohol and drugs. Substance abuse, although offering some relief, may in turn increase fears and further the debilitating cycle. Anxiety-reduction treatments can result in lowered self-reports of anxiety but little difference in such measures as test-taking performance. There are effective anxiety-reducing techniques, however, ranging from therapeutically-oriented approaches (e.g., systematic desensitization or relaxation) to cognitive interventions (e.g., structured instruction or increasing competence and feelings of competence). Interventions may be easier and more productive that work on the anxiety than on the drinking behavior.

Anger involves stress leading to physiological arousal (e.g., increased heart rate, rapid breathing, warm face) and covert statements or thoughts (e.g., cognition about getting even with someone or planning hostile actions). Intense feelings of agitation may be prerequisite to coping through substance abuse or may be triggered by an altered state of mind in the presence of stimuli that would ordinarily not produce rage. Frustrations and barriers encountered by persons with disabilities may bring about such intense feelings of anger. Drug use and drinking may also be defiant behavior intended as retribution against society or a given person. Interventions that involve both physical and mental relaxation along with factual information and coping escape routes have proven relatively effective. In such stress inoculation therapy, there is attention to preparing for provocation, confronting the provocation, and reflecting after one's reaction to the provocation. The insult of disability often constitutes severe and persistent provocation. The peaks and valleys of substance abuse in tandem with disabling conditions and accompanying day-to-day stressors create an architecture for anger that is difficult to dismantle.

In recent years, the distinction between alcohol users and drug users has blurred due to the fact that most individuals entering treatment in the 90s are "polysubstance abusers" (Doweiko, 1996; George, 1990). For example, a person who prefers cocaine may use alcohol to "come down." A person abusing alcohol may use Valium to quell the "shakes" in the morning. Such individuals become dependent on a number of different substances, and their behaviors support a "self-medication hypothesis." Khantzian (1985) proposed that many people with underlying psychiatric conditions use substances to suppress symptoms such as anger and anxiety. Anxiety reduction treatments, including deep breathing, relaxation, and self-talk, may be warranted to assist the consumer in managing anxiety more effectively. Anger management might include cognitive-behavioral techniques and assertiveness training. Although the convoluted antecedents and consequences of disabling conditions, substance abuse, anger, and anxiety are not easily understood, the present results provide a platform for revised thinking. More effective interventions demand painstaking research to explicate the causes, effects, and associates operating within this deadly network.

Author Notes

This research was supported, in part, by the West Virginia Rehabilitation Research and Research and Training Center. Appreciation is expressed to Lori Britton and Debra Hardesty for manuscript preparation.

References

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Richard T. Walls, West Virginia University, Rehabilitation Research and Training Center, PO Box 6122, Morgantown, WV 26506-6122. Email: [e-mail]