Who Is in Charge of Your Recovery? The Effectiveness of Reality Therapy for Female Drug Offenders in Taiwan

Abstract

This study was designed to fulfill a twofold purpose. First, a 12-session reality therapy drug treatment program to help female drug abusers achieve a better recovery was developed. Second, based on previous research in reality therapy, the Index of Sense of Self-Control in Recovery for Drug Offenders was developed, and the instrument was validated using principal components analysis and confirmatory factor analysis. Later, ANCOVA was used to test the effectiveness of the treatment program. The participants were 48 female drug offenders, who were randomly assigned to equal-sized experimental and control groups. The results of the study showed significant differences in the posttest scores for the sense of self-determination and sense of self-control for the members of the two groups.

Keywords

reality therapy drug treatment female drug offender sense of self-determination sense of self-control Taiwan

Introduction

For years, the number and percentage of prison inmates in Taiwan classified as drug offenders has continued to climb steadily. According to official statistics of the Ministry of Justice (2012a), the figures increased from 25,956 (41%) at the end of 2008 to 28,668 (44%) after the first 6 months of 2012. Among the offenders, 47.1% were heroin abusers, 45% were amphetamine abusers, and 6% were ketamine abusers (Ministry of Justice, 2012b). The percentage of females among new inmates classified as drug offenders was 42.9% of 4,137 in 2009, 43.7% of 3,136 in 2010, 44.2% of 3,543 in 2011, and 44.2% of 1,711 in the first 6 months of 2012, whereas the percentage of males was 27.9% of 38,199 in 2009, 28.9% of 33,623 in 2010, 30.1% of 32,916 in 2011, and 30.3% of 15,913 in the first 6 months of 2012. Apparently, a higher percentage of female inmates were classified as drug offenders as compared with their male counterparts (Ministry of Justice, 2012c). Deng, Vaughn, and Lee (2003) analyzed data from 700 incarcerated drug users in Taiwan to distinguish gender differences in the frequency of drug use and the drug of choice. They found that 30% of the females used drugs two or three times a day, whereas only 20% of their male counterparts did so. They also found that more females used illicit drugs compared with their male counterparts; for instance, 80% of the women and 76% of the men used amphetamines, 64% of the women and 57% of the men used heroin, and 9% of the women and 5% of the men used marijuana. In her study of female drug offenders, Wang (2007) reported that 90% were addicted to heroin. The high percentage of inmates classified as drug offenders underscores the value of developing a more comprehensive drug prevention and intervention program in Taiwan, especially for female drug offenders.

Two pioneering studies in Taiwan in the field of substance-abuse treatment were focused on responsibility and recovery. To obtain their goal, the scholars (Hsiao, 1997; Xu, 1984) implemented reality therapy-based treatment for male juvenile delinquents with a history of substance abuse and found that this type of treatment increased the participants’ sense of responsibility for their own recovery and their emotional stabilization. In 1998, the criminal justice system in Taiwan adopted a new orientation to consider substance abuse as a disease based on a medical model rather than criminal behavior. Since then, a few more empirical studies have engaged in testing the effectiveness of psychologically based substance-abuse treatment in correctional settings in Taiwan (Law & Guo, 2012). First of all, as Marlatt (1985) has pointed out, many drug abusers attribute their drug usage either to outside factors, such as pressure from others to use drugs, or to excuses based on internal attributions, such as thinking that they are unable to function unless they use drugs. Jiang (1999) conducted a cognitive therapy-based drug treatment program with male drug offenders in Taiwan and found that the program was effective in decreasing their maladaptive beliefs on drug usage and reducing the amount of amphetamines ingested. C. C. Lee (2005) implemented reality therapy for male drug offenders in Taiwan and discovered that the therapy enhanced their sense of self-control (SSC). Furthermore, Jiang (2007) developed a drug treatment program based on a combination of art and family and group counseling in Taiwan. His study revealed that this treatment of male drug offenders was successful in increasing self-confidence, patience, and self-understanding in the recovery process and in enabling the participants to pursue healthier lives.

Although the evidence of the effectiveness of drug treatment for males seems promising, the need for drug treatment programs for females in Taiwan has long been overlooked. Recently, based on empirical evidence indicating that female drug abusers have lower self-esteem than their male counterparts (Dodge & Potocky, 2000; Messina & Prendergast, 2001; Sowards, O’Boyle, & Weissman, 2006), Wang (2007) conducted self-assertiveness training for female drug offenders in Taiwan and found that after 6 weeks of training, the participants’ interpersonal efficacy and interpersonal interaction had significantly improved. Law and Guo (2012) conducted a hope-based substance-abuse treatment program focused on female drug offenders in Taiwan and reported that after treatment, the participants’ self-esteem was significantly increased.

To continue the efforts in this line, some other potential factors that may contribute to female drug usage should be investigated further. Self-blame has been denoted as a potential factor contributing to drug usage behavior among females, especially for victims suffering from posttraumatic stress disorder symptoms due to trauma from familial violence (Janoff-Bulman & Thomas, 1989). Illiceto et al. (2010) also found that heroin addicts have significantly elevated levels of self-blame. Thus, empowering the SSC and sense of self-determination (SSD) should be taken into consideration as essential components in female drug treatment programs. As self-control and self-determination are central concepts of reality therapy, it could be the most appropriate treatment when treating female drug offenders. Although the effectiveness of reality therapy treatment in helping juvenile delinquents in Taiwan has been confirmed (Hsiao, 1997; C. C. Lee, 2005; Xu, 1984), the implications of such studies in regard to drug treatment for female offenders are limited. Thus, this study was structured as a two-group pretest and posttest control group design to investigate the effectiveness of a reality therapy-based drug treatment program for female drug offenders in Taiwan.

Literature Review

Basic Concepts of Reality Therapy

Reality therapy was founded by Glasser (1965, 1998), who emphasized that an individual is driven to fulfill five basic needs: survival, love, power, fun, and freedom: Survival refers a basic need for food, shelter, and clothing; love refers to a sense of belonging and caring; power refers to a sense of recognition and worth; fun refers to a sense of enjoyment and pleasure; and freedom refers to a sense of autonomy and choice.

