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Client perceptions of incest and substance abuse
Addictive
Pergamon
Behaviors, Vol. 22, No. 4, pp. 447-45’). 1997 Copyright 0 1997 Elsevier Science Ltd Printed in the USA. All rights reserved
0306_4603/Y7 $17.00+ .oO
PI1 s03ofA603(%)ooo55-x
CLIENT PERCEPTIONS
OF INCEST AND SUBSTANCE ABUSE
TIMOTHY
and JAMES E. BORDIERI
P. JANIKOWSKI
Southern Illinois University at Carbondale
NOREEN
M. GLOVER
Syracuse University Abstract - Clients receiving substance abuse treatment from 35 treatment facilities throughout the United States were surveyed using the Substance Abuse and Incest Survey-Revised (SAIS-R). A total of 732 participants responded to the survey; 518 (71%) were males, 204 (28%) were females, and 10 (1%) did not indicate gender. Participants had a mean age of 33.8 years, were predominately Caucasian (61.6%), never married (45.2%). were currently unemployed (69.4%). and had completed an average of 11.7 years of education. Of the entire sample, 266 (36.3%) reported having been victims of incest; 151 were males and 113 were females (2 did not indicate gender). The group reporting incest histories had a significantly greater percentage of females that did the group not reporting incest histories (x2 = 48.1, p < .OOl). Participants with incest histories were asked about their perceptions regarding incest, substance abuse. and counseling. Item responses were examined using descriptive statistics and factor analysis. The factor analysis on SAIS-R perception items identified five factors that accounted for 68.9% of the variance; these factors were Stigma and Resistance to Counseling: Substance Abuse and Incest; Ambivalence: Fear and Anticipation; and Receptivity to Counseling. Results are presented and the implications for substance abuse treatment and counseling are discussed. 0 1997 Elsevier Science Ltd
Incest is understood to be sexual contact with a person who has close blood or social ties (i.e.. relative). Close blood or social ties include parents, step-relatives, grandparents. uncles, aunts. cousins, siblings, in-laws, and quasi-family members (e.g.. a parent’s sexual partner; Benward & Densen-Gerber, 1975: Vander Mey & Neff. 1984). Unfortunately, the incidence of incest in the United States is not well known: it is difficult to determine because the stigma associated with incest makes victims and family members reluctant to report the problem (Hyde & Kaufman, 1984). Further, national data on the incidence of childhood incest are not kept (National Council on Child Abuse; personal communication, Jan. 8, 1992). Nonetheless, Hyde and Kaufman (1984) projected that approximately 9% of the female population would have incestuous encounters with an older adult relative. Most research on incest focuses on females with less attention being given to male victims. In a review of the literature discussing male incest cases, Pierce (1987) stated that males constituted between 12% and 33% of the sexually abused children who are reported. Of these cases. between 6% and 50% were abused by parents or step-parents. Parents United, a self-help group for victims of incest and their families, estimates that 25% of all women and nearly the same percentage of men in the United States will be sexually molested bcfore age 18. They further state that more than 70% of these molestations are committed by a family member or close family friend, thus constituting an incestuous contact (Yearly. 1982). This research was supported by a grant from the ALCOA foundation. Requests for reprints should be sent to Timothy P. Janikowski, Rehabilitation Education, Southern Illinois University at Carbondale. Carbondale. IL 62901-4609. 0 1997 Elsevier Science Ltd. All rights reserved. 447
Institute, College of
448
T. P. JANIKOWSKI
et al.
Recently, researchers have begun to examine the adult consequences of having experienced an incestuous assault. Hyde and Kaufman (1984) referred to incest as a “psychological nightmare that continues into adulthood requiring some kind of behavioral and psychological adaptation” (p. 148). When the effects of the sexual traumatization are not treated, psychological dysfunction may emerge, including amnesia, phobias, anxiety states, low selfesteem, and guilt (Hyde & Kaufman, 1984). Given the strong and lasting impact that sexual victimization has on adult emotional and social functioning, it is not unreasonable to expect victims to turn to alcohol or other drugs because of these negative effects (Rohsenow, Corbett, & Devine, 1988). Drugs may in fact be used as a strategy to cope with the emotional distress caused by incest, because drugs enable victims to numb feelings, suppress memories, and dull psychological pain (Bass & Davis, 1988). Unfortunately, these “coping” behaviors often become serious addictive problems in and of themselves (Young, 1990). Research indicates that persons who have a history of sexual abuse are at increased risk for the development and maintenance of substance abuse (Covington, 1986; Rohsenow et al., 1988). It must also be noted, however, that those who abuse substances may be more susceptible or at greater risk for incest contact. Although it is difficult to ascribe causation or primacy to either, there is clearly a relationship between substance abuse and incest. For instance, Glover (1992) found that 36% of substance abuse clients who reported incest histories were under the influence at the time of the contact and they believed that up to 53% of the perpetrators of the contact were under the influence at the time. Incest histories also appear to be especially prevalent among women in substance abuse treatment (Coleman, 1987; Evans & Schaefer, 1987; Hammond, Jorgenson, & Ridgeway, 1979; Wilsnack, 1984), but are found also in a substantial proportion of male substance abusers (Glover, Janikowski, & Benshoff, 1995). Also, it has been suggested that recovering substance abusers who have childhood incest histories and remain untreated for incest have an increased probability of substance abuse relapse (Barnard, 1989; Young, 1990). Clearly, clients with histories of incest present unique challenges for substance abuse treatment and counseling. Hence, it is necessary for substance abuse treatment professionals to become more aware of incest victims on their caseloads. Further, counselors should understand how their clients with incest histories view the relationship between incest and substance abuse. Also, it is important to examine client feelings about incest counseling in the context of substance abuse treatment. Such knowledge would enable counselors to more effectively help these clients and reduce substance abuse relapse and treatment recidivism. The purpose of the present study was to examine the attitudes and perceptions of incest victims who were addicted to alcohol or drugs. Specifically, clients enrolled in not-for-profit substance abuse treatment facilities throughout the United States were surveyed; those who reported a history of incest were questioned about their perceptions toward themselves, incest, substance abuse, and counseling. Their responses to survey items were examined using descriptive statistics and the factor analysis technique. It was hoped that results would make substance abuse treatment facilities and staff more aware of the numbers of incest victims receiving substance abuse treatment. The factor analysis of items examining client perceptions was intended to identify common factors underlying these perceptions. These factors may be used as the basis for developing a brief screening device or interview questions aimed at identifying clients who believe their past incest contact affects their substance abuse, and to examine these beliefs and client willingness to incorporate incest-related counseling into substance abuse treatment.
Incest and substance abuse
449
METHOD
Instrumentation
The original Substance Abuse and Incest Survey (SAIS) was developed by Glover (1992) to investigate the incidence and characteristics of incest among substance abuse clients. The SAIS consisted of 6 items addressing demographic questions, 10 items on substance abuse treatment history, 4 items related to incest and incest counseling, an Incest History Table used to examine the nature of incest contacts, and 44 items regarding attitudes and perceptions about incest and substance abuse treatment (Janikowski & Glover. 1994). An examination of the temporal consistency of the SAIS found that 82% of items responses were identical when the SAIS was re-administered after a 2-week time period (Glover, 1992). This level of consistency was considered to be acceptable. given the historical nature of the survey items. Final instrument
The SAIS was revised for present study to increase its comprehensiveness and readability. Five experts in the fields of substance abuse or survey construction were used to examine the content validity of the SAIS-R: all five experts held doctoral degrees and were experienced researchers employed at a Midwestern university. The panel recommended three primary changes to the SAIS-R: (1) expand a table used to better report incest history, (2) make several structural changes to enhance the visual presentation of items, and (3) add 9 new items to increase the comprehensiveness of items regarding client perceptions of incest and substance abuse. The final version of the SAIS-R consisted of 6 items regarding client demographics, a table of 4 columns X 27 rows used for reporting incest history. and 53 items addressing substance abuse. treatment, and client attitudes or perceptions. Because of the focus of the present article, the remaining discussion of the instrument will be limited to the demographic items and the 28 Likert-type perception items that were subjected to a factor analysis. The first section of the SAIS-R consisted of 6 items regarding client: age, education, gender, race, marital status, and work status. The last section of the survey consisted of 28 items (numbered 26 through 53) that asked participants about their attitudes toward their incest history and substance abuse, and attitudes toward receiving incestrelated counseling as a part of their substance abuse treatment. Participants responded to each of these items by circling one of the following responses, which they .‘felt best described your opinion”: SA (Strongly Agree). A (Agree), N/A (Not Applicable). D (Disagree), or SA (Strongly Disagree). Incorporation of the N/A response into the Likert-scale was done to ensure that all participants responded to all survey items so that clients without incest histories would not complete the survey more rapidly than those who had been incest victims. Procedure
Facilities were selected from a nonprobability sample of the 10 federal regions of the United States. Public. not-for-profit substance abuse treatment facilities were randomly sampled from each of the regions using the National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs: 1992 Survey. See Table 1 for a description of the regions and states represented in the present study. One hundred and twenty-three facility administrators were contacted initially by telephone in order to describe the study and to determine their willingness to partici-
450
T. P. JANIKOWSKI
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Table 1. Ten federal regions of the United States and number of substance abuse treatment facilities surveyed in each region Region (No. of Facilities) Region I (3)
Region 3 (4)
State Connecticut Maine Massachusetts New Hampshire Vermont Rhode Island Delaware District of Columbia Maryland Pennsylvania Virginia West Virginia
Region (No. of Facilities) Region 2 (3)
New Jersey New York Puerto Rico Virgin Islands
Region 4 (4)
Alabama Florida Georgia Kentucky Mississippi North Carolina South Carolina Tennessee Arkansas Louisiana New Mexico Oklahoma Texas
Region 6 (3) Region 5 (4)
Region 7 (4)
Region 9 (4)
Illinois Indiana Michigan Minnesota Ohio Wisconsin Iowa Kansas Missouri
Arizona California Hawaii Nevada
State
Region 8 (3)
Region IO (3)
Colorado Montana North Dakota Nebraska South Dakota Utah Wyoming Alaska Idaho Oregon Washington
Nore. Total number of facilities surveyed equaled 35.
