Node-Link Mapping and Psychological Problems

Journal of Substance Abuse Treatment, Vol. 17, No. 4, pp. 321–329, 1999 Copyright © 1999 Elsevier Science Inc. Printed in the USA. All rights reserved. 0740-5472/99 $–see front matter

PII S0740-5472(99)00013-6

ARTICLE

Node-Link Mapping and Psychological Problems Perceptions of a Residential Drug Abuse Treatment Program for Probationers

Michael Czuchry, phd and Donald F. Dansereau, phd Institute of Behavioral Research, Department of Psychology, Texas Christian University, Fort Worth, TX

Abstract – The current study examined program perceptions of 367 probationers admitted to a 4-month residential drug abuse treatment facility that focuses on group counseling. Prior research has shown that many individuals within the criminal justice system have both psychological and drug abuse problems, and that they often have limited success in drug abuse treatment programs. The current study examined whether the benefits of node-link mapping, a visual representation counseling technique that is especially beneficial in group counseling environments, would extend to individuals with psychological problems. Probationers were randomly assigned to mapping-enhanced or standard counseling. Those residents who had higher levels of psychological problems (based on a global indicator of psychological problems), and who received mapping-enhanced counseling, had more favorable perceptions of their counselors and fellow community members over time than their counterparts who received standard counseling. © 1999 Elsevier Science Inc. All rights reserved. Keywords – psychological problems; node-link mapping; counselor effectiveness; community effectiveness; treatment effectiveness.

INTRODUCTION

cussed in counseling sessions (see Figure 1 for an example of a free map), and preformed guide maps provide graphic structures and guiding questions to facilitate discussion (see Figure 2 for an example of a guide map). Prior research on node-link mapping has shown that maps facilitate the effectiveness of group counseling (e.g., Knight, Dansereau, Joe, & Simpson, 1994), and appear to be beneficial especially for clients with attentional problems (Czuchry, Dansereau, Dees, & Simpson, 1995; Dansereau, Joe, & Simpson, 1995; Joe, Dansereau, & Simpson, 1994). Mapping also appears to increase client participation in group sessions (Newbern, Dansereau, & Dees, 1997; Pitre, Dansereau, Newbern, & Simpson, 1998), and leads to greater coverage of collateral issues (e.g., addressing fears, depression/anxiety, education skills or goals, health, family, friends, and legal problems) that can undermine treatment progress and increase the possibility of relapse (Pitre, Dansereau, & Simpson, 1997). In general, mapped sessions are perceived to be deeper by

The current study examines the impact of node-link mapping, a visual representation technique for enhancing counseling, on probationers with co-occurring drug and psychological problems. Node-link mapping uses nodes to encapsulate ideas and links to depict the relationship among ideas. Free maps are produced collaboratively by counselor and client(s) to represent information dis-

This work was supported by the National Institute on Drug Abuse (Grant No. R01 DA08608). The interpretations and conclusions, however, do not necessarily represent the position of NIDA or the Department of Health and Human Services. We would like to thank the staff and counselors at the Tarrant County Correctional Facility in Mansfield, Texas, for their assistance in conducting this research project. Requests for reprints should be addressed to Michael Czuchry, Institute of Behavioral Research, Department of Psychology, Texas Christian University, TCU Box 298920, Fort Worth, TX 76129.

Received October 21, 1997; Accepted December 8, 1998.

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clients and counselors (Knight, Dansereau, et al., 1994; Newbern et al., 1997). These characteristics of mappingenhanced counseling should benefit individuals with psychological problems by increasing their attentional focus, encouraging greater participation in treatment, and by providing a forum to express personal issues. Specifically, the goal of the current study was to examine whether the benefits of node-link mapping would extend to probationers with co-occurring drug and psychological problems in a residential group counseling environment. The importance of this investigation is indi-

cated by the prevalence of psychological problems that coexist with addictive disorders in drug treatment settings (Jainchill, De Leon, & Pinkham, 1986; McLellan, Luborsky, Woody, O’Brien, & Druley, 1983; Platt, 1995; Ries, 1993; Ross, Glaser, & Germanson, 1988; Sacks, Sacks, De Leon, Bernhardt, & Staines, 1997; Sternberg, 1989; Woody et al., 1983; Woody, McLellan, & O’Brien, 1990). Diagnostic studies have found that 50 to 90% of patients admitted to drug abuse treatment have co-occurring substance use and psychological disorders (e.g., Sacks et al., 1997). Prior research conducted in the