Furthermore, according to Glasser (1965, 1998), each person begins creating his or her quality world at birth and continues re-creating this quality world throughout life. In this quality world, people instill their own ideals in terms of people they want to be with, what they want to experience, and the belief systems that govern their behavior. Furthermore, each behavior is a chosen action that consists of four components: action, thinking, feeling, and physiology. Taken together, these components are referred to as total behavior.

Control theory was a central theme of reality therapy around the 1970s. Glasser declared that “we are much more in control of our lives than we realize” (Glasser, 1998, p. 4). More specifically, the theory held that if individuals have a sense of control over their lives and are able to fulfill their basic needs, they experience a sense of satisfaction; on the other hand, feeling out of control will lead to dissatisfaction (Corey, 2013; Wubbolding, 2000, 2011). In the 1990s, Glasser replaced the concept of control theory with choice theory. Choice theory was built around his strong belief that effective control is the result of making better choices and that appropriate choices will intrinsically enhance motivation (Glasser, 1998). In the light of this theory, a reality therapist should aim to teach clients choice-making skills and at the same time encourage them to be willing to take responsibility for making choices that will fulfill their basic needs and be in line with their picture of a quality world (Corey, 2013; Wubbolding, 2000, 2011).

Accordingly, reality therapy-based drug treatment was designed to focus on teaching clients to understand their needs and how to fulfill those needs through appropriate choices (Mottern, 2002), to be responsible for their own choices (Glasser, 1965, 1998; Moore, 2001; Wubbolding, 2011), and to set priorities among their needs through the WDEP evaluation system (Wubbolding, 2000, 2011). In this system, W stands for wants (i.e., asking clients to clarify and prioritize their wants), D stands for doing (i.e., asking clients where their current choices are taking them), E stands for evaluation (i.e., asking clients to evaluate whether their current choices are taking them where they want to go), and P stands for plan (i.e., asking clients to make an effective plan to fulfill their wants without hurting themselves or others; Glasser, 1990; Wubbolding, 1990).

The Reality Therapy Explanation of Drug Abuse

Based on the concepts of reality therapy, the causes of female drug abuse can be explained as a series comprising stages of regression (Glasser, 1965, 1998; Wubbolding, 2011).

Stage 1: Dissatisfaction With Basic Needs

According to Glasser (1965, 1998)’s description, individuals are driven to fulfill five basic needs; they begin creating their quality world at birth and continue re-creating this quality world throughout life. Unfortunately, a significant number of female drug offenders suffer from emotional, physical, and sexual abuse (Baker, 2001; Hiebert-Murphy & Woylkiw, 2000; Nelson-Zlupko, Dore, Kauffman, & Kaltenbach, 1996; Nyamathi, Longshore, Keenan, Lesser, & Leake, 2001; Sacks, McKendrick, & Banks, 2008) and dysfunctional family settings and dynamics (Finnegan & McNally, 1997; Nelson-Zlupko et al., 1996). Such traumatic experiences may be a factor contributing to limitation of the choices available to fulfill a female drug offender’s needs and thus to a feeling of apathy (Wubbolding, 2011). When individuals repeatedly encounter such limitations, they may begin using drugs as substitute gratification, a way to let themselves believe that their needs are being fulfilled. The subsequent integration of substance use and abuse into the individual’s quality world makes later attempts to change difficult (Mottern, 2002).

Stage 2: Developing Negative Symptoms

When an individual continues to fail to fulfill her basic needs in Stage 1, she may develop negative symptoms in all four areas of total behavior. For instance, an individual engaging in negative behavior that is harmful to herself or others, for example, engaging in substance abuse, may subsequently think herself powerless and become emotionally upset. In addition, physical symptoms may also manifest as a result of the substance misuse. Eventually, the substance usage has become such an integrated component of the individual’s quality world that it is now essential to fulfillment of her needs. She may fulfill these needs, for example, by using drugs with friends to fulfill her need for love, belonging, and fun (Wubbolding, 2011) and letting the powerful stimulation of the drug fulfill her need for freedom (Mottern, 2002).

Stage 3: Becoming Addicted

When regressive behavior has reached this stage, the individual has become biologically and psychologically addicted to substances (Wubbolding, 2011). As her basic needs are now being continuously satisfied through drug usage, the individual’s quality world has been re-created to the point that the substance-abuse cycle has become firmly entrenched and is difficult to remove (Mottern, 2002).

Self-Control, Self-Determination, and Recovery

Based on the previous review, the importance of teaching female substance-abuse offenders effective decision-making skills during their recovery is apparent. However, human beings have a tendency to blame others for their own problems and often do not realize that their drug-abuse behaviors could end up hurting themselves or others. Thus, to better serve female drug abusers, the linkage between the SSC and SSD and drug abuse should be investigated in detail.

Self-Control, Drug Abuse, and Recovery

Gottfredson and Hirschi (1990) and Hirschi (2004) presented a theory of self-control in the criminology field and indicated that individuals with SSC are able to consider the potential costs of their actions and tolerate delayed gratification to achieve a long-term goal. In contrast, studies have found that individuals lacking in self-control were at a higher risk of engaging in criminal behavior (Gottfredson & Hirschi, 1990; Hirschi, 2004), alcohol consumption (Brody & Ge, 2001; Gibson, Schreck, & Miller, 2004; Shamloo & Cox, 2010; Wolfe & Higgins, 2008), and tobacco use (Novak & Clayton, 2001).

