Abstract
Objectives
Self-efficacy, the belief in one’s ability to moderate or abstain from heavy drinking and drug use, predicts outcomes following substance use disorder (SUD) treatment. The current study examined whether self-efficacy was associated with treatment outcomes in a trial of mindfulness-based relapse prevention (MBRP), cognitive-behavioral relapse prevention (RP), and treatment as usual (TAU). We hypothesized self-efficacy would mediate the effects of treatment on substance use outcomes.
Methods
Secondary analyses of a randomized clinical trial of MBRP, RP, versus TAU among individuals with SUD in an aftercare setting (n = 286; 71.5% male; 42.1% non-White) were performed. Change in self-efficacy, measured via the Drug Taking Confidence Questionnaire at baseline, post-treatment, 6-month follow-up, and 12-month follow-up, was examined using latent growth mediation models on 12-month heavy drinking and drug use.
Results
Greater self-efficacy at post-treatment and increases in self-efficacy over time predicted a significantly higher probability of no drug use and no heavy drinking at 12-month follow-up. Greater self-efficacy at post-treatment was also associated with significantly fewer days of heavy drinking among those who drank, and mediated the association between treatment condition and probability of no drug use and fewer heavy drinking days at 12-month follow-up. Those who received MBRP had the highest self-efficacy at post-treatment, which was associated with greater probability of no drug use and fewer heavy drinking days.
Conclusions
Self-efficacy is an important treatment target for individuals with SUD. These results highlight the potential utility of MBRP in improving self-efficacy and suggest self-efficacy may be one mechanism by which MBRP is effective.
Parent Trial Registration
https://ClinicalTrials.gov; registration number: NCT01159535.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data Availability
We are unable to publicly make available data as participants did not explicitly consent to public data sharing and public data sharing was not in our protocol. However, we have made available the analyses of the present secondary analysis (code and output) on the Open Science Framework (https://osf.io/9mf6v/).
References
Adamson, S. J., Sellman, J. D., & Frampton, C. M. (2009). Patient predictors of alcohol treatment outcome: A systematic review. Journal of Substance Abuse Treatment, 36(1), 75–86. https://doi.org/10.1016/j.jsat.2008.05.007
Alcoholics Anonymous (1952). Twelve steps and twelve traditions. Alcoholics Anonymous World Services, Inc.
Bandura A (1977) Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review 84(2), 191–215. https://doi.org/10.1037/0033-295X.84.2.191
Baum, W. M. (2002). From molecular to molar: A paradigm shift in behavioral analysis. Journal of the Experimental Analysis of Behavior, 78(1), 95–116. https://doi.org/10.1901/jeab.2002.78-95
Bowen, S., Chawla, N., & Marlatt, G. A. (2011). Mindfulness-based relapse prevention for addictive behaviors: A clinician’s guide. Guilford Press.
Bowen, S., Witkiewitz, K., Clifasefi, S. L., Grow, J., Chawla, N., Hsu, S. H., Carroll, H. A., Harrop, E., Collins, S. E., Lustyk, M. K., & Larimer, M. E. (2014). Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: A randomized clinical trial. JAMA Psychiatry, 71(5), 547–556. https://doi.org/10.1001/jamapsychiatry.2013.4546
Brandon, S., Pallotti, C., & Jog, M. (2021). Exploratory study of common changes in client behaviors following routine psychotherapy: Does psychological flexibility typically change and predict outcomes? Journal of Contemporary Psychotherapy, 51(1), 49–56. https://doi.org/10.1007/s10879-020-09468-2
Burling, T. A., Reilly, P. M., Moltzen, J. O., & Ziff, D. C. (1989). Self-efficacy and relapse among inpatient drug and alcohol abusers: A predictor of outcome. Journal of Studies on Alcohol, 50(4). https://doi.org/10.15288/jsa.1989.50.345
Córdoba-Salgado, O. (2017). Extended behavior-context relations: A molar view of functional analytic psychotherapy. Behavior Analyst, 40(1), 257–273. https://doi.org/10.1007/s40614-017-0090-0
Daley, D. C. & Marlatt, G. A. (2006) Overcoming your alcohol or drug problem: Effective recovery strategies: Therapist guide. Oxford University Press.