pate. One hundred and thirteen (91.9%) agreed to a review of prepared documents describing the study. The prepared documents included the following materials: (1) a cover letter explaining the purpose of the study, confirmation that the study had a human subjects committee review and approval, and an outline of procedures to administer the survey; (2) a “Letter of Explanation to Participant” describing the study; (3) a client consent form: (4) a facility consent form: (5) the SAIS-R instrument, and (6) a copy of a j-minute video where the second author read the definition of incest and incest contact and gave directions necessary for completing the survey. After mailing materials to facility administrators, each was re-contacted via telephone the following week in order to determine willingness to have his or her facility participate in the study. The sampling time frame continued for approximately a year, during which 123 facilities were contacted and 42 (34%) agreed to participate. These 42 facilities were sent the requested number of surveys. Each facility contact person requested a specific number of surveys based upon his or her estimate of the greatest possible number of clients available during the anticipated time of the survey administration. Seven of the 42 facilities, however, dropped out of the study prior to administering the survey citing such reasons as the staff being too busy, lack of client interest in the study, or lack of staff preparation to deal with incest issues. Of the 35 facilities that ultimately participated in the study, 1,340 (100%) surveys were mailed and 768 (57.3%) completed surveys were returned. Of the returned surveys, 31 were com-
Incest and substance abuse
4.51
pleted by participants who were ineligible to participate in the study because they were under age 18; these 31 surveys were excluded from all analyses. Therefore, survey data were complete on 732 participants, comprising a 54.6% return-rated based on the 1,340 surveys mailed. Because each of the facilities may not have presented the survey to the greatest possible number of clients. the 54.6% return rate may be an underestimate of the true return rate. No client information that could have identified individuals was recorded, and all clients were identified using identification numbers only. Participants were informed that the study was reviewed and approved by the Carbondale Committee for Research Involving Human Subjects and that the committee determined that the research procedures used adequately safeguarded the participant’s privacy, welfare, civil liberties, and rights. All clients volunteered to complete the survey and were not compensated for their participation. Data collection Clients were informed by the facility contact person that they were being asked to participate in a study that entailed a paper and pencil survey asking questions about their substance abuse histories and possible incest histories. Clients at each facility were informed about the nature of the information to be gathered and were not required to attend the instructions presentation by the administrator or to complete the survey. Clients also were given an opportunity to withdraw following the administrator’s instructions presentation, or at any time during the collection of the data. Clients who wished to participate were assembled in a group at each facility and then shown the video presentation. The 5-minute video described the nature of the research; defined the terms: incest, incest contact, and victim: and gave instructions for completing the survey. The directions video defined incest as sexual contact with a person who has close blood or social ties. Close blood or social ties include: parents. step-relatives, grandparents, uncles. aunts, cousins. siblings, in-laws, and quasi-family members (for example, a parent’s sexual partner). Incest contact was defined to be the unwanted touching of the sex organs or other body parts for the purpose of sexual arousal, vaginal or anal penetration, mouth to penis, mouth to vagina, or mouth to anus contact. masturbation on self or other family members in the presence of the related person, or other acts with explicit or implicit sexual intent with the related person. Following the video presentation, the administrator read the Informed Consent Form to the group of participants. Questions relating to procedure were then addressed by the site administrator. Clients agreeing to participate were given survey envelopes containing a “Letter of Explanation to the Participant,” an “Informed Consent Form.” and the SAIS-R. Participants were then instructed to arrange themselves in a manner that would allow for privacy before completing the survey. Clients also were instructed to remain in their seats until all surveys were completed and collected. When finished. clients placed their survey in the provided envelope and sealed it. A larger envelope was then passed around the room to collect all of the surveys. The final participant sealed the envelope and returned it to the administrator. Clients were dismissed and the administrator mailed the surveys to the researchers.
RESULTS
As indicated earlier, the present article focuses on the demographic items and the 28 Likert-type items regarding perceptions of incest and substance abuse. Information
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about the nature of the incest contacts (i.e., the 4 X 27 table) and the remaining 25 items may be found in Glover, Janikowski, and Benshoff (1996). Participants
A total of 732 usable surveys were collected form the 1,340 surveys mailed to public and not-for-profit substance abuse treatment facilities throughout the United States. All participants responding to the survey were receiving treatment for alcohol abuse, drug abuse, or both. Five hundred eighteen (71%) of the participants were male and 204 (28%) were female; 10 (1%) participants did not indicate gender. Respondents’ ages ranged from 18 to 72 years (M = 33.8, SD = 9.2). In terms of ethnicity, the sample was comprised of 2 (0.3%) Asians, 149 (20.4%) Blacks, 451 (61.6%) Caucasians, 88 (12.0%) Hispanics, and 23 (3.1%) Native Americans. Eleven (1.5%) participants indicated “other” as race identification and 8 (1.1%) did not indicate race. Participants’ education ranged from 1 to 26 years (M = 11.7, SD = 2.2). In terms of marital status, 110 (15.0%) indicated that they were currently married, 181 (24.7%) were divorced, 82 (11.2%) were separated, 331 (45.2%) had never been married, 20 (2.7%) were widowed, and 8 (1.1%) did not indicate marital status. Regarding employment, 145 (19.8%) participants were employed full-time, 65 (8.9%) were employed parttime, 508 (69.4%) were unemployed; 14 (1.9%) participants did not indicate work status. In response to item 12, “Have you ever had an incest contact?“, 266 (36.3%) responded “Yes,” 409 (55.9%) responded “No,” 53 (7.2%) indicated “Not Sure,” and 4 (.5%) did not respond to this item. Item 12 was used to separate participants into incest history and nonincest history groups. The Incest History group was comprised of 266 participants (151 males, 113 females, and 2 who did not report gender). The nonincest history group was comprised of 409 participants (329 males, 73 females, and 7 who did not report gender). To examine differences between groups, chi square and t-test analyses were performed on demographic responses of the incest and nonincest groups (the 53 people who indicated “Not Sure” and 4 who did not respond to item 12 were not included in this analysis). Chi-square comparisons were performed on items regarding gender, race, marital status, and work status. The only significant difference between the incest and nonincest groups was on gender (x2, p < .OOl, II = 666). indicating that a significantly greater percentage of females were in the incest group (n = 113; 42.5%) than in the nonincest group (n = 73; 17.8%). The t-test analyses were used to examine differences between the incest and nonincest groups on items regarding age and years of education; no significant differences were found between the groups. The remainder of the Results section is restricted to the incest history group (n = 266) and will examine descriptive statistics and the factor analysis of 28 items (numbered 26 through 53) that asked participants about their perceptions toward their incest history and substance abuse, and receiving incest-related counseling as a part of their substance abuse treatment. The 28 perception items were answered using a 5-point continuum: “Strongly Agree,” “Agree,” “N/A,” “Disagree,” or “Strongly Disagree.” For purposes of analysis, these items were transformed into a Likert-type agreement scale where small values indicated greater agreement (i.e., 1 = Strongly Agree, 2 = Agree, 3 = Disagree, and 4 = Strongly Disagree). The N/A or “not applicable” responses wee discarded and not included in the analysis. The greatest level of agreement (i.e., lowest mean Likert score) was 2.1 found on item 31 (Counseling for incest should be made part of my substance abuse treatment) and item 49 (I would talk about incest with my counselor if he/she asked me about it). The greatest level of
Incest and
453
substanceabuse
disagreement (i.e., the highest mean Likert score) was 3.4 found on item 30 (I am afraid that I’ll have incest contacts in the future) and item 35 (I do not talk about incest with my counselor because he/she will think 1 am a homosexual). A principal components factor analysis was performed using the FACTOR program provided by SPSS-X (SPSS Inc., 1988). The factor analysis was performed in order to reduce the 28-item space and identify factors that might underlie participant responses to the Likert-type items. A varimax factor rotation was employed; six factors met a cut-off criteria having an eigenvalue of 1.0 or greater. Factor six consisted of only one item, however, and was therefore dropped. The remaining five factors accounted for 68.9% of the response variance, and Tables 2 through 6 report the means, standard deviations. and factor loadings on each item under each factor. The five factors were labeled (1) Stigma and Resistance to Counseling (10 items accounting for 37.5% of response variance); (2) Substance Abuse and Incest (7 items accounting for 14.4% of the variance): (3) Ambivalence (5 items accounting for 7.3% of the variance); (4) Fear and Anticipation (3 items accounting for 5.0% of the variance): and (5) Receptivity to Counseling (2 items accounting for 4.7% of the variance). As can be seen by inspecting Tables 2-6, all factor loadings exceeded .46 and are well within traditionally accepted values for factor assignment. D 1S C
LJ S S 1 0
N
The incidence of incest among clients in substance abuse treatment is thought to be well above that usually reported in the general population (Janikowski & Glover, 1994). Results of the present study found a sizable proportion (36.3%) of substance abuse clients reporting histories of incest. When examined by gender, the majority of
Table 2. Content,
means, standard deviations, and factor loading of SAIS-R (Stigma and Resistance to Counseling)
33. 34. 3.5. 36. 38. 40. 43. 44. 4-i.
