Addictive Behaviors 32 (2007) 1669 – 1680

Participation in specific treatment components predicts

alcohol-specific and general coping skills
Kelly Forys a,⁎, John McKellar a,b , Rudolf Moos a,b
a
VA Palo Alto Health Care System 795 Willow Road, 152 Menlo Park, CA 94025, USA
b
Stanford University School of Medicine 300 Pasteur Drive Stanford, CA 94305, USA

Abstract

This study identified which aspects of substance abuse treatment in community residential facilities (CRFs)
were correlated with patients' post-treatment coping. A total of 2376 patients supplied demographic information
and completed measures at baseline (coping and abstinence self-efficacy) and one year after treatment (coping,
level of drug and alcohol use, and substance-related problems). Staff provided information about treatment
orientation and patients' participation in treatment (e.g., life skills training, vocational counseling). The data were
used to predict coping 1 year after treatment. As expected, higher levels of general approach coping and alcohol-
specific coping and lower levels of general avoidance coping were associated with less 1-year alcohol and drug use
and fewer drinking problems. Patients' greater level of participation in life skills counseling predicted more
approach coping at 1 year. In addition, positive social relationships and participation in 12-step self-help groups
predicted less general avoidance coping and more alcohol-specific coping at 1 year post-treatment. Life skills
training, 12-step self-help groups, and enhancement of supportive relationships during CRF treatment for
substance abuse are related to healthy coping. Future research should examine the effect of these components in
less intensive programs and with women.
© 2006 Elsevier Ltd. All rights reserved.

Keywords: Approach coping; Avoidance coping; Self-help groups; Substance use disorder; Treatment outcomes

⁎ Corresponding author. Present address: Directorate of Health Promotion and Wellness U.S. Army Center for Health
Promotion and Preventive Medicine (CHPPM) 5158 Blackhawk Rd, APG, MD 21010-5403, USA. Tel.: +1 410 436 7406; fax:
+1 410 436 7381.
E-mail addresses: [email protected] (K. Forys), [email protected], [email protected] (J. McKellar).

0306-4603/$ - see front matter © 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.addbeh.2006.11.023
1670 K. Forys et al. / Addictive Behaviors 32 (2007) 1669–1680

1. Introduction

1.1. Coping and treatment outcome

Approach and avoidance coping style is one common framework for understanding coping (Moos,
Brennan, Schutte, & Moos, 2006; Roth & Cohen, 1986; Skinner, Edge, Altman, & Sherwood, 2003).
An individual can either approach a problem and make active efforts to resolve it or avoid a problem
and focus mainly on managing emotions associated with it. In the context of substance use, an
individual can use drugs or alcohol as an avoidance strategy to try to reduce distress or depression or,
alternatively, can rely on active/approach methods, such as problem solving and seeking social
support, to cope with stress.
In general, more reliance on approach than on avoidance coping is predictive of better substance
use outcomes (Chung, Langenbucher, Labouvie, Pandina, & Moos, 2001; Madden, Hinton, Holman,
Mountjouris, & King, 1995; Wunschel, Rohsenow, Norcross, & Monti, 1993). More specifically, a
decrease in avoidance coping during treatment seems to predict better substance use outcomes at 1-
year (Chung et al., 2001), as does total the number of approach coping strategies employed (Maisto,
Connors, & Zywiak, 2000). Patients' coping skills are also related to longer-term outcomes.
Approach coping at a 1-year follow-up predicted less substance use at a 5-year follow-up (Lemke &
Moos, 2003) and approach coping at 2 years after treatment predicted better physical functioning at
10-years post-treatment (Finney & Moos, 1992). Finally, in a study of the factors related to long-
term alcohol use disorder outcome (Moos & Moos, 2005), individuals who relied less on avoidance
coping at a 1-year follow-up were more likely to be stably remitted over a 16-year follow-up
period.
Some coping researchers (Coyne & Racioppo, 2000) have recommended that assessment of coping
should not only include global measures, such as approach and avoidance, but also specific coping
behaviors. Measurement of both global and specific aspects of coping can help to clarify the relationship
between coping and substance use outcomes by identifying whether positive changes in substance use are
more driven by changes in general coping style (approach and/or avoidance), changes in alcohol-specific
coping, or both.

1.2. Theoretical orientation and treatment

The relatively robust connection between coping and substance use has led researchers to examine how
specific treatments influence coping. Most studies investigating this relationship have focused on
cognitive behavioral therapies (CBT), such as coping skills training, which posit that deficits in the ability
to cope with life stressors in general, and alcohol or drug cues in particular, lead to excessive drinking and/
or drug use. Accordingly, CBT typically includes explicit components focused on teaching coping skills.
Most studies in this area contrast CBT to a comparison treatment and then measure patients' coping skills
before and after treatment to determine if patients who receive CBT change more in coping skills, and if
changes in coping skills are related to positive outcome.
Despite the strong theoretical rationale linking cognitive and behavioral SUD treatments to improved
coping, the results of these studies have been somewhat disappointing. For example, a review of 10
studies found evidence for a link between improvement in coping and positive SUD outcomes, but little
support for the specificity of this relationship to CBT when compared to other treatments (Morgenstern &
 K. Forys et al. / Addictive Behaviors 32 (2007) 1669–1680 1671

Longabaugh, 2000). More recent investigations of this hypothesis have yielded similar results (Litt,
Kadden, Cooney, & Kabela, 2003; Longabaugh et al., 2005).