Gause, N. K., Elliott, J. C., Delker, E., Stohl, M., Hasin, D., & Aharonovich, E. (2018). Association between change in self-efficacy to resist drinking and drinking behaviors among an HIV-infected sample: Results from a large randomized controlled trial. Journal of Health Psychology, 23(6), 829–839. https://doi.org/10.1177/1359105316664127
Grant, S., Colaiaco, B., Motala, A., Shanman, R., Booth, M., Sorbero, M., & Hempel, S. (2017). Mindfulness-based relapse prevention for substance use disorders: A systematic review and meta-analysis. Journal of Addiction Medicine, 11(5), 386–396. https://doi.org/10.1097/ADM.0000000000000338
Greenfield, B. L., Roos, C., Hagler, K. J., Stein, E., Bowen, S., & Witkiewitz, K. A. (2018). Race/ethnicity and racial group composition moderate the effectiveness of mindfulness-based relapse prevention for substance use disorder. Addictive Behaviors, 81, 96–103. https://doi.org/10.1016/j.addbeh.2018.02.010
Hallgren, K. A., & Witkiewitz, K. (2013). Missing data in alcohol clinical trials: A comparison of methods. Alcoholism: Clinical and Experimental Research, 37(12), 2152–2160. https://doi.org/10.1111/acer.12205
Hallgren, K. A., Epstein, E. E., & McCrady, B. S. (2019). Changes in hypothesized mechanisms of change before and after initiating abstinence in cognitive-behavioral therapy for women with alcohol use disorder. Behavior Therapy, 50(6), 1030–1041. https://doi.org/10.1016/j.beth.2019.01.009
Hartzler, B., Witkiewitz, K., Villarroel, N., & Donovan, D. (2011). Self-efficacy change as a mediator of associations between therapeutic bond and one-year outcomes in treatments for alcohol dependence. Psychology of Addictive Behaviors, 25(2), 269–278. https://doi.org/10.1037/a0022869
Hayes, S. C., & Hofmann, S. G. (2021). “Third-wave” cognitive and behavioral therapies and the emergence of a process-based approach to intervention in psychiatry. World Psychiatry, 20(3), 363–375. https://doi.org/10.1002/wps.20884
Hayes, S. C., Hofmann, S. G., & Stanton, C. E. (2020). Process-based functional analysis can help behavioral science step up to novel challenges: COVID-19 as an example. Journal of Contextual Behavioral Science, 18, 128–145. https://doi.org/10.1016/j.jcbs.2020.08.009
Holzhauer, C. G., Hildebrandt, T., Epstein, E., McCrady, B., Hallgren, K. A., & Cook, S. (2020). Mechanisms of change in female-specific and gender-neutral cognitive behavioral therapy for women with alcohol use disorder. Journal of Consulting and Clinical Psychology, 88(6), 541–553. https://doi.org/10.1037/ccp0000492
Hsiao, Y. Y., Tofighi, D., Kruger, E. S., Lee Van Horn, M., MacKinnon, D. P., & Witkiewitz, K. (2019). The (lack of) replication of self-reported mindfulness as a mechanism of change in mindfulness-based relapse prevention for substance use disorders. Mindfulness, 10(4), 724–736. https://doi.org/10.1007/s12671-018-1023-z
Huebner, R. B., & Tonigan, J. S. (2007). The search for mechanisms of behavior change in evidence-based behavioral treatments for alcohol use disorders: Overview. Alcoholism: Clinical and Experimental Research, 31(S3), 1s–3s. https://doi.org/10.1111/j.1530-0277.2007.00487.x
Ilgen, M., McKellar, J., & Tiet, Q. (2005). Abstinence self-efficacy and abstinence 1 year after substance use disorder treatment. Journal of Consulting and Clinical Psychology, 73(6), 1175–1180. https://doi.org/10.1037/0022-006X.73.6.1175
Irvin, J. E., Bowers, C. A., Dunn, M. E., Wang, M. C., & Bowers, A. (1999). Efficacy of relapse prevention: A meta-analytic review. Journal of Consulting and Clinical Psychology, 67(4), 563–570. https://doi.org/10.1037//0022-006x.67.4.563
Kadden, R. M., & Litt, M. D. (2011). The role of self-efficacy in the treatment of substance use disorders. Addictive Behaviors, 36(12), 1120–1126. https://doi.org/10.1016/j.addbeh.2011.07.032
Kelly, J. F., & Claire Greene, M. (2014). Where there’s a will there’s a way: A longitudinal investigation of the interplay between recovery motivation and self-efficacy in predicting treatment outcome. Psychology of Addictive Behaviors, 28(3), 928–934. https://doi.org/10.1037/a0034727
Korecki, J. R., Schwebel, F. J., Votaw, V. R., & Witkiewitz, K. (2020). Mindfulness-based programs for substance use disorders: A systematic review of manualized treatments. Substance Abuse: Treatment, Prevention, and Policy, 15(1). https://doi.org/10.1186/s13011-020-00293-3
Kruger, E. S., Serier, K. N., Pfund, R. A., McKay, J. R., & Witkiewitz, K. (2021). Integrative data analysis of self-efficacy in 4 clinical trials for alcohol use disorder. Alcoholism: Clinical and Experimental Research, 45, 2347–2356.