items for Factor
I
Item Content
M
SD
Loading
I do not talk about incest with my counselor because I don’t trust him/her enough. I do not talk about incest with my counselor because 1am afraid others will find out. 1do not talk about incest with my counselor because I feel ashamed about it. I do not talk about incest with my counselor because he/she will think I am a homosexual. I do not talk about incest with my counselor because he/she will think 1 am weak. I do not talk about incest with my counselor because 1 feel that it was my fault. I do not talk about incest with my counselor because it is too painful to talk about. I do not talk about incest with my counselor because I don’t want to think about it. I do not talk about incest with my counselor because it is too private. I do not talk about incest with my counselor because I have also been a victim of other sexual abuse that was not incest.
3.0
1.0
.83
3.0
1.0
.82
2.1
1.1
.85
3.4
0.8
.ss
3.2
0.8
54
3.1
1.0
59
2.8
1.1
.71
2.6
I.1
.1:,
2.1
1.1
.79
3.0
1.0
53
Item No. 32.
perception
NOW. 1 = Strongly
Eigenvalue = 10.49.
Agree:
2 =
Agree: 3 = Disagree; 4 = Strongly Disagree; n ranged from 201 to 230.
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T. P. JANIKOWSKI
et al.
Table 3. Content, means, standard deviations, and factor loading of SAIS-R perception items for Factor 2 (Substance Abuse and Incest) Item No. 26. 27. 28. 29. 31. 50. 51.
Item Content
M
SD
Loading
Incest has caused me problems with drinking. Incest has caused me problems with taking drugs. I have used alcohol to help me forget about incest contacts. I have used drugs to help me forget about incest contacts. Counseling for incest should be made a part of my substance abuse treatment. If I talked to my counselor about incest I think it would help me with my substance abuse problem. If I were to get counseling for incest, I would like to have group counseling with others who have had incest contacts.
2.8 2.8
1.1 1.1
.89 .95
2.7
1.1
.8.5
2.7
1.1
.89
2.5
1.2
.63
2.5
1.1
.66
2.6
1.0
.47
Note. 1 = Strongly Agree; 2 = Agree; 3 = Disagree; 4 = Strongly Disagree; n ranged from 201 to 230. Eigenvalue = 4.04.
the 204 females in the entire sample (113; 55.4%) reported past incest contacts. This percentage exceeds most other studies regarding the incidence of incest for females in substance abuse treatment facilities (Benward & Densen-Gerber, 1975; Cohen & Densen-Gerber, 1982; Covington, 1982; Hammond et al., 1979; Schaefer & Evans, 1985). It is difficult to account for this result; however, one explanation may be that earlier studies underestimated the incidence of incest because of client reluctance to reveal information about this sensitive topic (this is a frequently referenced concern in the literature). To counteract the potential for under-reporting, the present study took a number of steps to ensure the confidentiality of respondents. First, survey items and instructions were designed in such a way that those with or without incest would complete it in the same amount of time; hence, no one could be identified with either group based on how quickly he or she completed the survey. Second, the study used two envelopes in
Table 4. Content, means, standard deviations, and factor loading of SAIS-R perception items for Factor 3 (Ambivalence) Item No. 39. 41. 45.
46. 52.
Item Content
M
SD
Loading
I do not talk about incest with my counselor because 1 don’t think that it will help me. I do not talk about incest with my counselor because it is not a problem for me. I do not talk about incest with my counselor because I have only vague feelings of having had a contact. I do not talk about incest with my counselor because I’m not sure if I have had an incest contact or not. If I were to get counseling for incest, I would like to meet alone with a counselor.
2.9
1.0
.67
2.6
1.1
.84
2.8
1.0
.54
3.2
0.8
.58
2.1
0.9
.53
Note. 1 = Strongly Agree; 2 = Agree: 3 = Disagree; 4 = Strongly Disagree; n ranged from 201 to 230. Eigenvalue = 2.06.
455
Incest and substance abuse
Table 5. Content, means, standard deviations, and factor loading of SAIS-R perception items for Factor 4 (Fear and Anticipation) Item No. 30.
37. 42.
Item Content
M
SD
Loading
1 am afraid that I’ll have incest contacts in the future. I do not talk about incest with my counselor because I am afraid legal problems will result. I do not talk about incest with my counselor because I think my counselor can’t deal with it.
3.4
0.9
.17
3.3
0.8
.69
3.2
0.9
51
Nore. 1 = Strongly Agree; 2 = Agree; 3 = Disagree: 4 = Strongly Disagree; n ranged from 201 to 230. Eigenvalue = 1.39.
the return of surveys, which may have added to participants’ sense of security of the data. Finally, the videotape presentation clearly gave definitions and instructions in a clear, but nonthreatening, manner and again reassured participants of their anonymity. Another explanation for the higher than expected percentage is that the current study overestimated the incidence of incest. Clients may have reported an incest history when none existed because they believed that they could use incest as an excuse; in other words, they rationalized their unacceptable drug taking by blaming it on trauma from incest. Either explanation is, of course, speculative, and both are further explored as limitations in this section. Of the 518 males surveyed in the present study, 151 (29.2%) indicated that they had a history of incest. Only two other studies were found reporting the incidence of incest histories among male substance abusers. The findings were similar with Watley and Densen-Gerber (1976) but fell somewhat below those of Glover et al. (1995). who included perpetrators as well as victims in their study of incest. More research on male victims of incest should be conducted so as to gain a more comprehensive estimate of its incidence. A factor analysis identified five factors that accounted for the majority of variance in client responses to Likert-type items examining perceptions toward substance abuse and incest. These factors were labeled (1) Stigma and Resistance to Counseling: (2) Substance Abuse and Incest; (3) Ambivalence; (4) Fear and Anticipation; and (5) Receptivity to Counseling. The factors appear to represent a continuum of responses to incest. Factor 1 accounted for the majority of variance and contained items that identified various sources of stigma associated with incest (e.g.. lack of trust, fear. shame). These sources of stigma can present significant obstacles to treatment for incest, in conjunction with substance abuse.
Table 6. Content. means. standard deviations, and factor loading of SAIS-R perception items for Factor 5 (Receptivity to Counseling) Item No. 4s. 49.
Item Content
M
SD
Loading
If 1were to talk about incest with a counselor, I would want a counselor of the same sex. 1 would talk about incest with my counselor if he/she asked me about it.
2.6
1.1
.69
2.2
1.0
.60
Note. 1 = Strongly Agree: 2 = Agree: 3 = Disagree: 4 = Strongly Disagree: n ranged from 201 to 230. Eigenvalue = 1.31.
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T. P. JANIKOWSKI et al.
