Stress and Coping Resources: Theory and Review
The present paper gives an overview of personal and social coping resources that help
to combat stressful encounters and daily stress. The theoretical perspective is mainly
inspired by the work of Bandura (1986, 1992), Hobfoll (1988, 1989) and Lazarus (1966,
1991). As an introduction, the cognitive-relational theory of stress, coping, and emotions
will be briefly characterized.
1. Stress Theory
Cognitive-relational theory defines stress as a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being (Lazarus & Folkman, 1984b, p. 19). Appraisals are determined simultaneously by perceiving environmental demands and personal resources. They can change over time due to coping effectiveness, altered requirements, or improvements in personal abilities.
The cognitive-relational theory of stress emphasizes the continuous, reciprocal nature of the interaction between the person and the environment. Since its first publication (Lazarus, 1966), it has not only been further developed and refined, but it has also been expanded recently to a meta-theoretical concept of emotion and coping processes (Lazarus, 1991, 1993a, 1993b; Lazarus & Folkman, 1987).
Within a meta-theoretical system approach Lazarus (1991) conceives the complex processes of emotion as composed of causal antecedents, mediating processes, and effects. Antecedents are person variables such as commitments or beliefs on the one hand and environmental variables, such as demands or situational constraints, on the other. Mediating processes refer to cognitive appraisals of situational demands and personal coping options as well as to coping efforts aimed at more or less problem-focused and emotion-focused. Stress experiences and coping results bring along immediate effects, such as affects or physiological changes, and long-term results concerning psychological well-being, somatic health and social functioning.
There are three meta-theoretical assumptions: transaction, process, and context. It is assumed, first, that emotions occur as a specific encounter of the person with the environment and that both exert a reciprocal influence on each other; second, that emotions and cognitions are subject to continuous change; and third, that the meaning of a transaction is derived from the underlying context, i.e., various attributes of a natural setting determine the actual experience of emotions and the resulting action tendencies.
Research has mostly neglected these meta-theoretical assumptions in favor of
unidirectional, cross-sectional, and rather context-free designs. Within methodologically
sound empirical research it is hardly possible to study complex phenomena such as emotions
and coping without constraints. Also, on account of its complexity and transactional
character leading to interdependencies between the involved variables, the
meta-theoretical system approach cannot be investigated and empirically tested as a whole
model. Rather, it represents a heuristic framework that may serve to formulate and test
hypotheses in selected subareas of the theoretical system only. Thus, in practical
research one has to compromise with the ideal research paradigm. Investigators have often
focused on structure instead of on process, measuring single states or aggregates of
states. However, stress has to be analyzed and investigated as an active,
unfolding process. More precisely, stress appraisal processes need to be predicted by
environmental and personal variables as antecedents, and coping strategies and long-term
effects need to be considered.
1.1 Stress Appraisals
Cognitive appraisals include two component processes, primary and secondary appraisals. Primary appraisal refers to the stakes a person has in a certain encounter. In primary appraisals, a situation is perceived as being either irrelevant, benign-positive or stressful. Those events classified as stressful can be further subdivided into the categories of benefit, challenge, threat and harm/loss.
A stress-relevant situation is appraised as challenging when it mobilizes physical and psychological activity and involvement. In the appraisal of challenge, a person may see an opportunity to prove herself or himself, anticipating gain, mastery or personal growth from the venture. The situation is experienced as pleasant, exciting, and interesting, and the person is hopeful, eager, and confident to meet the demands.
Threat occurs when the individual perceives being in danger, and it is experienced when the person anticipates future harm or loss. Harm or loss can refer to physical injuries and pain or to attacks on one's self-esteem. Although in threat appraisal future prospects are seen in a negative light, the individual still seeks ways to master the situation faced. The individual is partly restricted in his or her coping capabilities, striving for a positive outcome of the situation in order to gain or to restore his or her well-being. Rather, threat is a relational property concerning the match between perceived coping capabilities and potentially hurtful aspects of the environment.
In the experience of harm/loss, some damage to the person has already occurred. Damages can include the injury or loss of valued persons, important objects, self-worth or social standing. Instead of attempting to master the situation, the person surrenders, overwhelmed by feelings of helplessness. Beck's cognitive theory of anxiety and depression (Beck & Clark, 1988) is in line with these assumptions, mentioning threat as the main cognitive content in anxiety compared to loss as its counterpart in depression.
Primary appraisals are mirrored by secondary appraisals which refer to one's
available coping options for dealing with stress, i.e., one's perceived resources to cope
with the demands at hand. The individual evaluates his competence, social support, and
material or other resources in order to readapt to the circumstances and to reestablish an
equilibrium between person and environment. In academic situations mostly the
task-specific competence or the prerequisite knowledge to cope with the task is of primary
importance. There is no fixed time order for primary and secondary appraisals. The latter
may come first. Moreover, they depend on each other and often appear at the same time.
Instead of primary and secondary, the terms 'demand appraisal' and 'resource appraisal'
might be more appropriate. Hobfoll (1988, 1989) has expanded the stress and coping theory
with respect to the conservation of resources as the main human motive in the struggle
with stressful encounters.
1.2 Antecedents of Stress Appraisals
Stress appraisals result from perceived situational demands in relation to perceived personal coping resources. Despite this relational conception one can imagine environmental conditions that are more likely to induce stress than others, provided the same person is confronted with them. One can also imagine individual differences in perceived personal resources that make people more or less vulnerable to the same environmental requirements.
