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Reintegration of women with histories of substance abuse into society

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Reintegration of women with histories of substance abuse into society
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VanDeMark, Nancy Rae
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English
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xv, 222 leaves : ; 28 cm

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Women -- Drug use -- United States ( lcsh )
Substance abuse -- Treatment -- United States ( lcsh )
Drug addicts -- Rehabilitation -- United States ( lcsh )
Drug addicts -- Rehabilitation ( fast )
Substance abuse -- Treatment ( fast )
Women -- Drug use ( fast )
United States ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 201-222).
General Note:
School of Public Affairs
Statement of Responsibility:
by Nancy Rae VanDeMark.

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|University of Colorado Denver
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ocm71813679
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LD1193.P86 2006d V36 ( lcc )

Full Text
i
REINTEGRATION OF WOMEN WITH HISTORIES OF SUBSTANCE ABUSE
INTO SOCIETY
A thesis submitted to the
University of Colorado at Denver and Health Sciences Center
in partial fulfillment
for the requirements of the degree of
Doctor of Philosophy
Public Affairs
by
Nancy Rae VanDeMark
B.A., Colorado State University, 1980
M.S.W., University of Denver, 1985
2006


2006 by Nancy Rae VanDeMark
All rights reserved.


This thesis for the Doctor of Philosophy
degree by
Nancy Rae VanDeMark
has been approved
by
Nancy Leech
Christine Martell
Janet Wood

Date


VanDeMark, Nancy R. (Ph.D., Public Affairs)
Reintegration of Women with Histories of Substance Abuse into Society
Thesis directed by Professor Peter deLeon
ABSTRACT
Substance abuse among women is a social problem of sizeable scope with
significant individual and societal consequences. U.S. policy toward individuals
with substance abuse problems relies on stigma, discrimination, and punishment;
withholding access to education, cash assistance, housing, social support, and
normal social roles. Based in the principles of the theories of reintegrative shaming
and social construction of target populations, this thesis investigates the
relationship between instrumental and social supports and participatory practices
and the propensity of women with recent histories of substance abuse to affiliate
with pro-social versus deviant lifestyles. Using a secondary data set, this cross-
sectional study examines the predictors of deviance using a combination of logistic
regression and inductive qualitative analysis with a sample of 325 women with
histories of substance abuse. Results of the logistic regression analyses reveal that
higher levels of instrumental support, affective support and participation in normal
roles are statistically significant predictors of lower levels of criminal and drug
IV


using behaviors when introduced into the model both individually and collectively.
Qualitative findings support the quantitative results, revealing that women perceive
these variables of instrumental support, affective support and participation in
normal roles of parent, employee, student, and citizen to be critical in facilitating
their return to pro-social lifestyles. They also note the importance of individual
characteristics such as optimism and strength and emphasize the importance of
their relationship with their children in motivating them to avoid deviant behaviors.
The author concludes that current policies that withhold support and access to
fulfill normal societal roles do not increase the propensity for women to shed
deviant identities and in fact may promote affiliation with deviance. Findings
suggest that current U.S. policy toward women with substance abuse histories is
ineffective and that consideration should be given for alternative policies that
actively facilitate re-entry of women in society.
This abstract accurately represents the content of the candidates thesis. I
recommend its publication.
Signed
Peter deLeon
v


ACKNOWLEDGEMENT
The completion of this dissertation would not have been possible without
the assistance and support of a number of people and organizations. The data set
analyzed for this thesis was the culmination of five years of groundbreaking work
by the Women with Co-occurring Disorders and Violence Steering Committee
which was funded by the U.S. Department of Health and Human Services, Public
Health Service, Substance Abuse and Mental Health Services Administration under
GFA No. TI 00-003. The commitment of the steering committee, funding agency
and women participating in the data collection process provides the foundation for
any insight that may be extracted from this work.
In addition, it is through my employment with the Arapahoe House Inc. that
I have gained a depth of understanding for the implications of substance abuse. I
would like to thank the staff and clients for sharing their insights into the
challenges facing people with substance abuse problems over the past decade.
I would also like to thank my dissertation committee, Linda deLeon,
Christine Martell, Janet Wood, Nancy Leech, and chairperson, Peter deLeon. All
of these members contributed substantial time and support for this work. In
vi


particular, I thank Peter deLeon, for his clear and timely guidance on the
dissertation process and Nancy Leech for her methodological assistance and
common sense approach to research.
Finally, I must express my thanks to my husband, Walter, for his support
and encouragement over the past four years.
Vll


CONTENTS
Figures..........................................................xiii
Tables............................................................xiv
CHAPTER
1. INTRODUCTION.....................................................1
Scope of the Substance Abuse Problem...................3
Approaches to the Substance Abuse Problem.............5
Substance Abuse Policy................................6
Framing the Research Question........................11
Thesis Outline.......................................13
2. CONTEXT OF CURRENT SUBSTANCE ABUSE POLICY.......................14
Establishing a Common Terminology.....................15
Concept of Recovery...................................17
Oversight and Financing for Treatment of Substance Abuse
and Dependence.......................................17
Social Costs of Substance Abuse......................19
Policy Related to Substance Abuse....................20
Mandatory Minimum Sentencing for Drug Offenders.20
Housing Policy and Drug Use....................23
Welfare Reform and Drug Use....................24
Education and Drug Offenders...................26
Vlll


Substance Involved Families in the Child Welfare
System.............................................27
Current State of Substance Abuse Policy............28
3. LITERATURE REVIEW...................................................30
Social Construction Theory................................30
Labeling Theory...........................................41
Empowerment and Participation.............................56
Social Support............................................72
Review....................................................82
4. METHODOLOGY.........................................................85
Research Question and Hypotheses..........................87
Data Set and Sampling.....................................91
Statistical Power Analysis.........................95
Random Sampling Procedures.........................97
Operational Definition of Variables.......................98
Dependent Variable.................................98
Independent Variables.............................103
Analysis of Qualitative Data Included in Independent
Variables.........................................103
Control Variables.................................111
Design...................................................112
Validity and Reliability.................................113
ix


Analysis...................................................116
Human Subjects Protection and Privacy......................120
Limitations................................................121
5. RESULTS OF QUANTITATIVE AND
QUALITATIVE ANALYSIS............................................124
Characteristics of Sample..................................124
Quantitative results.......................................129
Instrumental Support as a Predictor of Alienation
Deviance............................................130
Affective Support as a Predictor of Alienation
Deviance............................................133
Participation as a Predictor of Alienation Deviance.134
Predicting Alienation Deviance from the Combination
of Instrumental Support, Affective Support and
Participation.......................................136
Instrumental Support as a Predictor of Behavioral
Deviance............................................139
Affective Support as a Predictor of Behavioral
Deviance............................................141
Participation as a Predictor of Behavioral Deviance.143
Predicting Behavioral Deviance from the Combination
of Instrumental Support, Affective Support and
Participation.......................................145
Results of the Qualitative Analyses........................148
Instrumental Support................................149
Affective Support from Family and Friends...........151
x


Participation in Family and Community...............154
Twelve-step Program Participation...................155
Treatment Providers and Treatment Activities........159
Coercion into Services..............................158
Psychological Characteristics.......................159
Re-living Painful Experiences.......................161
Acknowledging and Accepting Past....................162
Relationship with Children..........................163
Summary of Quantitative and Qualitative Findings...........164
6. CONCLUSIONS...........................................................165
Instrumental Support.......................................165
Affective Support..........................................168
Empowerment and Participation..............................172
Problem Complexity.........................................179
Individual Psychological Qualities.........................181
Causal Relationships Between Punishment and Deviance.......182
Degenerative Policy........................................185
Shame versus Stigma........................................187
Strengths and Limitations of the Study.....................191
Implications for Future Research...........................194
Implications for Future Policy.............................198
xi


APPENDIX .........................................200
REFERENCES........................................201
Xll


FIGURES
Figure
3.1 Social construction of target populations.................................35
3.2 Application of the theory of reintegrative shaming to substance
-abusing women................................................................84
6.1 Summary of findings and implications for future research.................197


TABLES
Table
4.1 Items Comprising Deviance Variable....................................102
4.2 Items Comprising Instrumental Support Variable........................106
4.3 Items Comprising the Affective Support Variable.......................108
4.4 Items Comprising the Participation Variable...........................110
4.5 Results of Check-coding...............................................115
4.6 Means and Standard Deviations for Independent and Dependent
Variables.............................................................117
4.7 Intercorrelations between Independent and Control Variables...........118
5.1 Source of Income......................................................125
5.2 Race of Study Participants............................................126
5.3 Current Living Situation..............................................128
5.4 Summary of Chi Square Analysis for Variables Predicting Alienation
Deviance..............................................................132
5.5 Logistic Regression Predicting Alienation Deviance from Instrumental
Support...............................................................132
5.6 Logistic Regression Predicting Alienation Deviance from Affective...134
Support
5.7 Logistic Regression Predicting Alienation Deviance from Participation.136
5.8 Logistic Regression Predicting Alienation Deviance from the
Combination of Independent Variable...................................138
xiv


5.9 Summary of Chi Square Analysis for Variables Predicting Alienation
Deviance............................................................140
5.10 Logistic Regression Predicting Behavioral Deviance from Instrumental
Support.............................................................141
5.11 Logistic Regression Predicting Behavioral Deviance from Affective
Support.............................................................142
5.12 Logistic Regression Predicting Behavioral Deviance from
Participation.......................................................145
5.13 Logistic Regression Predicting Behavioral Deviance from the
Combination of Independent Variables................................147
5.14 Number of Mentions of Themes Emerging in Response to Open-ended
Questions...........................................................149
xv


CHAPTER 1
INTRODUCTION
Substance abuse constitutes a social problem of great importance to the
contemporary American society. A large proportion of the population in the United
States misuses alcohol and illicit drugs to the extent that their use causes significant
health, economic, and family consequences or results in a physical dependence on
the substance (Substance Abuse and Mental Health Services Administration, 2003).
Hundreds of billions of dollars are spent each year to reduce the influx of drugs, to
decrease the habitual demand for drugs through treatment, and to deal with
consequences of alcohol and drug use and abuse (Office of National Drug Control
Policy, 2002). The economic costs of substance abuse borne by federal and state
government and individuals were estimated to exceed $325 billion in 1998 and are
expected to continue to grow steadily (Harwood, 2000; Office of National Drug
Control Policy, 2002). The nearly $18 billion spent in 2001 on substance abuse
treatment represents a small proportion of the total economic burden related to
substance abuse in the United States (Mark et al., 2005). Most of the economic
costs associated with the use of illicit drugs and alcohol are borne by the criminal
justice and healthcare systems (Harwood, 2000; Office of National Drug Control
Policy, 2002).
1


In addition to the economic costs, individuals and families suffer untold
personal consequences of substance abuse. These problems may include
interpersonal problems including conflict and estrangement from family (Center for
Substance Abuse Treatment, 2004), increased risk for health problems including
premature death (Harwood, 1999; McGinnis & Foege, 1999), depression and
suicide (Substance Abuse and Mental Health Services Administration, 2001), loss
of personal freedom through incarceration (National Center on Addiction and
Substance Abuse, 1998), and employment-related problems (Substance Abuse and
Mental Health Services Administration, 1997).
Unlike other health problems, public sources outpace private health
insurance in financing substance abuse treatment. This support is spread among
federal, state and local governments. Over three-quarters (76%) of the spending on
substance abuse is provided by federal, state or local governments with nearly 40%
provided by state and local sources (Mark et al., 2005). In the current climate of
constrained budgets, many states are facing increasing challenges in sustaining the
level of financing necessary to address the consequences of alcohol and drug abuse
(National Conference of State Legislatures, 2004; Scanlon, 2002). Thus
improving the effectiveness of policies aimed at reducing substance abuse and its
associated social problems is both timely and important.
2


Scope of the Substance Abuse Problem
According to the National Survey on Drug Use and Health (Substance
Abuse and Mental Health Services Administration, 2003), 22 million people or
9.4% of the U.S. population are experiencing problems with substance abuse.
Substance abuse among youth is high, with over half (53%) of students in 12th
grade having tried illicit drugs and 78% having consumed alcohol (Johnston,
O'Malley, & Bachman, 2003). Although estimates of the prevalence of substance
abuse or dependence in the United States are lower for women as compared with
men (6% of women over the age of 12 as compared with 12% of men), substance
abuse among women represents both a large (approximately 7 million women) and
growing problem. One indicator of the growth of the problem in women is
reflected in the nearly equivalent percentages (roughly 9%) of female and male
youth with substance abuse or dependence in 2002 (Substance Abuse and Mental
Health Services Administration, 2003). Moreover, womens role as a caretaker of
children exacerbates the problem as nearly 15,000 women who entered treatment
for substance abuse in 2002 were pregnant (Substance Abuse and Mental Health
Services Administration, 2003). As compared with their male counterparts, women
with substance abuse problems are more vulnerable to physical health
consequences, are at increased risk for mental health problems, more often
experience physical or sexual abuse, and are more likely to care for minor children
(Brady & Ashley, 2005).
3