For the present study, however, participants disagreed that the sources of stigma were preventing them from discussing their incest histories with their counselors. Six of the 10 items in this factor had mean responses of 3.0 or more (3 = Disagree), and the remaining four items had mean responses of 2.6 to 2.8. Hence, stigma wasn’t found to be a major obstacle to clients’ willingness to discuss the topic of incest with substance abuse counselors. Data reported in Glover (1995) indicate that about 40% of clients with incest histories have made their counselors aware of their past incest. Only 15% of these clients with incest histories, however, were receiving incest-related counseling in the context of their substance abuse treatment. It appears, therefore, that substance abuse treatment counselors are aware of less than half of the incest victims who may be on their caseloads, and most of these clients remain untreated for their incest-related issues, despite the fact that some clients believe that incest has caused them problems with drinking or taking drugs. Factor 2 contained items that examined the association, in the participants’ view, between incest and the development of substance abuse. A substantial proportion of clients (especially females) in substance abuse treatment report having been victims of incest and, for some but not all, this victimization has affected the development and maintenance of their substance abuse. Item responses in Factor 2 that directly examined the linkage between incest and substance abuse received mid-range ratings by clients (lower ratings indicated stronger agreement; 1 = Strongly Agree; 4 = Strongly Disagree): Item 28, “I have used alcohol to help me forget about incest contacts” (M = 2.7); Item 29, “I have used drugs to help me forget about incest contacts” (M = 2.7); Item 26, “Incest has caused me problems with drinking” (M = 2.8); and Item 27, “Incest has caused me problems with taking drugs” (M = 2.8). Other items in Factor 2 also had mid-range ratings: Item 31, “Counseling for incest should be made part of my substance abuse treatment” (M = 2.5); and Item 50, “If I talked to my counselor about incest I think it would help me with my substance abuse problem” (M = 2.5). The standard deviation values for all items in Factor 2 were between 1.0 and 1.2, which means that participants seemed to straddle the scale between agreement and disagreement, with about half of the participants agreeing and the other half disagreeing with the item statement. Factor 3 contained items that presented some of the ambivalent feelings clients might have had about incest and substance abuse. The item with the greatest level of agreement, of all factor items, was Item 52: “If I were to get counseling for incest, I would like to meet alone with a counselor” (M = 2.1). This item underscores the private nature of incest-related issues. For some clients, incest was not viewed as a problem (Item 41, M = 2.6). Other items represented vague feelings about incest (Item 45, M = 2.8), or the perception that incest-related counseling wouldn’t be helpful (Item 39, M = 2.9). Both of these items tended to receive ratings of disagreement rather than agreement. It seems to be important to take an individualized approach when dealing with incest among substance abuse treatment clients. Some clients may have resolved their feelings about their pasts’ and incest may be a nonissue, while the opposite is true for others. it is important, therefore, to determine who may or may not benefit from incest counseling while in substance abuse treatment. Items contained in Factor 4 received mean ratings that indicated disagreement. It appeared that clients, as a group, did not anticipate problems with future incest contacts (Item 30, M = 3.4), were not concerned about possible legal consequences (Item 37, M = 3.3), nor did they think that their counselors were unable to deal with incest (Item 42, M = 3.2). This last point is of importance for substance abuse treatment
Incestand substanceabuse
451
counselors; clients appear to believe that their counselors are competent in addressing this sensitive topic. It would be interesting, in future research, to see whether counselors hold a similar view toward themselves. Finally, Factor 5 contained two items that related to receptivity toward counseling. Item 49 (“I would talk about incest with my counselor if he/she asked me about it”) received one of the strongest average agreement ratings (M = 2.2) by the group. One conclusion to be drawn from this finding is that, if substance abuse treatment counselors initiated an exploration of incest with their clients, clients would be open to sharing such information and counselors would be in the position to determine whether or not incest was instrumental in the development and maintenance of substance abuse. Responses to Item 48 (“If I were to talk about incest with a counselor I would want a counselor of the same sex”; M = 2.6) indicated that participants seemed to again straddle the agreement continuum regarding preference for their counselors’ gender. A few limitations to the present study exist that warrant discussion. First and foremost was the voluntary, survey design of the study. Clients could self-select themselves out of the study, allowing for clients with incest histories to avoid the study if it was too threatening. As with all survey research, it is not possible to know how nonrespondents differed from respondents. Responses to survey research are also subject to response bias. Participants may have wanted to make themselves appear in a favorable light and skewed their answers in a socially positive direction. Countering this social desirability response is the tendency for substance abuse clients to engage in rationalizing the source of their problems. Clients could use incest as an excuse for substance abuse behavior, thus absolving themselves of personal responsibility for their problems; this would have led to an overestimation of the incidence of incest. The topic of incest is particularly susceptible to the phenomenon of response bias; however. participants were encouraged to respond honestly and their responses were confidential so neither the researchers nor the facility staff knew who completed a particular survey. Sampling was another limitation to the study. Although the present study used a relatively large national sample (N = 768), this number represents a small proportion of the clients enrolled in nonprofit substance abuse treatment facilities across the United States. This, combined with the fact that there was an over-representation of males (n = 518; 71%), somewhat limits the generalizability of the study’s results. Finally, factors identified by the factor analysis are, in part. a consequence of the items created for the survey. Survey items, however, were specially selected for their relevance to incest and substance abuse counseling: in addition, a panel of experts was employed to examine survey comprehensiveness. Nonetheless, other factors underlying the relationship between incest and substance abuse may exist and need to be explored in future research. Three clear recommendations can be made from the results of the present study. First, because incest is prevalent among substance abuse treatment clients (especially females). treatment facilities should regularly screen all clients for incest histories as a part of their facility-intake procedure. In fact, one of the primary purposes for developing the SAIS-R was to bring to light the high incidence of incest histories among clients in substance abuse treatment. The factor analysis of the SAIS-R perception items was conducted. in part, to identify items that tap into client feelings about incest’s relationship to the development of substance abuse and client views about receiving incest counseling in the context of substance abuse treatment. The factor items of the SAIS-R could be easily incorporated into a confidential, short screening questionnaire that could be given to all clients upon admission. This screening form could lead to
T. P. JANIKOWSKI
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et al.
early identification and allow counselors to explore the issue of incest with clients who may need substance abuse counseling that integrates incest as contributory factor. Other potential uses of the SAIS-R, especially those areas not dealing with the Likerttype perception items, are discussed in Glover et al. (1996). Second, it is recommended that substance abuse treatment staff become prepared to deal with this relatively pervasive problem in their caseloads. If the facility staff is unqualified to deal with incest as a counseling issue, they should establish formal referral relationships with incest treatment professionals. Substance abuse treatment could then take place in a coordinated fashion with incest counseling. The formal relationship between the two specializations would allow both parties to exchange information and for each to educate the other with regard to treatment strategies and issues. Third, it is recommended that substance abuse treatment facilities should either hire staff with expertise in incest counseling or train their existing staff to deal with the issue. Clearly, the high incidence of this problem can no longer be ignored by substance abuse treatment facilities. As indicated early, informal staff education could be obtained from incest treatment professionals in the field. Facilities could also engage in more formal inservice training and continuing education through workshops and conferences. Preservice education also needs to introduce incest issues into its course work (e.g., identification, counseling strategies, integration with substance abuse treatment). The Council for Accreditation of Counseling and Related Educational Programs (CACREP) and Council on Rehabilitation Education (CORE) accredit programs that often offer substance abuse courses or concentrations; these organizations may wish to examine their curricular content to ensure that graduates of their programs are capable of identifying and dealing with incest issues in the context of substance abuse treatment. In conclusion, this study and other research (Coleman, 1987; Evans & Schaefer, 1987; Glover et al., 1995; Hammond et al., 1979; Wilsnack, 1982; Young, 1990) have demonstrated a linkage, at least for some clients, between past incest and the development and maintenance of substance abuse. Unfortunately, most substance abuse treatment facilities are reluctant to address incest as a substance abuse treatment issue; it has been estimated that fewer than 20% of substance abuse treatment facilities offer specialized groups dealing with past sexual or incest trauma (Yandrow, 1989). Incest is a taboo shrouded in secrecy, and treatment facilities and their counselors may be unwilling to confront this sensitive topic openly. This reluctance is important because it may contribute to clients’ perpetuating life-long secrets that may be at the root of their substance abuse problems.
REFERENCES Barnard, C. P (1989). Alcoholism and sex abuse in the family: Incest and marital rape. Journal
of Chemical
Dependency
Treatment, 3,131-144. Bass, E., & Davis, L. (1988). The courage IOheal. New York: Harper & Row.
Benward, J., & Densen-Gerber, J. (1975). Incest as a causative factor in antisocial behavior: An exploratory study. Contemporary Drug ProbIer& 4,323-340. Cohen. E S.. & Densen-Gerber. J. (1982). A studv of the relationshiu between child abuse and drug addiction in 178 patients: Preliminary results, Chili Abuse and Negle& 6,383-387. Coleman, E. (1987). Child physical and sexual abuse among chemically dependent individuals. Journal of Chemical Dependency Treatment, 1,27-38. Covington, S. S. (1982). Dysfunction and abuse: A descriptive study of alcoholic and non-alcoholic women, Ph.D. dissertation, Union Graduate School, Cincinnati, OH. Covington, S. (1986). Physical, emotional, and sexual abuse. Focus on Family, May/June, 10, 11,37,4245.
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Evans, S., & Schaefer, S. (1987). Incest and chemically dependent women: Treatment implications Journal of Chemical Dependency Treatment, 1,141-173. Glover, N. M. (1992). lncesr history and enroltment in substance abuse treatment. Unpublished master’s thesis, Southern Illinois University, Carbondale, 1L. Glover, N. M. (199.5). Adult substance abuse treatment: The incidence of incest histories among clients and their perceptions regarding treatment. Unpublished doctoral dissertation, Southern Illinois University. Carbondale, IL. Glover, N. M., & Janikowski. T., & Benshoff, J. J. (1995). The incidence of incest histories among clients receiving substance abuse treatment. Journal of Counseling & Development, 73.475-480. Glover, N., Janikowski,T. I?, & Benshoff (1996). A national study of incest and substance abuse. Journal of Substance Abuse Treatment, 13(3), l-9.
