self-efficacy, standards, and abstinence violation: a comparison between newly sober and long-term...

Journal of Substance Abuse, 1, 221-229 (1989)

Self-Efficacy, Standards, and Abstinence Violation: A Comparison Between Newly

Sober and Long-Term Sober Alcoholics

Steven M. Ross Patrick J. Mi l le r

Rita Y. Emmerson Ellen H. Todt

Veterans Administration Medical Center Salt Lake City, UT

Recent theory and empirical data suggest that self-efficacy plays an important role in resistance to relapse for substance abusers. Another key in the relapse process, according to Marlatt and Gordon (1985), is the abstinence violation effect, which comprises self-attribution for failure and affective reaction to violation of self-imposed standards. The combination of unrealistically high standards and low self-efficacy for following those standards may potentiate the risk for relapse. A 25-item questionnaire designed to assess self-efficacy and standards was administered to alcoholics newly admitted to an inpatient treatment program and alcoholics who had been sober for at least 1 year. The groups did not differ with regard to having high standards, but the successfully abstinent alcoholics had significantly higher self-efficacy expectations than the newly sober alcoholics. These results suggest that treatment programs may need to include interventions which decrease unrealistic standards as well as those designed to increase self-efficacy expectations.

In alcoholism treatment, outcome studies have reported relapse rates of up to 80% by 6 months posttreatment (Armor, Polich, & Stambul, 1978; Emrick, 1974). Consequently, the importance of systematic study of relapse phenomena has been recognized by those engaged in alcoholism treatment and research. Marlatt and Gordon (1980, 1985) have proposed a conceptual framework with application to both understanding the relapse process and developing interventions for long-term maintenance of abstinence. Two key elements of this model are (a) self-efficacy for abstaining, and (b) the abstinence violation effect (AVE), a cognitive-affective reaction to violation of dichotomous, self- imposed standards regarding the proscribed behavior. The AVE comprises two factors, a causal attribution of personal responsibility for the lapse and

A portion of this article was presented at the annual meeting of the Association for the Advancement of" Behavior Therapy, November 15-17, Houston, TX, 1986. This research was supported by the Veterans Administration.

Correspondence and requests for reprints should be sent to Steven M. Ross, VA Medical Center-116A9, 500 Foothill Blvd., Salt Lake City, UT 84148.

221

222 S. M. Ross, P. I. Mil ler, R. Y. Emmerson, and E. H. Todt

an affective reaction (e.g., guilt and self-anger) to the attribution. According to the model, self-efficacy for abstaining increases with the successful resolution of high-risk situations and contributes to maintenance of abstinence. However, should a relapse occur, the intensity of the AVE will largely determine whether the initial slip will escalate into a full-blown relapse.

Investigations of the role of self-efficacy in addictions and relapse have recently begun to appear in the literature. In smoking cessation, C o n d i o t t e and Lichtenstein (1981) reported that post t reatment self-efficacy scores were highly predictive of relapse status, and the actual relapse situation, during the follow-up period. Researchers at the Addiction Research Foundation in Toron to have repor ted on the development and psychometric properties of an instrument for measuring self-efficacy for alcohol-related situations (Annis, 1984; Annis 8 :̀ Davis, 1988). The Situational Confidence Questionnaire (SCQ) includes items covering areas of difficulty experienced by alcoholics in terms of excessive drinking or relapse and yields an overall efficacy rating as well as a rating for each of several categories which correspond to the major determinants of relapse proposed by Marlatt and Gordon (1980). Clinical research (Annis 8 :̀ Davis, 1988) on outpatients in t reatment indicated a positive correlation between scores on the SCQ and control over drinking behavior. In addition, we have found that relative to alcoholics who had been sober for at least 1 year, newly abstinent individuals scored significantly lower on total efficacy as well as on seven of the eight subscales of the SCQ (Miller, Ross, Emmerson, 8,: Todt , in press).

There has apparently been no systematic study of the AVE in regard to alcoholic relapse, al though it has recently been examined in relation to smoking relapse following an initial smoking episode (Curry, Marlatt, & Gordon, 1987). Results showed that subjects who relapsed following a slip reported significantly higher AVEs (operationalized as a combination of in- ternal, stable, and global causal attributions) than those who regained abstinence. Fur thermore, this measure emerged as the strongest predictor of subsequent smoking when included in a discriminant analysis with other factors associated with the initial smoking episode. Relapsers also reported significantly more guilt after smoking their first cigarette than did lapsers.