With respect to the relevance of situational stressors, Lazarus (1991) mentions formal properties, such as novelty, event uncertainty, ambiguity and temporal aspects of the stressing conditions. For example, demands that are difficult, ambiguous, unannounced, not preparable, to be worked on both for a long time and under time pressure, are more likely to induce threat perceptions than easy tasks that can be prepared for thoroughly and can be solved under convenient pace and time conditions. Regarding content, environmental aspects can be distinguished with respect to the stakes involved by the kind of a given situation. For example, threatening social situations imply interpersonal threat, the danger of physical injury is perceived as physical threat, and anticipated failures endangering self-worth indicate ego-threat. Lazarus additionally distinguishes between task-specific stress, including cognitive demands and other formal task properties, from failure-induced stress, including evaluation aspects such as social feedback, valence of goal, possibilities of failure, or actual failures. By and large, unfavorable task conditions combined with failure-inducing situational cues are likely to provoke feelings of distress.
With respect to the relevance of perceived personal resources, Lazarus (1991)
mentions commitments and beliefs. Commitments represent motivational structures such as
personal goals and intentions that in part determine perceptions of situational stress
relevance and the stakes at hand. Provided the stakes are really relevant, beliefs as
personal antecedents of stress appraisals come into play. Beliefs are convictions and
expectations of being able to meet situational requirements. With 'generalized beliefs',
as opposed to situation-specific appraisals of control, 'dispositional resource' or
'vulnerability factors' are meant, such as locus of control, general self-efficacy, trait
anxiety, or self-esteem . Given a stressful situation, low dispositional control
expectancies make people vulnerable to distress, whereas perceptions of high dispositional
competence represent a positive resource factor (Bandura, 1992; Jerusalem & Schwarzer,
2. Dimensions of Coping
Different ways of coping have been found to be more or less adaptive. In a meta-analysis, Suls and Fletcher (1985) have compiled studies that examined the effects of various coping modes on several measures of adjustment to illness. The authors concluded that avoidant coping strategies seem to be more adaptive in the short run whereas attentive-confrontative coping is more adaptive in the long run. It remains unclear, however, how the specific coping responses of a patient struggling with a disease can be classified into broader categories. There are many attempts to reduce the total of possible coping responses to a parsimonious set of coping dimensions. Some researchers have come up with two basic dimensions-such as instrumental, attentive, vigilant, or confrontative coping on the one hand, in contrast to avoidant, palliative, and emotional coping on the other (for an overview see Parker & Endler, 1996; Schwarzer & Schwarzer, 1996; Suls & Fletcher, 1985). A well-known approach has been put forward by Lazarus and Folkman (1984), who discriminate between problem-focused and emotion-focused coping. Another conceptual distinction has been suggested between assimilative and accomodative coping, the former aiming at an alteration of the environment to oneself, and the latter aiming at an alteration of oneself to the environment (Brandtstädter, 1992). This pair has also been coined "mastery versus meaning" (Taylor, 1983, 1989) or "primary control versus secondary control" (Rothbaum, Weisz, & Snyder, 1982). These coping preferences may occur in a certain time order when, for example, individuals first try to alter the demands that are at stake, and, after failing, turn inward to reinterpret their plight and find subjective meaning in it.
Coping has also a temporal aspect. One can cope before a stressful event takes place, while it is happening (e.g., during the progress of a disease), or afterwards. Beehr and McGrath (1996) distinguish five situations that create a particular temporal context: (a) Preventive coping: Long before the stressful event ocurs, or might occur; for example, a smoker might quit well in time to avoid the risk of lung cancer; (b) Anticipatory coping: when the event is anticipated soon; for example, someone might take a tranquillizer while waiting for surgery; (c) Dynamic coping: while it is ongoing; for example, diverting attention to reduce chronic pain; (d) Reactive coping: after it has happened; for example, changing one's life after losing a limb; and (e) Residual coping: long afterward, by contending with long-run effects; for example, controlling one's intrusive thoughts years after a traumatic accident has happened.
Five coping strategies were identified Klauer and Filipp (1993) that turned up as dimensions in a factor analysis: (a) Seeking social integration, (b) rumination, (c) threat minimization, (d) turning to religion, and (e) seeking information. These factors were established as subscales of a psychometric inventory that was used in the present study (see also Aymanns, Filipp, & Klauer, 1995).
There are many other attempts to conceptualize coping dimensions, and those mentioned above may serve as examples (for an overview see Zeidner & Endler, 1996).
Which of the above dimensions is suitable for a valid description of
an actual coping process depends on a number of factors, among them the particular stress
situation, one's history of coping with similar situations, and one's personal and social
coping resources, or the opposite, one's specific vulnerability. The following main
sections of this article deal with a more detailed account of the coping resources.
3. Personal Coping Resources
Individuals who are affluent, healthy, capable, and optimistic are seen as resourceful and, thus, are less vulnerable toward the stress of life. It is of most importance to be competent to handle a stressful situation. But actual competence is not a sufficient prerequisite. If the individual underestimates his potential for action, no adaptive strategies will be developed. Therefore, perceived competence is crucial. This has been labelled 'perceived self-efficacy' or 'optimistic self-beliefs' by Bandura (1992, 1995). The subsequent section will focus on this particular personal resource factor.