Hammond. D. C., Jorgenson, G. Q., & Ridgeway, D. M. (1979). Sexual adjustment of female alcoholics. Salt Lake City: University of Utah Press Hyde, M. L., & Kaufman, P A. (1984). Women molested as children: Therapeutic and legal issues in civil actions American Journal of Forensic Psychiatry, 5,147-157. Janik0wski.T. I?, & Clover, N. M. (1994). Incest and substance abuse: Implications for treatment professionals Journal of Substance Abuse Treatment,3,177-183. Pierce, L. H. (1987). Father-son incest: Using the literature to guide practice. Social Casework, 67.85-92. Rohsenow, D. J., Corbett, R., & Devine, D. (1988). Molested as children: A hidden contribution to substance abuse? Journal of Substance Abuse Treatment, 5(l), 13-18. Schaefer, S., & Evans, S. (1985). Women’s sexuality and the process of recovery. Journal of Chemical Dependency Treatment, 1,91-120. SPSS Inc. (1988). SPSS-X: User‘s guide (3rd ed.). Chicago: Author. Vander Mey, B. J.. & Neff. R. L. (1984). Adult-child incest: A review of research and treatment. Adolescence, 17,717-735.
Watley, R., & Densen-Gerber. J. D. (1976). Incesr: An analysis of rhe vicrim and the aggressor. New York: Odyssey Institute. Wilsnack, S. C. (1982). Alcohol abuse and alcoholism in women. In W. M. Pattison & E. Kaufman (Eds.), Encyclopedic handbook of alcoholism, New York: Gardner. Wilsnack, S. C. (1984). Drinking, sexuality and sexual dysfunction in women. In S. C. Wilsnack & L. J. Beckman (Eds), Alcohol problems in women: Antecedents, consequences, and interventions. New York: Guilford Press. Yandrow,V. (1989). Alcoholism in women. Psychiatric Annals, 19,243247. Yearly, J. (1982). Incest and chemical dependency. Journal of Psychoactive Drugs, 14,133-135. Young, E. (1990).The role of incest in relapse. Journal of Psychoactive Drugs, 22,249-258.
Pergamon
Behaviors, Vol. 22, No. 4, pp. 447-45’). 1997 Copyright 0 1997 Elsevier Science Ltd Printed in the USA. All rights reserved
0306_4603/Y7 $17.00+ .oO
PI1 s03ofA603(%)ooo55-x
CLIENT PERCEPTIONS
OF INCEST AND SUBSTANCE ABUSE
TIMOTHY
and JAMES E. BORDIERI
P. JANIKOWSKI
Southern Illinois University at Carbondale
NOREEN
M. GLOVER
Syracuse University Abstract - Clients receiving substance abuse treatment from 35 treatment facilities throughout the United States were surveyed using the Substance Abuse and Incest Survey-Revised (SAIS-R). A total of 732 participants responded to the survey; 518 (71%) were males, 204 (28%) were females, and 10 (1%) did not indicate gender. Participants had a mean age of 33.8 years, were predominately Caucasian (61.6%), never married (45.2%). were currently unemployed (69.4%). and had completed an average of 11.7 years of education. Of the entire sample, 266 (36.3%) reported having been victims of incest; 151 were males and 113 were females (2 did not indicate gender). The group reporting incest histories had a significantly greater percentage of females that did the group not reporting incest histories (x2 = 48.1, p < .OOl). Participants with incest histories were asked about their perceptions regarding incest, substance abuse. and counseling. Item responses were examined using descriptive statistics and factor analysis. The factor analysis on SAIS-R perception items identified five factors that accounted for 68.9% of the variance; these factors were Stigma and Resistance to Counseling: Substance Abuse and Incest; Ambivalence: Fear and Anticipation; and Receptivity to Counseling. Results are presented and the implications for substance abuse treatment and counseling are discussed. 0 1997 Elsevier Science Ltd
Incest is understood to be sexual contact with a person who has close blood or social ties (i.e.. relative). Close blood or social ties include parents, step-relatives, grandparents. uncles, aunts. cousins, siblings, in-laws, and quasi-family members (e.g.. a parent’s sexual partner; Benward & Densen-Gerber, 1975: Vander Mey & Neff. 1984). Unfortunately, the incidence of incest in the United States is not well known: it is difficult to determine because the stigma associated with incest makes victims and family members reluctant to report the problem (Hyde & Kaufman, 1984). Further, national data on the incidence of childhood incest are not kept (National Council on Child Abuse; personal communication, Jan. 8, 1992). Nonetheless, Hyde and Kaufman (1984) projected that approximately 9% of the female population would have incestuous encounters with an older adult relative. Most research on incest focuses on females with less attention being given to male victims. In a review of the literature discussing male incest cases, Pierce (1987) stated that males constituted between 12% and 33% of the sexually abused children who are reported. Of these cases. between 6% and 50% were abused by parents or step-parents. Parents United, a self-help group for victims of incest and their families, estimates that 25% of all women and nearly the same percentage of men in the United States will be sexually molested bcfore age 18. They further state that more than 70% of these molestations are committed by a family member or close family friend, thus constituting an incestuous contact (Yearly. 1982). This research was supported by a grant from the ALCOA foundation. Requests for reprints should be sent to Timothy P. Janikowski, Rehabilitation Education, Southern Illinois University at Carbondale. Carbondale. IL 62901-4609. 0 1997 Elsevier Science Ltd. All rights reserved. 447
Institute, College of
448
T. P. JANIKOWSKI
et al.
Recently, researchers have begun to examine the adult consequences of having experienced an incestuous assault. Hyde and Kaufman (1984) referred to incest as a “psychological nightmare that continues into adulthood requiring some kind of behavioral and psychological adaptation” (p. 148). When the effects of the sexual traumatization are not treated, psychological dysfunction may emerge, including amnesia, phobias, anxiety states, low selfesteem, and guilt (Hyde & Kaufman, 1984). Given the strong and lasting impact that sexual victimization has on adult emotional and social functioning, it is not unreasonable to expect victims to turn to alcohol or other drugs because of these negative effects (Rohsenow, Corbett, & Devine, 1988). Drugs may in fact be used as a strategy to cope with the emotional distress caused by incest, because drugs enable victims to numb feelings, suppress memories, and dull psychological pain (Bass & Davis, 1988). Unfortunately, these “coping” behaviors often become serious addictive problems in and of themselves (Young, 1990). Research indicates that persons who have a history of sexual abuse are at increased risk for the development and maintenance of substance abuse (Covington, 1986; Rohsenow et al., 1988). It must also be noted, however, that those who abuse substances may be more susceptible or at greater risk for incest contact. Although it is difficult to ascribe causation or primacy to either, there is clearly a relationship between substance abuse and incest. For instance, Glover (1992) found that 36% of substance abuse clients who reported incest histories were under the influence at the time of the contact and they believed that up to 53% of the perpetrators of the contact were under the influence at the time. Incest histories also appear to be especially prevalent among women in substance abuse treatment (Coleman, 1987; Evans & Schaefer, 1987; Hammond, Jorgenson, & Ridgeway, 1979; Wilsnack, 1984), but are found also in a substantial proportion of male substance abusers (Glover, Janikowski, & Benshoff, 1995). Also, it has been suggested that recovering substance abusers who have childhood incest histories and remain untreated for incest have an increased probability of substance abuse relapse (Barnard, 1989; Young, 1990). Clearly, clients with histories of incest present unique challenges for substance abuse treatment and counseling. Hence, it is necessary for substance abuse treatment professionals to become more aware of incest victims on their caseloads. Further, counselors should understand how their clients with incest histories view the relationship between incest and substance abuse. Also, it is important to examine client feelings about incest counseling in the context of substance abuse treatment. Such knowledge would enable counselors to more effectively help these clients and reduce substance abuse relapse and treatment recidivism. The purpose of the present study was to examine the attitudes and perceptions of incest victims who were addicted to alcohol or drugs. Specifically, clients enrolled in not-for-profit substance abuse treatment facilities throughout the United States were surveyed; those who reported a history of incest were questioned about their perceptions toward themselves, incest, substance abuse, and counseling. Their responses to survey items were examined using descriptive statistics and the factor analysis technique. It was hoped that results would make substance abuse treatment facilities and staff more aware of the numbers of incest victims receiving substance abuse treatment. The factor analysis of items examining client perceptions was intended to identify common factors underlying these perceptions. These factors may be used as the basis for developing a brief screening device or interview questions aimed at identifying clients who believe their past incest contact affects their substance abuse, and to examine these beliefs and client willingness to incorporate incest-related counseling into substance abuse treatment.