Furthermore, substance abuse is related to other social problems that
interfere with the ability of individuals to participate fully in society. It is highly
associated with involvement in the criminal justice system, with more than 36% of
the adults on parole or probation reporting substance abuse or dependence
(Substance Abuse and Mental Health Services Administration, 2003). Criminal
justice involvement among women has grown by 48% since 1990, with 950,000
women under the supervision of correctional agencies in 1998. Over half of these
women reported using drugs or alcohol at the time of their offense and 60%
reported using drugs in the month prior to their offense. Complicating then-
societal and individual burden, approximately 70% of these women were mothers
of minor children (Greenfeld & Snell, 2000).
Public child welfare agencies are also affected by substance abuse, with
85% of states reporting that substance abuse and poverty were the top two
problems facing families involved in the child protection system. In 1999, it was
estimated that 560,000 children were in foster care in the U.S. and over half of
these children had a parent with a substance abuse problem (Child Welfare League
of America, 2001). Children of substance-abusing parents involved with the child
welfare system are more likely to be placed in foster care than other children
involved in the child welfare system thus placing tremendous financial and social
burden on local communities (U.S. Department of Health and Human Services,
1999). Further increasing the costs to individuals and society, children with
4


substance-abusing parents are at greater risk to develop substance abuse problems
of their own in later life (Child Welfare League of America, 2001; Kilpatrick,
Saunders, & Smith, 2003; Widom, 2000), to experience emotional and behavioral
disorders (Grant, 2000; Kilpatrick et al., 2003; Widom, 2000), and to engage in
crime and delinquency (Reich, Earls, Frankel, & Shayka, 1993; West & Prinz,
1987; Widom & Maxfield, 2001).
Approaches to the Substance Abuse Problem
As with all social problems, substance abuse can be viewed from a number
of distinct perspectives (Yanow, 2000). Some argue that the social problem of
substance abuse in the United States is socially constructed or that the problem is
not an objective reality but is merely a reflection of the values and ethics of
society (Best, 1995; Fischer, 2003; Goode & Ben-Yehuda, 1994). Others claim
that problems of substance abuse and dependence are pathological diseases
requiring medical treatment (American Medical Association, 2004a, 2004b; Join
Together, 2003). As such, the second group asserts that policy should be aimed at
improving access to medical interventions, such as treatment, in contrast with
punishment. A third group claims that substance abuse problems are evidence of
moral weakness and that approaches emphasizing personal responsibility and
punishment are in order (Navy Personnel Command, 2002; U.S. Department of
Health and Human Services, 1999). A fourth common view contends that these
5


problems are indicative of other societal ills, such as pervasive poverty and
inequality and that they will not be successfully addressed except through more
equitable distribution of social opportunity (Best, 1995). Each of these
perspectives, along with the values and moral orientation of the claims makers,
dictates a presumed cause and solution for the problem (Best, 1995).
Substance Abuse Policy
This thesis suggests an alternative approach to examining the effect of
substance abuse policy by investigating the relationship between conditions such as
economic stability, stable housing, social support, and participatory practices with
the propensity of women with recent histories of substance abuse to affiliate with
pro-social versus deviant lifestyles. This argument is based on the presumption that
the predominant approach to substance abuse in federal policy has been one that
assumes moral weakness, personal responsibility, and is best resolved through a
punishment regimen. This bias toward a moral view of substance abuse is reflected
in the current 2:1 ratio of spending on interdiction and criminal sanctions as
compared with treatment, prevention and research (Office of National Drug Control
Policy, 2002), the widespread use of mandatory sentencing for drug offenses, and
the abundance of public policies that punish individuals with histories of substance
abuse. Although both men and women who currently abuse or have histories of
substance abuse are subject to punitive policies, women are particularly vulnerable
6


as a result of their position in society. Their role as mothers and caretakers
encourages intense public scrutiny of their behaviors especially dining pregnancy
(Boyd, 1999; Campbell, 2000; Schur, 1984). Pregnant women have long been
subject to judgment for behaviors that are socially defined to be harmful to the
fetus (Gardner, 1994). Boyd (1999) describes this burden in her study of
substance-abusing mothers.
Pregnant women and mothers with substance abuse problems face
obvious stigma and sanctions. The social stigma surrounding
maternal drug use takes a personal toll on women. Women drug
users, and especially mothers who use drugs, are viewed as more
deviant than their male counterparts, and this stereotype contributes
to their silencing and lack of legitimacy, (p. 210)
State and local policies can lead to involuntary treatment, and in some
cases, incarceration of women for substance use during pregnancy. Federal
policies such as the Adoption and Safe Families Act (ASFA), promoting expedient
decisions regarding placement of children involved in the child welfare system,
place particularly stringent burdens on mothers with substance abuse histories. In
addition to the inevitable social roles demanded by motherhood, the
overrepresentation of women in poverty and low-paying jobs, combined with
discriminatory housing, support, and education policies compound the strain on
women with substance abuse problems.
Low income and poverty are also thought to be significant problems
among women in the United States. Not only do females have significantly
7


lower average incomes as compared with their male counterparts, more
recently their median income declined by 0.6 percent from 2002 to 2003,
while the median income of men remained unchanged during the national
economic downturn (DeNavas-Walt, Proctor, & Milles, 2004). Similarly,
the poverty rate for female-headed households increased from 2002-2003
while the rate for male-headed households remained stable during the same
time period (DeNavas-Walt et al., 2004). Substance-abusing women in
particular are exposed to poverty and reliance on public assistance at higher
rates than males with similar problems (Green et al., 2002) and lack of
income is related to higher rates of arrest and drug use in women attempting
to recover from substance abuse (Atkinson, Montoya, Trevino, & Richard,
2000; Holtfreter, Reisig, & Morash, 2004; Noone, Dua, & Markham, 1999;
Oggins, Guydish, & Delucchi, 2001; Walton, Blow, & Booth, 2000). Drug-
dependent women experience the combined impact of poverty and its
complex relationship to criminal behaviors and substance abuse.
Some policy theorists argue that the process of problem definition is
malleable and based on the societal values and meanings associated with the
problem (Fischer, 2003; Rochefort & Cobb, 1993; Rochefort & Cobb, 1994;
Schneider & Ingram, 1997; Stone, 2002). This view of the policy process is based
in theories of social construction, arguing that as there is no single way to view the
world, the world is best understood through social relationships, and these
8


relationships produce an ever-changing understanding of the world (Gergen, 1999).
Examined from this perspective, policy is shaped by a struggle to create and
control systems of shared meaning (Fischer, 2003, p. 13); developed through an
exchange of competing views. This process of exchange can be manipulated by
policy actors by dramatizing or downplaying the problem and therefore forcing
the issue into the policymaking arena or facilitating avoidance of the issue
(Rochefort & Cobb, 1994 p. 3). Since perceptions of the importance of an issue
are shaped by cultural values, pressure from interest groups, scientific knowledge,
and professional groups (Rochefort & Cobb, 1994), often those engaged in the
struggle to control meaning are not representative of a full range of positions and
voices including those who are affected by the condition (Fischer, 2003). This
perspective maintains that the manner in which substance abuse and people with
substance abuse problems are portrayed in policy is fashioned by societal norms
and values and that powerful groups are privileged in the process of framing the
problem. This is evidenced in the heavy penalties for possession of small amounts
of drugs like crack cocaine that are more often used by inner city minority
populations while alcohol, having more costly social consequences and used by a
broader socio-economic group, is largely ignored (Harwood, 1999; Mokdad,
Marks, Stroup, & Gerberding, 2004).
Anne Schneider and Helen Ingram (1997) expand this argument, proposing
that policies are ineffective when, rather than promoting equal treatment and
9


justice, they differentially stigmatize certain populations while elevating others in
importance. Building on social construction theory, they contend that policy
designs reflect and manipulate social constructions of target populations
(Schneider & Ingram, 1997, p. 102) or socially derived understandings of the
population affected by a policy. They argue that these social constructions of target
populations are capable of worsening rather than resolving the problem that is the
target of policy.
Their concept of social construction of target populations (Schneider &
Ingram, 1997) asserts that policy is designed based on societal understandings of
the value and worthiness of the people who are targeted by policy matters,
moreover, the policy itself has the ability to directly influence societal perceptions
of the relative importance of people (Schneider & Ingram, 1997). In a more
specific application of social construction theory in the criminal justice field, John
Braithwaites theory of reintegrative shaming (Ahmed, Harris, Braithwaite, &
Braithwaite, 2001; Braithwaite, 1989,1995,1999, 2000,2001, 2002,2004) affirms
that the stigmatizing and punitive policy approaches applied to criminals are not
only ineffective in addressing the problem, they actually reinforce and perpetuate
the problem. As applied to substance abuse, these theories contend that policy
designs that stigmatize and punish people reinforce the perception of both the
individuals with substance abuse problems and citizens at large that people who
have experienced these problems are fundamentally bad and deviant and deserve to
10


be punished. As such, they perpetuate the very behaviors and attitudes they are
designed to eliminate. Yet treatment outcome studies and anecdotal accounts of
recovery reveal stories of individuals who escape from the self perception of
deviance to participate fully in society. Braithwaite (1995; 1999; 2000; 2001)
contends that this propensity to escape deviant lifestyles may be the result of the
availability of avenues for reintegration into society for these individuals.
Framing the Research Question
This dissertation accepts and extends Schneider and Ingrams theory of
social construction of target populations. In particular, it builds on reintegrative
shaming theorys (Ahmed et al., 2001; Braithwaite, 1989,2000) contention that
offering avenues for individuals to rejoin society increases the likelihood that they
will shed a deviant identity, while blocking access to mainstream society reinforces
the likelihood that the person will internalize the deviant label. This approach to
examining substance abuse has powerful implications for both policy and policy
theory. First, it expands Schneider and Ingrams (1997) theory, exploring how
some individuals appear to be resilient to internalizing the deviant identity while
others embrace it. Second, it applies Braithwaites theory to substance abuse, and
third, it examines how specific policy approaches toward substance abuse may
reinforce rather than subvert the very behaviors they are aimed at alleviating.
11


The purpose of this thesis, then, is to investigate the relationship between
instrumental social support (such as income and housing stability), affective social
support, and participation in normal social roles and relationships, and the
propensity for women with histories of drug dependence to affiliate with the
behaviors and attitudes that reflect alienation from societal norms. This study
utilizes secondary data collected during a treatment outcomes study supported by
the U.S. Department of Health and Human Services, Substance Abuse and Mental
Health Services Administration from 2000-2003.1 Using this data set that includes
a variety of behavioral and attitudinal measures of psycho-social functioning within
a population of women with recent histories of drug dependence, the dissertation
addresses the primary research questions: (1) What characteristics predict
identification of women with histories of drug dependence with non-deviant versus
deviant identities, and (2) how might a greater understanding of these
characteristics result in policies that more effectively impact deviant behaviors
among drug-dependent women?
1 The Cooperative Agreement to Study Women with Alcohol, Drug Abuse and Mental Health
(ADM) Disorders who have Histories of Violence: Phase II was funded by the U.S. Department of
Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services
Administration under GFA No. TI 00-003 issued March 2000.
12


Thesis Outline
The following chapters describe the theoretical and methodological
approaches and present the results and conclusions of a study aimed at
investigating this research question. Chapter 2 provides an overview of the basic
concepts associated with substance abuse and substance abuse policy and funding
in the United States. Chapter 3 presents the theoretical basis for understanding the
problem and the variables to be included in analysis. Chapter 4 offers a description
of the methodological approach used in data analysis while Chapter 5 presents the
research findings and Chapter 6 discusses the significance and implications of these
findings.
13


CHAPTER 2
CONTEXT OF CURRENT SUBSTANCE ABUSE POLICY
As we have seen, substance abuse is a highly prevalent and costly problem
in the U.S, affecting nearly one in ten Americans over the age of 12. Of those
affected by substance abuse, 3.2 million abuse both alcohol and drugs, nearly 15
million have problems with alcohol alone, and nearly 4 million misuse illicit drugs
but not alcohol (Mark et al., 2005). The economic costs of alcohol and drug abuse
are estimated to far outweigh the amount spent for treatment of alcohol and drug
problems ($325 billion as compared with 18 billion) (Harwood, 2000; Office of
National Drug Control Policy, 2002), suggesting that the consequences of
substance abuse accumulate outside the treatment system. Although affected by
substance abuse at a lower rate than men, women are particularly vulnerable to the
consequences of substance abuse. They are at greater risk for health consequences
associated with substance abuse, are more often caregivers to minor children, and
are generally faced with greater social stigma as compared with their male
counterparts (Brady & Ashley, 2005). The combination of these factors may
increase the economic and social costs of substance abuse among women.
Undeniably, substance abuse constitutes a public policy concern with
enormous fiscal and personal costs and far-reaching public impact. As with most
14


specialized areas of policy, the substance abuse field has developed with distinct
terminology and assumptions. This chapter is intended to provide a common
understanding of the contextual issues within the field of substance abuse that
underpin this thesis.
Establishing a Common Terminology
During the course of history, a myriad of terms have been used to
characterize the use and misuse of alcohol, legal drugs and illicit drugs, the people
who suffer from these problems, and the treatment of their problems (White, 1998).
In addition, the understanding and characterization of the problems of alcohol
versus drug misuse have developed within distinct trajectories. As a result, no one
or two sets of terms are uniformly accepted by the professional treatment field, in
policies related to such problems, or by the general population.
Over the history of the United States, a variety of terms have been used to
describe people who misuse alcohol including drunk, inebriate, alcoholic, problem
drinker, and alcohol addict (White, 1998). In addition, the evolution of language
related to misuse of drugs has included terms such as addict, drug abuser, drug
dependent, dope fiend, and substance abuser. In recent years, alcohol has often
come to be included as a drug in the description of drug addict and the use of
phrases such as alcohol, tobacco, and other drugs have become popular political
15