Behavioural change is facilitated by a personal sense of control. If people believe that they can take action to solve a problem instrumentally, they become more inclined to do so and feel more committed to this decision. While outcome expectancies refer to the perception of the possible consequences of one's action, perceived self-efficacy pertains to personal action control or agency (Bandura, 1992; Maddux, 1995; Wallston, 1994). A person who believes in being able to cause an event can conduct a more active and self-determined life course. This "can do"-cognition mirrors a sense of control over one's environment. It reflects the belief of being able to master challenging demands by means of adaptive action. It can also be regarded as an optimistic view of one's capacity to deal with stress.
Self-efficacy makes a difference in how people feel, think and act. In terms of
feeling, a low sense of self-efficacy is associated with depression, anxiety, and
helplessness. Such individuals also have low self-esteem and harbor pessimistic thoughts
about their accomplishments and personal development. In terms of thinking, a strong sense
of competence facilitates cognitive processes and academic performance. Self-efficacy
levels can enhance or impede the motivation to act. Individuals with high self-efficacy
choose to perform more challenging tasks. They set themselves higher goals and stick to
them (Locke & Latham, 1990). Actions are preshaped in thought, and people anticipate
either optimistic or pessimistic scenarios in line with their level of self-efficacy. Once
an action has been taken, high self-efficacious persons invest more effort and persist
longer than those with low self-efficacy. When setbacks occur, the former recover more
quickly and maintain the commitment to their goals. Self-efficacy also allows people to
select challenging settings, explore their environments, or create new situations. A sense
of competence can be acquired by mastery experience, vicarious experience, verbal
persuasion, or physiological feedback (Bandura, 1992). Self-efficacy, however, is not the
same as positive illusions or unrealistic optimism, since it is based on experience and
does not lead to unreasonable risk taking. Instead, it leads to venturesome behaviour that
is within reach of one's capabilities.
3. 1 Personal Coping Resources and the Onset,
Progression, and Offset of Illness
The relationship between self-efficacy and specific health outcomes, such as recovery from surgery or adaptation to chronic disease, has been studied. Patients with high efficacy beliefs are better able to control pain than those with low self-efficacy (Altmaier, Russell, Kao, Lehmann, & Weinstein, 1993; Litt, 1988; Manning & Wright, 1983). Self-efficacy has been shown to affect blood pressure, heart rate and serum catecholamine levels in coping with challenging or threatening situations (Bandura, Cioffi, Taylor, & Brouillard, 1988; Bandura, Reese, & Adams, 1982; Bandura, Taylor, Williams, Mefford, & Barchas, 1985). Cognitive-behavioral treatment of patients with rheumatoid arthritis enhanced their efficacy beliefs, reduced pain and joint inflammation, and improved psychosocial functioning (Holman & Lorig, 1992; O'Leary, Shoor, Lorig, & Holman, 1988; Smith, Dobbins, & Wallston, 1991; Smith & Wallston, 1992). Optimistic self-beliefs have turned out to be influential in the rehabilitation of chronic obstructive pulmonary disease patients (Kaplan, Atkins, & Reinsch, 1984; Toshima, Kaplan, & Ries, 1992). Recovery of cardiovascular function in postcoronary patients is similarly enhanced by beliefs in one's physical and cardiac efficacy (Ewart, 1992; Taylor, Bandura, Ewart, Miller, & DeBusk, 1985). Obviously, perceived self-efficacy predicts the degree of therapeutic change in a variety of settings (Bandura, 1992, 1995).
Dispositional optimism (Scheier & Carver, 1985) is a similar theoretical construct
pertaining to a positive outlook on the future. However, perceived self-efficacy pertains
explicitly to one's personal coping resources (Schwarzer, 1994). Thus, the corresponding
label "optimistic self-beliefs" (Bandura, 1995) denotes that perceived
self-efficacy represents a narrower concept of optimism than the broader one proposed by
Scheier and Carver (1985). Presurgery optimism has been found beneficial, for example
among cancer patients (Carver & Scheier, 1993; Friedman, Nelson, Baer, Lane, Smith,
& Dworkin, 1992) and heart patients (Fitzgerald, Tennen, Affleck, & Pransky, 1993;
Scheier et al., 1989). (For a general review of the relationship between optimism and
health see Bandura, 1995; Peterson & Bossio, 1991; Scheier & Carver, 1992;
3.2 Personal Coping Resources and Health Behaviors
In the following section, the relationship between self-efficacy and specific health
behaviours is reviewed. A number of studies on adoption of health practices have
measured self-efficacy to assess its potential influences in initiating behaviour change.
As people proceed from considering precautions in a general way toward shaping a
behavioural intention, contemplating detailed action plans, and actually performing a
health behaviour on a regular basis, they begin to crystallize beliefs in their
capabilities to initiate change. In an early study, Beck and Lund (1981) exposed dental
patients to a persuasive communication designed to alter their beliefs about periodontal
disease. Neither perceived disease severity nor outcome expectancy were predictive of
adoptive behaviour when perceived self-efficacy was controlled. Perceived self-efficacy
emerged as the best predictor of the intention to floss (r = .69) and of the actual
behaviour, frequency of flossing (r = .44). Seydel, Taal and Wiegman (1990) report
that outcome expectancies as well as perceived self-efficacy are good predictors of
intention to engage in behaviours to detect breast cancer (such as breast
self-examination) (see also Meyerowitz & Chaiken, 1987; Rippetoe & Rogers, 1987).