FIGURE 1. An example of a free map produced in a counseling session. From Mapping New Roads to Recovery (p. 101) by D.F. Dansereau, S.M. Dees, L.R. Chatham, J.F. Boatler, & D.D. Simpson, 1993. Bloomington, IL: Lighthouse Institute. Reprinted with permission.

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FIGURE 2. An example of a guide map.

same residential criminal justice drug treatment program as the current study found 80% of probationers had psychological problems (using Millon Clinical Multiaxial Inventory-II [MCMI-II] diagnostic criteria), 72% had drug abuse problems, and 58% of probationers had concurrent psychopathology and drug problems (Hiller, Knight, & Simpson, 1996). The most prevalent problems included dysfunctional personality styles, such as antisocial disorder, although depression accounted for 14% of the problems. These percentages are consistent with other research on criminal offenders (Abram, 1990; Teplin, 1990, 1994). Although the relationship between coexisting psychological and drug problems and treatment outcome is somewhat complicated (e.g., conduct disorder, antisocial personality disorder, and hostility are related to poorer treatment outcomes [Alterman, Rutherford, Cacciola, McKay, & Woody, 1996; Broome, Flynn, & Simpson, in press; Crowley, Mikulich, MacDonald, Young, & Zerbe, 1998; Holdcraft, Iacono, McGue, 1998; Kranzler, Del

Boca, & Rounsaville, 1996], whereas depression may facilitate treatment engagement and effectiveness [Alterman et al., 1996; Broome et al., in press; Holdcraft et al., 1998; Kranzler et al., 1996]), it appears that, in general, the greater the number of psychological problems (Kranzler et al., 1996) or the greater the psychiatric severity (i.e., the number, duration, frequency, and intensity of a range of symptoms; McLellan, Luborsky, O’Brien, Barr, & Evans, 1986; McLellan, Luborsky, Woody, O’Brien, & Druley, 1983; Woody et al., 1984), the more difficulty individuals have with treatment. These difficulties are especially problematic in treatment programs that focus on group counseling. In these settings, it would be expected that those with psychological problems would have unmet needs and, as a consequence, less favorable perceptions of program effectiveness and potentially less positive treatment outcomes. The current study was designed to examine program perceptions, midway and toward the end of treatment, of

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probationers who were engaged in a 4-month residential treatment program. The study focused on perceptions because other indicators of treatment outcome (i.e., session attendance, urinalysis, dropouts) were not available in the current setting; probationers were required to attend all sessions, were monitored closely throughout the duration of residential treatment, and would violate their conditions of parole by dropping out of treatment. It should be noted that client perceptions in drug abuse treatment and criminal justice settings have been shown to be reliable and valid (e.g., Bonito, Nurco, & Shaffer, 1976; McLellan et al., 1986; Rounsaville, Kleber, Wilber, Rosenberger, & Rosenberger, 1981; Sobel & Sobel, 1978). More specifically, ratings similar to those included in the current study are predictive of treatment outcomes (e.g., Woody, McLellan, Luborsky, & O’Brien, 1987), and are important indicators in their own right. We expected that, in comparison to standard treatment, mapping enhanced counseling would facilitate program perceptions of clients who had psychological problems of greater severity (based on a global indication of psychological problems). METHOD The study was conducted at a 140-bed residential substance abuse facility for probationers in Mansfield, Texas. Judges mandate offenders to this program primarily for violating conditions of probation or parole, either in conjunction with or as the direct result of substance abuse problems. Residents received 4 months of substance abuse treatment in a modified therapeutic community and 3 months of aftercare. Two counselors per community (four communities of 26–38 probationers are treated concurrently) provided group counseling, education classes that addressed life skills, graduate equivalency degree (GED) training, and other substance abuse education. Probationers who were mandated to receive treatment were placed on a waiting list until enough residents (26–38) could form a new community. Over the course of the study, these communities were randomly assigned to receive mapping-enhanced or standard counseling. Contact between residents of different communities was restricted, and observations of counseling sessions revealed no diffusion of treatment (i.e., node-link mapping was not used in the standard [control] communities). Participants Residents. Probationers admitted to the substance abuse treatment facility between January and November 1995 formed the sample for this study. Of the 415 probationers admitted, 381 (comprising a series of 12 communities consisting of 6 mapping and 6 standard) agreed to participate in the research project. Seventy-three percent of this sample were male, 57% White, 35% African American, 7% Mexican American, and 2% American Indian.