Li, W., Howard, M. O., Garland, E. L., McGovern, P., & Lazar, M. (2017). Mindfulness treatment for substance misuse: A systematic review and meta-analysis. Journal of Substance Abuse Treatment, 75, 62–96. https://doi.org/10.1016/j.jsat.2017.01.008
Lilienfeld, S. O. (2017). Psychology’s replication crisis and the grant culture: Righting the ship. Perspectives on Psychological Science, 12(4), 660–664. https://doi.org/10.1177/1745691616687745
MacKinnon, D. P., Lockwood, C. M., Hoffman, J. M., West, S. G., & Sheets, V. (2002). A comparison of methods to test mediation and other intervening variable effects. Psychological Methods, 7(1), 83–104. https://doi.org/10.1037/1082-989X.7.1.83
MacKinnon, D. P. (2008). Introduction to statistical mediation analysis. Taylor & Francis Group/Lawrence Erlbaum Associates.
Magill, M., Kiluk, B. D., Mccrady, B. S., Tonigan, J. S., & Longabaugh, R. (2015). Active ingredients of treatment and client mechanisms of change in behavioral treatments for alcohol use disorders: Progress 10 years later. Alcoholism: Clinical and Experimental Research, 39(10), 1852–1862. https://doi.org/10.1111/acer.12848
Magill, M., Ray, L., Kiluk, B., Hoadley, A., Bernstein, M., Scott Tonigan, J., & Carroll, K. (2019). A meta-analysis of cognitive-behavioral therapy for alcohol or other drug use disorders: Treatment efficacy by contrast condition. Journal of Consulting and Clinical Psychology, 87(12), 1093–1105. https://doi.org/10.1037/ccp0000447
Magill, M., Tonigan, J. S., Kiluk, B., Ray, L., Walthers, J., & Carroll, K. (2020). The search for mechanisms of cognitive behavioral therapy for alcohol or other drug use disorders: A systematic review. Behaviour Research and Therapy, 131. https://doi.org/10.1016/j.brat.2020.103648
Maisto, S. A., Roos, C. R., O’Sickey, A. J., Kirouac, M., Connors, G. J., Tonigan, J. S., & Witkiewitz, K. (2015). The indirect effect of the therapeutic alliance and alcohol abstinence self-efficacy on alcohol use and alcohol-related problems in project MATCH. Alcoholism: Clinical and Experimental Research, 39(3), 504–513. https://doi.org/10.1111/acer.12649
Majer, J. M., Chapman, H. M., & Jason, L. A. (2016). Abstinence self-efficacy and substance use at 2 years: The moderating effects of residential treatment conditions. Alcoholism Treatment Quarterly, 34(4), 386–401. https://doi.org/10.1080/07347324.2016.1217708
Mallik, D., Kaplan, J., Somohano, V., Bergman, A., & Bowen, S. (2021). Examining the role of craving, mindfulness, and psychological flexibility in a sample of individuals with substance use disorder. Substance Use and Misuse, 56(6), 782–786. https://doi.org/10.1080/10826084.2021.1899220
McGuire, T. G., & Miranda, J. (2008). Racial and ethnic disparities in mental health care: Evidence and policy implications. Health Aff (millwood), 27(2), 393–403. https://doi.org/10.1377/hlthadd.27.2.393
McKnight-Eily, L. R., Okoro, C. A., Strine, T. W., Verlenden, J., Hollis, N. D., Njai, R., Mitchell, E. W., Board, A., Puddy, R., & Thomas, C. (2021). Racial and ethnic disparities in the prevalence of stress and worry, mental health conditions, and increased substance use among adults during the COVID-19 pandemic - United States, April and May 2020. Morbidity and Mortality Weekly Report, 70 (5), 162–166. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm
Mechanisms of Behavior Change Satellite Committee. (2018). Novel approaches to the study of mechanisms of behavior change in alcohol and other drug use disorders. Journal of Studies on Alcohol and Drugs, 79(2), 159–162. https://doi.org/10.15288/jsad.2018.79.229
Miller, W. R., & Wilbourne, P. L. (2002). Mesa grande: A methodological analysis of clinical trials of treatment for alcohol use disorders. Addiction, 97(3), 265–277. https://doi.org/10.1046/j.1360-0443.2002.00019.x
Miočević, M., O’Rourke, H. P., MacKinnon, D. P., & Brown, H. C. (2018). Statistical properties of four effect-size measures for mediation models. Behavior Research Methods, 50(1), 285–301. https://doi.org/10.3758/s13428-017-0870-1
Monti, P.M., Kadden, R.M., Rohsenow, D.J., Cooney, N.L., & Abrams, D.B. (2002). Treating alcohol dependence: A coping skills training guide (2nd ed.). Guilford Press.