Perceived self-efficacy was found to predict outcomes of a controlled-drinking programme
(Sitharthan & Kavanagh, 1990). Perceived self-efficacy has also proven to be a
powerful personal resource in coping with stress (Lazarus & Folkman, 1987). There is
also evidence that perceived self-efficacy in coping with stressors affects immune
function (Wiedenfeld et al., 1990). Subjects with high efficacy beliefs
are better able to control pain than those with low self-efficacy (Altmaier, Russell, Kao,
Lehmann & Weinstein, 1993; Litt, 1988; Manning & Wright, 1983). Self-efficacy has
been shown to affect blood pressure, heart rate and serum catecholamine levels in coping
with challenging or threatening situations (Bandura, Cioffi, Taylor & Brouillard,
1988; Bandura, Reese & Adams, 1982; Bandura, Taylor, Williams, Mefford & Barchas,
1985). Recovery of cardiovascular function in postcoronary patients is similarly enhanced
by beliefs in one's physical and cardiac efficacy (Taylor, Bandura, Ewart, Miller &
DeBusk, 1985). Cognitive-behavioural treatment of patients with rheumatoid arthritis
enhanced their efficacy beliefs, reduced pain and joint inflammation, and improved
psychosocial functioning (O'Leary, Shoor, Lorig & Holman, 1988). Obviously, perceived
self-efficacy predicts degree of therapeutic change in a variety of settings (Bandura,
3. 2. 1 Personal Coping Resources and Sexual Risk Behaviour
Perceived self-efficacy has been studied with respect to prevention of unprotected sexual behaviour, e.g., the resistance of sexual coercions, and the use of contraceptives to avoid unwanted pregnancies. For example, teenage women with a high rate of unprotected intercourse have been found to use contraceptives more effectively if they believed they could exercise control over their sexual activities (Levinson, 1982). Gilchrist and Schinke (1983) taught teenagers through modeling and role-playing how to deal with pressures and ensure the use of contraceptives. This mode of treatment significantly raised their sense of perceived efficacy and protective skills. Sexual risk-taking behaviour such as not using condoms to protect against sexually transmitted disease has also been studied among homosexual men with multiple partners and intravenous drug users. Beliefs in one's capability to negotiate safer sex practices emerged as the most important predictor of such behaviours (Basen-Engquist, 1992; Basen-Engquist & Parcel, 1992; Kasen, Vaughn & Walter, 1992; McKusick, Coates, Morin, Pollack & Hoff, 1990; O'Leary, Goodhart, Jemmott & Boccher-Lattimore, 1992).
Influencing health behaviours that contribute to the prevention of AIDS has become an urgent issue. Perceived self-efficacy has been shown to play a role in such behaviours. Kok, De Vries, Mudde and Strecher (1991) reported a study from their Dutch labouratory that analyzed the use of condoms and clean needles by drug addicts. Intentions and behaviours were predicted by attitudes, social norms, and especially by efficacy beliefs. Perceived self-efficacy correlated with the intention to use clean needles (.35), reported clean needle use (.46), the intention to use condoms (.74), and reported condom use (.67) (Paulussen, Kok, Knibbe & Kramer, 1989). Bandura (1995) has summarized a large body of research relating perceived self-efficacy to the exercise of control over HIV infection.
Condom use not only requires some technical skills, but interpersonal negotiation as
well (Bandura, 1995; Brafford & Beck, 1991; Coates, 1990). Convincing a resistant
partner to comply with safer sex practices can call for a high sense of efficacy to
exercise control over sexual activities. Programmes were launched to enhance self-efficacy
and to build self-protective skills in various segments of the population to prevent the
spread of the HIV virus. In particular, studies with homosexual men have focussed on their
perceived efficacy to adopt safer sex (Ekstrand & Coates, 1990; McKusick et al.,
1990). Jemmott and his associates have conducted a number of interesting intervention
studies designed to raise self-regulatory efficacy (Jemmott, Jemmott & Fong, 1992;
Jemmott, Jemmott, Spears, Hewitt et al., 1992).
3.2 2 Personal Coping Resources and Physical Exercise
Motivating people to do regular physical exercise depends on several factors, among them optimistic self-beliefs of being able to perform appropriately. Perceived self-efficacy has been found to be a major instigating force in forming intentions to exercise and in maintaining the practice for an extended time (Dzewaltowski, Noble & Shaw, 1990; Feltz & Riessinger, 1990; McAuley, 1992, 1993; Shaw, Dzewaltowski & McElroy, 1992; Weinberg, Grove & Jackson, 1992; Weiss, Wiese & Klint, 1989). Dzewaltowski (1989) has compared the predictiveness of the Theory of Reasoned Action (Fishbein & Ajzen, 1975), and Social Cognitive Theory in the field of exercise motivation. The exercise behaviour of 328 students was recorded for seven weeks and then related to prior measures of different cognitive factors. Behavioural intention was measured by asking the individuals the likelihood that they will perform exercise behaviour. Attitude toward physical exercise, perceived behavioural control, and beliefs about the subjective norm concerning exercise were assessed. The Theory of Reasoned Action fit the data, as indicated by a path analysis. Exercise behaviour correlated with intention (.22), attitude (.18), and behavioural control beliefs (.13). In addition, three social cognitive variables were assessed: (a) strength of self-efficacy to participate in an exercise program when faced with impediments, (b) thirteen expected outcomes multiplied by the evaluation of those outcomes, and finally, (c) self-satisfaction or dissatisfaction with their level of activities and with the multiple outcomes of exercise. Exercise behaviour was correlated with perceived self-efficacy (.34), outcome expectancies (.15), and dissatisfaction (.23), as well as with the interactions of these factors. The higher the three social cognitive constructs were at the onset of the programme, the more days they exercised per week. Persons who were confident that they could adhere to the strenuous exercise programme were dissatisfied with their present level of physical activity and expected positive outcomes, and they exercised more. The variables in the Theory of Reasoned Action did not account for any unique variance in exercise behaviour after the influences of the social cognitive factor was controlled. These findings indicate that Social Cognitive Theory provides powerful explanatory constructs.