To test the role of self-control in drug abuse, Wills and his colleagues first defined self-control as the ability to plan and problem-solve, and then conducted a longitudinal study of the development of self-control in adolescents from sixth to ninth grades. They discovered that participants whose capacity for self-control was well developed had lower rates of drug use (Wills & Stoolmiller, 2002). Consistently, other scholars have noted that individuals with higher scores in self-control had lower scores in tendency toward substance abuse (Patock-Peckham, Cheong, Balhorn, & Nagoshi, 2001; Simons & Carey, 2002; Wills, Sandy, & Shinar, 1999). In addition to the focus on the direct impact of self-control on drug use, many scholars are concerned with the role of self-control in moderation of substance abuse. For instance, Wills, Ainette, Stoolmiller, Gibbons, and Shinar (2008) investigated the buffering effect of self-control on adolescent substance abuse. Their study revealed that three risk factors that have been shown to have a strong impact on adolescents’ substance abuse—negative family life events, unpleasant adolescent life events, and peer substance use—were significantly reduced as the individuals’ SSC increased. Moreover, many scholars are concerned with the relationship between self-control, drug use, and stress management. Because individuals with a lower SSC tend to have higher levels of emotional distress and because distress from a stressful life has been identified as a factor that leads to drug abuse and relapse (Tate, Brown, Glasner, Unrod, & McQuaid, 2006; Tate et al., 2008), scholars have paid close attention to the factor of self-control when studying substance abuse and recovery. It was no surprise when Wills, Sandy, and Yaeger (2000) found that a higher SSC in adolescents was positively associated with more ability in emotional regulation. That, in turn, enhanced the individual’s ability to adopt positive coping mechanisms rather than turning to substance abuse to deal with problems. Furthermore, Romer, Duckworth, Sharson, and Park (2010) explored how the development of self-control in adolescents was related to the ability to delay gratification in youth aged 14 to 22 years. After intensive study, they concluded that youth with the ability to delay gratification will be less likely to use drugs; the ability to delay gratification proved to be a source of self-control.

Regarding the impact of self-control in recovery, Packer, Best, Day, and Wood (2009) revealed that lower self-control was significantly associated with greater intensity of drug use among participants in a court-mandated treatment program. Cole, Logan, and Walker (2011) conducted an investigation regarding how self-control and their perceived control of their lives affected the stress of participants in substance-abuse treatment programs and found that the more the participants felt they were in control, the less likely they were to feel stressed. Kelly, Deane, McCarthy, and Crowe (2011) reported that in their study, perceived behavioral control was found to be predictive of the participant’s motivation to enter treatment after detoxification. Similarly, Moos (2007) suggested that adding active ingredient components to recovery programs (i.e., a supportive atmosphere, setting a goal and establishing structure, practicing coping skills, enhancing self-efficacy, involvement in abstinence-oriented activities, finding a role-model, etc.) helped to enhance substance abusers’ sense of responsibility for their own recovery.

Self-Determination and Recovery

Although the role of self-control in the drug abuse and recovery fields has been widely investigated, as shown previously, to date, empirical studies of self-determination have mainly focused on recovery. Deci and Ryan (1985) developed a self-determination theory based on the concept of social cognition. In the self-determination theory, the term motivation was specified as including amotivation, external motivation, introjected motivation, identified motivation, integrative motivation, and intrinsic motivation in an autonomous continuum. Individuals with amotivated experience believe that changing their behavior is impossible. External motivation occurs when clients believe their treatment-seeking behavior was mandated by external demands. Introjected motivation occurs when the main impetus toward behavior change begins to undergo a transformation from external control to internalized factors. However, as they are still in a partially internalized status, clients encounter feelings of conflict regarding treatment, and their motivation for changing is somewhat unstable and ambivalent. Identified motivation is a more stabilized self-determined form of regulation; it occurs when the clients themselves find value in behavior change and make a personal commitment to the treatment and the goals they have identified. Integrated motivation occurs when the clients have completed treatment but continue seeing a therapist to ensure that their new behavior can be maintained. Finally, intrinsic motivation occurs when the clients engage in the new behaviors naturally and experience the satisfaction inherent in them (Deci & Ryan, 1985; Groshkova, 2010; Klag, Creek, & O’Callaghan, 2010; Markland, Ryan, Tobin, & Rollnick, 2005). Among these six types of motivation, Ryan, Plant, and O’Malley (1995) found that for clients with higher levels of external and intrinsic motivation, the attendance and retention rates in the treatment were high; however, intrinsic motivation was found to be more effective in bringing about behavior change. If the individual’s internal motivation was low, even if the external motivation remained high, their treatment had a poor result. Deci and Ryan (2002) confirmed that intrinsic motivation could promote clients’ involvement in behavior change. Furthermore, Wild, Cunningham, and Ryan (2006) noted that in contrast to external motivation, which was often related to legal referral to enter treatment, and introjected motivation, which was often associated with feeling guilty for the continued drug abuse, identified motivation positively predicted reduction of substance usage.

Furthermore, self-determination theory addresses how social perception can affect the motivation for behavior change and identifies three fundamental psychological human needs that can promote more autonomous forms of motivation. These are the need for autonomy (i.e., opportunities to make choices), the need for competence (i.e., a belief that outcomes are under the individual’s own control), and the need for relatedness (i.e., having a supportive networking system). When the social environment nurtures these factors and supports clients in an autonomic fashion, more autonomous motivation for being in treatment to achieve behavior change will be elicited as a result (Deci & Ryan, 1985, 1991, 2000, 2002; Groshkova, 2010; Klag et al., 2010; Markland et al., 2005).

Consistent with the above notion, scholars have found that a supportive environment, such as treatment that allows clients to participate and make decisions in setting up treatment goals, can successfully enhance the client’s ability to self-regulate healthy behavior, make a commitment to the treatment goal, and find motivation to work toward recovery, and even to reduce substance usage (Deci & Ryan, 2002; Groshkova, 2010; Simoneau & Bergeron, 2003; Wild et al., 2006). Substance abusers and homeless persons from a peer-supported program also reported that focusing on self-determination had a significant impact on their motivation for drug-abuse recovery (Boisvert, Martin, Grosek, & Clarie, 2008). Similarly, Maeyer, Vanderplasschen, and Broekaert (2009) conducted a focus group discussion with substance abusers receiving services and noted that participants regarded allowing them to make their own choices and set their own goals as a priority. Furthermore, Ryan et al. (1995) discovered that even when participants were under mandatory treatment, promoting strong internalized motivation was the key to better attendance and retention in treatment. Although there is no empirical evidence to support the predictive role of a self-determined goal in the recidivism of a drug offender, a study targeted on domestic violence offenders found that setting a self-determined goal could negatively predict recidivism (M. Y. Lee, Uken, & Sebold, 2007).