strategies to emphasize the harmful qualities of the legal substances of alcohol and
tobacco.
As a result of the use of the Diagnostic and Statistical Manual of Mental
Disorders (DSM) of the American Psychological Association in private sector
healthcare billing for alcohol and drug related problems, the terms substance
abuse and substance dependent have become commonly used by treatment
providers. The DSM version IV (American Psychiatric Association, 2000) uses the
term substance use disorder to encompass acute intoxication as well as the chronic
problems associated with use of alcohol and drugs. Substance abuse is a diagnostic
term that indicates that the individual is experiencing personal health, emotional,
work, legal, family, or school problems resulting from the use of illicit drugs,
alcohol, or prescription medicines that are misused. Substance dependence refers to
the physical addiction resulting in tolerance to the effects of the substance,
withdrawal symptoms when not using the substance, attempts to control or cut
down on use, excessive time spent securing or using the substance, and persistent
problems associated with use. In summary, substance abuse denotes that an
individual is experiencing social and personal problems as a result of the use of the
substance, while substance dependence suggests a physiological or psychological
reliance on the substance. For the purposes of this thesis, the use of substances
involving illicit drugs, alcohol or misuse of prescription drugs will be referred to as
substance abuse while the physiological or psychological addiction to alcohol,
16


illicit or prescription drugs will be defined as substance dependence. The term
drug-dependent will be used to describe individuals who evidence physical or
psychological reliance on illicit drugs as contrasted with alcohol or prescription
drugs.
Concept of Recovery
In addition to the diversity of terms used to describe the individual who
misuses substances, there are a number of different terms used to describe those
who have a history of misuse but no longer abuse substances (White, 1998). These
terms include dry, redeemed, recovered, recovering, former addict, and ex-
alcoholic. The term recovering has become popular within the treatment field
because it signifies a belief in the chronic nature of the problems of substance
dependence and the need for constant attention to recovery. For the purposes of
this thesis, recovering and recovery will be used to describe those who once
experienced a problem with substances but do not experience these problems
currently.
Oversight and Financing for Treatment of Substance Abuse and Dependence
Treatment of substance abuse and dependence occurs in a variety of
institutions and settings. This includes public and non-profit treatment centers
17


established expressly for this purpose, jails and correctional facilities, residential
settings for children, independent providers, schools, hospitals, churches, and other
community based organizations (Mark et al., 2005). The Substance Abuse and
Mental Health Services Administration (SAMHSA) within the U.S. Department of
Health and Human Services is charged with oversight of federally funded substance
abuse prevention and treatment activities (U.S. Department of Health and Human
Services, 2005). These responsibilities include oversight of competitive and block
grant programs and data collection related to prevalence and treatment in the
United States. This includes approximately $1.7 billion in block grants to states
and another $400 million in discretionary grants budgeted in fiscal year 2006.
Each state is required to designate a Single State Authority responsible to
administer the federal alcohol and drug block grant funds flowing to the state.
In contrast to other health problems, mental health and substance abuse
treatment are often uncovered or afforded only limited coverage within private
health plans. This results in a greater burden of financing being placed on the
public sector with approximately 76% of the total costs of substance abuse
treatment being spent in the public sector as compared with 45% of all health care
costs (Mark et al., 2005; Scanlon, 2002). The proportion of the costs of substance
abuse treatment supported by the public sector has grown each year since 1991;
public payers represented 76% of the payments for substance abuse treatment in
2001 as compared with 62% in 1991 (Mark et al., 2005). This burden is shared by
18


the federal, state and local sources with 38% of the total spending borne by the
federal government and 30% of these costs supported by state and local sources
(Mark et al., 2005; Scanlon, 2002). These expenses include Medicaid and
Medicare as well as federal block grant and state general fund dollars.
Social Costs of Substance Abuse
Over half (56%) of the economic costs associated with substance abuse in
1998 were the result of alcohol abuse and these costs were estimated to have risen
nearly 4% each year since 1992 (Harwood, 2000). The costs of drug abuse
experienced even larger growth with an increase of nearly 6% each year between
1992 and 1998 (Office of National Drug Control Policy, 2002). These costs
include spending on alcohol and drug research, treatment and prevention, health
expenditures related to the consequences of drug and alcohol use, lost productivity
due to premature death and imprisonment, the impact of crime, motor vehicle
crashes and fire losses (Harwood, 2000; Office of National Drug Control Policy,
2002). The cost of alcohol and drug abuse have clearly outpaced population
growth and consumer price increases and are expected to continue to grow at this
accelerating pace (Office of National Drug Control Policy, 2002).
19


Policy Related to Substance Abuse
Although the concept of a war on drugs first emerged during the Nixon
administrations, the decades of the 1980s and 1990s were characterized by dramatic
policy change and spending related to drug demand and supply reduction (Burke,
1992; Rushefsky, 2002; Thevenot, 1999). Most of the policies and resources
directed at both drug demand and supply reduction employed criminal justice
solutions (Rushefsky, 2002); often policies were punitive in nature,
disproportionately targeting women and minority populations (Burke, 1992;
Lapidus et al., 2005). These policies included mandatory sentencing for drug
offenders, one strike, you re out or zero tolerance policies in public housing,
restricting education loans, cash assistance, and food stamps to drug offenders and
elimination of social security benefits for individuals with drug related disabilities
(Burke, 1992; Lapidus et al., 2005; Rushefsky, 2002).
Mandatory Minimum Sentencing for Drug Offenders
In the year 2000, over 450,000 people were incarcerated in state and federal
jails and prisons on drug charges, costing taxpayers nearly $10 billion each year
(Beatty, Holman, & Schiraldi, 2000). Between 1980 and 1997, drug arrests
(largely individuals charged with possession) tripled and drug offenders comprised
more than half of the state prison capacity (Beatty et al., 2000). During this period,
the number of prison admissions on drug charges experienced a 247% increase
20


(Beatty et al., 2000) and the vast majority of those incarcerated were ethnic
minorities. Although the rates of minority imprisonment for violent offenses did
not change between 1986 and 1991, the increase in the rate of imprisonment of
African-Americans charged with drug-related offenses was four times the rate of
increase for whites (Beatty et al., 2000). African-American men are estimated to
represent 13% of the drug users in the United States but 62% of the approximately
400,000 people incarcerated on drug offenses (Human Rights Watch, 2000b).
The rate of incarceration of women has also skyrocketed with the number of
women in state and federal prisons increasing from a population of 12,300 in 1980
to 82,800 in 1997; furthermore, drug offenses account for nearly half (49%) of this
increase in incarcerated women (Mauer, Potler, & Wolf, 1999). Critics of
mandatory sentencing argue that these women are often minor or peripheral players
in drug trading, committing drug-related crimes for partners on whom they are
dependent or using drug trade as a way to modestly supplement their inadequate
income (Lapidus et al., 2005; Thevenot, 1999).
The increases in incarceration rates of drug offenders along with the
overrepresentation of minorities and rapidly increasing rate of incarceration of
women are attributed in part to the shifts in policy related to the war on drugs
initiated in the 1980s and in particular the emphasis on mandatory drug sentencing
(Beatty et al., 2000; Human Rights Watch, 2000a; Lapidus et al., 2005; Thevenot,
1999)
21


Mandatory sentences typically utilize the amount of a drug involved in the
crime to determine the length of the sentence. They disregard other factors, such as
complicating circumstances and first-time offenses, in the determination of the
sentence (Lapidus et al., 2005; Thevenot, 1999). Despite their popularity,
mandatory minimum sentencing laws have been widely criticized as ineffective
(Beatty et al., 2000; Caulkins, Rydell, Schwabe, & Chiesa, 1997; Lapidus et al.,
2005; Thevenot, 1999), too costly to taxpayers with little benefit (Beatty et al.,
2000; Caulkins et al., 1997; Gardiner & McKinney, 1991), disproportionately
targeting minority populations (Beatty et al., 2000; Human Rights Watch, 2000a;
Sabet, 2005; Thevenot, 1999), and unnecessarily burdening women and families
(Lapidus et al., 2005; Thevenot, 1999). Critics have argued that providing access
to treatment, alternative sanctions, and other services for many of the drug
offenders currently incarcerated presents a more cost-effective and humane
approach to reducing drug demand (Beatty et al., 2000; Caulkins et al., 1997;
Human Rights Watch, 2000a; Lapidus et al., 2005; Thevenot, 1999). In defense of
their approach, proponents of mandatory sentencing cite the deterrent effect of a
tough approach to drug trafficking and other drug related crimes (Caulkins et al.,
1997; Thevenot, 1999).
22


Housing Policy and Drug Use
The past fifteen years have presented a series of policies aimed at barring
substance abusers from public housing. One provision of the Anti-Drug Abuse Act
(1988) required that public housing authorities evict tenets when they or their
families were found to have engaged in criminal activity (Dilworth, 1997; Human
Rights Watch, 2004); which could naturally include substance use activities. In
1990, these laws were strengthened, resulting in what has been called the federal
governments one strike policy. This policy prohibited housing authority
officials from providing applicants who otherwise qualified for housing assistance
from receiving any preferential access to housing if they had engaged in criminal
activity on or near public housing sites or if their guests had engaged in these
activities. The 1996 Housing Opportunity Extension Act recommended that local
authorities exclude applicants with drug-related criminal histories from federally
supported housing and allowed local authorities to evict or bar an applicant who
was believed to be using drugs (Human Rights Watch, 2004; Join Together, 2003).
Again, in 1998, these laws were strengthened with federal policy recommending
that local authorities deny housing if a household member had a past drug-related
or criminal history that might affect the safety and health of others (Human Rights
Watch, 2004; Join Together, 2003). In effect, drug abusers were categorized with
sex offenders and those manufacturing methamphetamine as exceedingly
dangerous to the health and well being of other public housing residents. Human
23


Rights Watch (2004) estimates that over a five-year period, 3.5 million people,
many of whom had substance abuse related charges, were determined to be
ineligible for housing due to felony convictions.
Supporters of these provisions contend that public housing must be drug
free in order for it to be safe for those individuals most in need of assistance and
taking a tough position on illegal drug use discourages dealing and other illegal
activities on these sites (Dilworth, 1997). Opponents argue that providing access to
treatment for substance abuse problems and even requiring treatment as a condition
of housing would be a more effective strategy to address the problem of drug use in
public housing on a long-term basis (Join Together, 2003).
Welfare Reform and Drug Use
The passage of the 1996 Personal Responsibility and Work Opportunity
Reconciliation Act (PRWORA) radically changed the public welfare system in the
U.S., transforming the system from an entitlement program under Aid to Families
with Dependent Children (AFDC) to a transitional assistance program entitled
Temporary Assistance for Needy Families (TANF) (Pollack, Danziger, Seefeldt, &
Jayakody, 2002; Rushefsky, 2002). PRWORA and related laws included special
provisions targeting individuals with substance abuse problems (Pollack et al.,
2002). In particular, PRWORA allowed states to use chemical testing to identify
substance use among TANF recipients. The Gramm Amendment provided for a
24


lifetime ban from food stamps and cash assistance for individuals with felony drug
convictions including drug possession and use in addition to distribution. However,
most states passed laws amending this TANF ban in some way (Pollack et ai.,
2002). In fact, very few states have fully enforced their federally granted freedom
to ban substance abusers from assistance; instead standardized screening and in
some states urine drug testing have most often used to identify individuals
requiring additional assistance. Once barriers to employment are identified,
substance abuse treatment is often offered (Pollack et al., 2002).
Proponents of banning individuals with drug offense histories from
assistance hold that drug use is widespread among welfare recipients and is a
central feature of welfare dependency. They further argue that testing can be an
effective tool to identify and address substance abuse (Pollack et al., 2002). Critics
of these policies contend that drug use is only slightly higher among female welfare
recipients as compared with women in the general population (Pollack et al., 2002).
They contend that these policies unduly target drug users over violent and other
offenders and that withholding money for food and shelter punishes not only the
individual with a drug problem but her dependent children (Join Together, 2003).
They propose required treatment as an alternative to withholding cash assistance,
arguing that providing treatment provides an opportunity for individuals to rejoin
society.
25


Education and Drue Offenders
In 1998, Congress amended the Higher Education Act to include provisions
that deny federal education assistance to individuals who have been convicted of
drug charges (Alcoholism and Drug Abuse Weekly, 2005; Join Together, 2003).
Although in recent years steps have been taken to repeal these provisions, as
recently as the summer of2005, proposed amendments upheld the loss of financial
aid for students convicted of drug possession while enrolled in school (Alcoholism
and Drug Abuse Weekly, 2005; Join Together, 2003). Proponents of the ban on aid
to students with drug convictions indicate that education and educational assistance
are privileges and that law breaking is a legitimate reason to deny or revoke such
privileges. They further contend that these types of sanctions can act as a deterrent
to drug use (Alcoholism and Drug Abuse Weekly, 2005). Critics argue that
denying educational assistance based on misdemeanor offenses in addition to
felonies is excessively punitive and stigmatizing toward individuals who use and
abuse drugs (Alcoholism and Drug Abuse Weekly, 2005). They argue that this ban
singles out drug users over individuals who commit drinking and driving offenses
and violent crimes and further estranges citizens from the potential for highly
productive lives (Join Together, 2003).
26


Substance Involved Families in the Child Welfare System
In 2000,2.8 million children were reported to child welfare agencies for
suspected child abuse or neglect. This figure doubled from the 1986 figure of 1.4
million children (Child Welfare League of America, 2001). It is estimated that over
half of the children in foster care have substance abuse problems themselves or
have parents with a substance abuse problem and that many would have been able
to remain safe at home if substance abuse treatment were available (Child Welfare
League of America, 2001). One study conducted by the Child Welfare League of
America (2001) concluded that child welfare agencies were able to provide
substance abuse treatment to fewer than a third of the families that needed it.
The Adoption and Safe Families Act (ASFA) of 1997, created to address
the problem of growing foster care rolls and children lingering in foster care
without plans for permanent placement, has created additional hurdles in delivery
of substance abuse services to parents involved with the child welfare system
(Legal Action Center, 2003; Semidei, Radel, & Nolan, 2001). ASFA established
limits on the time spent on reunification of families and created an expedited
process of permanency planning (Legal Action Center, 2003; Semidei et al., 2001).
The most profound impact on substance-involved families has been the timetable
for termination of parental rights (Legal Action Center, 2003; Semidei et al., 2001).
This provision requires caseworkers to begin permanency planning immediately
following removal of the child from the home (Legal Action Center, 2003).
27


