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Although several innovative substance abuse counseling strategies have emerged recently, none have exhibited greater promise than those based on self-efficacy theory. Numerous studies provide evidence of the clinical effectiveness of a self-efficacy approach to addictive behaviors (Baer, Holt, & Lichtenstein, 1986; Lichtenstein & Glasgow, 1997; Rollnick & Heather, 1982; Rychtarik, Prue, Rapp, & King, 1992). However, the benefits such an approach offers counselors whose practice is closely regulated by third party payers has not been reviewed thoroughly. Therefore, our purpose, here, is to present the advantages a self-efficacy approach has for substance abuse counselors working in a rapidly changing health care environment. Specifically, a rationale for self-efficacy addiction counseling, a review of the tenets of self-efficacy theory, a model to operationalize self-efficacy theory for addiction counseling, and the implications a self-efficacy approach has for substance abuse counselors who work in managed care settings (including different levels of care, brief interventions, and outcome evaluation) are discussed.
When confined to a discussion of substance abuse, self-efficacy pertains to an individual's perceptions of his or her ability to mobilize necessary motivation, knowledge, and behavior to control or abstain from use of alcohol or other drugs (DiClemente, 1986). For example, an individual who possesses a strong belief in his or her ability to resist a craving for a cigarette is more likely to avoid nicotine use than are individuals who exhibit less self-regulatory confidence. Several studies have identified specific sources of efficacy related to addictive behaviors. However, of particular interest here is the model proposed by Marlatt, Baer, and Quigley (1995) that identified five categories of self-efficacy related to substance abuse: (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 : Resistance self-efficacy refers to an individual's perceived ability to withstand attempts to persuade them to use a "recreational" substance for the first time (Marlatt et al., 1995). Resistance self-efficacy is closely related to what counselors have traditionally referred to as a prevention approach. For example, research indicates that children and adolescents who successfully complete refusal skilltraining, and thus increase their resistance self-efficacy, are more confident in their ability to resist peer pressure and are significantly better able to avoid first time use of tobacco, alcohol, or other drugs (Belcher & Shinitzky, 1998; Herrmann & McWhirter, 1997).
Harm Reduction Self-Efficacy: After initial use, many people begin to experiment further with psychoactive substances. The vast majority of these individuals are not addicted, but many do experience serious physical, psychological, and social problems related to excessive alcohol and drug use and are in need of a method to minimize problematic drug use. Research indicates that a harm reduction approach is an effective method to help these individuals minimize these maladaptive behaviors by improving their perceived capacity to restrict personal use of alcohol and drugs (Tatarsky, 1998). For example, young adults who have problems related to drinking, but are not considered alcohol dependent, are often counseled effectively to moderate their frequency and quantity of alcohol consumption.
Action Self-Efficacy: Action self-efficacy is defined as a person's belief in their ability to actualize the behaviors necessary to stop or reduce the use of a psychoactive drug (Marlatt et al., 1995). Many people who become addicted to alcohol or other drugs are unable to stop using simply because they do not perceive themselves as capable of reducing or quitting. However, personal ability related to cessation of an addiction can be raised or lowered depending on how the actions of the individual and others are interpreted (Bandura, 1997). For example, a person who has witnessed a friend's successful attempt to quit smoking may conclude that he or she also could overcome nicotine cravings and stop smoking cigarettes. Alternatively, a person who has previously tried to quit smoking and succumbed to cravings might falsely conclude that past experiences accurately predict future accomplishments and, therefore, refuse to try again.
Coping Self-Efficacy: Individuals who successfully negotiate the action stage and achieve abstinence are often faced with high-risk situations that threaten their newly established self-efficacy. Unfortunately, the relapse rate is high among those who do not perceive themselves as capable of coping with stress provoking events (e.g., family discord, peer pressure, financial problems, or temptation) without the use of a drug. However, research indicates that those who receive relapse prevention counseling are more confident in their ability to cope effectively when confronted with crisis situations (Annis & Davis, 1989; DiClemente, Fairhurst, & Piotrowski, 1995; Monti, Rohsenow, Michalec, Martin, & Abrams, 1997). For example, recovering clients who have received instruction in and rehearsed strategies for refusing a drink offered by an associate or friend are significantly more confident that they can avoid relapse (Monti, Gulliver, & Myers, 1994).
Recovery Self-Efficacy: Unfortunately, many who achieve sobriety often experience setbacks or relapses in the quest to maintain long-term recovery. However, it is not the relapse but rather the interpretation of the event that guides an individual's future drag-related behaviors (Bandura, 1997). Those with higher levels of recovery self-efficacy view the relapse as a learning experience and intensify their efforts to return to and maintain sober behaviors. Those who lack personal confidence in their ability to recover from a setback often view themselves as powerless and unable to manage cravings, pressures, and temptations and fail to take further action to return to abstinent behaviors.
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