Overview of This Study

Based on an understanding of the causes of drug abuse and empirical evidence demonstrating the links between self-control, self-determination, drug abuse and recovery, an essential component of any drug-abuse treatment should be enhancing clients’ feelings of self-control and self-determination. Although to date very few studies in either the United States or Taiwan have examined the effectiveness of the use of reality therapy with female drug offenders, some research (Glasser, 1965; Hammerley, Cavelle, & Forayth, 1992; Hsiao, 1997; C. C. Lee, 2005; Xu, 1984) has indicated that reality therapy promotes a SSC and strengthens SSD, both of which are very important to the success of substance-abuse treatment. For instance, Glasser (1965) revealed that this type of treatment could help female drug offenders reduce drug usage and improve interpersonal relationships. Hammerley et al. (1992) confirmed that reality therapy could help adolescent drug offenders develop an increased awareness of their own needs, build up their self-identity, and solve problems on the basis of a problem-focused approach rather than an emotion-focused approach. In Taiwan, Xu (1984) found that after reality therapy treatment, juvenile delinquents with substance-abuse charges showed significant improvement in their willingness to take responsibility for their own recovery and emotional stabilization. Hsiao (1997) found that, 4 weeks after undergoing reality therapy, juvenile delinquents with drug-abuse charges showed significant improvement in their willingness to assume responsibility for their recovery. When it was implemented for male drug offenders, C. C. Lee (2005) discovered that after 8 weeks of reality treatment, inmates showed significant improvement in self-concept and SSC.

Building upon these findings, this study has developed an instrument for the purpose of program evaluation as well as a 12-session reality therapy-based drug treatment program for female drug offenders. It was hypothesized that this program would help female drug offenders in Taiwan strengthen their SSC and their SSD.

Method

Development of the Assessment Instrument

Development Procedure

A new instrument, the Index of Sense of Self-Control in Recovery for Drug Offenders (ISSRDO), was developed by the authors of this study, who have many years of experience working in the field of treatment for drug offenders and have educational backgrounds in counseling. Their work was based on the following steps to ensure the professional character of the instrument. First, an extensive literature review on the theories of reality therapy, self-control, and self-determination and the linkage of each with drug treatment was conducted. Second, the 20 questions of the index were developed based on the theoretical structure that has emerged from previous research studies. Ratings were made on a variation of a Likert-type scale, with responses ranging from 1 (strongly disagree), 2 (disagree), 3 (slightly disagree), 4 (slightly agree), 5 (agree), to 6 (strongly agree). Third, three experts from the field were invited to review the first draft of the instrument, and several revisions were made based on their suggestions to improve the quality of the questionnaire. Fourth, two groups of female inmates with drug-related offenses were recruited for instrument validation.

Participants and Statistics Analysis for Instrument Validation

Pilot testing and confirmation testing were conducted to validate the instrument prior to the data collection portion of this study. First, principal components analysis was used on the factor structure of the ISSRDO. The Kaiser-Meyer-Olkin Measure of Sampling Adequacy (KMO-MSA) and Bartlett’s Test of Sphericity (BTS) were utilized to test the factorability of the pilot data set. Then, a factor analysis was conducted to test the construct validity of the inventory. The pilot run sample consisted of 149 female drug offenders from a correctional institution in central Taiwan; these inmates were invited to voluntarily participate. The average age of the participants was 40 (ranging from 18 to 50). Among them, 48% were single, 19% were married, and 33% were divorced. In regard to their educational background, 83% of the participants had completed middle school, and 17% had completed either senior or vocational high school.

In addition, a Confirmatory Factor Analysis was performed to further validate the inventory using the Structural Equation Model to reconfirm the model structure derived from the pilot study and for the purpose of testing its reliability. To ensure generalizability, another group of 197 female drug offenders from the same correctional institution were invited to participate voluntarily to further validate the scale using structural equation modeling and for the purpose of testing the instrument’s reliability. The average age of the participants was 39 years (ranging from 18 to 52). As for marital status, 46% were single, 17% were married, and 37% were divorced. Among them, 84% of the participants had completed middle school, and 16% had completed senior or vocational high school. The chi-square test for independence was used to examine whether there were differences in distribution between the two groups on each demographic variable at a significance level of .05. Because none of the chi-square values reached the level of significance (p > .05), homogeneity between the two pilot groups was confirmed.

Current Study

Participants

Based on the severity of their substance addiction, 48 female prison inmates were referred for the treatment as a mandatory requirement by the social worker and were randomly assigned into experimental and control groups with 24 women in each group. The ages of the 24 participants in the experimental group ranged from 18 to 43 years (M = 32 years), and the average age of first instance of drug use was 15 years. Among the participants, 45% were single, 22% were married, and 33% were divorced. Fifty percent of them had children. As for educational background, 80% of the participants were middle school graduates, and 20% were senior or vocational high school graduates. In regard to their last employment prior to arrest, 25% reported self-employment, 32% were in service occupations, 22% were engaged in prostitution, and 21% reported being housekeepers or that they had no jobs. Drug-related offenses were their major or only offenses.

The ages of the participants in the control group ranged from 18 to 44 years (M = 33 years), and the average age for their first instance of drug use was 16 years. Among the participants, 48% were single, 17% were married, and 35% were divorced. Forty-nine percent of them had children. As for educational background, 82% of the participants were middle school graduates, and 18% were senior or vocational high school graduates. In regard to their last employment prior to arrest, 23% reported self-employment, 33% were in service occupations, 24% were engaged in prostitution, and 20% reported being housekeepers or had no jobs. As none of the chi-square values of the demographic variables reached the level of significance (p > .05), homogeneity between the two groups was confirmed (Table 1).