The role of efficacy beliefs in initiating and maintaining a regular program of physical exercise has also been studied by Desharnais, Bouillon and Godin (1986), Fuchs (in press), Long and Haney (1988), Sallis et al. (1986), Sallis, Hovell, Hofstetter and Barrington (1992), and Wurtele and Maddux (1987). Endurance in physical performance was found to be dependent on experimentally created efficacy beliefs in a series of experiments on competitive efficacy by Weinberg, Gould and Jackson (1979), Weinberg, Gould, Yukolson and Jackson (1981) and Weinberg, Yukelson and Jackson (1980). In terms of competitive performance, tests of the role of efficacy beliefs in tennis performance revealed that perceived efficacy was related to 12 rated performance criteria (Barling & Abel, 1983).
Patients with rheumatoid arthritis were motivated to engage in regular physical
exercise by enhancing their perceived efficacy in a self-management program (Holman &
Lorig, 1992). In applying self-efficacy theory to recovery from heart disease, patients
who had suffered a myocardial infarction were prescribed a moderate exercise regimen
(Ewart, 1992). Ewart found that efficacy beliefs predicted both underexercise and
overexertion during programmed exercise. Patients with chronic obstructive pulmonary
diseases tend to avoid physical exertion due to experienced discomfort, but rehabilitation
programmes insist on compliance with an exercise regimen (Toshima, Kaplan & Ries,
1992). Compliance with medical regimens improved after patients suffering from chronic
obstructive pulmonary disease received a cognitive-behavioural treatment designed to raise
confidence in their capabilities. Efficacy beliefs predicted moderate exercise (r =
.47), whereas perceived control did not (Kaplan, Atkins & Reinsch, 1984).
3.2 3 Personal Coping Resources and Nutrition and Weight Control
Dieting and weight control are health-related behaviours that can also be governed by self-efficacy beliefs (Bernier & Avard, 1986; Chambliss & Murray, 1979; Hofstetter, Sallis & Hovell, 1990; Glynn & Ruderman, 1986; Shannon, Bagby, Wang & Trenkner, 1990; Slater, 1989; Weinberg, Hughes, Critelli, England & Jackson, 1984). Chambliss and Murray (1979) found that overweight individuals were most responsive to behavioural treatment where they had a high sense of efficacy and an internal locus of control. Other studies on weight control have been published by Bagozzi and Warshaw (1990) and Sallis, Pinski, Grossman, Patterson and Nader (1988). It has been found that self-efficacy operates best in concert with general life style changes, including physical exercise and provision of social support. Self-confident clients of intervention programs were less likely to relapse to their previous unhealthy diet.
In sum, perceived self-efficacy has been found to predict intentions and actions in
different domains of health functioning. The intention to engage in a certain health
behaviour and the actual behaviour itself are positively associated with beliefs in one's
personal efficacy. Efficacy beliefs determine appraisal of one's personal resources in
stressful encounters and contribute to the forming of behavioural intentions. The stronger
people's efficacy beliefs, the higher the goals they set for themselves, and the firmer
their commitment to engage in the intended behaviour, even in the face of failures (Locke
& Latham, 1990).
3. 2 4 Personal Coping Resources and Addictive Behaviours
Another area in the health field where perceived self-efficacy has been studied extensively is smoking. Quitting the habit requires optimistic self-beliefs which can be instilled in smoking cessation programmes (Baer & Lichtenstein, 1988; Carmody, 1992; Devins & Edwards, 1988; Haaga & Stewart, 1992; Ho, 1992; Karanci, 1992; Kok, Den Boer, DeVries, Gerards, Hospers & Mudde, 1992). Efficacy beliefs to resist temptation to smoke predict reduction in the number of cigarettes smoked (r = -.62), the amount of tobacco per smoke (r = -.43), and the nicotine content (r = -.30) (Godding & Glasgow, 1985). Pretreatment self-efficacy does not predict relapse, but posttreatment self-efficacy does (Kavanagh, Pierce, Lo & Shelley, 1993). Mudde, Kok and Strecher (1989) found that efficacy beliefs increased after treatment, and those who had acquired the highest levels of self-efficacy remained successful quitters as assessed in a one-year period (see also Kok et al., 1991). Various researchers have verified relationships between perceived self-regulatory efficacy and relapse occurrence or time of relapse, with correlations ranging from -.34 to -.69 (Colletti, Supnick & Payne, 1985; Condiotte & Lichtenstein, 1981; DiClemente, Prochaska & Gibertini, 1985; Garcia, Schmitz & Doerfler, 1990; Wilson, Wallston & King, 1990). Hierarchies of tempting situations correspond to hierarchies of self-efficacy: the more a critical situation induces craving, the greater the perceived efficacy needed to prevent relapse (Velicer, DiClemente, Rossi & Prochaska, 1990). In a program of research on smoking prevention with Dutch adolescents, Kok et al. (1992) conducted several studies on the influence of perceived self-efficacy on nonsmoking intentions and behaviours. Cross-sectionally, they could explain 64% of the variance of intentions as well as of behaviour, which was due to the overwhelming predictive power of perceived self-efficacy (r = .66 for intention, r = .71 for reported behaviour) (DeVries, Dijkstra & Kuhlman, 1988). These relationships were replicated longitudinally, although with somewhat less impressive coefficients (DeVries, Dijkstra & Kok, 1989). Also, studies of the onset of smoking in teenagers have shown that perceived self-efficacy mediates peer social influence on smoking (Stacy, Sussman, Dent, Burton & Flay, 1992).
