Social-Environmental Mechanisms of Behavior Change: A Focus on Support for Abstinence Ken Leonard Research Institute on Addictions, University at Buffalo, State University of New York, Buffalo, NY, USA Mechanisms of Behavioral Change Satellite Meeting June 20, 2014 Seattle (well Bellevue anyway), Washington
Definitions of Social Support for Abstinence Arises from the general construct of social support. Support refers to the positive, potentially health promoting or stress buffering, aspects of relationships such as instrumental aid, emotional caring or concern, and information. In essence, supportive relationships directly provide something that people need to stay healthy or to adapt to stress. (House, Umberson, & Landis, 1988)
Types of social support Instrumental Aid, Emotional Caring, and Information (House, Umberson, and Landrey, 1988) Materials Support, Emotional Support, and Cognitive support (Jacobsen, 1986) At the same time, there was a recognition that the nature of the stressor could call for specificity in the type of support needed.
Key Turning Point for Alcohol Research On an interpersonal level, we differentiate social support for alcohol involvement from social support for subjective well-being (Beattie, Longabaugh, Elliott, Stout, Fava, & Noel (1993) Alcohol-specific social support is expressed in behaviors by others in the individual s environment that stimulate and/or reinforce alcohol consumption or abstinence. Longabaugh, Beattie, Noel, Stout, & Malloy, 1993)
Related Constructs Social Integration; the existence or quantity of social ties or relationships Social network structure; the structural properties of the different dyadic and network of relationships such as composition, reciprocity, density). The absence of social conflict Social Control and Regulation
Key point 1; Alcohol-specific social support is conceptually broad and can encompass structure of network and behaviors by those in network. Considerable diversity over time and between research groups.
Network Structure Percent of heavy drinkers in the social network Percent of abstinent, recovering alcoholics in the social network
Pressure/support for drinking/not drinking Maximum encouragement of alcohol involvement by important other Maximum encouragement of not drinking by important other Minimum encouragement of alcohol involvement by important other Least encouragement to drink by important other
Alcohol involvement in social activities Least drinking by others in important activities Drinking alone (vs with others) in the past year Most drinking by others in important activities
Relationship conflict Quarrel with others while drinking in the past 30 days
Key Point 2: Many of the studies relevant to social support for abstinence arise from research focused on 12 step programs, which has implications for MOBC model
Idealized MOBC mediational model Mediator Alcohol Intervention Alcohol Involvement
In the context of the 12 step literature and SSFA What is the intervention Addiction Treatment AA Involvement Treatment designed to foster AA involvement What is the mediator AA Involvement Support for abstinence
AA Involvement Social Support for Abstinence Alcohol Intervention Alcohol Involvement
Key Point 3: At the broad level, support for all of these paths, mostly from studies looking at 1 or 2 of the paths AA Involvement 4 Social Support for Abstinence 4 many Alcohol Intervention 1 many Alcohol Involvement
Major problem is that support for each individual path is not support for the model, particularly for studies addressing only a single path.
Key Point 4: Handful of studies that examine three of the four constructs AA or other Self Help involvement Social Support for Abstinence Alcohol Intervention Substance abuse
Humphreys, et al 1999 (assessed coping and general support as mediators also) Self Help group involvement Most friends don t use A or D Support recovery Alcohol Intervention Substance abuse
Kaskutas, Bond & Humphreys, 2002 (also included social support network size) AA Involvement Number HD Number encourage Alcohol Intervention Alcohol problem severity
Bond, Kaskutas, & Weisner, 2003 AA effect on abstinence largely through AA based support AA Involvement Alcohol Intervention % HD % Encouraged reduction Stronger effect if AA support Abstinence
Laudet, et al 2004 Comorbid psychiatric illness and substance abuse Double trouble in recover attendance Alcohol Intervention.26* -.26* (-.18 +) General and Recovery Support -.24* Substance use 1 year later
Kelly, et al 2011 Mediation effects for pro-drinking networks for both samples and outcomes- Pro-abstinent network mediates PDA both sample AA Attendance 0-3 months Alcohol Intervention Signif Outpt and AC Highly Significant for outpt and aftercare Pro-drinking and pro-abstinent people and activities Network * for OP Net and act * for PDA for AC PDA and DDD 4-9 months 12-15 months
Litt et al, 2007 Treatment effect on PDA not significant with AA and Support in model generally replicated at 2 year followup AA Attendance % abstinent and Reaction of IP to not drinking Network, Network +ContM Case management PDA
Conclusions Several different interventions can increase self help engagement and involvement (but many still do not engage) Those who are involved with AA have better outcomes. This is mediated in part by a shift in the social network, it appears that this more through the addition of recovery oriented individuals than through the reduction in drinking oriented individuals.
Areas for further exploration AA social network support vs broader social network support Alternative strategies to impact support for abstinence- with exception of Litt- Narrow view of potential impact of social network- focus largely on composition