Table 1.

Characteristics of Participants in Experimental and Control Groups.

Characteristics	Experimental group	Control group
Age range	18 to 43	18 to 44
Average age	32	33
Average age of first instance of drug use	15	16
Marital status
Single	45%	48%
Married	22%	17%
Divorced	33%	35%
With children
Yes	50%	51%
No	50%	49%
Educational background
Middle school graduate	80%	82%
Senior or vocational high school graduate	20%	18%
Last employment prior to arrest
Self-employed	25%	23%
Service occupation	32%	33%
Prostitution	22%	24%
Housekeeper or no job	21%	20%

Research Design and Treatment Program

This study was approved by the first author’s Institutional Review Board, and permission was received from the research site prior to data collection. To strengthen internal validity and to ensure that participants’ changes were from the treatment itself and not due to history, maturation, testing effect, and so on, this study had a two-group pretest and posttest control group design (Spata, 2003). Both groups took the ISSRDO at the same time as a pretest in a group setting before the first session was held. Then, the participants in the experimental group received 12 sessions of reality therapy-based drug treatment, which was conducted in the institution, meeting once per week for 2 hr for a total of 12 sessions, whereas the control group participants were put on a waiting list for the same treatment program in another term, and thus received no treatment for the duration of the research. Because their participation was mandatory, no compensation was given for their time.

The drug treatment was conducted by the coauthor of this study in Mandarin Chinese, the participants’ native language. Right after the experimental group had completed the 12th session, participants of experimental and control groups filled out the ISSRDO at the same time for the posttest. The questionnaires were completed in a group setting in a self-administered style in approximately 15 min. To assure participants that the data collected would be kept confidential so that it would be feasible for them to participate in the pre–posttest design, the participants were informed prior to the research that their names would not be included in any form in the research report. The following 12 treatment sessions, based on Wubbolding’s (2011) proposed three stages of effective behavior, were designed for this study primarily by the first author of the study. The treatment modality for the group was a structured format with a group size of 24 participants; the three stages in this treatment process were implemented as described in the following paragraphs.

Stage 1: Develop the SSD to commit to change

According to self-determination theory, when participants are allowed to become involved in setting treatment goals, the resulting increase in motivation leads to a greater willingness to seek help (Wild et al., 2006). Therefore, three sessions to promote participants’ commitment to the treatment were designed for this stage.

Session 1: Participants shared their expectations for the treatment and their commitment to working toward those expectations.

Session 2: The transtheoretical model of motivation (DiClemente & Prochaska, 1998) was introduced, and participants were encouraged to identify their successes or struggles through each stage of recovery and reaffirm their commitment to recovery.

Session 3: Participants drew on their past successes to recall how their commitment had impacted those successes. Then, participants were encouraged to create a commitment statement for their current struggle, based on those past successes.

Stage 2: Develop positive total behavior

Based on Wubbolding (2011)’s suggestion that individuals who make healthy choices in their actions and thinking increase their chance of fulfilling their needs and, as a result, increase their chance for happiness, Sessions 4 through 9 were designed to help participants fulfill these goals.

Session 4: Participants in this session were invited to share their goals and problem-solving experiences and evaluate how their current actions were leading them toward their life goals, based on the concepts of the five basic needs and total behavior. If they determined that modification of their goals was necessary, then they were encouraged to make a new plan and create a commitment statement for that plan.

Session 5: This session was designed to help participants accept and recognize their abilities as a foundation for future development through such activities as having participants list their abilities in a picture of a lighthouse. In this activity, it was explained that the more abilities the participants were able to list, the more energy they would have to shine their light toward recovery. The participants were then invited to commit to taking responsibility for continuing to enrich the lighthouses to further enlighten their efforts toward recovery.

Session 6: This session was designed to teach participants self-assertiveness and coping skills that could enable them to feel powerful enough to reject the temptation to use drugs. Then participants were encouraged to declare their willingness to take responsibility for their actions.

Sessions 7 to 9: These three sessions were designed to increase the participants’ awareness of how anger and stress relate to drug use by identifying possible causes of anger or stress, to help participants understand how anger or stress triggers drug use, and to teach anger management skills and ways of coping with stress based on the WDEP.

Stage 3: Develop a SSC for recovery

According to Glasser (1965, 1998), each behavior is a chosen action, and once the self-control capacity is well developed, an individual’s rate of substance use will decrease (Wills et al., 2008). Therefore, the last three sessions were designed to improve participants’ SSC.

Sessions 10 and 11: These two sessions were designed to enhance the participant’s SSC, to identify and break down recovery goals into smaller, attainable objectives, and to make an action plan for achieving those objectives and committing to the responsibility of following through with the plan.

Session 12: In this session, participants shared descriptions of their SSD and SSC throughout the process of recovery and committed to continued effort in pursuing life without drugs.

Statistical Analysis

This study aimed to evaluate the effectiveness of a reality therapy-based drug treatment program for female drug offenders in Taiwan by comparing the means of each ISSRDO subscale for the experimental and control groups. Mean changes in the scores of the two groups in each subscale were compared using ANCOVA. Prior to testing with ANCOVA, homogeneity within the regression coefficient was tested using the pretest scores on each ISSRDO subscale; if the data met the requirement for homogeneity within the regression coefficient, ANCOVA would be considered appropriate for use in further analysis. Then, considering changes in the posttest scores for the two groups on each subscale as the dependent variables, the pretest scores of each subscale of ISSRDO from both groups served as a covariate. The significant alpha level was set at .05.