Overcoming addictive behaviours such as substance use, alcohol consumption, and smoking poses a major challenge for those who are dependent on these substances as well as for professional helpers. Smoking, for example, remains the number one public health problem in spite of declining prevalence rates (Shiffman, 1993). Almost one hundred scientific publications per year deal with the issue of smoking cessation. Clinical approaches include multisession, multicomponent counseling or therapy programmes where individuals or small groups receive abstinence and relapse prevention training, often combined with medical treatment. The most promising pharmaceutical aid is the use of a nicotine patch that achieves a transdermal nicotine substitute to help counteract withdrawal symptoms.
On the other end of the treatment continuum lie community interventions, including work site cessation programs. This acknowledges the fact that only one tenth of smokers make use of formal clinical programs. In contrast, most are self-quitters who need only minimal assistance (Cohen et al., 1989; Curry, 1993; Orleans, Kristeller & Gritz, 1993). While relapse rates after professional treatment lie typically between 70% and 90%, those of self-quitters are even higher. Nevertheless, investments in the public health approach are more cost-effective because it reaches a much larger target population and, thus, results in higher overall numbers of persons quitting (Lichtenstein & Glasgow, 1992).
The community-wide minimal treatment programmes benefit from what was learned in clinical settings, although it is not yet clear what the most effective ingredients really are. It seems as if more is better, i.e., treatment packages that consist of many heterogeneous components are superior to theory-based single strategy approaches.
It has also been found that readiness to quit makes a difference. In clinical settings, most clients are self-referred and therefore highly motivated for behavioural change. Public health messages, in contrast, have to be addressed to smokers who are at different stages of motivation (DiClemente et al., 1991). Precontemplators who do not consider quitting at all need a different message than contemplators who struggle with the pros and cons of quitting. Furthermore, those who are ready for action need different kinds of assistance than those who just have quit and face a relapse crisis.
From a social-cognitive viewpoint, the key ingredients of any psychological treatment should be (a) the identification of high-risk situations that stimulate smoking, (b) the development and cultivation of perceived self-efficacy, and (c) the application of adequate coping strategies. This can be described as a competent self-regulation process where individuals monitor their responses to taxing situations, observe similar others facing similar demands, appraise their coping resources, create optimistic self-beliefs, plan a course of action, perform the critical action, and evaluate its outcomes.
Marlatt et al. (1995) propose five categories of self-efficacy that are related to stages of motivation and prevention: (a) Resistance Self-Efficacy, (b) Harm-Reduction Self-Efficacy, (c) Action Self-Efficacy, (d) Coping Self-Efficacy, and (e) Recovery Self-Efficacy. Resistance Self-Efficacy pertains to the confidence in one's ability to avoid substance use prior to its first use. This implies resistance against peer pressure to smoke, drink or take drugs. It has been repeatedly found that the combination of peer pressure and low self-efficacy predicts the onset of smoking and substance use in adolescents (Conrad, Flay & Hill, 1992). Ellickson and Hays (1991) studied the determinants of future substance use in 1,138 eighth and ninth graders in ten junior high schools. As potential predictors of onset, they analyzed prodrug social influence, resistance self-efficacy, and perception of drug-use prevalence. Social influence or exposure to drug users combined with low self-efficacy for drug resistance turned out to predict experimentation with drugs nine months later. Interestingly, resistance self-efficacy was no longer predictive in the subsample of students who were already involved with drugs.
In a study on smoking onset, Stacy, Sussman, Dent, Burton and Flay (1992) examined prosmoking social influence and resistance self-efficacy in a sample of 1,245 California high school students. Perceived self-efficacy moderated the effect of peer pressure. As expected, many adolescents succumbed to prosmoking influence, but those high in resistance self-efficacy were less vulnerable toward interpersonal power.
With these findings in mind, one would expect that the training of resistance skills would raise resistance self-efficacy, which in turn would reduce future drug use. However, intervention studies that have included such a training have not yet been very promising (Hansen, Graham, Wolkenstein & Rohrbach, 1991; Ellickson, Bell & McGuigan, 1993).
Harm-reduction self-efficacy pertains to one's confidence to be able to reduce the risk after having become involved with tobacco or drugs. Once a risk behaviour has commenced, the notion of resistance loses its significance. It is then of superior importance to control further damage and to strengthen the belief that one is capable of minimizing the risk. This is particularly useful since most adolescents at least experiment with cigarettes and alcohol, which can be regarded as a normal stage in puberty when youngsters face developmental tasks including self-regulation in tempting situations. Substance use can be seen as being normative rather than deviant and might reflect a healthy exploratory behaviour and a constructive learning process (Newcomb & Bentler, 1988; Shedler & Block, 1990). The conflict here is between solving normative developmental tasks on the one hand, and, on the other, initiating a risk behaviour that might accumulate and habitualize to a detrimental lifestyle pattern. Thus, the question is, "How can a drug be curiously explored without becoming the gateway drug?" The answer lies in the notion of harm-reduction self-efficacy. The individual must acquire not only the competence and skills, but also the optimistic belief in control of the impending risk. The aim of secondary prevention is to let adolelscents experiment while at the same time empowering them to minimize and eliminate substance use later on.
