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Stress and Coping Resources: Theory and Review

Ralf Schwarzer

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, 1992).
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 andaccomodative 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; Schwarzer, 1994.)
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, 1992, 1995).
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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