Results

Development of the Assessment Instrument

Principal Components Analysis

The KMO-MSA and BTS were utilized to test the factorability of the pilot data set. The analysis revealed that the figures were significant (p < .001), and the KMO-MSA was 0.920, indicating that factor analysis was appropriate for this data. Factor analysis was then used for factor extraction, and it was found that one question (#10) performed poorly and failed to load well on any factor (<.30). After deleting question 10 based on principal components analysis principles, two factors with eigenvalues greater than 1 were extracted; these factors could account for 71.710% of the variance. Commonalities ranged from 0.459 to 0.844 for each item. The results of factor loading after varimax rotation are shown in Table 2.

Table 2.

The Results of Factor Loading of ISSRDO After Varimax Rotation.

	Factor	SSC	SSD
	Item number	1	2
16	I believe I have the ability to use positive coping strategies to overcome stress.	.868
20	I am willing to take responsibility for making the effort toward the goals and plans I have set up for recovery.	.850
11	I believe I have the ability to overcome the difficulties I am facing during recovery.	.843
15	I am willing to work hard to manage my emotions so that I can be happier.	.830
17	I am willing to use positive coping strategies to overcome stress.	.796
19	I have set up a clear and concrete plan for recovery.	.785
18	I believe that a successful recovery is possible and I am willing to take charge in pursuing self-growth.	.779
14	I believe I have the ability to manage angry emotions.	.776
13	I believe I have the ability to refuse the temptation of drugs.	.762
12	I am willing to actively say “no” to all temptations from drugs and be responsible for my life.	.736
9	In pursuing my recovery goal, I am willing to take the responsibility to be in control.	.712
4	I believe that determination and willingness are essential to being able to recover successfully.		.889
2	I am determined to reach my recovery goal.		.889
1	Recovery is a gradual process; I am willing to maximize my best effort during this process.		.886
3	I promise to devote my best effort to reach my recovery goal.		.882
7	Knowing my life goals has enhanced my motivation for recovery.		.821
5	Recalling my past successes in overcoming difficulties could increase my confidence during drug recovery.		.758
8	I believe I am in control of my recovery.		.555
6	I clearly understand my needs and future goals.		.547

Note: ISSRDO = index of sense of self-control in recovery for drug offenders; SSC = sense of self-control; SSD = sense of self-determination.

The extracted factors were labeled SSC and SSD. SSC assesses the participant’s ability to overcome obstacles and set up plans to pursue her goals. SSD assesses the participant’s motivation to overcome obstacles and follow her plans to reach those goals. As a test of the reliability of this instrument, Cronbach’s alpha was used to measure internal consistency reliability. The results revealed that the Cronbach’s alpha coefficient of the whole inventory was .959; the coefficients for the subscales were SSC (.959) and SSD (.936), indicating excellent reliability for this instrument based on the guidelines from Ornum, Dunlap, and Shore (2008) that a Cronbach’s alpha coefficient of .7 could be considered adequately reliable for the pilot testing.

Confirmatory Factor Analysis

Confirmatory factor analysis was performed using the remaining 19 items to further validate the scale as well as to confirm its reliability using the Structural Equation Model. The goodness-of-fit indices and Cronbach’s alpha coefficients based on this analysis can be found in Table 3.

Table 3.

Confirmation Testing Results of ISSRDO.

Construct and items	Cronbach’s alpha	Construct reliability	Averaged variance extracted	Standardized loadings	t
SSC	.955	.956	.662
16				.823	—
20				.857	14.846***
11				.818	13.810***
15				.801	13.535***
17				.855	14.863***
19				.814	13.761***
18				.848	14.532***
14				.744	12.096***
13				.780	12.774***
12				.792	13.009***
9				.810	13.493**
SSD	.930	.932	.636
4				.857	—
2				.893	17.031***
1				.903	17.411***
3				.901	17.595***
7				.818	14.717***
5				.754	12.909***
8				.586	9.005***
6				.588	9.050***
CMIN/df = 4.144, RMSEA = .127, NFI = .828, CFI = .863, IFI = .864, RFI = .806

Note: ISSRDO = index of sense of self-control in recovery for drug offenders; SSC = sense of self-control; SSD = sense of self-determination; CMIN = minimum discrepancy; RMSEA = root mean square error of approximation; NFI = normal fit index; CFI = comparative fit index; IFI = incremental fit index; RFI = relative fit index. “—” refers to a parameter fixed at 1.0 in the original solution to fix the scale of the latent variable.

p < .01. ***p < .001.

According to the guidelines suggested by scholars (Byrne 2001; Kline, 2005), the values of minimum discrepancy (CMIN)/df, root mean square error of approximation (RMSEA), normal fit index (NFI), comparative fit index (CFI), incremental fit index (IFI), and relative fit index (RFI) indicated only a moderate to reasonable model fit; however, the convergent validity was supported by the evidence that all t values for each indicator were significant and all standardized loadings were greater than 0.50 (Hair, Black, Babin, Anderson, & Tatham, 2006). The average variance extracts were 0.662 and 0.636. The Cronbach’s alpha coefficient for the whole scale was .958; the coefficients for the subscales were SSC (.955) and SSD (.930), indicating that each factor had excellent reliability (Ornum et al., 2008). The results showed that the model was a good fit and confirmed that the selected items, which appropriately fell into the SSC and SSD subscales, could be finalized.

Effectiveness of the Treatment Program

Forty-eight clients, none of whom dropped out of the treatment program during the research period, participated in this research. The means and standard deviations of the pretest and posttest for each subscale of the ISSRDO are shown in Table 4.

Table 4.

Sample Size, Mean, and Standard Deviation of Pretest and Posttest Scores.

	Experimental group (n = 24)				Control group (n = 24)
	Pretest		Posttest		Pretest		Posttest
Subscales	M	SD	M	SD	M	SD	M	SD
SSC	5.30	0.44	5.61	0.40	5.49	0.47	5.24	0.28
SSD	5.44	0.41	5.74	0.35	5.74	0.34	5.39	0.44

Note: SSC = sense of self-control; SSD = sense of self-determination.