An intervention study to accomplish this goal has been conducted at the Addictive Behaviours Research Center at the University of Washington (Baer, 1993; Baer, Marlatt, Kivlahan, Fromme, Larimer & Williams, 1992). College students received one of three treatments: (a) an alcohol-information class dealing with negative consequences of alcohol, (b) a moderation-oriented cognitive-behavioural skills-training class, and (c) an assessment-only control group. The second treatment group was trained to enhance their harm-reduction self-efficacy, which indeed resulted in the greatest decrease in alcohol consumption.
The above two types of self-efficacy are related to prevention. When, however, it comes to behaviour change for those who are already addicted, the focus turns to action, coping, and recovery. Action self-efficacy concerns the confidence to attain one's desired abstinence goal (or controlled use). If, for example, someone sets a date for quitting, then a commitment is made, moving the person beyond the mere contemplation stage. When intentions to quit are translated into preparatory acts, the individual needs optimistic self-beliefs to make detailed plans how to refrain from the substance, imagine success scenarios, and take instrumental actions. This applies to unaided cessation as well as to formal treatment settings. Action self-efficacy has been found to predict attempts to quit smoking (Marlatt, Curry & Gordon, 1988; Sussman et al., 1989). As early as 1981, many smoking cessation studies have included self-efficacy to predict abstinence (Baer, Holt & Lichtenstein, 1986; Colletti et al., 1985; Condiotte & Lichtenstein, 1981; DiClemente et al., 1985; Garcia et al., 1990; Godding & Glasgow, 1985; Ho, 1992; Karanci, 1992; Kok et al., 1992; Wilson et al., 1990). These findings corroborate consistently the beneficial influence of optimistic self-beliefs, but this effect is restricted to posttreatment self-efficacy. Typically, pretreatment self-efficacy does not predict relapse, but posttreatment self-efficacy does. This generalizes, by the way, to a broad range of domains of human functioning (Marlatt, Baer & Quigley, 1994; Kavanagh et al., 1993; Kok et al., 1992). Pretreatment self-efficacy is not based on personal experience with quitting and is, therefore, inappropriate for the prediction of treatment outcomes. During the cessation training, self-efficacy is being developed with a realistic sense of one's capabilities, resulting in more accurate self-knowledge that allows one to foresee one's most likely reactions in tempting situations.
Coping self-efficacy relates to anticipatory coping with relapse crises. After one has made a successful attempt to quit, long-term maintenance is at stake. At this stage, quitters are confronted with high-risk situations, such as experiencing negative affect or temptations in positive social situations. Lapses are likely to occur unless the quitter can mobilize alternative coping strategies. Believing in one's coping reservoir assists in making sound judgments and in initiating adaptive coping responses. Relapse prevention training aims at making use of a variety of situation-tailored coping strategies which in turn enhances coping self-efficacy (Curry, 1993; Gruder et al., 1993; Marlatt & Gordon, 1985). This includes behavioural as well as cognitive coping modes.
Recovery self-efficacy is closely related to coping self-efficacy, but both tap different aspects within the maintenance stage (similar to the distinction between resistance and harm-reduction self-efficacy in the prevention stage). If a lapse occurs, individuals can fall prey to the "abstinence violation effect", i.e., they attribute their lapse to internal, stable and global causes, dramatize the event, and interpret is as a full-blown relapse (Marlatt & Gordon, 1985). High self-efficacious individuals, however, avoid this effect by making a high-risk situation responsible and by finding ways to control the damage and to restore hope. Self-efficacy for recovery of abstinence after an initial lapse has been found to promote long-term maintenance. Clinical interventions focus on specific recovery strategies after setbacks, such as reviewing and reattributing the situation, balancing alternative ways of coping, making an immediate plan for recovery (e.g., renew initial commitment to quit, mobilize social support, reframe the lapse as a normal event within a productive learning process) (Curry & Marlatt, 1987). This restores self-efficacy and helps to return quickly to the path of maintenance. However, Haaga and Stewart (1992) found that not high but moderate self-efficacy for recovery leads to the best survival rates (continuation of abstinence). If this finding can be replicated in further research, it would reflect an "overconfidence effect," since too high self-efficacy would embolden trials of risk behaviours.
As these examples from research on addictive behaviours demonstrate, it is essential to
identify several stages at which self-efficacy operates in different manners. Specific
kinds of self-efficacy are protective as the individual moves through the process of peer
influence, substance experimentation, cessation, and abstinence maintenance. Psychological
interventions have to be stage-tailored
4. Social Coping Resources
Social support can assist coping and exert beneficial effects on various health outcomes (see reviews in Rodin & Salovey, 1989; Sarason, Sarason, & Pierce, 1990; Schwarzer & Leppin, 1989, 1991; Veiel & Baumann, 1992). Social support has been defined in various ways, for example as "resources provided by others" (Cohen & Syme, 1985), as "coping assistance" (Thoits, 1986), or as an exchange of resources "perceived by the provider or the recipient to be intended to enhance the well-being of the recipient" (Shumaker & Brownell, 1984, p. 13). Several types of social support have been investigated, such as instrumental support (e.g., assist with a problem), tangible support (e.g., donate goods), informational support (e.g., give advice), emotional support (e.g., give reassurance), among others. The definition and measurement problems involved in studying the social support construct, however, have remained an issue for debate (Dunkel-Schetter & Bennett, 1990; Kessler, 1992; Schwarzer, Dunkel-Schetter, & Kemeny, 1994; Turner, 1992; Vaux, 1992).