Incest and substance abuse
449
METHOD
Instrumentation
The original Substance Abuse and Incest Survey (SAIS) was developed by Glover (1992) to investigate the incidence and characteristics of incest among substance abuse clients. The SAIS consisted of 6 items addressing demographic questions, 10 items on substance abuse treatment history, 4 items related to incest and incest counseling, an Incest History Table used to examine the nature of incest contacts, and 44 items regarding attitudes and perceptions about incest and substance abuse treatment (Janikowski & Glover. 1994). An examination of the temporal consistency of the SAIS found that 82% of items responses were identical when the SAIS was re-administered after a 2-week time period (Glover, 1992). This level of consistency was considered to be acceptable. given the historical nature of the survey items. Final instrument
The SAIS was revised for present study to increase its comprehensiveness and readability. Five experts in the fields of substance abuse or survey construction were used to examine the content validity of the SAIS-R: all five experts held doctoral degrees and were experienced researchers employed at a Midwestern university. The panel recommended three primary changes to the SAIS-R: (1) expand a table used to better report incest history, (2) make several structural changes to enhance the visual presentation of items, and (3) add 9 new items to increase the comprehensiveness of items regarding client perceptions of incest and substance abuse. The final version of the SAIS-R consisted of 6 items regarding client demographics, a table of 4 columns X 27 rows used for reporting incest history. and 53 items addressing substance abuse. treatment, and client attitudes or perceptions. Because of the focus of the present article, the remaining discussion of the instrument will be limited to the demographic items and the 28 Likert-type perception items that were subjected to a factor analysis. The first section of the SAIS-R consisted of 6 items regarding client: age, education, gender, race, marital status, and work status. The last section of the survey consisted of 28 items (numbered 26 through 53) that asked participants about their attitudes toward their incest history and substance abuse, and attitudes toward receiving incestrelated counseling as a part of their substance abuse treatment. Participants responded to each of these items by circling one of the following responses, which they .‘felt best described your opinion”: SA (Strongly Agree). A (Agree), N/A (Not Applicable). D (Disagree), or SA (Strongly Disagree). Incorporation of the N/A response into the Likert-scale was done to ensure that all participants responded to all survey items so that clients without incest histories would not complete the survey more rapidly than those who had been incest victims. Procedure
Facilities were selected from a nonprobability sample of the 10 federal regions of the United States. Public. not-for-profit substance abuse treatment facilities were randomly sampled from each of the regions using the National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs: 1992 Survey. See Table 1 for a description of the regions and states represented in the present study. One hundred and twenty-three facility administrators were contacted initially by telephone in order to describe the study and to determine their willingness to partici-
450
T. P. JANIKOWSKI
et al.
Table 1. Ten federal regions of the United States and number of substance abuse treatment facilities surveyed in each region Region (No. of Facilities) Region I (3)
Region 3 (4)
State Connecticut Maine Massachusetts New Hampshire Vermont Rhode Island Delaware District of Columbia Maryland Pennsylvania Virginia West Virginia
Region (No. of Facilities) Region 2 (3)
New Jersey New York Puerto Rico Virgin Islands
Region 4 (4)
Alabama Florida Georgia Kentucky Mississippi North Carolina South Carolina Tennessee Arkansas Louisiana New Mexico Oklahoma Texas
Region 6 (3) Region 5 (4)
Region 7 (4)
Region 9 (4)
Illinois Indiana Michigan Minnesota Ohio Wisconsin Iowa Kansas Missouri
Arizona California Hawaii Nevada
State
Region 8 (3)
Region IO (3)
Colorado Montana North Dakota Nebraska South Dakota Utah Wyoming Alaska Idaho Oregon Washington
Nore. Total number of facilities surveyed equaled 35.
pate. One hundred and thirteen (91.9%) agreed to a review of prepared documents describing the study. The prepared documents included the following materials: (1) a cover letter explaining the purpose of the study, confirmation that the study had a human subjects committee review and approval, and an outline of procedures to administer the survey; (2) a “Letter of Explanation to Participant” describing the study; (3) a client consent form: (4) a facility consent form: (5) the SAIS-R instrument, and (6) a copy of a j-minute video where the second author read the definition of incest and incest contact and gave directions necessary for completing the survey. After mailing materials to facility administrators, each was re-contacted via telephone the following week in order to determine willingness to have his or her facility participate in the study. The sampling time frame continued for approximately a year, during which 123 facilities were contacted and 42 (34%) agreed to participate. These 42 facilities were sent the requested number of surveys. Each facility contact person requested a specific number of surveys based upon his or her estimate of the greatest possible number of clients available during the anticipated time of the survey administration. Seven of the 42 facilities, however, dropped out of the study prior to administering the survey citing such reasons as the staff being too busy, lack of client interest in the study, or lack of staff preparation to deal with incest issues. Of the 35 facilities that ultimately participated in the study, 1,340 (100%) surveys were mailed and 768 (57.3%) completed surveys were returned. Of the returned surveys, 31 were com-
Incest and substance abuse
4.51
pleted by participants who were ineligible to participate in the study because they were under age 18; these 31 surveys were excluded from all analyses. Therefore, survey data were complete on 732 participants, comprising a 54.6% return-rated based on the 1,340 surveys mailed. Because each of the facilities may not have presented the survey to the greatest possible number of clients. the 54.6% return rate may be an underestimate of the true return rate. No client information that could have identified individuals was recorded, and all clients were identified using identification numbers only. Participants were informed that the study was reviewed and approved by the Carbondale Committee for Research Involving Human Subjects and that the committee determined that the research procedures used adequately safeguarded the participant’s privacy, welfare, civil liberties, and rights. All clients volunteered to complete the survey and were not compensated for their participation. Data collection Clients were informed by the facility contact person that they were being asked to participate in a study that entailed a paper and pencil survey asking questions about their substance abuse histories and possible incest histories. Clients at each facility were informed about the nature of the information to be gathered and were not required to attend the instructions presentation by the administrator or to complete the survey. Clients also were given an opportunity to withdraw following the administrator’s instructions presentation, or at any time during the collection of the data. Clients who wished to participate were assembled in a group at each facility and then shown the video presentation. The 5-minute video described the nature of the research; defined the terms: incest, incest contact, and victim: and gave instructions for completing the survey. The directions video defined incest as sexual contact with a person who has close blood or social ties. Close blood or social ties include: parents. step-relatives, grandparents, uncles. aunts, cousins. siblings, in-laws, and quasi-family members (for example, a parent’s sexual partner). Incest contact was defined to be the unwanted touching of the sex organs or other body parts for the purpose of sexual arousal, vaginal or anal penetration, mouth to penis, mouth to vagina, or mouth to anus contact. masturbation on self or other family members in the presence of the related person, or other acts with explicit or implicit sexual intent with the related person. Following the video presentation, the administrator read the Informed Consent Form to the group of participants. Questions relating to procedure were then addressed by the site administrator. Clients agreeing to participate were given survey envelopes containing a “Letter of Explanation to the Participant,” an “Informed Consent Form.” and the SAIS-R. Participants were then instructed to arrange themselves in a manner that would allow for privacy before completing the survey. Clients also were instructed to remain in their seats until all surveys were completed and collected. When finished. clients placed their survey in the provided envelope and sealed it. A larger envelope was then passed around the room to collect all of the surveys. The final participant sealed the envelope and returned it to the administrator. Clients were dismissed and the administrator mailed the surveys to the researchers.
RESULTS
As indicated earlier, the present article focuses on the demographic items and the 28 Likert-type items regarding perceptions of incest and substance abuse. Information
452
T. P. JANIKOWSKI
et al.