However, even if treatment were immediately available, it is not uncommon for a
course of substance abuse treatment to extend nine months in length. The extended
length of substance abuse treatment and the relapsing nature of substance abuse
problems create difficulty in assessing the potential safety of the home within the
ASFA mandated deadlines. Without close coordination between substance abuse
and child welfare systems and increases in resources for treatment, substance-
abusing families are likely to experience unnecessary separations that in some cases
will result in permanent loss of custody and unnecessary suffering for both children
and families (Child Welfare League of America, 2001; Join Together, 2003;
Semidei et al., 2001) and strain on an already burdened system of child placement.
Current State of Substance Abuse Policy
Clearly, substance abuse is a costly and important social policy issue in the
United States that has captured a great deal of attention and resources over the
course of the past quarter century. Few social problems have such a widespread
effect on society. Nonetheless, existing policies such as mandatory minimum
sentencing and educational, housing and cash assistance bans have been widely
criticized as ineffective in addressing the problem of drug use (Thevenot, 1999). In
addition, critics argue that the policies related to the war on drugs have been
fraught with injustice, racially discriminatory, and threatening to civil liberties
(Human Rights Watch, 2000a, 2004; Join Together, 2003; Lapidus et al., 2005;
28


Thevenot, 1999). This thesis investigates the impact of punitive and stigmatizing
policies and practices toward drug-dependent women.
29


CHAPTER 3
LITERATURE REVIEW
To provide the foundation for exploration of the predictors of affiliation
with socially constructed identities, a review of theory on social construction and
social construction of target populations is presented. A discussion of labeling
theory and the impact of reintegration and stigma as they relate to substance abuse
is also offered. Third, the literature on theories related to empowerment and
participation is reviewed. Finally, the relationship between instrumental and
affective social support and substance abuse recovery is addressed.
Social Construction Theory
Social construction theory is based on the argument that there is no single
view of reality but instead that reality is the ever-changing product of
relationships (Gergen, 1999). The origins of social construction theory can be
traced to Karl Mannheims (1936) work Ideology and Utopia in the late 1920s that
was translated into English in the following decade. In his proposals about the
relationship of the social to knowledge, Mannheim suggests that scientific
knowledge is a consequence of social relationships (Gergen, 1999). Thomas Kuhn
(1962) and Berger and Luckmann (1967) advanced the development of the theory
30


through their description of the socially derived nature of subjectivity, suggesting
that meaning is derived from the interaction between the individual and the world
and there is no objective meaning (Gergen, 1999). This conceptualization of
knowledge challenged the empirical realists who believed that an objective
reality or truth exists and can be discovered through scientific pursuits (Bacchi,
1999; Gergen, 1999).
Social construction, as it relates to the definition of social problems,
contends that social problems are not neutral or objective phenomenon subject to
examination and repair but instead are interpretations of conditions that have been
subjectively defined as problematic and demanding of some type of corrective
action (Bacchi, 1999). This perspective asserts that objective reality or facts about
the problem have a limited or no part in the definition of social problems (Bacchi,
1999; Best, 1995). Problem definition is a process of labeling a phenomenon as a
problem based on values and morality, and calling for action to attend to the
problem (Bacchi, 1999; Rochefort & Cobb, 1994).
It is only recently that the attention of policy theorists has shifted from the
interest group exercise of influence in the policy-making process to the target
populations of policy (Donovan, 2001). Focusing on target populations redirects
attention from organized interest groups and their relationship to policy making to
how policy itself exerts influence on those who participate in the policy-making
process as well as those who gain and lose as the result of a specific policy
31


(Donovan, 2001). Schneider and Ingram (1990; 1993; 1997; 2005a) are among
those who have developed the concept of target populations of policy. They assert
that problem definition is shaped by power differentials and that popular social
constructions of problems are used by elites to craft policy that will be more easily
adopted and implemented. They contend that policy elites deliberately select and
manipulate social constructions and define the target population to design policy
that wins them favor. This process of identifying a particular construction of a
problem and manipulating it to win favor for a particular target population
generally privileges the strong, burdens the weak, and often includes the generation
of negative stereotypes that provide justification for the policy tools to be used. In
addition to affecting others perceptions through stigmatizing stereotypes, they
contend that these labels are internalized by those targeted, influencing their view
of public institutions, citizenship and themselves.
People who consistently find themselves selected for burdens and
ignored when beneficial policy might be provided are likely to
become alienated from public life and lose legitimacy in the eyes of
others. In contrast, persons who consistently find themselves
selected for benefits and spared the burdens of public policy are
likely to overestimate the importance and legitimacy of their own
claims on government. (Schneider & Ingram, 1997, p. 88)
These types of policy designs assign stereotypes and stigma to maximize
the benefit to powerful groups and the burden on the powerless. Schneider and
Ingram (1997) argue that this approach to policy design is both undemocratic and
destructive. Others extend this argument, suggesting that policies that use moral
32


condemnation may actually threaten their success in addressing the problem (Hitte,
1999).
The power of policy design is illustrated in a study by Soss (2000; 2005)
comparing Aid to Families with Dependent Children (AFDC) and Social Security
and Disability Income (SSDI) program participants. He found that AFDCs
paternalistic policies requiring means testing as compared with SSDI (that does not
require means testing) resulted in degradation, discouraged assertiveness, and
undermined confidence in government responsiveness among AFDC benefit
recipients. He concluded that ...Welfare policies built around the premise that
clients are incompetent, dependent and deviant are unlikely to reduce the political
marginality of the poor or enhance their esteem in the eyes of others. (Soss, 2000,
p. 200)
Schneider and Ingram (1997) identify the definition of target populations
for policy as a primary feature of problematic policy design. The four-group matrix
of target populations -- advantaged, contenders, dependents and deviants is
defined by the degree of access to political power and the perception that the
members of the target population deserve the benefits as opposed to the burden
associated with policy design (Figure 3.1). Groups with high levels of political
power who are perceived as deserving of benefits are labeled as advantaged. The
advantaged are able to wield political power to discourage policies that place
burden on them and encourage policies from which they will benefit. Contenders
33


are powerful but are perceived to be undeserving of benefit; therefore, any policies
that offer benefits to this group must do so furtively. Special interest groups such
as corporations fall into the category of contender. Dependents have little political
power but are viewed as deserving of the benefits of society; dependents include
children and other vulnerable populations. Policy theorists such as Theda Skocpol
(1992) support this contention, arguing that lack of political power among children
and their advocates has resulted in a failure of U.S. policy to protect these
vulnerable populations. Finally, deviants are neither politically powerful nor
perceived to be deserving of benefits. In fact, deviants are characterized as
dangerous to society and deserving punishment.
Schneider and Ingram contend that each of these groups is typified by
divergent views of their degree of dangerousness, helplessness, goodness or
importance. Policy tools are selected for their match with the desired view of the
target population; for example, a target population that is dangerous (e.g.,
criminals) should be engaged with tools that promote punishment (e.g.,
incarceration).
34


Figure 3.1. Social construction of target populations.
Deserving Undeserving
Stronger
Political
Power
Weaker
In keeping with social construction theory, Schneider and Ingram (1997)
assert that individuals in these target populations not only internalize the
characterization of themselves but this influences their orientation toward
government and politics. They argue that each of the groups characterized develop
a different orientation to government that can be supportive, suspicious,
disinterested or oppressed and they can view politics as open, corrupt, elitist or
abusive.
From a social construction perspective, substance abuse, along with all
social problems, is subject to an ever-changing conceptualization influenced by a
variety of actors with differing views and power to influence its popular
understanding. This perspective contrasts with technical and empirical approaches
Advantaged Contenders
Dependents Deviants
Schneider, A. L., & Ingram, H., (1997, p. 109)
35


that view social problems as objective realities, understood with analytical
techniques that expose facts and truth (Fischer, 2003).
Social construction theorists contend that substance abusers have been
defined as deviant by elites, who use this label as a mechanism to block access to
economic and social opportunities (Schur, 1984). Schneider and Ingram (2005a)
describe this as degenerative politics characterized by manipulation of symbols or
logic, and deceptive communication that masks the true purpose of policy (p.l 1).
These negative characterizations in politics or policy create a self-fulfilling
prophecy with women, in particular, internalizing the concept of deviance and
inferiority (Boyd, 1999; Schur, 1984). In this example, vulnerable populations,
such as female drug addicts, are maintained in a position of powerlessness through
a combination of sanctions and internalization of negative self concepts.
Moreover, some view the characterization of substance abusers as subject to
varying levels of social concern shaped by political events. Good and Ben-Yehuda
(1994) discuss the development of drug policy and observe that although there have
been periodic moral panics related to substance abuse when conventional social
life was threatened, its construction has been relatively stable. They describe two
moral panics in recent history; the war on drugs in the late 1980s and the crack
baby of the early 1990s. Both of these events in drug policy led to an emphasis on
different drugs and social groups. The war on drugs emphasized harsh sentencing
laws for predominantly minority drug offenders while the crack baby agenda
36


focused on inner city pregnant women. Good and Ben-Yehuda (1994) argue that
both of these social constructions reflected moral panics in that they had clearly
identified groups to blame, the groups were perceived as responsible for
undermining predominant social values (viewed as evil), the views were based on
exaggerated or fabricated risk, and they emphasized or capitalized on a new
problem or a new definition of a problem.
The social and political nature of these constructions is demonstrated when
the consequences of illegal drug use and crack-affected births are compared with
the consequences of alcohol use and the prenatal effects of maternal alcohol and
tobacco use. The economic costs to society associated with use of alcohol are
estimated to be two-thirds higher than the economic costs associated with drug use
(Harwood, 1999). Alcohol use is more prevalent than drug use and is a
contributing cause in five times more deaths than illicit drug use each year in the
U.S. (Mokdad et al., 2004). In addition, the consequences of fetal exposure to
alcohol and tobacco have equal or more severe long-term effects than fetal
exposure to cocaine (Chiriboga, 2003; Kistin, Handler, Davis, & Ferre, 1996;
Seifer et al., 2004; Slotkin, 1998). Because alcohol and tobacco use is widespread
in the white upper and middle in addition to lower classes and the use of crack has
largely been identified with the inner city African-American population, the costs
to society of widespread alcohol use and abuse have been largely underplayed by
policy makers while the threats associated with the crack baby epidemic have
37


been overplayed. This is a clear example of the role of social constructions of
target populations in the development of policy related to substance abuse.
Schneider and Ingram (1997) place substance abusers in the deviant
categorization of target populations of policy, arguing that they have little or no
political power and few advocates. The predominant perception of this group is one
of criminals who should be punished. This stigmatizing portrayal enhances the
likelihood that these individuals will not be reintegrated into society but instead
will continue to exist outside societal norms producing grave consequences for the
individuals affected as well as society as a whole (Nicholson-Crotty & Meier,
2005).
Although the theory of social construction of target populations (Schneider
& Ingram, 1990,1993,1997; 2005a) provides a valuable backdrop for examining
the potential impact of policy on individuals, it has a number of shortcomings. The
theory fails to explain how or why some individuals appear to be more resilient
than others in resisting the negative influence of degenerative policies despite
anecdotes recounting the experience of individuals who have histories of drug
dependence and incarceration who are rehabilitated and rejoin society.
Additionally, it fails to explicate how individuals or groups move between the cells
in the four-group matrix (deLeon, 2005); for example how deviants move to
become advantaged. Schneider and Ingram (2005b) begin to respond to this
criticism in their discussion of changes in group definition that can be
38


accomplished when policy arenas become oversubscribed but this seems to be more
of a passive process of waiting out the lifespan of a policy rather than reflect active
efforts to change a social construction of a group. This theory does not take into
account the relationship between individual experiences that precede or follow the
labeling or how individuals reconcile their membership in more than one target
group (Soss, 2005). In addition, the complexity of interaction between the various
individual, social and political forces creating definitions of target populations is
not accounted for fully in the current conceptualization of the theory.
Public policies do not merely reflect the character of their target
populations; policies also transform larger target groups by
transforming the political, social, economic and legal settings in
which groups exist. The constant redefinition of group identities in
the political arena is an effect of politics and policy as much as a
cause. (Lieberman, 1995, p. 441)
Nicholson-Crotty and Meier (2005) attempt to address this criticism of the
theory by identifying three conditions that must be met in order for deviant social
constructions to be adopted in policy design: the target group must be easily
identified by the larger public; a moral entrepreneur must be available to guide the
negative formulation of the identity; and the entire target group must be identified
with fear or moral weakness. Although this expansion of the theory assists in
explaining the complexity of the policy process related to formulation of deviant
target groups, it does not take into account the individual level factors or policies
that influence the negative consequences associated with stigmatizing labels. In
39