A process similar to the AVE has also been found to be associated with binge eating by overweight individuals (Gormally, Black, Daston, 8 :̀ Rardin, 1982). These authors employed an I 1-item Cognitive Factors Scale to appraise whether subjects had unrealistically high dieting standards or low efficacy expectations for sustaining a diet. Results suggested that binge eating was strongly associated with a combination of low self-efficacy for dieting a n d stringent dieting standards. It was concluded that "High standards are self- defeating when a person feels little sense of personal efficacy to follow them." (p. 51) T h e authors also suggested that severity of binge eating following a slip in control was related to the emotional consequences of overeating.

It has become increasingly apparent that an adequate account of alcoholic relapse must explain not only why some individuals maintain abstinence and others do not, but also why, having experienced a lapse, some will go on to

Self-Efficacy 223

total relapse and others will not. There is also increasing recognition that relapse is not a unidimensional phenomenon (Brownell, Marlatt, Lichtenstein, 8,: Wilson, 1986) but rather involves some interaction of individual, environ- mental, and physiological factors. However, there is growing evidence that cognitive factors, such as self-efficacy and the AVE, may play a central role in relapse (or the maintenance of abstinence) for many individuals.

The present study represents preliminary efforts to extend examination of such cognitive factors to alcoholic populations using a brief self-report instrument. The Alcohol Cognitive Factors Scale (ACOFS) was developed to assess both efficacy expectations for maintaining abstinence and factors associated with the AVE, such as unrealistically stringent standards and self- attribution for failure. Of interest was the ability of the instrument to discriminate individuals who had successfully maintained long-term abstinence from those who had not. A second purpose of the study was to compare the discriminant validity of the self-efficacy port ion of the instrument with another measure of self-efficacy, the SCQ.

METHOD

Subjects

The subjects were two groups of VA Medical Center patients. Individuals in one group had just entered an inpatient alcohol t reatment program (n=46) while individufils in the other group were graduates of VA treatment programs who had been abstinent a minimum of 12 months at the time of the testing (n=25). T h e patients included had a DSM-III (American Psychiatric Asso- ciation, 1980) primary diagnosis of alcohol dependence without other psychiatric disorders, polysubstance abuse, or organic brain syndrome. Mean age for the short-term sober (STS) group was 44.5 (+9.1) years, and for the long- term sober (LTS) group 50.6 (___ 11.7) years. Both groups reported 13 (+2) years of education. T h e two groups were similar in regard to alcohol history and drinking-related problems: 80% of each group reported having been through up to as many as six previous t reatment episodes for aJcoholism, and the two groups reported similar numbers of life complications (health, social, and legal problems) associated with alcohol use. As might be expected, individuals in the STS group were more likely than LTS subjects to be currently unemployed (74% vs. 36%) and separated or divorced (67% vs. 20%).

Materials

T h e ACOFS consists of 25 items designed to appraise whether subjects had unrealistically high behavioral standards (18 items) or low self-efficacy expectations in regard to maintaining sobriety (7 items). T h e standards and efficacy items were based on those developed by Gormally et al. (1982) for use ~ith binge eaters, modified so as to be relevant to alcohol use. The

224 S. M. Ross, P. J. Miller, R. Y. Emmerson, and E. H. Todt

standards scale included alcohol-related items (e.g., "It would be possible for me to have a slip and not consider it a major setback," " I f I want to stay sober I must avoid everyone and everything associated with alcohol") as well as more general personal standard-setting items (e.g., "I get angry or disgusted with myself whenever I make a mistake," "I tend not to do something unless I am going to do it very well"). The efficacy scale included such items as "I have no problem controlling my drinking," "When someone offers me a drink I can turn it down," "When it comes to alcohol I can take it or leave it." Subjects were instructed to rate each statement as a self-descript0r on a 7-point Likert scale, with 1 corresponding to "Very much like me" and 7 t o "Not at all like me." A high total score for the standards items indicated that an individual adopted very restrictive standards, both in general and in regard to alcohol, and tended to attribute failure to meet these standards to personal shortcomings. A high total score on the efficacy items indicated low self-efficacy expectations for maintaining sobriety.

Design and Procedure

Both groups completed a personal information questionnaire, the SCQ (Annis, 1984), and the ACOFS during a single session. For individuals in the STS group this occurred during the first week of a 4-week substance abuse treatment program. A detailed analysis of the SCQ results has been reported elsewhere (Miller et al., in press).