Prior to testing with ANCOVA, the homogeneity within the regression coefficient was tested for each subscale; the results showed that there was no significant interaction between the groups in the pretest scores for SSC (F = .3.916, p > .05, partial η² = .082) and SSD (F = 2.027, p > .05, partial η² = .044; see Table 5). This was an indication that the data met the requirement for homogeneity within the regression coefficient so that ANCOVA was appropriate for use in further analysis. The results of ANCOVA for both subscales of the ISSRDO are shown in Table 6.

Table 5.

ANOVA Summary Table for Homogeneity Within the Regression Coefficient.

Subscales	Sources	Sum of squares	df	M ²	F	Partial η²
SSC	Group × Pretest	0.431	1	0.431	3.916	.082
	Error	4.847	44	0.110
SSD	Group × Pretest	0.311	1	0.311	2.027	.044
	Error	6.739	44	0.153

Note: SSC = sense of self-control; SSD = sense of self-determination.

Table 6.

Results of ANCOVA for the Two Subscales of ISSRDO.

Subscales	Sources	Sum of squares	df	M ²	F	Partial η²
SSC	Contrast	1.380	1	1.380	11.768**	.207
	Error	5.279	45	0.117
SSD	Contrast	1.653	1	1.653	10.552**	.190
	Error	7.050	45	0.157

Note: ANCOVA = analysis of covariance; ISSRDO = index of sense of self-control in recovery for drug offenders; SSC = sense of self-control; SSD = sense of self-determination.

p < .01.

As the results in Table 5 indicate, after significant adjustment by the covariates of the pretest scores for SSC and SSD, there were significant differences between the members of the two groups in the posttest scores for SSC (F = 11.768, p < .01, partial η² = .207) and SSD (F = 10.552, p < .01, partial η² = .190). The experimental group had significantly higher scores for SSC (estimated marginal means = 5.598) and SSD (estimated marginal means = 5.763), as compared with the control group’s scores for SSC (estimated marginal means = 5.251) and SSD (estimated marginal means = 5.362). These results revealed that after reality therapy-based drug treatment, the participants had a better SSC and SSD for working toward their recovery than those participants who had not received treatment.

Discussion

The first part of this study was devoted to developing a new instrument, the ISSRDO, to evaluate the effectiveness of a reality therapy-based drug treatment program. The results confirmed that the ISSRDO items formed a factorially good fit with the model, indicating that the selected items properly explained the extent to which the SSC and SSD reflected the clients’ ability to overcome obstacles and set up plans to pursue their goals and their motivation to overcome obstacles and follow plans to reach those goals. Furthermore, based on the guidelines from Ornum et al. (2008), the excellent reliability results from Cronbach’s alpha coefficient for SSC and SSD subscales indicated that the drug offenders’ SSC and SSD in recovery could be reliably determined from their response to the ISSRDO items. Furthermore, the items of SSC and SSD were constructed from similar concepts, and the highly convergent validity confirms that the constructs of SSC and SSD are related.

The second part of this study was devoted to developing a 12-session reality therapy-based drug treatment program for female drug offenders in Taiwan. As Janoff-Bulman and Thomas (1989) pointed out, one potential factor that contributes to drug-abuse behavior in females is self-blame. In contrast, higher self-control has been found to have a significant association with lower substance use (Packer et al., 2009; Wills et al., 2008; Wills & Stoolmiller, 2002). Empirical evidence has revealed that it is essential for drug treatment programs to aim to enhance a client’s self-control (Kelly et al., 2011; Wills et al., 2008; Wills & Stoolmiller, 2002). Thus, several sessions of our reality therapy-based drug treatment program were designed to help female drug offenders learn to make healthy choices, which it was hoped would increase their SSC during the recovery process, as Wubbolding (2011) predicted. Thus, we initially hypothesized that a reality therapy-based drug treatment program would help strengthen female drug offenders’ SSC. In line with previous research in Taiwan (Hsiao, 1997; C. C. Lee, 2005; Xu, 1984), this expectation was fulfilled in the evidence provided by this study; it was revealed that when the female drug offenders had completed the reality therapy-based drug treatment program, their SSC was significantly enhanced as compared with those in the control group, who did not attend the program.

The assumption underlying the second hypothesis was that a reality therapy-based drug treatment program would help female drug offenders strengthen their SSD. This hypothesis was based on the work of Mottern (2002), who noted that when constructive choices to fulfill individuals’ basic needs are blocked, they may choose to use drugs as a substitute. As a result, the expectation of continued drug use may be built into their picture of a quality world unless their SSD in recovery is empowered with opportunities to fulfill their basic needs appropriately (Boisvert et al., 2008; Deci & Ryan, 1985, 2002; Groshkova, 2010; Maeyer et al., 2009; Simoneau & Bergeron, 2003; Wild et al., 2006). Several empirical studies have revealed evidence that it is essential for drug treatment programs to aim to enhance a client’s power of self-determination in regard to her own recovery (Boisvert et al., 2008; Deci & Ryan, 1985, 2002; Groshkova, 2010; Maeyer et al., 2009; Simoneau & Bergeron, 2003; Wild et al., 2006). Accordingly, several sessions in our reality therapy-based drug treatment program were designed to empower self-determination in the recovery of female drug offenders. The results of this study were consistent with our prediction and with previous research in Taiwan as well (Hsiao, 1997; C. C. Lee, 2005; Xu, 1984). Specifically, as compared with a control group who did not attend the program, the female drug offenders who had completed the reality therapy-based drug treatment showed a significant increase in their SSD to support recovery.

Conclusion

As a pioneering investigation into this line of research, the findings of this study are a useful contribution to the practice of and literature on reality therapy-based drug treatment for female drug offenders in Taiwan. However, several limitations of the study and recommendations for further research should be mentioned.

Limitations of This Study and Recommendations for Further Investigation

First, we are concerned that the positive results of this study might be limited to the immediate short term. It is essential to replicate this treatment program with 3- and 6-month follow-up evaluations to determine the long-term effects regarding the participants’ SSC and SSD in recovery as well as their actual drug use behavior post-release. Another concern is focused on the sampling size and range. Because the sample utilized for ISSRDO validation included female drug offenders from only one correctional institution in central Taiwan, further studies should expand the sampling for instrument validation to correctional institutions in different regions of Taiwan and to include male drug offenders to achieve a larger and more diverse sample size to increase the representative power of the sample and enhance the generalizabity of the instrument.