effect, the theory of social construction of target populations with the
enhancements suggested by Nicholson-Crotty and Meier (2005) attends to the
initial deviance but not the individual or policy mechanisms that influence people
to continue with deviant behaviors and it fails to adequately distinguish between a
moral entrepreneur and a political entrepreneur (deLeon, 2005).
Schneider and Ingram (2005a; 2005b) discuss the interaction of policy
change and altering social constructions, identifying strategies or events such as
subdividing and combining target groups, use of scientific evidence, relying on
incremental changes in demographics and altering social identity of the group. In
particular, they cite barriers to participation in governance as critical impediments
limiting groups labeled as undeserving stating groups suffer from a negative
identity that must first be overcome before sufficient trust and motivation is found
for political participation (2005a, p. 24). Although their discussion helps to
illuminate the barriers to a groups movement from one construction to another, it
yields little in the way of prescriptive approaches to facilitate this movement
(deLeon, 2005). Soss (2005) takes this idea of participation further and builds on
Patemans (1970) concepts of incremental participation, arguing that how policies
are designed can promote or inhibit welfare recipients beliefs about welfare
programs and willingness to voice grievances. This leads to increased political
efficacy and possibly political advocacy. He also argues that further investigation
is needed to better understand individual differences in internalization of policy
40


messages, strategies to influence participation in governance and the influence of
contradictory policies.
This relationship between group identity and participation is an important
element of Schneider and Ingrams work that has yet to be fully developed. As it
stands currently, the theory is more descriptive than prescriptive, offering few
specific suggestions about how to change social constructions of undeserving
groups and specifically how policy and social constructions work together to
eliminate degenerative policy. Developing a more precise understanding of the
characteristics of individuals who are able to alter their behaviors from deviant to
pro-social and the policy context in which this is accomplished presents a logical
extension to Schneider and Ingrams work.
Labeling Theory
Labeling theory proposes that the assignment of a label in this case, a
drug addict -- creates or perpetuates the deviant behavior (Clinard & Meier, 2001;
Link & Cullen, 1990; Spector & Kitsuse, 1987). In its application to deviance,
labeling theory assumes that social processes define a behavior or group of people
as a problem, assigning characteristics that have the power to segregate the person
labeled from society (Spector & Kitsuse, 1987). Using Schneider and Ingrams
(1997) characterization, individuals who abuse substances are labeled as deviant,
violent, and dangerous. This stigmatization and separation in turn blocks access to
41


customary activities (Spector & Kitsuse, 1987) and power (Sullivan & Wilson,
1995). Becker (1974) describes the effect of this labeling and the associated
stigmatization on normal roles and routines stating,
.. ..labeling places the actor in circumstances which make it harder
for him to continue the normal routines of everyday life and thus
provoke him to abnormal actions (as when a prison record makes
it harder to earn a living at a conventional occupation and so
disposes its possessor to move to an illegal one), (p.42)
One variation of labeling theory societal reaction or interaction theory --
proposes that elite groups create definitions of normal and deviant behaviors and
deliberately manipulate these definitions to maintain their power base, thus
institutionalizing oppression (Gove, 1975; Lemert & Winter, 2000). These
interaction theories promote the concept of secondary deviance or the idea that
labeling and the intended discrimination and stigma that accompanies it is
internalized. This causes those labeled to act in ways that are a-social, thus
perpetuating the societal reaction and behaviors labeled as deviant (Clinard &
Meier, 2001; Davies & Tanner, 2003; Spector & Kitsuse, 1987). This secondary
deviance constitutes a reaction to the label, analogous to a social construction, that
becomes a self-fulfilling prophesy, excluding the labeled from socially accepted
groups and moving them toward deviant groups (Clinard & Meier, 2001; Spector &
Kitsuse, 1987). For substance abusers, this categorization might be realized in
cases where individuals are exposed to differential treatment during hiring and
42


begin to see themselves as undeserving, subsequently resorting to illegal means of
securing income and therefore losing custody of their children.
This concept of secondary deviance has been tested empirically in a
population of adult men with substance abuse and mental illness. Link and
colleagues (1997) examined the relationship between stigma and symptoms of
depression one year following treatment in a sample of 84 men with both mental
illness and substance abuse. They found that when controlling for symptoms or
behaviors associated with mental illness and substance abuse, there was no change
in experiences of stigma or the use of coping mechanisms of secrecy and
withdrawal one year later. In fact, experiences with devaluation, discrimination
and rejection explained more than 10 percent of the variance in symptoms of
depression. They argued that stigma persisted even after symptoms had abated and
this stigma had lasting negative effects on quality of life and resulted in secondary
deviance. Li and Moore (2001) investigated 304 individuals involved in services
from three state vocational rehabilitation agencies who had experienced onset of
drug use at roughly the same time as the onset of their disability. They discovered
that perceived discrimination played a role in subsequent deviant behaviors (illicit
drug use) among individuals with disabilities. They further found that an
individuals belief that people with disabilities were likely to experience
discrimination was a significant predictor of lack of acceptance of disability status,
attitudes of entitlement and subsequent illicit drug use. Li and Moore (2001)
43


concluded that perceived discrimination or a belief that one is negatively labeled by
society has an effect on the likelihood that disabled individuals will accept their
disability and this acceptance plays a role in drug use among this population.
However, they were unable to demonstrate a direct causal relationship between
discrimination and drug use, recognizing that other variables are at work in the
deviant behavior or drug use in this population.
Critics of labeling and social reaction theories attack the failure of these
theories to explain the initial deviant act and contend that social reaction is the
result of deviant acts per se, not labeling or stigma (Clinard & Meier, 2001; Gove,
1975; Link & Cullen, 1990). Neither the Link (1997) or Li and Moore (2001)
studies are able to address the events that predispose deviant behaviors although
further investigation of the relationship between onset of disability and onset of
drug use has the potential to address this question. Since both of these studies
involve individuals who are seeking services, neither of them is able to respond to
one of the major criticisms of labeling theory in its application to individuals with
mental illness and substance abuse. Critics argue that the application of labels,
particularly when they lead to access to services, such as treatment, are more
helpful than destructive (Link & Cullen, 1990). Studies involving treatment
populations have been unable to address this criticism.
These studies have additional limitations. Link and his colleagues (1997)
rely on a very specialized sample of treatment-seeking men with both substance
44


abuse and mental illness while Li and Moores (2001) work includes individuals
who were enrolled in vocational rehabilitation and had experienced a concurrent
onset of disability and drug use. These reflect unique populations and may not be
easily generalized to a population of drug-dependent women who are not
necessarily disabled.
Feminist theorists further developed labeling theories, proposing that the
stigma and the discrimination associated with labeling is intensified among women
and in particular women who are involved with the criminal justice system (Davies
& Tanner, 2003; Sullivan & Wilson, 1995). Davies and Tanner (2003), in a
longitudinal study involving nearly 6000 males and females, found that both less
severe deviant acts (such as being expelled from school) as well as serious acts
(such as conviction of a crime and jail time) had more significant consequences in
terms of employment stability and lack of income in later life for females as
compared with males. They concluded that girls and women endure additional
burden of labeling and stigma associated with deviant acts as compared with boys
and males. *
Motherhood as it relates to substance-abusing women also offers
opportunities for discrimination. As illustrated by the moral panic associated with
crack babies (Goode & Ben-Yehuda, 1994), it is clear that constructions and
labeling of drug users as unfit mothers by the media and anti-drug crusaders are
particularly common. Since motherhood is governed by a strict set of societal
45


norms regarding propriety and acceptable caretaking behaviors, women who do not
adhere to societal norms are labeled as deviant or unfit mothers (Boyd, 1999;
Schur, 1984). Substance abuse during pregnancy or among mothers is a violation
of societal norms regarding motherhood and subject to extreme stigma. Boyd
(1999) demonstrated the power of stigma to further marginalize substance-abusing
mothers in her qualitative study of 28 women. Her findings suggested that systems,
such as social services and drug treatment, were delivered in a manner that is
judgmental and has punitive overtones. She concluded that women are held
responsible for their pregnancy outcomes when many other environmental and
social factors, such as poverty and violence, have equal or greater potential to harm
the child. This exploratory study provides the basis for further investigation of the
role of gender in internalization of deviant labels.
Research has revealed the lasting effects of stigmatization on individuals
with mental illness (Link, Mirotznick, & Cullen, 1991), delinquency (Davies &
Tanner, 2003), and substance abuse (Link et al., 1997). The effects of stigma are
noted in increased demoralization (Link et al., 1991), increased depression (Link et
al., 1997) greater unemployment (Davies & Tanner, 2003; Link et al., 1991), lower
income (Davies & Tanner, 2003), and reliance on socially isolating strategies such
as secrecy and withdrawal to avoid discriminatoiy experiences (Link et al., 1991).
In their work with people experiencing both mental illness and substance
abuse, Link et al. (1997) noted that the reaction to labeling as a function of
46


withdrawal and secrecy continues after the defining symptoms are no longer
present. They observed that it is unknown whether these symptoms are a result of
the continuation of stigmatizing events, the difficulty people face in shedding the
stigmatizing self-identity, or lasting pain and trauma related to the experience with
stigma. Nonetheless, people in recovery from substance abuse problems report that
stigma is a prominent deterrent to on-going recovery and they experience fear of
discrimination long after they have stopped using alcohol and drugs. In a random
national survey of recovering persons and their families, 40% reported
embarrassment or shame as a barrier to recovery, while 19% reported fear of job
discrimination as a barrier. Although the majority (87%) said that it is important
for the public to better understand alcohol and drug problems, only 50% stated that
they would be willing to participate in a public education campaign (Peter D. Hart
Research Associates Inc., 2001). In addition, among a sample of 84 men in
recovery from both mental illness and substance abuse, 65% reported that people
will look down on others who have experienced drug abuse, 72% reported that they
did not believe they would be hired if the employer knew of their drug use history,
16% reported being denied an apartment and 24% reported being paid lower wages
due to their history (Link et al., 1997). Finally, in a study of 310 individuals
participating in a self-help group for people with co-occurring mental illness and
substance abuse, the two greatest reported challenges to recovery were dealing with
feelings and finding work or adequate economic support (Laudet, Magura, Vogel,
47


& Knight, 2000b). Not surprisingly, these individuals felt that stigma played an
important role in the inability of people with concomitant mental illness and
substance abuse problems to become productive and economically self-sufficient,
with 73% of the respondents disagreeing with a statement that most people would
believe that a person with co-occurring [mental health and substance abuse]
disorders is trustworthy and 55% disagreeing with the statement that most people
will hire a person with a co-occurring disorder if he or she is qualifiedfor the job
(Laudet et al., 2000b). The literature makes a convincing case that individuals with
substance abuse and mental health problems experience pervasive effects of
labeling on their ability to participate in a meaningful way in society.
Yet, labeling theory fails to explain why some individuals are able to break
free from a label of addict or criminal and make significant positive changes in
their lives when others appear to live out labeling theorys prediction of secondary
deviance. John Braithwaites theory of reintegrative shaming (Ahmed et al., 2001;
Braithwaite, 1995, 1999,2000,2001) builds on labeling theory and offers an
explanation for differences in individual responses to labeling. Reintegrative
shaming theory integrates the contention that disapproval is necessary to maintain
social control with labeling theorys argument that labeling a behavior as deviant
perpetuates crime. Braithwaite proposes that shaming or social disapproval is
necessary to discourage crime but that shaming itself can be either integrative or
disintegrative. The theory purports that different approaches to social control beget
48


different behaviors: stigmatizing shaming promotes deviant behavior and
reintegrative shaming promotes non-deviant behavior.
Braithwaite (1995) has argued that disintegrating or stigmatizing shaming is
an act of disapproval that is disrespectful, promotes humiliation and although it
includes ceremony that acknowledges the deviant act, it provides no mechanism to
forgive the deviant act and as a result no avenue for the individual to rejoin society.
He describes stigmatizing shaming as an event that promotes the person as evil
rather than just the act as evil; as a result, deviance becomes a master identity that
shapes the identity of the individual. Use of stigmatizing forms of shaming blocks
access to education, employment and income and increases the probability that the
individual will perpetuate their deviant behavior (Braithwaite, 1999, 2000, 2001).
Braithwaite (2000) proposes that disrespect begets disrespect; and by labeling an
individual as a bad person rather than a good person who has done a bad deed (p.
287), the individual is likely to continue to practice or personify the bad deed.
In contrast, reintegrative shaming, according to Braithwaite (1995), is
characterized jointly by disapproval and respect. It includes ritual acknowledgment
of the deviance followed by a gesture of forgiveness. The central feature of
reintegrative shaming is its reliance on relationships of mutual dependence.
Reintegrative shaming builds on the attachments and bonding of the offender with
the community. This community is defined to include family members, neighbors,
victims of the crime, teachers, coworkers and clergy or all the people who support
49


victims and offenders (Maxwell & Morris, 2001, p. 273). This approach to
offenders behaviors promotes interdependence and a communitarian view of social
networks, arguing that human relationships of interdependence built on respect and
forgiveness are essential to the process of reintegration into the community
(Braithwaite, 1999,2000,2001). This reintegrating form of shaming identifies
those persons of importance to the offender who are affiliated with a pro-social
lifestyle and employs these relationships to reinforce the importance of the offender
as a person and the reason the deviant act is wrong. Additionally, it makes an
attempt to build the connections of the offender with this pro-social community.
The theory of reintegrative shaming has been explored empirically with
mixed results. One approach to this investigation has emphasized the concept of
shaming and its role in rehabilitation while other investigations have emphasized
the characteristics of the reintegration process. In their study of offenders
participating in court versus conferences built on the principles of reintegrative
shaming, Ahmed and her colleagues (2001) found that effectiveness of the
communication of social disapproval (shaming) was predicted by the level of
respect the offender had for the individual disapproving of the behavior, the degree
to which the offender believed the behavior was wrong and the perception that
others viewed it as wrong. They concluded that the act of social disapproval or
shaming as described by Braithwaite is conceptually distinct from reintegrating
versus stigmatizing activities. However, their conclusions support Braithwaites
50