Sixty-five percent had a high school degree or GED. Fifty-seven percent of probationers engaged in some illegal drug use on at least a weekly basis in the 6 months prior to treatment. The percentages (based on all 381 probationers) for weekly drug use (including alcohol) in the 6 months prior to treatment were as follows: 47% used alcohol, 28% used marijuana, 30% used cocaine or crack, and 4% used heroin. Individuals with incomplete data were not included in the current analyses; the final sample was based on 367 individuals. Counselors. Ten counselors participated, including 6 females, 1 African American, and 9 White. All but one had 4-year college degrees, five were certified alcohol and drug abuse counselors, two were social-work certified, two had HIV training certification, and eight had other relevant certifications. Counselors had an average of 6 years of counseling experience and had been at the treatment facility for an average of 5 years. Measures A comprehensive system for evaluating background information, individual differences, and during-treatment progress was based on previous research, development, and psychometric efforts (Simpson, Joe, Dansereau, & Chatham, 1997). Shortly after admission of the probationers, counselors administered individual intake interviews to collect information on the following areas: sociodemographic information, family and peer relations, health and psychological status, criminal and drug involvement, and AIDS-risky behavior. Within the first 4 weeks of treatment, residents completed a self-rating measure that assessed self-esteem, depression, anxiety, and other psychosocial attributes. Probationers rated their counselors, other residents in their community, security staff, and educational, process, and community meetings both midway (at approximately 8 weeks) and toward the end of treatment (at approximately 14 weeks). Psychological Problems. A global assessment of psychological problems was developed using the same measures and items as Joe, Brown, and Simpson (1995), although we further extended their criteria to include items that assessed self-esteem. Two indices of psychological problems were assessed during the structured intake interview, the Suicide Index (thoughts or attempts at suicide) and the Pathology Index (hallucinations; significant anxiety or tension; difficulty understanding, concentrating or remembering; difficulty controlling violent behavior; and serious depression). Psychological problems also were assessed via the depression, anxiety, and selfesteem scales from the self-rating measure. These scales have been shown to be psychometrically sound (Knight, Holcom, & Simpson, 1994). The depression scale is highly correlated with the Symptom Check List-90 (SCL-90) Depression subcale and the Beck Depression