Moos, R. H., & Moos, B. S. (2006). Rates and predictors of relapse after natural and treated remission from alcohol use disorders. Addiction, 101(2), 212–222. https://doi.org/10.1111/j.1360-0443.2006.01310.x
Müller, A., Znoj, H., & Moggi, F. (2019). How are self-efficacy and motivation related to drinking five years after residential treatment? A longitudinal multicenter study. European Addiction Research, 25(5), 213–223. https://doi.org/10.1159/000500520
Roos, C. R., Bowen, S., & Witkiewitz, K. (2017). Baseline patters of substance use disorder severity and depression and anxiety symptoms moderate the efficacy of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 85(11), 1041–1051. https://doi.org/10.1037/ccp0000249
Roos, C. R., Stein, E. R., Bowen, S., & Witkiewitz, K. (2019). Individual gender and group gender composition as predictors of differential benefit from mindfulness-based relapse prevention for substance use disorder. Mindfulness, 10(8), 1560–1567. https://doi.org/10.1007/s12671-019-01112-y
Roos, C. R., Bowen, S., & Witkiewitz, K. (2020). Approach coping and substance use outcomes following mindfulness-based relapse prevention among individuals with negative affect symptomology. Mindfulness, 11, 2397–2410. https://doi.org/10.1007/s12671-020-01456-w
Ruggero, C. J., Kotov, R., Hopwood, C. J., First, M., Clark, L. A., Skodol, A. E., Mullins-Sweatt, S. N., Patrick, C. J., Bach, B., Cicero, D. C., Docherty, A., Simms, L. J., Michael Bagby, R., Krueger, R. F., Callahan, J. L., Chmielewski, M., Conway, C. C., Clercq, B. de, Dornbach-Bender, A., … Zimmermann, J. (2019). Integrating the hierarchical taxonomy of psychopathology (HiTOP) into clinical practice. Journal of Consulting and Clinical Psychology, 87(12), 1069–1084. https://doi.org/10.1037/ccp0000452
Sawer, F., Davis, P., & Gleeson, K. (2020). Is shame a barrier to sobriety? A narrative analysis of those in recovery. Drugs: Education, Prevention and Policy, 27(1), 79–85. https://doi.org/10.1080/09687637.2019.1572071
Shorey, R. C., Elmquist, J., Gawrysiak, M. J., Strauss, C., Haynes, E., Anderson, S., & Stuart, G. L. (2017). A randomized controlled trial of a mindfulness and acceptance group therapy for residential substance use patients. Substance Use and Misuse, 52(11), 1400–1410. https://doi.org/10.1080/10826084.2017.1284232
Sklar, S. M., & Turner, N. E. (1999). A brief measure for the assessment of coping self-efficacy among alcohol and other drug users. Addiction, 94(5), 723–729. https://doi.org/10.1046/j.1360-0443.1999.94572310.x
Sliedrecht, W., de Waart, R., Witkiewitz, K., & Roozen, H. G. (2019). Alcohol use disorder relapse factors: A systematic review. Psychiatry Research, 278, 97–115. https://doi.org/10.1016/j.psychres.2019.05.038
Sobell, L. C. & Sobell, M. B. (1992). Timeline follow-back: A technique for assessing self-reported alcohol consumption. In R. Z. Litten & J. P. Allen (Eds.), Measuring alcohol consumption: Psychosocial and biochemical methods. Humana Press. https://doi.org/10.1007/978-1-4612-0357-5_3
Striley, C. W., & Hoeflich, C. C. (2021). Converging public health crises: Substance use during the coronavirus disease 2019 pandemic. Current Opinion in Psychiatry, 34(4), 325–331. https://doi.org/10.1097/YCO.0000000000000722
Tofighi, D., Hsiao, Y. Y., Kruger, E. S., MacKinnon, D. P., Lee Van Horn, M., & Witkiewitz, K. (2019). Sensitivity analysis of the no-omitted confounder assumption in latent growth curve mediation models. Structural Equation Modeling, 26(1), 94–109. https://doi.org/10.1080/10705511.2018.1506925