contention that shaming is an essential part of reducing the likelihood that an
individual will re-offend and that the way in which the individual is reintegrated
into society is also critical.
In a test of reintegrative shaming theory, Tittle and his colleagues (2003)
investigated both the role of shaming as defined by participating in or being the
subject of gossip and its relationship to past and projected deviant acts in a
household survey of 406 adults. They found that being the subject of gossip was
related to past and present deviant acts but that interdependency with others had
inconclusive effects on deviance. The authors acknowledged a number of
limitations, including the difficulty investigating subtle concepts of shame versus
humiliation in a telephone interview and their failure to measure the construct of
moralizing. They also acknowledged that their measurement of the construct of
interdependency actually captured dependency on others rather than a relationship
of mutual dependency.
In a quasi-experimental design comparing drug court (defined as a non-
stigmatizing approach) and usual court procedures (defined as a stigmatizing
approach), Miethe and colleagues (2000) found that drug court defendants were
almost twice as likely to recidivate than those who were not assigned to drug
courts. Although the authors original hypotheses were that drug courts were less
stigmatizing than regular courts, they concluded that the approach of the drug court
judge, who was experienced by observers to be hostile and degrading toward
51


defendants, was more stigmatizing than the normal court experience and this
explained the recidivism rate. This study evidenced obvious limitations in its
definition of the critical independent variables of stigmatizing versus reintegrating
approaches.
In another test of reintegrative shaming theory, Hay (2001) examined the
relationship between parental use of reintegrative approaches to expressing
disapproval through a survey of 197 high school students The study asked
students to indicate the extent to which they believed their parents used moralizing
and/or reintegrating approaches such as communicating to the youth that he or she
was a good person despite the behavior, telling the youth he or she is a bad person,
the parents reliance on convincing the youth he or she is immoral, attempting to
induce shame or guilt about the behaviors as well as inducing the youth to
apologize. The author found that higher levels of moralizing and reintegrative
techniques were associated with lower levels of projected rule-breaking among
adolescents. Like Ahmed and colleagues (2001), Hay (2001) concluded that
shaming and reintegration are independent and additive constructs that explain
delinquency. He further discussed the high correlation between interdependency
and reintegrating approaches as presenting the possibility that reintegrative
techniques may only be related to delinquency because of the presence of
interdependency between parent and child. This study casts doubt on Braithwaites
original theory by concluding that the shaming is independent of reintegration;
52


however, it does lend support for the portion of the theory that argues for the
importance of establishing or re-establishing relationships when attempting to
intervene in crime and delinquency. Nonetheless, the use of self-reported
projection of future deviant behavior raises doubts about validity of the
measurement of deviance in this study.
Building upon Braithwaites emphasis on social relationships, Chamlin and
Chochran (1997) analyzed secondary data from 364 cities with one million or more
in annual United Way contributions to determine if Braithwaites contention that
crime rates were related to the communitys level of altruism. In this study, they
assumed that altruism served as an indicator of communitarianism or strength of
social networks as defined by Braithwaite. They found that altruism, as defined by
higher levels of United Way contribution, was related to lower property and violent
crime rates; however, altruism did not appear to have the power to mediate the
impact of poverty and predominance of single-headed households on crime rates.
This study provides evidence of the relationship between social networks and crime
rates at a macro level and reinforces the findings from other studies that crime and
deviance are complicated phenomena that are not clearly influenced by one
variable alone. The lack of a relationship between altruism and crime rates in areas
where poverty and single-headed households are predominant exposes the
possibility that altruism is related to some other more powerful variables not
measured in this study.
53


In a study of the use of family conferencing based on reintegrative shaming
theory, 108 juveniles and their parents were followed at four and six years after
their convictions (Maxwell & Morris, 2001). Results of this study demonstrated
that family conferences with offenders moderate the impact of early life factors,
demonstrating reduced recidivism as compared with a matched comparison of
young offenders. The study suggests that feelings of remorse, absence of shame
(not feeling like a bad person), active participation in conferencing, acceptance of
the crime, and meeting the victim were the most critical factors predicting lower
recidivism. Remorse was determined to be the most critical factor influencing
reduced likelihood of recidivism with remorse defined as remembering the
conference, completing tasks, feeling sorry and showing it, and feeling they had
repaired the damage (p. 253). Not experiencing humiliation was the second most
critical factor predicting lower recidivism. This study supports Braithwaites
contention that communication of the disapproval associated with the deviant act in
a way that is not humiliating or shaming to the individual is critical in minimizing
recidivism to deviant acts. It also depicts the distinction between guilt and shame,
arguing that Braithwaites conception of shaming is more descriptive of guilty
remorse than humiliation and shame. This distinction could be particularly
important in its application to women with substance abuse problems. It may be
that guilt associated with their past behaviors and its impact on others, including
their children, provides a motivator to make positive life changes while
54


experiencing shame or humiliation causes them to withdraw from these normal
social relationships becoming more estranged from society.
In his discussion of substance abuse, Braithwaite (2001) argues that
reintegration focuses on changing the identity of the individual from that of a drug
addict to one that is no longer a drug addict and has the ability to help others.
Experiencing a repentant role is thought to be one way of making this transition,
providing an explanation for the success of Alcoholics Anonymous (Braithwaite,
1989; Houts, 1995). Contrary to Tittle and colleagues (2003) definition of
interdependence that includes only dependence on others, 12-step support groups
highlight mutually dependent relationships that emphasize acknowledgment of
wrongdoing, making amends and then helping others. This mutual self-help
approach seems to fit well with the principles of reintegrative shaming theory and
is consistent with the literature on the relationship between social support,
specifically attendance at 12-step meetings, and long-term recovery from alcohol
and drug abuse (Moos & Moos, 2004; Walton, Blow, Bingham, & Chermack,
2003; Weisner, DeLucchi, Matzger, & Schmidt, 2003).
The theory of reintegrative shaming offers some explanations for individual
variation in reaction to social construction and labeling. It offers a vehicle to
incorporate both individual and societal level predictors of deviance and points
directly to policies that may be altered to reduce secondary deviance. However, to
date, research on reintegrative shaming has been inconclusive. The research has
55


been fraught with problems of self-reported deviance, lack of common definition of
the key constructs of the theory, and, in some cases, poorly conceptualized designs.
In addition, much of the work has focused on societal level interventions, such as
sentencing procedures and community building in situations where victims of
crime are readily identifiable. As a result, the theory has not been systematically
tested in its applicability to so-called victimless crimes like substance abuse.
This thesis suggests a broader application for the theory at both the individual and
policy level. Not only does it apply the theory to a new population women who
have experienced recent substance abuse it expands the definition of stigmatizing
and reintegrating shaming to policy level issues, such as discriminatory laws,
policies that promote disengagement of individuals from normal social roles and
participation in organizations and policy-making.
Empowerment and Participation
The relationship between the powerful and powerless in policy contexts is
critical to the theory of social construction of target populations. The lack of
political power is a primary characteristic that distinguishes those who are deviant
from those who are advantaged in Schneider and Ingrams (1997) characterization
of target populations. The powerlessness of those who are labeled as deviant is
expressed in a variety of ways, including imprisonment, loss of custody of children,
discrimination in housing and employment, and denial of rights to participate in
56


election of political leadership. Thus, their ability to participate in the normal
social roles typically granted to parents, employees, citizens and community
members is effectively blocked. According to Braitwaites definition of
reintegration, meaningful participation through adopting respected social roles of
interdependence is essential to reduce the propensity for deviance.
Yet, the relationship between empowerment and participation is complex
and likely to be bi-directional. Participation theorists recognize that people lacking
political power often view the system as closed to them and therefore do not access
it (Bachrach & Baratz, 1962; Bachrach & Botwinick, 1992; Box, 1998), yet they
argue that power is attained through participation itself rather than being a
precursor to participation (Bachrach & Botwinick, 1992; Barber, 2003; Pateman,
1970). This contention sets the stage for arguments for more opportunities to
participate in governance. Those who advocate for a stronger participatory
democracy base their case in the importance of equity in the act of citizen
participation (Bachrach & Botwinick, 1992; Box, 1998; deLeon & deLeon, 2002;
deLeon, 1997; Kraemer, 1969). This argument holds that it is neither democratic
nor equitable for large sectors of the population to be excluded from decisions that
affect them. The lack of equitable access to the policy-making arena is the central
argument for participation itself as a means to promote the power needed to sustain
participation (Bachrach & Botwinick, 1992).
57


Robert Dahl (1956) promotes broad participation of individuals and groups
with varying perspectives and intensity of conviction. He contends that individuals
are able to identify their views, communicate these views either as individuals or
through collective efforts and these views are considered in governance. He
describes polyarchal democracy, as a place where many groups compete in the
expression of their perspectives. The importance of promoting means of
expression of diverse opinions is also present in the work of John Dewey and
Jurgen Habermas who advance democratic discourse involving individuals with a
variety of perspectives as essential to democracy (deLeon, 1997). These
perspectives emphasize the importance of the knowledge of ordinary citizens as
compared with scientific understanding, promoting discourse as both a strategy for
improved governance but also to reduce apathy and non-participation in policy
development. deLeon (1997) and Dryzek (1990) further expand on these theories
offering participatory policy analysis as an cure for indifference and
disenfranchisement among ordinary citizens.
Barber (2003, p. 155 [emphasis in original]) builds on these the theoretical
perspectives with the contention that to participate is to create a community that
governs itself, and to create a self-governing community is to participate;
participation is both a means and an end in moving toward his conceptualization of
Strong Democracy. Conversely, as participation in decision making is denied over
time, individuals begin to accept non-participation as their assigned role, thus,
58


being powerless reinforces and perpetuates powerlessness (Gaventa, 1980).
However, this powerlessness can be overcome by creating mechanisms to openly
express grievances, that is, encouraging participation.
Nevertheless, these theorists advocating greater participation are not blind
to the challenges associated with participation among those that are poor and from
lower classes. Dahl describes the barriers to participation to include apathy and
lack of resources (Pateman, 1970) but argues for participation as an incremental
rather than perfect solution to political inequity (deLeon, 1997). J.S. Mill and later
Carole Pateman promote incremental approaches to participation in local
government and the workplace as ways to build collective spirit in individuals
(Pateman, 1970). These incremental approaches respond to the most damning
criticism of participation -- the practical problems associated with widespread
participation due to the sheer number of people and diversity of perspectives
coupled with the barriers to engaging individuals in the process (Box, 1998;
deLeon, 1997; Pateman, 1970). Without considering some of the other challenges
associated with promoting widespread participation, the obstacles to political
participation among those labeled as deviant alone are daunting. For these
individuals, not only is the political system difficult to access due to poverty or lack
of education, the system is actively oriented to avert their participation (as
evidenced in the presidential elections in Florida in 2000 or Ohio in 2004).
Criminal offenders, including those who are drug-dependent, are often prevented
59


from participation in politics by the removal of their voting rights and in the most
extreme instances physical estrangement ffom avenues for participation through
incarceration or confinement in treatment programs. The problem of participation
among this group is qualitatively different than those who Schneider and Ingram
would label as dependent; those who are only powerless yet are perceived to
deserve benefits of society. Although Schneider and Ingram discuss these
differential impediments to participation (Schneider & Ingram, 2005a), the
complexities associated with negative social construction of a group and their
perceived deservedness to participate are not actively addressed in the literature
on participatory democracy.
Participation theorists do acknowledge the problems inherent in promoting
widespread political participation and as a result describe the potential to engage
citizens in politics through smaller scale efforts such as participatory policy
analysis (deLeon, 1997), participatory workplaces (Pateman, 1970), citizen
governance (Box, 1998), and public and community-based organizations (deLeon
& deLeon, 2002; Kraemer, 1969). Pateman (1970) argues for participation itself as
a mechanism to foster the skills and knowledge necessary for broader participation.
She draws on the work of John Stuart Mills, proposing that opportunities for
participation at all levels of political systems (e.g. industry, neighborhoods) provide
an opportunity -akin to training wheelsfor people to exert control over their
lives thus encouraging participation in other political systems. Building on Alexis
60


deTocquevilles ideas about the role of participation in civic associations, Pateman
(1970) contends that participation promotes democratic attitudes and the
connection between the individual and the social environment. These incremental
forms of participation seem to hold promise in addressing the complicated issue of
allowing individuals who do not conform to societal standards to participate in
political decisions of grave importance to the country. These forms of incremental
participation, if effective in teaching people to participate in larger societal forums,
might provide opportunities to engage or re-engage deviant individuals in society
through providing some control over their more immediate environment. For
example, offering individuals in correctional setting or treatment centers the
opportunity to participate in self-governance might reinstate the connection
between their own individual behaviors and the larger community. This has been a
practice used for decades in the substance abuse treatment system under the label of
therapeutic community and mutual or self-help groups (Freeman, 2001; Kaplan &
Broekaert, 2003; Whiteley, 2004).
Use of a broader definition of participation, which could include a range of
activities from participation in politics to exerting control over ones employment,
neighborhood or treatment center, fits well with Braithwaites contention that
reintegration relies on establishment of important social roles of all types. This
includes macro-level roles, such as organizer and advocate, as well as micro-level
roles such as employee and parent. It recognizes that exerting control over ones
61