RESULTS

For each subject, a mean self-efficacy score and a mean standards score was calculated. Group means and standard deviations for these scores, as well as item means and standard deviations, are summarized in Table 1. T-test comparisons indicated significantly higher self-efficacy scores for LTS com- pared to STS alcoholics, t(69) = 5.03, p < .001. However there were no differences between the groups with regard to standards, t(69) = 0.85, p > .10. The correlation between efficacy as measured by the SCQ and efficacy as measured by the items in the ACOFS was significant, r = .60, p < .01, indicating 36% shared variance for these two measures of self-efficacy. A discriminant function analysis was performed, with the ACOFS Self-Efficacy Total and Standards Total and the SCQ Total scores as predictor variables. The ACOFS Self-Efficacy Total entered at the first step, F(1,69) = 23.69, p < .00I, as the.best discriminator between groups, (Wilks' lambda = .74) and correctly classified 80% of the LTS alcoholics and 69.6% of the STS alcoholics (canonical variables = .78 and - . 4 3 for LTS and STS, respectively). ACOFS Standards Total and SCQ Total Scores did not significantly improve the discriminant function, Fs(1,69) = 0.18, 1.43, respectively, ps > .05.

Self-Efficacy 225

Table 1. Group Means (and Standard Deviations) for Individual ACOFS Items and Total Scores

M and SD LTS STS

Standards Items 1. When I decide to stop drinking, I drink nothing

at all.

2. When I want to stop drinking, I find it best to set very high abstinence goals for myself.

3. If I want to stay sober, I must avoid everyone and everything associated with alcohol.

4. I drink to forget my mistakes.

5. 1 tend not to do something unless I am going to do it very well.

6. If I take a drink when I 'm trying to be sober, I 'd feel like I'd blown it, like I 'm a total failure.

7. I set very high standards for myself.

8. I get very angry or disgusted with myself whenever I make a mistake.

9, I feel like I 'm running out of chances to straighten out my life.

10. If I drank again after "going on the wagon" I would be angry with myself over my lack of willpower.

11. It is okay for me to have a drink or two every now and then.

12. It would be possible for me to have a slip and not consider it a major setback.

13. If I were to drink after going through an alcoholism treatment program it would mean that I was a failure.

14. I strongly believe in the saying "One drink, one drunk."

15. If I fell off the wagon after a period of sobriety it would mean that all of my previous efforts to be abstinent were in vain.

16. When I am "on the wagon" I tend to be very strict with myself.

17. When I stop drinking I try to be always on guard against any thoughts about drinking or urges to take a drink.

18. If I don't succeed at remaining abstinent this time I will probably feel it's a "lost cause."

Total Standards

6.2 (1.8) 5.9 (1.6)

5.8 (1.7) 4.7 (2.5)

2.4 (2.0) 4.9 (2.3)*

3.1 (2.3) 4.0 (2.6)

5.9 (1.3) 5.4 (1.8)

5.2 (2.1) 5.2 (2.2)

6.2 ( l . l ) 5.9 (1.4)

4.8 0.6) 5.0 (2.0)

3.2 (2.1) 5.6 (1.0)*

5.8 (1.7) 6.0 (1.7)

6.4 (1.4) 5.5 (2.3)

4.7 (2.4) 3.8 (2.5)

4.1 (2.3) 4.6 (2.4)

5.2 (Z.5) 5.0 (2.4)

4.3 (2.6) 4.1 (2.2)

5.6 (1.7) 5.1 (2.0)

5.3 (1.7) 5.7 (1.8)

3.4 (2.1) 3.4 (2.0)

4.9 (0.8) 5.0 (l.O)

(continued on p. 226)

226 S .M. Ross, P. J. Miller, R. Y. Emmerson, and E. H. Todt

Table 1. Group Means (and Standard Deviat ions) for Individual ACOFS I tems and Total Scores (Continued)

M and SD LTS STS

Self-Efficacy I tems 1. I usually get discouraged and start drinking

again if I have a "slip." 2. I have no problem controlling my drinking. 3. VChen I want to stay sober, I can avoid

drinking buddies and drinking places. 4. When someone offers me a drink, I can

turn it down. 5. I don't persist very long when I'm trying to

stay sober. 6. When it comes to alcohol, I can takei t or

leave it. 7. Sometimes in the back of my mind, I know

I'll get drunk again.

Total Self-Efficacy

2.7 (2.2) 4.7 (2.3)* 4.0 (2.5) 5.1 (2.2)*

2.4 (2.2) 2.7 (2.1)

1.5 (1.4) 2.9 (2.3)*

1.6 (1.2) 4.1 (2.1)*

5.3 (2.5) 5.6 (2.2)

2.8 (1.8) 4.4 (2.0)*

2.9 (0.9) 4.2 (1.2)*

Note. Higher scores reflect higher standards and lower self-el~cacy. LTS = Long-Term Sober; STS -- Short-Term Sober.