Social support has been found advantageous in the recovery from surgery in heart patients. Kulik and Mahler (1989) have studied men who had undergone coronary artery bypass surgery. Those who received many visits by their spouses were, on average, released somewhat earlier from hospital than those who received only few visits. In a longitudinal study, the same authors also found positive effects of emotional support after surgery (Kulik & Mahler, 1993). Similar results were obtained by other researchers (Fontana et al., 1989; King et al., 1993).
4.1 Social integration and Health
The extent to which individuals are well integrated in their communities and to which their social relationships are strong and supportive is associated with health. Maintaining close personal relationships to others can be understood as social resource factor that can, to a certain degree, protect against illness and premature death. There is a large body of empirical evidence that indicates such a beneficial influence of social integration on health. Starting with the well-known Alameda County Study (Berkman & Syme, 1979), eight community-based prospective epidemiological investigations have documented a link between lack of social integration on the one hand and morbidity and all-cause mortality on the other (Berkman, 1995). Those who are the most socially isolated are at the highest risk for a variety of diseases and fatal outcomes. However, the corresponding effect sizes are very small as has been documented in a meta-analysis (Schwarzer & Leppin, 1989).
There is also growing evidence about the causal pathways that involve social factors in the development of disease although much further research is needed to understand the mechanisms that render social ties beneficial for the organism. Being socially embedded or the lack of it can influence the onset of illness, its progression, or recovery from it. Several major studies, for example, have found a link between social integration and survival rates of patients who had experienced a myocarcial infarct. Ruberman et al. (1984) studied 2,320 male survivors of acute MI and found that cardiac patients who were socially isolated were more than twice as likely to die over a 3-year period than those who were socially integrated. In a Swedish study of 150 cardiac patients it was found that those who were socially isolated had a three times higher 10-year mortality rate than those who were socially integrated (Orth-Gomer, Unden, & Edwards, 1988). Diagnosis of coronary artery disease and subsequent death was linked to marital status in a study based on 1,368 patients, most of them being men (Williams et al., 1992). Those who were unmarried or without a confidant were over three times as likely to die within five years compared with those who had a close confidant or who were married. Marital status and recurrent cardiac events were also linked in a study be Case et al. (1992) who identified a higher risk of cardiac deaths and nonfatal infarctions among those who lived alone. In another prospective study on 100 men and 94 women who were hospitalized for an MI it was found that mortality rates within a 6-month period were related to the social support reported by these patients (Berkman, Leo-Summers, & Horwitz, 1992). They identified the number of persons representing major sources of emotional support. In analyzing these data, the researchers distinguished men and women with one, two, and more than two such sources. There was a consistent pattern of death rates, the highest of which was associated with social isolation and the lowest of which pertained to two or more sources of emotional support, independent of age, gender, comorbidity, and severity of MI.
These five studies have focussed on the survival time after a critical event. Obviously, the recovery process can be modified by the presence of a supportive social network. A sense of belonging and intimacy can facilitate the coping process one way or the other. As potential pathways for this facilitation, physiological or behavioral mechanisms have been mentioned. Among the multiple physiological pathways, an immunological and a neuroendocrine link has been investigated (Ader, Felton, & Cohen, 1991). It is known that losses and bereavement are followed by immune depression, in particular it compromises natural killer cell activity and cellular immunity. This, in turn, reduces overall host resistance, so that the individual becomes more susceptible to a variety of diseases, including infections and cancer. The quality of social relationships, for example marital quality, has been found a predictor of immune functioning (Kiecolt-Glaser et al., 1987, 1992). Social stress, in general, tends to suppress immune functioning (Cohen et al., 1995; Cohen & Williamson, 1991; Herbert et al., 1994).
The neuroendocrine system is closely related to high cardiovascular reactivity and physiological arousal that are seen as antecedents of cardiac events. In a study by Seeman et al. (1994), emotional support was associated with neuroendocrine parameters such as urinary levels of epinephrine, norepinephrine, and cortisol in a sample of elderly people. The link with emotional support was stronger than the one with instrumental support or mere social integration.
The behavioral pathway has been suggested by studies where social networks were stimulating health behaviors that prevented the onset of illness, slowed its progression, or influenced the recovery process (Cohen, 1988). For example, abstinence after smoking cessation was facilitated by social support (Mermelstein et al., 1986). Alcohol consumption was lower in socially embedded persons (Berkman & Breslow, 1983) although other studies have found that social reference groups can trigger more risky behaviors, including alcohol consumption (Schwarzer, Jerusalem, & Kleine, 1990). Participation in cancer screenings can be promoted by social ties (Kang & Bloom, 1993; Suarez et al., 1994).
Among the health behaviors that have a close link to social integration and social support is physical exercise (McAuley, 1993). Perceived support by family and friends can help develop the intention to conduct exercise and the initiation of the behavior (Sallis, Hovell, & Hofstetter, 1992; Wankel, Mummery, Stephens, & Craig, 1994). Long-term participation in exercise programs or maintenance of self-directed exercise is probably more strongly determined by actual, instrumental support than by perceived and informational support (Fuchs, 1996). Duncan and McAuley (1993) have found that social support does influence exercise behaviors indirectly by improving one's self-efficacy. The latter might be an important mediator in this process. The reason could be that not only a sense of belonging and intimacy is perceived as supportive but also the verbal persuasion to be competent or the social modeling of competent behaviors.
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