Node-Link Mapping

Inventory (r 5 .81 and r 5 .75, respectively), the Anxiety subscale is highly correlated with the SCL-90 Anxiety subscale (r 5 .74), and the Self-Esteem Subscale is negatively correlated with both the Depression and Anxiety subscales. In the current study, a composite score was computed by first computing z-scores for each subscale (Self-Esteem scores were reversed), and then calculating a mean score across the subscales (including the Suicide Index and Pathology Index). It should be noted that this measure represents a global indication of psychological problems and not a clinical diagnosis. A median split was used to designate residents into either lower or higher levels of psychological problems. Evaluation of the Treatment Program. Midway and toward the end of treatment, residents rated 25 items on 7point Likert scales anchored at 1 (disagree strongly”), at 4 (“not sure”), and at 7 (“agree strongly”). These items were primarily related to probationers’ perceptions of their counselors and residents in their community. A principal components factor analysis was conducted and produced two of the factors (with eigenvalues .1.0) used in the current study. These factors, with individual items loading .50 or higher, were labeled “Counselor Effectiveness” and “Community Effectiveness.” Items for counselor effectiveness were preceded by the stem Your counselors,” and included the following items: respect you, motivate you, help you focus on specific problems, help you develop self-confidence, are easy to talk to, are trusted by you, understand your situation, focus your thinking and planning, developed a reasonable treatment plan, help you be realistic, help you make life changes, teach useful ways to solve problems, remember important details from earlier sessions, speak in an understandable way, and, are well-organized and prepared. Items for community effectiveness were preceded by the stem “Some community members,” and included the following items: help you be realistic, motivate you, understand your situation/problem, respect you, help you develop self-confidence, teach you useful ways to solve problems, are trusted by you, are easy to talk to, speak in an understandable way, and, help you make life changes. The alpha reliability coefficients were .96 and .97 for counselor effectiveness and community effectiveness, respectively. The other factors used in the study, “Security Staff Effectiveness” and “Treatment Effectiveness,” were based on a factor analysis conducted in a previous study (Pitre, Dees, Dansereau, & Simpson, 1997). Treatment effectiveness was modified in the current study to include only those items that reflected the effectiveness of meetings and treatment overall. Residents rated 16 items on 7-point Likert scales anchored at 1 (“terrible”), at 4 (“okay”), and at 7 (“great”). Items for treatment effectiveness included the following items: education group meetings, community group meetings, process group meetings, organization of meetings and activities, and overall evaluation of the treatment program. Items

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for security staff effectiveness included the following items: helpfulness of security staff, caring of security staff, and rules and regulations. In the current study, the alpha reliability coefficients were .88 and .87 for treatment effectiveness and security staff effectiveness, respectively. RESULTS As described earlier, communities (n 5 12) were randomly assigned to experimental conditions, which created a nested hierarchical design. Recent discussions of traditional statistical procedures that use individuals as the unit of analysis (including nested procedures) has suggested that these may be problematic due to the possibility of inflated Type I error (Murray & Wolfinger, 1994; Zucker, 1990). A conservative approach to address this problem is to use communities as the unit of analysis (Bryk & Raudenbush, 1992). We used a modified version of this approach so that we could examine potential differences associated with residents who had either lower or higher levels of psychological problems. Community means were computed for individuals with lower and higher levels of psychological problems (based on a median split on this factor), which created a total sample of 24 cases (12 communities, 2 levels of psychological problems within each community). However, to examine whether additional effects would be evident from a more traditional approach, we also conducted a supplementary analysis using individuals as the unit of analysis. A repeated-measures multivariate analysis of variance using communities as the level of analysis was conducted, with counseling method (mapping vs. standard) and psychological problems (low vs. high) as the independent variables, and counselor, community, staff, and treatment effectiveness at midterm and endterm as the multiple dependent variables. There was a significant three-way multivariate interaction between counseling method, psychological problems, and time, F(4, 17) 5 2.97, p , .05. There was also a significant multivariate main effect for time, F(4, 17) 5 6.93, p , .01. As can be seen in Tables 1 and 2, perceptions of counselor, community, security staff, and treatment effectiveness generally improved over the course of treatment. However, ratings of counselor and staff effectiveness decreased slightly for standard residents with more psychological problems, and ratings of treatment effectiveness decreased slightly for standard residents with fewer psychological problems (see Table 2). Univariate analyses revealed significant interactions between counseling method and psychological problems at endterm for both counselor effectiveness, F(1, 20) 5 4.86, p , .05, and community effectiveness, F(1, 20) 5 10.29, p , .01. Post-hoc comparisons showed that at endterm, mapping residents with more psychological problems rated both counselor and community effectiveness higher than their counterparts who received standard counseling, t(23) 5 2.64, p , .05 and