* p < .05.

DISCUSSION

T h e r e were large differences between LTS and STS groups in self-efficacy expectations. Thus , the not ion o f mastery over abstinence was clearly in evidence for LTS subject s. These findings are consistent with general self- efficacy theory applied to a more specific clinical population, abstinent and nonabst inent alcoholics. These results also provide evidence for the construct and discriminant validity o f the ACOFS as a means of assessing self-efficacy expectations in alcoholics.

Five o f the seven efficacy items showed significant differences between groups as did the total efficacy score. While the total standards score did not differ between groups, two individual items showed significant differences. These results are in terpre ted to indicate that an increase in self-efficacy may play an impor tan t role in sobriety, but that high s tandard setting may ei ther (a) not play a role in relapse prevent ion or (b) add to the ongoing vulnerability of both STS and LTS groups. In a t tempt ing to shed some more light on this issue, it is worth looking at the two items which showed a significant difference between groups. T h e two items were " I f I want to stay sober, I must avoid everyone and everything associated with alcohol" and "I feel like I 'm running out of chances to s traighten out my life." Clearly, the STS group may have set an unrealistically high s tandard in the case o f the former item, because it is virtually impossible to avoid all alcohol-related stimuli in

Self-Efficacy 227

contemporary society. This is not, of course, unrelated to the notion of efficacy because self-efficacy allows one to cope with problem stimuli rather than attempt to avoid them. Perhaps for many individuals, high standard setting is an attempt at an alternate self-control strategy, albeit an ineffective one, to counteract a sense of low efficacy.

The second item may represent an at tempt to artificially elevate one's treatment motivation by warning oneself that one is running out o f time and chances for recovery. Although there is certainly some truth to this, given the mortality and morbidity statistics for alcoholics, it may also represent an ineffective substitute for enhanced self-efficacy.

The lack of difference between groups in regard to total standard score is consistent with earlier speculation that alcoholics who had been exposed to more traditional alcohol treatment values may be subject to the reinforce- ment of cognitions which are dysfunctional for sobriety (Rollnick & Heather, 1982; Wilson, 1978). In this case, both LTS and STS subjects endorsed items which were indicative of unrealistically high standards, for example, " I f I take a drink when I'm trying to stay sober, I 'd feel like I'd blown it, like I'm a total failure" and "I strongly believe in the saying, one drink, one drunk."

Interestingly, these results are also consistent with the notion of negative self-efficacy (NSE) proposed by Rollnick and Heather (1982). According to these authors, NSE may occur when an individual subscribes to beliefs which lead to dichotomous thinking and a sense of helplessness when stringent abstinence standards are violated. For example, many treatment modalities emphasize that the popular slogan "One drink, one drunk," may, in fact, contribute to a sense of NSE if the person engages in one drink. Negative self-efficacy may set the stage for a full-blown relapse after the AVE occurs, because it may add to one's sense of futility and helplessness in maintaining sobriety and in achieving standards which are unattainable.

Although there was some degree of overlap between the SCQ and ACOFS, the fact that only 36% of the variance was shared suggests that the two instruments are not measuring the same constructs. The SCQ was designed to identify specific areas of higher and lower efficacy for clinical intervention in preventing drinking to excess, whereas the ACOFS was designed to assess more general components of a theoretical model related to abstinence. Al- though both instruments showed encouraging classification functions, the ACOFS was superior to the SCQ. This may reflect the fact that the ACOFS is based on a more general concept of self-efficacy for abstinence rather than specific drinking-related situations. Because some proportion of STS subjects are future LTS subjects, a lower hit rate for the STS classification would be expected and did, indeed, occur.

These findings have important treatment implications. Not only should treatment agencies work on increasing self-efficacy expectations, perhaps they should also work on decreasing unrealistic standards. One way of doing this would be to reframe traditional wisdom, making sure that clients in treatment understand that statements like "One drink, one drunk" should be taken

Self-Efficacy 229

Rollnick, S., & Heather, N. (1982). The application of Bandura's self-efficacy theory to abstinence- oriented alcoholism treatment. Addictk,e Behat,iors, 7, 243-250.

Wilson, G.T. (1978). Booze, beliefs and behavior. In P.E. Nathan, G.A. Marlatt, & T. Loberg (Eds.), Alcoholism: New directions in behavioral research and treatment (pp. 315-339). New York: Plenum.

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