own life creates a condition where participation in decisions that affect others lives
is possible. Again, this points to the role of participation in promoting participation
at grander levels. Empowerment theorists (Freeman, 2001; McWhirter, 1991;
Zimmerman, 1995) further develop this concept of a continuum of participation,
advocating for levels of empowerment that build gradually from individually
focused to politically focused empowerment.
Empowerment can be conceptualized as the opposite of powerlessness or a
process of gaining power and control over ones life. McWhirter (1991) stresses
that empowerment encompasses an individuals relationships with others as well as
the larger community. Her definition includes developing control over ones life
and supporting the empowerment of others. This extension of the concept of
empowerment to social and political relationships is not uncommon. This
perspective is evident in Zimmermans (1995) work. He defines empowerment to
include attitudes and behaviors that reflect a perception of self-efficacy, knowledge
of how to influence socio-political systems, and engagement in activities that
attempt to influence these systems.
Empowerment theorists conception of empowerment is somewhat similar
to Braithwaites reintegrative shaming theory. Both recognize the importance of
individual and societal level variables, the role of stigma in blocking access to pro-
social lifestyles and emphasize the importance of having control over ones
environment and rejoining society. The concept of disempowerment in
62


empowerment theories (Freeman, 2001) can be equated to Braitwaites concept of
stigmatizing shaming (Braithwaite, 1989), while empowerment equates to
reintegrative shaming practices. As with participation theorists, empowerment
theorists argue that behavioral changes include actions aimed at social change and
are essential aspects of empowerment (McWhirter, 1991; Perkins & Zimmerman,
1995; Zimmerman, 1995). For example, providing the opportunity to participate is
not as important as providing the participatory experience. Again, this argues for
attention to the incremental ways that individuals can participate in their most
immediate and relevant environment as a strategy to build participation in larger
contexts such as politics.
Consistent with the theory of reintegrative shaming, some theorists
recognize the role of social policies that are structural in nature on empowerment
(Lord & Hutchinson, 1993; Pancer & Cameron, 1994; Poole, 1995). Policies that
disenfranchise by denying voting rights as a result of disability or moral weakness
can be found in nearly all states (Schriner, 2005). Poole (1995) cites
unemployment and poverty as disempowering influences that must be overcome in
the empowerment process. Policies and practices that promote choice and
participation in such basic issues as where someone lives and their ability to get a
job can make a grave difference in their personal empowerment. In a study of
stakeholder participation in a housing project, Pancer and Cameron (1994)
discovered that having decision-making authority over housing was associated with
63


independent functioning while Lord and Hutchinson (1993), in a qualitative study
of 41 individuals who had experienced extensive powerlessness, found that support
in the form of housing and employment assistance along with participation were
key variables positively related to self-confidence, personal control and additional
participation.
These studies suggest that merely providing the opportunity to participate
may not be enough to facilitate empowerment (Lord & Hutchinson, 1993; Pancer &
Cameron, 1994). Providing access to safe, drug-free housing where an individual
can participate in decisions about how the housing is operated and have role models
and support systems for participation are important to promote reintegration for
individuals who have been estranged from society. This is contrasted with policies
that deny individuals safe housing in an attempt to punish them for their past drug
use thus pushing them toward deviant affiliations.
Yet the research on the role of structural supports in promoting
empowerment is not without limitations. First, it relies heavily on qualitative
studies (Lord & Hutchinson, 1993; Pancer & Cameron, 1994) that are not given to
generalization. Second, the Pancer & Cameron (1994) study points out some of the
potential problems associated with participation, most notably the burden of
participation. When individuals with a variety of very important social roles are
asked to give their time to a collective effort like governance of a housing program,
this time is diverted from some other important role, for example, time with their
64


children or other family members (Pancer & Cameron, 1994). It is likely that
continued exploration of the role of participation in individuals lives may result in
the discovery that more is not always better but instead there is an ideal mix of
types of participation that creates optimal individual and community performance.
The literature on empowerment and participation fails to acknowledge the inherent
trade offs associated with participation and instead views the benefits as
overwhelming the negative consequences (Freeman, 2001; Lord & Hutchinson,
1993). This idealized view of participation may be helpful in furthering policies
that promote participation with currently disenfranchised populations but does not
help to address the sustainability of participation at the individual level.
In addition to research on the role of participation in the broader human
services area, stakeholder or consumer participation in decision-making has been
utilized in the mental health and education fields since the 1960s (Pancer &
Cameron, 1994). Built on empowerment theories, a variety of types of
participation have been utilized, including enhanced involvement in treatment
planning, service on advisory and governing boards. These strategies are intended
to increase democratic participation and self-determinism by modeling participation
in organizational governance and participation in decisions that affect the lives of
others. These strategies are often coupled with mobilizing people to speak out in
political arenas on policies that affect social conditions for individuals with mental
health and substance abuse problems.
65


to the substance abuse problem rather than everyday problems facing people as
parents, children and friends.
In addition to this gap in Freemans work, very little empirical evidence
exists demonstrating the relationship between participation and empowerment in
substance abuse settings. Among the few discussions in this area, Carter (2002)
and LaFave (1999) explore the role of participation and empowerment in substance
abuse treatment settings, concluding that that offering substance-abusing women
choices about treatment, teaching them to make complaints about their care and
facilitating communication skills can increase their personal and political power
and ultimately improve their life situation. They provide descriptions of existing
programs aimed at enhancing outcomes among women in treatment but fail to
provide empirical evidence of the connection between empowerment and positive
outcomes. Baldwin and her colleagues (1999) demonstrated that substance-abusing
women who participate in interventions aimed at increasing personal power and
influence experienced increased trust, enhanced feelings of success, and an
expanded ability to take responsibility for their lives. Their qualitative study of 42
pregnant and parenting women with substance abuse problems evaluated an
intervention aimed at increasing personal efficacy and empowerment. The group
intervention focused on enhancing decision-making and problem-solving skills and
improving work etiquette. Although this study has limits in its generalizability, it
suggests that establishing a sense of responsibility and success in the social roles
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associated with daily life is an important component of participation that may be
missing in discussions of empowerment through participatory activities during the
treatment process.
The concept of a continuum of participation activities that ranges from
fulfilling meaningful social roles to participating in politics is a theme throughout
the participation and empowerment literature. There seems to be agreement that to
promote participation in venues that are more distant from daily life, one must
build in opportunities to fully participate in daily life. Freemans (2001) conceptual
framework for development of empowerment with substance-abusing individuals
builds on this theme. She identifies three strategies that can be used to empower
individuals with substance abuse problems within substance abuse service sites.
One set of strategies focuses on individual level change; seeking to enhance
personal self-efficacy and self-esteem but does not focus on the external
environment. The second approach involves people in shaping the service system.
It includes participation in program design and policies, service on advisory boards
and participation in peer support activities. These peer-support activities
emphasize a bi-directional relationship where both providing and receiving support
from peers is important. The third approach to empowerment seeks to involve
individuals in the larger socio-political system, promoting peer-led activism,
community volunteerism and participation in political campaigns. In addition,
Freeman suggests that the more systemic issues, such as access to healthcare and
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adequate income and housing, are essential to empowerment of recovering persons.
Thus participation that leads to empowerment can occur at multiple levels,
individual, relational, political and systemic; all are important to empowerment and
reintegration of individuals affected by substance abuse.
Yet, this comprehensive view of empowerment seems to miss an important
set of activities. Substance abuse professionals have theorized about the
importance of normalized social relationships, particularly the relationship with
children, as critical to recovery from substance abuse (Finkelstein, 1994), yet little
research has been completed to test this relationship empirically. Freeman (2001)
also fails to explicitly address this in her framework. This failure to address these
normal social roles may be a result of treatment providers focus on activities that
occur within the treatment setting rather than activities outside the treatment
experience. Results from a qualitative study investigating natural recovery outside
of formal treatment systems concludes that the social context in which individuals
live has an important influence on their ability to recover from substance abuse
problems (Granfield & Cloud, 2001). The authors cite healthy, supportive
relationships and communities that provide socio-economic and employment
opportunities as important factors in individuals ability to resist or recover from
substance abuse problems.
Although the research in substance abuse contains many examples of the
potential power of supportive relationships in sustaining recovery from substance
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abuse (Laudet, Magura, Vogel, & Knight, 2000a; Magura et al., 2003; Noone et al.,
1999; Walton et al., 2000; Weisner et al., 2003), less exploration has been done on
the role of helping others, another distinct form of participation. This idea that
being helped and helping others are both critical to reintegration into society is
essential to Braitwaites concept of interdependence. In an application to the
substance abuse field, Pagano and her colleagues (2004) conducted a longitudinal
study of 1726 individuals with alcohol problems, finding that those who were
engaged in helping others in similar circumstances were significantly less likely to
relapse during the year following treatment. The importance of helping others in
order to help yourself has been a cornerstone of 12-step self-help groups that has
primarily been researched from the perspective of how the support of others
promotes recovery (Humphreys, Moos, & Cohen, 1997; Walton et al., 2000;
Weisner et al., 2003). The role of helping others in sustaining recovery has not
been explicitly investigated. More investigation is needed into the relationship
between helping others in everyday roles such as friendly visitor, adult child of
elderly parents, parent of dependent children and community member and moving
people from deviant to pro-social lifestyles is needed.
The concept of self-efficacy or the ability to affect desired results, an active
ingredient that motivates people to remain in recovery from alcohol and drug
problems, is also believed to be related to participation. (Bandura, 1999,1995;
Marlatt, Baer, & Quigley, 1995). Bandura (1999) argues that having active
70


influence over the environment and the power to create a positive atmosphere for
recovery are essential for substance-abusing individuals. The goal of participation
is for individuals to exert influence over their immediate and more distant
environments. This emphasis on the marriage of individual and sociological
factors is echoed in Braitwaites (1989; 2000; 2001) contention that the movement
of individuals from deviant to prosocial lifestyles requires change in both
individual and social factors.
In contrast with the assertion that participation can only follow
empowerment, these discussions reinforce the idea that self-efficacy or
empowerment can be enhanced by active participation. This is a critical theoretical
distinction is empowerment a necessary condition for participation or does
participation enhance empowerment? The approach taken to this question
determines whether participation serves as an independent or dependent variable in
the exploration of empowerment. It is assumed for the purposes of this dissertation
that participation is the independent variable and that participation in some form
promotes both more participation (Pateman, 1970) and an enhanced sense of
control over ones environment. Yet, neither participation nor empowerment is
likely to occur if an individual is struggling for survival. Jones (2004), in his
application of Maslows (1943) theory on hierarchy of needs, argues that offenders,
particularly those who are incarcerated, are in need of assistance with basic needs
of shelter and safety in order to develop the positive social relationships and esteem
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needed to lead pro-social lives. The relationship between basic needs, such as
adequate income, safe housing and meaningful employment, is often overlooked
when designing policies and programs for individuals with drug dependence.
Instead, policies and programs often move directly to the esteem and relationship
needs of individuals with little regard that it may be far more difficult to develop
these other areas if basic physical and safety needs are not met. In addition, living
in situations where the threat of interpersonal violence is present provides an
example of the absence of a safe environment. Service delivery systems are often
more in tune to physically sub-standard housing or drug-infested neighborhoods as
threats and have a tendency to ignore the influence of living under a threat of
violence at the hands of friend or loved one on a persons ability to work toward
recognition and positive relationships. Empowerment must include supportive
personal relationships that are absent of the effects of interpersonal violence and the
ability to assume basic roles, including the ability to meet the basic needs of ones
family. These are fundamental aspects of having power over onesown life. These
aspects of personal power are often overlooked in the literature on empowerment
and in addressing drug dependence among women.
Social Support
Social support theories contend that social support is the key element
leading to reduction in crime, drug use and other social problems (Colvin, Cullen,
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& Vender Ven, 2002; Cullen, Wright, & Chamlin, 1999; Holtfreter et al., 2004).
Social support is defined as the provision of affective and/or instrumental
(material) resources. (Cullen et al., 1999, p. 198) and includes informal supports
from families, friends and communities as well as formal support provided by
workplace and government agencies (Colvin et al., 2002). Instrumental support
includes such things as material and financial aid, while affective or expressive
support includes such things as affirmation of self worth and assistance with
opportunities to participate fully in society (Colvin et al., 2002). It is argued that
consistent delivery of social support prevents crime, while erratic support enhances
ones attraction to support from groups involved in illegal activity (Colvin et al.,
2002).
Research demonstrates that affective support provided through participation
in peer support groups predicts decreased alcohol consumption in alcohol-
dependent populations (Walton et al., 2000; Weisner et al., 2003) and increased
levels of abstinence in individuals in recovery from substance dependence and
mental illness (Magura et al., 2003). In addition, social support is associated with
improved mental health (Laudet et al., 2000a; Laudet et al., 2000b; Timko &
Sempel, 2004), reduced substance abuse (Laudet et al., 2000a; Noone et al., 1999;
Timko & Sempel, 2004), and improved personal well-being in formerly substance-
abusing populations (Laudet et al., 2000a). In addition, quality of friendships and
73


attendance at Alcoholics Anonymous has been found to predict absence of relapse
eight years later (Humphreys et al., 1997).
Although the evidence of the connection between social support and
recovery from substance abuse is accumulating, much of the work completed
specifically addresses individuals with primary problems of alcohol dependence
(Humphreys et al., 1997; Noone et al., 1999; Weisner et al., 2003) or serious and
persistent mental illness (Laudet et al., 2000a; Laudet et al., 2000b; Magura et al.,
2003) rather than individuals primarily affected by drug dependence. In addition,
these studies rely on self-reported relapse (Laudet et al., 2000a; Laudet et al.,
2000b; Walton, Blow, & Booth, 2001; Weisner et al., 2003), often include small
and specialized samples (Knight, Logan, & Simpson, 2001; Timko & Sempel,
2004) that are overrepresented by men (Timko & Sempel, 2004), and suffer from
high or differential study attrition (Noone et al., 1999; Weisner et ah, 2003). In
particular, more work is needed to demonstrate the relationship between social
support and drug dependence among women.
Nonetheless, the research on the relationship between affective support and
reduction in substance abuse points to its importance in facilitating long-term
recovery from substance-abusing behaviors and highlights the need to better
understand the range and characteristics of effective social support. Much of the
research into the relationship between social support and long-term recovery
centers on the use of formal peer support networks but does not focus on the quality
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of primary social relationships, particularly the quality of partnership relationships
in terms of interpersonal violence.
The quality of social relationships appears to a have a role in ongoing
recovery from drug dependence especially for women but the findings to date are
somewhat equivocal. A study of 87 women entering residential substance abuse
treatment demonstrated that women who affiliated with friends who were not using
drugs or engaging in criminal behaviors demonstrated lower levels of illegal drug
use, intoxication and criminal behavior and were three times more likely to
complete treatment than women associating with friends who were engaging in
these deviant behaviors (Knight etal., 2001). In a study of 1350 men and women
entering substance abuse treatment, researchers found that individuals living with
an active drug or alcohol user had three times greater risk of relapse in the six
months following entry into treatment as compared with individuals who did not
live with an active substance abuser (Kedia & Williams, 2003). In another study of
873 men and women entering drug treatment, Broom (2002) found that individuals
who lived with one or more persons who used drugs or drank heavily were three
times more likely to use cocaine and two and a half times more likely to drink
frequently in the 12 months following admission to treatment than those who did
not live with peers who used. In a separate study of 62 women entering substance
abuse treatment and their partners, McCollum and colleagues (2005) found that the
association between relationship quality and later substance use was complicated.
75