Williams, I. L. (2016). The intersection of structurally traumatized communities and substance use treatment: Dominant discourses and hidden themes. Journal of Ethnicity in Substance Abuse, 15(2), 95–126. https://doi.org/10.1080/15332640.2014.1003671
Witkiewitz, K., & Marlatt, G. A. (2004). Relapse prevention for alcohol and drug problems: That was zen, this is tao. American Psychologist, 59(4), 224–235. https://doi.org/10.1037/0003-066X.59.4.224
Witkiewitz, K., Donovan, D. M., & Hartzler, B. (2012). Drink refusal training as part of a combined behavioral intervention: Effectiveness and mechanisms of change. Journal of Consulting and Clinical Psychology, 80(3), 440–449. https://doi.org/10.1037/a0026996
Witkiewitz, K., Greenfield, B. L., & Bowen, S. (2013). Mindfulness-based relapse prevention with racial and ethnic minority women. Addictive Behaviors, 38(12), 2821–2824. https://doi.org/10.1016/j.addbeh.2013.08.018
Witkiewitz, K., Warner, K., Sully, B., Barricks, A., Stauffer, C., Thompson, B. L., & Luoma, J. B. (2014). Randomized trial comparing mindfulness-based relapse prevention with relapse prevention for women offenders at a residential addiction treatment center. Substance Use and Misuse, 49(5), 536–546. https://doi.org/10.3109/10826084.2013.856922
Witkiewitz, K., McCallion, E., Vowles, K. E., Kirouac, M., Frohe, T., Maisto, S. A., Hodgson, R., & Heather, N. (2015). Association between physical pain and alcohol treatment outcomes: The mediating role of negative affect. Journal of Consulting and Clinical Psychology, 83(6), 1044–1057. https://doi.org/10.1037/ccp0000033
Witkiewitz, K., Montes, K. S., Schwebel, F. J., & Tucker, J. A. (2020). What is recovery? Alcohol Research: Current Reviews, 40(3), 1–12. https://doi.org/10.35946/arcr.v40.3.01
Witkiewitz, K., Pfund, R. A., & Tucker, J. A. (2022). Mechanisms of behavior change in substance use disorders with and without formal treatment. Annual Review of Clinical Psychology, 18, 497–525. https://doi.org/10.1146/annurev-clinpsy-072720-014802
Yu-Hsin Liao, K., Stead, G. B., & Liao, C.-Y. (2021). A meta-analysis of the relation between self-compassion and self-efficacy. Mindfulness, 12, 1878–1891. https://doi.org/10.1007/s12671-021-01626-4
Funding
This research was made possible by funding from the National Institute on Drug Abuse (R01DA025764 and UH3DA051241).
Author information
Authors and Affiliations
Contributions
DML: wrote the manuscript and collaborated on the analyses of the present study. ES: collaborated in the writing and editing of the final manuscript, specifically regarding the “Method” section. SB: conceptualized the study and collaborated in the writing and editing of the final manuscript. KW: conceptualized the study, conducted the analyses of the present paper, and collaborated on the writing and editing of the final manuscript.
Corresponding author
Ethics declarations
Ethics Statement
All procedures of the parent trial were approved by the University of Washington Institutional Review Board.
Informed Consent
Written informed consent was obtained from all participants of the parent trial.
Conflict of Interest
The authors declare no competing interests.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Moniz-Lewis, D.I.K., Stein, E.R., Bowen, S. et al. Self-Efficacy as a Potential Mechanism of Behavior Change in Mindfulness-Based Relapse Prevention. Mindfulness 13, 2175–2185 (2022). https://doi.org/10.1007/s12671-022-01946-z
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12671-022-01946-z