about the nature of the incest contacts (i.e., the 4 X 27 table) and the remaining 25 items may be found in Glover, Janikowski, and Benshoff (1996). Participants
A total of 732 usable surveys were collected form the 1,340 surveys mailed to public and not-for-profit substance abuse treatment facilities throughout the United States. All participants responding to the survey were receiving treatment for alcohol abuse, drug abuse, or both. Five hundred eighteen (71%) of the participants were male and 204 (28%) were female; 10 (1%) participants did not indicate gender. Respondents’ ages ranged from 18 to 72 years (M = 33.8, SD = 9.2). In terms of ethnicity, the sample was comprised of 2 (0.3%) Asians, 149 (20.4%) Blacks, 451 (61.6%) Caucasians, 88 (12.0%) Hispanics, and 23 (3.1%) Native Americans. Eleven (1.5%) participants indicated “other” as race identification and 8 (1.1%) did not indicate race. Participants’ education ranged from 1 to 26 years (M = 11.7, SD = 2.2). In terms of marital status, 110 (15.0%) indicated that they were currently married, 181 (24.7%) were divorced, 82 (11.2%) were separated, 331 (45.2%) had never been married, 20 (2.7%) were widowed, and 8 (1.1%) did not indicate marital status. Regarding employment, 145 (19.8%) participants were employed full-time, 65 (8.9%) were employed parttime, 508 (69.4%) were unemployed; 14 (1.9%) participants did not indicate work status. In response to item 12, “Have you ever had an incest contact?“, 266 (36.3%) responded “Yes,” 409 (55.9%) responded “No,” 53 (7.2%) indicated “Not Sure,” and 4 (.5%) did not respond to this item. Item 12 was used to separate participants into incest history and nonincest history groups. The Incest History group was comprised of 266 participants (151 males, 113 females, and 2 who did not report gender). The nonincest history group was comprised of 409 participants (329 males, 73 females, and 7 who did not report gender). To examine differences between groups, chi square and t-test analyses were performed on demographic responses of the incest and nonincest groups (the 53 people who indicated “Not Sure” and 4 who did not respond to item 12 were not included in this analysis). Chi-square comparisons were performed on items regarding gender, race, marital status, and work status. The only significant difference between the incest and nonincest groups was on gender (x2, p < .OOl, II = 666). indicating that a significantly greater percentage of females were in the incest group (n = 113; 42.5%) than in the nonincest group (n = 73; 17.8%). The t-test analyses were used to examine differences between the incest and nonincest groups on items regarding age and years of education; no significant differences were found between the groups. The remainder of the Results section is restricted to the incest history group (n = 266) and will examine descriptive statistics and the factor analysis of 28 items (numbered 26 through 53) that asked participants about their perceptions toward their incest history and substance abuse, and receiving incest-related counseling as a part of their substance abuse treatment. The 28 perception items were answered using a 5-point continuum: “Strongly Agree,” “Agree,” “N/A,” “Disagree,” or “Strongly Disagree.” For purposes of analysis, these items were transformed into a Likert-type agreement scale where small values indicated greater agreement (i.e., 1 = Strongly Agree, 2 = Agree, 3 = Disagree, and 4 = Strongly Disagree). The N/A or “not applicable” responses wee discarded and not included in the analysis. The greatest level of agreement (i.e., lowest mean Likert score) was 2.1 found on item 31 (Counseling for incest should be made part of my substance abuse treatment) and item 49 (I would talk about incest with my counselor if he/she asked me about it). The greatest level of
Incest and
453
substanceabuse
disagreement (i.e., the highest mean Likert score) was 3.4 found on item 30 (I am afraid that I’ll have incest contacts in the future) and item 35 (I do not talk about incest with my counselor because he/she will think 1 am a homosexual). A principal components factor analysis was performed using the FACTOR program provided by SPSS-X (SPSS Inc., 1988). The factor analysis was performed in order to reduce the 28-item space and identify factors that might underlie participant responses to the Likert-type items. A varimax factor rotation was employed; six factors met a cut-off criteria having an eigenvalue of 1.0 or greater. Factor six consisted of only one item, however, and was therefore dropped. The remaining five factors accounted for 68.9% of the response variance, and Tables 2 through 6 report the means, standard deviations. and factor loadings on each item under each factor. The five factors were labeled (1) Stigma and Resistance to Counseling (10 items accounting for 37.5% of response variance); (2) Substance Abuse and Incest (7 items accounting for 14.4% of the variance): (3) Ambivalence (5 items accounting for 7.3% of the variance); (4) Fear and Anticipation (3 items accounting for 5.0% of the variance): and (5) Receptivity to Counseling (2 items accounting for 4.7% of the variance). As can be seen by inspecting Tables 2-6, all factor loadings exceeded .46 and are well within traditionally accepted values for factor assignment. D 1S C
LJ S S 1 0
N
The incidence of incest among clients in substance abuse treatment is thought to be well above that usually reported in the general population (Janikowski & Glover, 1994). Results of the present study found a sizable proportion (36.3%) of substance abuse clients reporting histories of incest. When examined by gender, the majority of
Table 2. Content,
means, standard deviations, and factor loading of SAIS-R (Stigma and Resistance to Counseling)
33. 34. 3.5. 36. 38. 40. 43. 44. 4-i.
items for Factor
I
Item Content
M
SD
Loading
I do not talk about incest with my counselor because I don’t trust him/her enough. I do not talk about incest with my counselor because 1am afraid others will find out. 1do not talk about incest with my counselor because I feel ashamed about it. I do not talk about incest with my counselor because he/she will think I am a homosexual. I do not talk about incest with my counselor because he/she will think 1 am weak. I do not talk about incest with my counselor because 1 feel that it was my fault. I do not talk about incest with my counselor because it is too painful to talk about. I do not talk about incest with my counselor because I don’t want to think about it. I do not talk about incest with my counselor because it is too private. I do not talk about incest with my counselor because I have also been a victim of other sexual abuse that was not incest.
3.0
1.0
.83
3.0
1.0
.82
2.1
1.1
.85
3.4
0.8
.ss
3.2
0.8
54
3.1
1.0
59
2.8
1.1
.71
2.6
I.1
.1:,
2.1
1.1
.79
3.0
1.0
53
Item No. 32.
perception
NOW. 1 = Strongly
Eigenvalue = 10.49.
Agree:
2 =
Agree: 3 = Disagree; 4 = Strongly Disagree; n ranged from 201 to 230.
454
T. P. JANIKOWSKI
et al.
Table 3. Content, means, standard deviations, and factor loading of SAIS-R perception items for Factor 2 (Substance Abuse and Incest) Item No. 26. 27. 28. 29. 31. 50. 51.
Item Content
M
SD
Loading
Incest has caused me problems with drinking. Incest has caused me problems with taking drugs. I have used alcohol to help me forget about incest contacts. I have used drugs to help me forget about incest contacts. Counseling for incest should be made a part of my substance abuse treatment. If I talked to my counselor about incest I think it would help me with my substance abuse problem. If I were to get counseling for incest, I would like to have group counseling with others who have had incest contacts.
2.8 2.8
1.1 1.1
.89 .95
2.7
1.1
.8.5
2.7
1.1
.89
2.5
1.2
.63
2.5
1.1
.66
2.6
1.0
.47
Note. 1 = Strongly Agree; 2 = Agree; 3 = Disagree; 4 = Strongly Disagree; n ranged from 201 to 230. Eigenvalue = 4.04.
the 204 females in the entire sample (113; 55.4%) reported past incest contacts. This percentage exceeds most other studies regarding the incidence of incest for females in substance abuse treatment facilities (Benward & Densen-Gerber, 1975; Cohen & Densen-Gerber, 1982; Covington, 1982; Hammond et al., 1979; Schaefer & Evans, 1985). It is difficult to account for this result; however, one explanation may be that earlier studies underestimated the incidence of incest because of client reluctance to reveal information about this sensitive topic (this is a frequently referenced concern in the literature). To counteract the potential for under-reporting, the present study took a number of steps to ensure the confidentiality of respondents. First, survey items and instructions were designed in such a way that those with or without incest would complete it in the same amount of time; hence, no one could be identified with either group based on how quickly he or she completed the survey. Second, the study used two envelopes in
Table 4. Content, means, standard deviations, and factor loading of SAIS-R perception items for Factor 3 (Ambivalence) Item No. 39. 41. 45.
46. 52.
Item Content
M
SD
Loading
I do not talk about incest with my counselor because 1 don’t think that it will help me. I do not talk about incest with my counselor because it is not a problem for me. I do not talk about incest with my counselor because I have only vague feelings of having had a contact. I do not talk about incest with my counselor because I’m not sure if I have had an incest contact or not. If I were to get counseling for incest, I would like to meet alone with a counselor.
2.9
1.0
.67
2.6
1.1
.84
2.8
1.0
.54
3.2
0.8
.58
2.1
0.9
.53
Note. 1 = Strongly Agree; 2 = Agree: 3 = Disagree; 4 = Strongly Disagree; n ranged from 201 to 230. Eigenvalue = 2.06.
455
Incest and substance abuse
Table 5. Content, means, standard deviations, and factor loading of SAIS-R perception items for Factor 4 (Fear and Anticipation) Item No. 30.
37. 42.
Item Content
M
SD
Loading
1 am afraid that I’ll have incest contacts in the future. I do not talk about incest with my counselor because I am afraid legal problems will result. I do not talk about incest with my counselor because I think my counselor can’t deal with it.
3.4
0.9
.17
3.3
0.8
.69
3.2
0.9
51
Nore. 1 = Strongly Agree; 2 = Agree; 3 = Disagree: 4 = Strongly Disagree; n ranged from 201 to 230. Eigenvalue = 1.39.
the return of surveys, which may have added to participants’ sense of security of the data. Finally, the videotape presentation clearly gave definitions and instructions in a clear, but nonthreatening, manner and again reassured participants of their anonymity. Another explanation for the higher than expected percentage is that the current study overestimated the incidence of incest. Clients may have reported an incest history when none existed because they believed that they could use incest as an excuse; in other words, they rationalized their unacceptable drug taking by blaming it on trauma from incest. Either explanation is, of course, speculative, and both are further explored as limitations in this section. Of the 518 males surveyed in the present study, 151 (29.2%) indicated that they had a history of incest. Only two other studies were found reporting the incidence of incest histories among male substance abusers. The findings were similar with Watley and Densen-Gerber (1976) but fell somewhat below those of Glover et al. (1995). who included perpetrators as well as victims in their study of incest. More research on male victims of incest should be conducted so as to gain a more comprehensive estimate of its incidence. A factor analysis identified five factors that accounted for the majority of variance in client responses to Likert-type items examining perceptions toward substance abuse and incest. These factors were labeled (1) Stigma and Resistance to Counseling: (2) Substance Abuse and Incest; (3) Ambivalence; (4) Fear and Anticipation; and (5) Receptivity to Counseling. The factors appear to represent a continuum of responses to incest. Factor 1 accounted for the majority of variance and contained items that identified various sources of stigma associated with incest (e.g.. lack of trust, fear. shame). These sources of stigma can present significant obstacles to treatment for incest, in conjunction with substance abuse.