They found that when partners assessed the relationship quality to be high and
women assessed the quality to be low, women were less likely to use alcohol or
drugs following treatment. The authors speculate that these findings may be related
to the differential relationship expectations of men and women and that these
expectations may be complicated by traditional versus emerging roles of women in
society. Although the findings of these studies are somewhat mixed, they
generally demonstrate with large samples that quality of relationship with peers and
partners contributes to subsequent drug use in populations in treatment.
Another variable influencing relationship quality is interpersonal violence.
Histories of interpersonal violence and trauma are very common among women
entering substance abuse treatment, with experts estimating that between 60% and
80% of individuals entering substance abuse treatment have a history of severely
violent traumatic events in their lifetime (Clark et al., 2001; Farley et al., 2004;
Hein, Nunes, Levin, & Fraser, 2000; Moncrieff et al., 1996; Najavits et al., 2003;
Najavits, Weiss, & Shaw, 1997; Rice et al., 2001). In addition, histories of trauma
and violence are associated with higher levels of use of drugs and alcohol post
treatment as compared with those without trauma histories (Brown, 2000; Brown,
Recupero, & Stout, 1995; Hein et al., 2000; Najavits et al., 2003). It is unknown
and possibly unimportant to understand fully whether the negative impact of
interpersonal violence on women struggling with substance abuse problems is the
result of the relationship quality or the perceived lack of safety in their living
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environment. The relationship of interpersonal violence and variables such as
opportunities to participate in important social roles and decisions affecting ones
own life are all intertwined in ways that are difficult to unravel. Nonetheless, there
is mounting evidence that the effect of quality of relationships with peers and
partners wields important influence on womens ability to shed deviant lifestyles.
Instrumental support comprises a combination of variables related to ones
ability to meet basic needs including amount, source and stability of income, safe
and stable housing and access to employment. This instrumental or concrete
support is a concept that Braithwaite (2004) emphasizes in his recent writing on
emancipation conferences. In its relationship to long-term abstinence, Walton and
colleagues (2003) found that lower income (over a quarter of the sample had
incomes of less than $10,000 while nearly 40% had incomes over $40,000) among
substance dependent individuals at entry into treatment was a significant predictor
of alcohol relapse two years later. Noone and his colleagues (1999) found that
stress (including financial stress) in the months prior to a twelve month follow-up
interview was significantly correlated with prevalence of daily drinking and the
number of days of drinking. However, neither of these studies presented effect
sizes, so it is difficult to gauge the magnitude of the role of these instrumental
supports on relapse. Nonetheless, these findings are consistent with studies of other
similar populations.
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Holtfreter and her colleagues (2004) presented a compelling case for the
importance of instrumental support in reducing recidivism risk among female
offenders. In their study of 402 women entering parole or probation, they find that
poverty increases the odds of rearrest 4.6 times and increases the odds of violation
of conditions of parole or probation 12.7 times as compared with women who did
not experience poverty. In addition, among the poor women in their sample, they
found that failure to receive state-sponsored services, such as cash assistance,
housing assistance and vocational services, increased the risk that they would
reoffend 3.3 times as compared with poor women who did receive services.
Although this study experienced very high attrition among the participants, it
nonetheless makes a strong case for the necessity to provide tangible support such
as housing and cash assistance for female offenders.
Complicating the role of income in predicting poorer substance abuse and
crime outcomes, women with substance abuse problems have fewer financial
resources than men in similar circumstances. In a sample of 293 members of a
Health Maintenance Organization referred for substance abuse treatment, women
had significantly lower income than men (mean annual income of $10,483 versus
$11,621, respectively) and women were less likely to be employed than their male
counterparts (76% of the women were employed as compared with 91% of the
men). In the same study, low income and employment problems among both men
78


and women predicted their failure to complete substance abuse treatment (Green et
al., 2002).
In another study of drug-dependent men and women who were not in
treatment, women demonstrated higher levels of reliance on public assistance and
prostitution than their male counterparts (Atkinson et al., 2000). Among the
women in this sample, 59% reported receiving welfare while 51% reported
receiving money from family or friends and 25% from prostitution, 13% from
selling or bartering goods and 9% from illegal activities other than prostitution.
Women and men also differ in their source of income following treatment, with
women being less likely to be employed (38% of women and 65% of men) and
more likely to rely on public assistance (58% of the women versus 36% of the men)
eighteen months after entry into treatment (Oggins et al., 2001). This is likely
related to the increased likelihood for women to be caring for children.
Although the evidence that substance dependent women often have very
low incomes and are likely to be reliant on public assistance and prostitution as
primary sources of income is quite clear, these studies suffer from limitations such
as small sample sizes (Green et al., 2002; Metsch et al., 1999), the limits of relying
on self report (Metsch et al., 1999; Oggins et al., 2001) and cross-sectional designs
that are confined in their ability to suggest a cause and effect relationship between
income and drug dependence or treatment success (Atkinson et al., 2000; Metsch et
al., 1999). Nonetheless, women with drug dependence do have significant
79


challenges related to economic support, whether compared to the general
population or to men in similar circumstances. These challenges are often
complicated by their propensity to be caring for dependent children. The ability of
drug-dependent women to achieve economic independence is likely to play a
significant role in womens ability to break free of unhealthy and deviant lifestyles
of dependence and crime.
This relationship between economic stability, internalization of
discrimination, and secondary deviance has been demonstrated empirically. Li
(2001) found that lower levels of income and education are related to perceptions
of social discrimination among individuals with disabilities. In a separate study of
opiate addicts entering treatment, Kosten and his colleagues (1987) conducted
follow-up interviews 2.5 years later and analyzed their outcomes based on source
of income (employment, public assistance or illegal) at the time of entry into
treatment. They found that those who relied on public assistance at the time of
treatment admission showed less change in employment and legal problems as
compared with the other two groups. They concluded that lower levels of income
(individuals on public assistance had the lowest overall income of all three groups)
may not exert a negative influence on substance abuse outcomes but that this group
may be less inclined to participate fully in society, maintaining illegal behaviors
and not being engaged in employment. These studies demonstrate that the
relationship between drug dependence, deviance, treatment and economic stability
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are complicated and that treatment occurs within the context of a society where
inequities related to responsibility for children, employment opportunities and
access to public assistance differ by gender and drug use status. Clearly, the
relationship between these variables is bi-directional and situational.
In addition to economic stability, housing is also a critical component of
instrumental support. In a study of 165 incarcerated women, women reporting the
need for drug treatment and those who did not indicate a need for drug treatment
were asked to rank their needs (Alemagno, 2001). Among the women indicating a
need for drug treatment, 84.1% reported a lack of stable housing and identified
housing to be their most important need as compared with 45% of those who did
not need drug treatment. The author concluded that stable housing and a legal
source of income are of primary importance to facilitate a transition to a new way
of life for this population.
In a separate study (Yahne, Miler, Irvin-Vitela, & Tonigan, 2002), twenty-
seven prostitutes were asked to prioritize their areas of concern. The most
commonly identified area of concern was basic needs including safety, food, health
care and housing followed by mental health and substance abuse treatment. In
addition, in a study of clients served in publicly funded substance abuse treatment
programs, McLellan and his colleagues (1998) found that enhanced programs that
addressed health, social and environmental problems of their clients including
medical screening and referral to drug-free housing were more effective in reducing
81


alcohol and drug use than programs that were not enhanced to address these issues.
They concluded that both rehabilitation and supportive services are essential
components of effective substance abuse treatment. Others have identified the need
for child-care to be a prominent need among women in treatment for substance
abuse (Finkelstein, 1994).
Again there are significant limitations to these studies of the relationship
between basic needs and reduction of drug use. Small samples (Yahne et al., 2002)
assembled by convenience (Alemagno, 2001; Yahne et al., 2002) and relying on
self-reporting (Alemagno, 2001) limit the ability to generalize to larger populations
as well as generating questions about the validity of the study methods employed.
Yet these studies support the theoretical work of Braithwaite, suggesting the
importance of having basic needs met as a precursor to moving away from deviant
behaviors of drug use.
Review
As depicted in Figure 3.2, this thesis builds primarily on Braithwaites
reintegrative shaming theory, arguing that women with histories of drug
dependence who identify with deviant identities as described by Schneider and
Ingram (1997) have been subject to stigmatizing shaming. This stigmatizing
shaming is characterized by a lack of access to safe and stable housing,
employment, education, and cash assistance; and the absence of positive, violence-
82


free support systems. This exclusion from normal, healthy social roles and
relationships and inability to meet basic needs promotes identification with deviant
identities. In short, these women have not had the opportunity to reform their
identities by becoming fully participating citizens and instead retain the master
identity of deviant.
Conversely, substance-abusing women who have the ability to meet their
basic needs, have access to violence-free supportive social networks and have the
opportunity to participate in socially respected and responsible social roles are
more likely to identify with pro-social identities. Participation as responsible
citizens in decisions that affect their lives and their community strengthens their
social relationships, enhances their ties to the community and promotes non-deviant
identity.
In summary, this thesis is based in the theoretical perspective that views
social constructions and the labels used to communicate these constructions as
exerting critical influence on how individuals and groups view themselves and their
relationship to society, thus, labels and stigma used in policy have significant
consequences. Policies that stigmatize and ostracize by denying access to
instrumental and social supports and avenues to fully participate in society may
actually perpetuate deviant behaviors such as criminal activity and illegal drug use.
This thesis fills a gap in the current literature by exploring the relationship between
the variables of instrumental support, social support and participation by examining
83


the relationship between these variables and deviance in a population of women
who have a history of drug abuse.
Figure 3.2. Application of the theory of reintegrative shaming to substance-
abusing women.
Woman attempts to recover
from drug dependence
Reintegrated
Presented with opportunities
to participate in meaningful
way in society through filling
respected social roles, helping
others & community efforts
Access to housing,
employment and income
support is facilitated.
Demonstrates deviant attitudes Does not demonstrate deviant
and behaviors attitudes and behaviors
Based on Braithwaite (1995; 1999; 2000; 2001)
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CHAPTER 4
METHODOLOGY
This chapter describes the methodological considerations and analytical
approach employed in this thesis including the study design, rationale, and
limitations; the hypotheses and variables included in the analysis; a description of
the population and sample; and the analyses conducted. In addition, it details the
data set from which the data were derived and briefly describes the original study to
provide context.
Research designs have been categorized into two divergent methodological
perspectives; qualitative approaches relying on interpretivist epistemologies and
quantitative approaches subscribing to positivist epistemologies. Over the past two
decades, a third methodological approach referred to as mixed methods or mixed
models has emerged (Tashakkori & Teddlie, 2003). Mixed methods designs
combine the use of qualitative and quantitative data and methods in a variety of
ways to explore research questions.
There have been a number of attempts to develop taxonomies of mixed
methods designs. Creswell (2003) employs one approach to setting out these
designs by designating them in terms of which approach (QUAL or QUAN) is most
prominent and the order of introduction of the approach. Tashakkori and Teddlie
85


(1998; 2003) contrast mixed methods with mixed model research; arguing that
mixed model designs integrate the qualitative and quantitative approaches
throughout the study rather than sequentially mixing approaches as in other mixed
methods research designs. They also use categorizations of mixed methods designs
based on the research purpose as either confirmatory or exploratory in nature.
Despite the varying strategies employed to describe mixed designs, these mixed
methodologists seem to agree that there are so many possible variations of mixed
methods or mixed model designs that creating a neatly organized taxonomy is
difficult if not impossible (Caracelli & Greene, 1997; Maxwell & Loomis, 2003;
Tashakkori & Teddlie, 2003).
For this reason, it is challenging to clearly describe the design of this
dissertation in terms of the mixed methods taxonomies. From a more descriptive
approach, if pure qualitative and pure quantitative studies were placed on opposite
ends of a continuum with mixed methods studies falling on a line between these
extremes, this thesis would fall closer to the quantitative pole of the continuum in
terms of research design. It is predominately a quantitative study using positivist
methodologies and relying principally on numbers and statistical analysis to reach
conclusions about the central phenomenon of interest. However, some of the data,
analyzed through statistical methods, were collected in response to open-ended
questions and analyzed using qualitative methods prior to assigning quantitative
codes. In addition to being coded with numbers, the qualitative findings have been
86