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M. Czuchry and D.F. Dansereau TABLE 1 Means and Standard Deviations for Self-Ratings of Effectiveness at Midterm and Endterm

Midterm Rating

Counselor effectiveness

Psychological Problems

M

SD

n

M

SD

n

Mapping

Low High Low High Low High Low High Low High Low High Low High Low High

5.46 5.51 5.68 5.53 5.52 5.32 5.71 5.28 4.97 4.96 5.05 4.82 3.30 3.32 2.88 3.01

.90 .68 .40 .26 .30 .43 .29 .42 .47 .61 .40 .23 .82 .37 .58 .47

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

5.72 6.01 5.82 5.49 5.73 5.86 6.10 5.47 5.29 5.23 5.03 4.88 3.50 3.61 3.07 2.95

.36 .24 .40 .35 .33 .25 .21 .34 .26 .45 .57 .44 .57 .60 .81 .64

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

Standard Community effectiveness

Mapping Standard

Treatment effectiveness

Mapping Standard

Security staff effectiveness

Endterm

Counseling Method

Mapping Standard

Note. Means were averaged within each community to statistically control for effects that the community may have had on the dependent variables.

t(23) 5 2.29, p , .05, respectively. As can be seen in Table 2, perceptions of counselor, community, treatment, and staff effectiveness consistently improved for mapping residents with more psychological problems. In contrast, the perceptions of standard residents with more psychological problems generally did not improve and even decreased slightly for two of the measures. There were also significant univariate main effects for psychological problems for ratings of community effectiveness at both midterm, F(1, 20) 5 4.45, p , .05, and endterm, F(1, 20) 5 4.48, p , .05, where residents with higher levels of psychological problems gave their community lower ratings than residents with lower levels. There was also a marginally significant univariate main effect for counseling method for ratings of staff effectiveness at endterm, F(1, 20) 5 4.01, p , .06, where mapping residents rated staff effectiveness higher than their standard counterparts. No other effects were significant. An analysis using individuals as the unit of analysis revealed the same pattern of results as those reported here as well as some additional effects.1 DISCUSSION In general, residents’ perceptions of counselor, community, treatment, and security staff effectiveness improved 1 In a reanalysis of the data (using individuals as the unit of analysis), we found the same pattern of results as those reported in the paper as well as some additional findings. There was a significant overall multivariate effect in favor of mapping. This effect was largely driven by higher ratings of treatment (at endterm) and security staff effectiveness (at midterm and endterm).

over time. By the end of treatment, mapping residents with higher levels of psychological problems perceived their counselors and communities to be more effective than standard residents with higher levels of psychological problems. Though not significant for treatment and security staff effectiveness, the pattern of means was consistent with the other ratings. The interaction between counseling method and psychological problems is particularly interesting. In the introduction, we suggested that maps may be helpful to clients with higher levels of psychological problems by facilitating their attentional focus, by encouraging more participation, and by facilitating the depth and breadth of the group counseling sessions. It is possible that mapping may have increased the involvement of individuals with higher levels of psychological problems at the expense of those with fewer problems. If the sessions were dominated by discussions of psychological problems, there would have been less time available to deal with other issues. As a consequence, the low problem clients in mapping may not have benefited as much from the enhancement (the means of the ratings tend to support this). Although the current study is unable to address directly whether more time was spent on psychological problems in mapping than in standard counseling sessions, previous research has shown that mapped sessions do lead to greater coverage of collateral issues including psychological problems (Pitre et al., 1997). Our research with node-link mapping typically has shown that mapping-enhanced counseling is more effective than standard counseling. However, the current study did not find an overall difference between mapping and standard counseling. Part of the reason for not de-

Node-Link Mapping

327 TABLE 2 Amount of Improvement in Perceptions of Effectiveness from Midterm to Endterm by Counseling Group and Low/High Psychological Problems