Table 6. Content. means. standard deviations, and factor loading of SAIS-R perception items for Factor 5 (Receptivity to Counseling) Item No. 4s. 49.
Item Content
M
SD
Loading
If 1were to talk about incest with a counselor, I would want a counselor of the same sex. 1 would talk about incest with my counselor if he/she asked me about it.
2.6
1.1
.69
2.2
1.0
.60
Note. 1 = Strongly Agree: 2 = Agree: 3 = Disagree: 4 = Strongly Disagree: n ranged from 201 to 230. Eigenvalue = 1.31.
456
T. P. JANIKOWSKI et al.
For the present study, however, participants disagreed that the sources of stigma were preventing them from discussing their incest histories with their counselors. Six of the 10 items in this factor had mean responses of 3.0 or more (3 = Disagree), and the remaining four items had mean responses of 2.6 to 2.8. Hence, stigma wasn’t found to be a major obstacle to clients’ willingness to discuss the topic of incest with substance abuse counselors. Data reported in Glover (1995) indicate that about 40% of clients with incest histories have made their counselors aware of their past incest. Only 15% of these clients with incest histories, however, were receiving incest-related counseling in the context of their substance abuse treatment. It appears, therefore, that substance abuse treatment counselors are aware of less than half of the incest victims who may be on their caseloads, and most of these clients remain untreated for their incest-related issues, despite the fact that some clients believe that incest has caused them problems with drinking or taking drugs. Factor 2 contained items that examined the association, in the participants’ view, between incest and the development of substance abuse. A substantial proportion of clients (especially females) in substance abuse treatment report having been victims of incest and, for some but not all, this victimization has affected the development and maintenance of their substance abuse. Item responses in Factor 2 that directly examined the linkage between incest and substance abuse received mid-range ratings by clients (lower ratings indicated stronger agreement; 1 = Strongly Agree; 4 = Strongly Disagree): Item 28, “I have used alcohol to help me forget about incest contacts” (M = 2.7); Item 29, “I have used drugs to help me forget about incest contacts” (M = 2.7); Item 26, “Incest has caused me problems with drinking” (M = 2.8); and Item 27, “Incest has caused me problems with taking drugs” (M = 2.8). Other items in Factor 2 also had mid-range ratings: Item 31, “Counseling for incest should be made part of my substance abuse treatment” (M = 2.5); and Item 50, “If I talked to my counselor about incest I think it would help me with my substance abuse problem” (M = 2.5). The standard deviation values for all items in Factor 2 were between 1.0 and 1.2, which means that participants seemed to straddle the scale between agreement and disagreement, with about half of the participants agreeing and the other half disagreeing with the item statement. Factor 3 contained items that presented some of the ambivalent feelings clients might have had about incest and substance abuse. The item with the greatest level of agreement, of all factor items, was Item 52: “If I were to get counseling for incest, I would like to meet alone with a counselor” (M = 2.1). This item underscores the private nature of incest-related issues. For some clients, incest was not viewed as a problem (Item 41, M = 2.6). Other items represented vague feelings about incest (Item 45, M = 2.8), or the perception that incest-related counseling wouldn’t be helpful (Item 39, M = 2.9). Both of these items tended to receive ratings of disagreement rather than agreement. It seems to be important to take an individualized approach when dealing with incest among substance abuse treatment clients. Some clients may have resolved their feelings about their pasts’ and incest may be a nonissue, while the opposite is true for others. it is important, therefore, to determine who may or may not benefit from incest counseling while in substance abuse treatment. Items contained in Factor 4 received mean ratings that indicated disagreement. It appeared that clients, as a group, did not anticipate problems with future incest contacts (Item 30, M = 3.4), were not concerned about possible legal consequences (Item 37, M = 3.3), nor did they think that their counselors were unable to deal with incest (Item 42, M = 3.2). This last point is of importance for substance abuse treatment
Incestand substanceabuse
451
counselors; clients appear to believe that their counselors are competent in addressing this sensitive topic. It would be interesting, in future research, to see whether counselors hold a similar view toward themselves. Finally, Factor 5 contained two items that related to receptivity toward counseling. Item 49 (“I would talk about incest with my counselor if he/she asked me about it”) received one of the strongest average agreement ratings (M = 2.2) by the group. One conclusion to be drawn from this finding is that, if substance abuse treatment counselors initiated an exploration of incest with their clients, clients would be open to sharing such information and counselors would be in the position to determine whether or not incest was instrumental in the development and maintenance of substance abuse. Responses to Item 48 (“If I were to talk about incest with a counselor I would want a counselor of the same sex”; M = 2.6) indicated that participants seemed to again straddle the agreement continuum regarding preference for their counselors’ gender. A few limitations to the present study exist that warrant discussion. First and foremost was the voluntary, survey design of the study. Clients could self-select themselves out of the study, allowing for clients with incest histories to avoid the study if it was too threatening. As with all survey research, it is not possible to know how nonrespondents differed from respondents. Responses to survey research are also subject to response bias. Participants may have wanted to make themselves appear in a favorable light and skewed their answers in a socially positive direction. Countering this social desirability response is the tendency for substance abuse clients to engage in rationalizing the source of their problems. Clients could use incest as an excuse for substance abuse behavior, thus absolving themselves of personal responsibility for their problems; this would have led to an overestimation of the incidence of incest. The topic of incest is particularly susceptible to the phenomenon of response bias; however. participants were encouraged to respond honestly and their responses were confidential so neither the researchers nor the facility staff knew who completed a particular survey. Sampling was another limitation to the study. Although the present study used a relatively large national sample (N = 768), this number represents a small proportion of the clients enrolled in nonprofit substance abuse treatment facilities across the United States. This, combined with the fact that there was an over-representation of males (n = 518; 71%), somewhat limits the generalizability of the study’s results. Finally, factors identified by the factor analysis are, in part. a consequence of the items created for the survey. Survey items, however, were specially selected for their relevance to incest and substance abuse counseling: in addition, a panel of experts was employed to examine survey comprehensiveness. Nonetheless, other factors underlying the relationship between incest and substance abuse may exist and need to be explored in future research. Three clear recommendations can be made from the results of the present study. First, because incest is prevalent among substance abuse treatment clients (especially females). treatment facilities should regularly screen all clients for incest histories as a part of their facility-intake procedure. In fact, one of the primary purposes for developing the SAIS-R was to bring to light the high incidence of incest histories among clients in substance abuse treatment. The factor analysis of the SAIS-R perception items was conducted. in part, to identify items that tap into client feelings about incest’s relationship to the development of substance abuse and client views about receiving incest counseling in the context of substance abuse treatment. The factor items of the SAIS-R could be easily incorporated into a confidential, short screening questionnaire that could be given to all clients upon admission. This screening form could lead to
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et al.
early identification and allow counselors to explore the issue of incest with clients who may need substance abuse counseling that integrates incest as contributory factor. Other potential uses of the SAIS-R, especially those areas not dealing with the Likerttype perception items, are discussed in Glover et al. (1996). Second, it is recommended that substance abuse treatment staff become prepared to deal with this relatively pervasive problem in their caseloads. If the facility staff is unqualified to deal with incest as a counseling issue, they should establish formal referral relationships with incest treatment professionals. Substance abuse treatment could then take place in a coordinated fashion with incest counseling. The formal relationship between the two specializations would allow both parties to exchange information and for each to educate the other with regard to treatment strategies and issues. Third, it is recommended that substance abuse treatment facilities should either hire staff with expertise in incest counseling or train their existing staff to deal with the issue. Clearly, the high incidence of this problem can no longer be ignored by substance abuse treatment facilities. As indicated early, informal staff education could be obtained from incest treatment professionals in the field. Facilities could also engage in more formal inservice training and continuing education through workshops and conferences. Preservice education also needs to introduce incest issues into its course work (e.g., identification, counseling strategies, integration with substance abuse treatment). The Council for Accreditation of Counseling and Related Educational Programs (CACREP) and Council on Rehabilitation Education (CORE) accredit programs that often offer substance abuse courses or concentrations; these organizations may wish to examine their curricular content to ensure that graduates of their programs are capable of identifying and dealing with incest issues in the context of substance abuse treatment. In conclusion, this study and other research (Coleman, 1987; Evans & Schaefer, 1987; Glover et al., 1995; Hammond et al., 1979; Wilsnack, 1982; Young, 1990) have demonstrated a linkage, at least for some clients, between past incest and the development and maintenance of substance abuse. Unfortunately, most substance abuse treatment facilities are reluctant to address incest as a substance abuse treatment issue; it has been estimated that fewer than 20% of substance abuse treatment facilities offer specialized groups dealing with past sexual or incest trauma (Yandrow, 1989). Incest is a taboo shrouded in secrecy, and treatment facilities and their counselors may be unwilling to confront this sensitive topic openly. This reluctance is important because it may contribute to clients’ perpetuating life-long secrets that may be at the root of their substance abuse problems.
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