A similar concern is focused on program implementation; because the participants in this study were mandated to attend the treatment program and were from only one institution, the lack of a representative sample limits the generalizability of our results to the general female drug offender population in Taiwan. Therefore, the application of these results in the treatment of female drug offenders should be viewed with caution. More studies in substance abuse–related areas and conducted in different institutions will be necessary for further confirmation of the results. Likewise, studies involving male drug offenders could be conducted to assess the relevance of this treatment program for that population. Furthermore, as Ryan et al. (1995) suggested, when dealing with clients who have been mandated to receive treatment, promoting strong internalized motivation is essential to ensure good attendance and retention. Fortunately, as this study was focused on promoting choice, the participants were encouraged to share their expectations with the group and to decide how they would fulfill their expectations within the early stages of the treatment process. In further studies, similar activities might be conducted more often (e.g., once every three sessions) so that the participants could gain a sense of control within the group process and increased motivation for participation.

Our third concern is that the small sample size of the participants in the treatment groups (Pearson & Lipton, 1999) may have diminished the statistical power of the results in detection of significant differences between experimental and control groups. Future studies should increase the sample size to increase the statistical power for comparison (Sheppard, 1999). Furthermore, although we relied on objective scales to collect behavioral data related to the complexity of drug-related recovery procedures, we are concerned that some of the changes might be difficult to describe through a purely objective scale. In addition, as the study was conducted in a correctional setting, it may have been difficult for the inmates to voice their true insights for fear of embarrassment about admitting weakness or out of concern that their personal information could be used against them in court. To maximize the accuracy of the data, further studies could add such measures as open-ended questions and face-to-face interviews to obtain data. We hope that, by handling participants’ self-reported data anonymously, randomly assigning participants to two groups, pretest and posttest control group design, and using ANCOVA for data analysis, we have maximized the rate of accuracy of the responses in this study. A final concern that needs to be addressed is that the two factors extracted in the ISSRDO could only account for 71.710% of the variance. This might indicate that there are a number of other items not currently selected that should be taken into consideration in further research.

Policy Implications

Teaching clients to stop blaming themselves and instead to face their recovery with confidence in their own capacity for self-determination and self-control seems to be a promising direction for the field of substance-abuse treatment. If the results of this study are confirmed by future studies, our findings have the following implications for policy.

First, several sources of empirical evidence have indicated that the majority of female drug offenders may have suffered traumatic experiences (Baker, 2001; Finnegan & McNally, 1997; Hiebert-Murphy & Woylkiw, 2000; Nelson-Zlupko et al., 1996; Nyamathi et al., 2001; Sacks et al., 2008), with a resulting tendency toward poor self-esteem (Dodge & Potocky, 2000; Messina & Prendergast, 2001; Sowards et al., 2006) and self-blame (Janoff-Bulman & Thomas, 1989). This vulnerability has limited their choices in their effort to fulfill their needs and led to substance usage (Packer et al., 2009; Wubbolding, 2011). As continuing substance usage is then built into their picture of a quality world, it becomes more difficult for them to change their behavior (Mottern, 2002), leading to a greater risk of relapse (Grella, Scott, Foss, Joshi, & Hser, 2003) or criminal behavior (Gottfredson & Hirschi, 1990; Hirschi, 2004). In contrast, scholars have discovered that well-developed self-control gives substance abusers a better chance of decreasing their rates of drug usage (Patock-Peckham et al., 2001; Simons & Carey, 2002; Wills et al., 1999; Wills & Stoolmiller, 2002), increases their motivation to enter treatment (Kelly et al., 2011), and enhances their sense of responsibility for their own recovery (Moos, 2007). As this study has confirmed the effectiveness of a reality therapy-based drug treatment program in enhancing the SSC in the substance-abuse recovery of female inmates in Taiwan, we recommend that correctional settings in Taiwan consider adopting this program to strengthen female drug offenders’ SSC, which would then enhance the possibility of their recovery.

Secondly, being willing to change and to stay abstinent is a long-term commitment, and offenders’ self-determination and positive expectations toward their goals are important elements in this commitment. Findings from several previous studies indicated that higher self-determination was a positive predictor for substance-abuse recovery (Groshkova, 2010; Wills et al., 2008; Wills & Stoolmiller, 2002). Unfortunately, in correctional settings, quite often drug offenders have been mandated to attend a drug treatment program as part of the sentence. As a result, they usually consider the therapy to be a punishment, and therefore usually have low motivation to attend and participate. Promoting strong internalized motivation has been shown to be a key component contributing to increased attendance and retention in mandatory treatment programs (Ryan et al., 1995) and increased capacity for self-regulation in choosing healthy behaviors (Groshkova, 2010). Many studies have found that a supportive environment, such as allowing clients to participate in deciding about and setting up treatment goals enhanced their motivation to commit to the treatment goal and led to reduced substance usage (Boisvert et al., 2008; Deci & Ryan, 2002; Groshkova, 2010; Maeyer et al., 2009; Simoneau & Bergeron, 2003; Wild et al., 2006). Based on our findings, female drug offenders in Taiwan who were mandated to participate in a reality therapy-based treatment program had significant improvement in their SSD in regard to achieving recovery. Thus, we recommend that correctional institutions should implement this program to serve that purpose.

Finally, we encourage correctional institutions in Taiwan to use the ISSRDO, the instrument we have developed and validated in this study, as an evaluation tool when conducting reality therapy-based drug treatment programs for female drug offenders. Furthermore, correctional institutions could administer the ISSRDO on a regular basis to evaluate female drug offenders’ SSC and SSD in drug recovery, and then provide them intervention programs as necessary to enhance their chance for a full recovery.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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