Counseling Group

Mapping Low High Standard Low High

Counselor

Resident

Treatment

Security Staff

Average Change

.26 .50

.21 .54

.32 .27

.20 .29

.25 .40

.14 2.04

.39 .19

2.02 .06

.19 2.06

.18 .04

tecting an overall mapping benefit may stem from the analytic approach used in the current study. We used communities (instead of individuals) as the level of analysis to guard against the possibility of inflated Type I error. This approach is overly conservative and reduces power for detecting differences. A re-examination of the data using individuals as the unit of analysis revealed significant overall effects in favor of mapping. This finding is consistent with previous research. We expected that individuals with higher levels of psychological problems (regardless of counseling condition) would rate program features as less effective than individuals with lower levels. Although true for ratings of community effectiveness at both mid- and endterm, the expected relationship did not hold for the other ratings. The main reason may be (based on rank orders of means) that mapping residents with more psychological problems generally rated program features as the same as (or higher than) residents with fewer psychological problems, whereas standard residents with more psychological problems generally rated program features lower than residents with fewer psychological problems. The predicted relationship does not appear to hold, then, partly because of the differential impact that mappingenhanced counseling has on individuals with psychological problems. Node-link mapping has been theorized to enhance communication and representation of critical issues (Dansereau, Joe, Dees, & Simpson, 1996; Pitre, Dansereau, & Joe, 1996) and facilitate the focus and attention of counselors and clients (Czuchry et al., 1995; Knight, Dansereau, et al., 1994). In a general sense, node-link mapping appears to be beneficial for clients who may be considered more difficult to treat. The question remaining is how psychological problems fit into the overall pattern of mapping results. It may be, for example, that the measure of psychological problems used in the current study is really a marker variable for other types of difficulties examined in previous node-link mapping research (e.g., attentional or communication difficulties). However, we examined correlations between the psychological problems factor used in the current study with measures of attention, verbal ability, and

education level (i.e., indicators used in previous studies), and found only modest correlations (i.e., r values all less than |.22|). The measure of psychological problems used in the current study, therefore, does not appear simply to be representing individual differences examined in previous studies. It may be that a common characteristic of individuals who have difficulties with treatment (whether these difficulties stem from communication, attentional, or psychological problems) is that they come to believe that they do not have the necessary resources to realize personal change. A common reaction for these individuals may be to disengage from treatment. Node-link mapping may generally serve to boost self-efficacy and encourage engagement by providing an easily accessible, concrete, visual tool that helps clients become more confident in their ability to make progress. These benefits of mapping may encourage clients to work through their difficulties and become more invested in the treatment process. For example, previous research has shown that node-link mapping appears to increase clients’ self-confidence and commitment to treatment (e.g., Dansereau, Joe, & Simpson, 1993). Another possibility is that individuals who have communication, attentional, or psychological problems generally have difficulty remaining adequately focused during counseling sessions. For example, individuals with more psychological problems may be distracted by their problems and find it difficult to focus on other important information. Maps may in some sense capture individuals’ attention, facilitating a more direct, outward focus of attention. It should be noted that, in this study, psychological problems were based on a global indicator and not a clinical diagnosis. Global indicators of psychological problems such as psychiatric severity provide important practical information for counselors and clinicians and, as mentioned in the introduction, have been linked to poorer treatment outcomes (e.g., McLellan et al., 1983; McLellan et al., 1986; Woody et al., 1984). Importantly, the current study extends prior research on node-link mapping by showing that mapping enhanced counseling is beneficial particularly for probationers with higher

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levels of psychological problems within a setting that lacked individual counseling. Further research is necessary to examine the exact means by which probationers with more psychological problems benefit from mapping. It may be that better coverage of issues, increased participation, increased focus, increased confidence, or some combination of these allow individuals with more psychological problems to become better engaged in the treatment process. Future research should examine the amount of time spent in mapped and unmapped counseling sessions addressing psychological problems and other issues to determine if increased coverage of these issues leads to more favorable outcomes for individuals with more psychological problems. A more open-ended descriptive approach that examines the aspects of mapping that clients find beneficial or problematic may also provide important insights that could influence the design of subsequent studies.

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