1.3. Common components of SUD treatment and coping

An alternative direction for understanding how treatment influences coping is to focus on whether
specific components of treatments predict improvement in coping. Some of the most common
components of SUD treatments include vocational training, individual or group psychotherapy, skill
building classes, and involvement in 12-step meetings during or after treatment. It seems clear that skill
building classes might enhance approach coping, and some prior work suggests that skills learned in 12-
step meetings (e.g., modeling from “sober” members) might also increase approach coping (Humphreys,
Mankowski, Moos, & Finney, 1999; Morgenstern, Labouvie, McCrady, Kahler, & Frey, 1997). Other
important aspects of treatment include social interaction with peers and engagement in social or
recreational activities. Social support has been associated with a decrease in avoidance coping in couples
therapy (McCrady, Hayaki, Epstein, & Hirsch, 2002) and 12-step self-help group meetings (Humphreys
et al., 1999; Timko, Finney, & Moos, 2005). Although these treatment components and concomitants
seem likely to improve coping, we are not aware of prior studies that have focused systematically on this
idea.
The current study takes a different approach to examining the relationship between treatment and
coping. Rather than focusing only on how coping predicts treatment outcome, or the conditions under
which coping better predicts outcome, we investigate how specific aspects of treatment predict post-
treatment coping. This focus allows us to consider two important questions: (1) Do treatment factors (e.g.,
treatment orientation, daily living skills training, participation in AA) predict coping at one year? (2) Do
specific components of treatment predict better coping above and beyond the influence of patients'
baseline characteristics?

2. Method

2.1. Participants

Participants in this study were patients with SUDs who were treated in a community residential facility
(CRF) affiliated with the Department of Veterans Affairs (VA). CRF programs provide a residential
environment to bridge the transition between inpatient treatment and independent life in the community
for selected patients with SUDS. A total of 2822 patients entered 88 CRF programs and completed intake
assessments. Of these, 2376 patients were assessed at both discharge and one-year follow-up. The patients
were predominantly unmarried men who had few social and economic resources and a history of
substance abuse problems. These participants had a mean education level of 12.9 years (SD = 1.7). Fifty-
two percent of the sample was White, 37% were Black, 5% were Hispanic, and 3% were Native
American. The remaining individuals identified themselves as “Other.” Eighty-three percent reported that
they had consumed alcohol in the three months prior to treatment. Eight percent had used heroin, and 45%
had used marijuana in the prior three months.
Diagnoses of SUD were made based on ICD-9 criteria. Similar to most treatment settings,
approximately 20% of this sample had a comorbid Axis I diagnosis. The average length of stay in a CRF
was 29.2 days (SD = 20.2, range 1–510 days). Immediately prior to entry into the CRF, 80% of patients
1672 K. Forys et al. / Addictive Behaviors 32 (2007) 1669–1680

had received inpatient SUD treatment, 10% had received inpatient psychiatric treatment, and 10% had
received SUD outpatient treatment. Approximately 50% of patients received additional mental health care
(SUD or psychiatric) in the year following discharge from the CRF.

2.2. Data collection procedures

Patients completed an Intake Information Form (IIF) on admission to the CRF. In addition, CRF staff
members completed measures evaluating each patient at discharge from the program. At twelve months
after discharge from the CRF, patients were contacted and asked to complete a Follow-up Information Form
(FIF) by mail and/or telephone interview covering the same information as the IIF. Thus, patients completed
data at intake and one-year follow-up. Discharge measures were completed by a program staff member.

2.3. Treatment settings

The 88 CRFs were community-based residential facilities that had contracted with the VA to provide
community care for VA substance use disorder SUD patients. The nationwide-sample of facilities was
selected based on geographic representativeness, number of VA referrals, and type of treatment
orientation. The CRFs were supervised alcohol- and drug-free environments that supported initiation and
maintenance of sobriety. The CRFs offered care to maintain residents' health and monitor their use of
medications and give residents opportunities to enhance their daily living skills, develop social and
interpersonal skills, and learn about and understand their disorder and the recovery process.
The facilities offered an array of services and activities including social and community support
services, psychological, nutritional, and vocational rehabilitation counseling; and physical exercise and
organized sports. Each CRF also had a 24-hour staff member who monitored residents' medication use,
health, and personal hygiene. Self-help groups such as Alcoholics Anonymous (AA) and Narcotics
Anonymous (NA) were offered as an ongoing part of the program. Additional information about the CRFs
has been published elsewhere (Moos & King, 1997).

2.4. Patients' characteristics at baseline

Demographic information including gender, age, ethnicity, employment, and education was collected.
The alpha coefficients presented for each scale were derived from each scale's source article.

2.4.1. Alcohol-specific coping (alpha = .92)

Patients' ability to cope with thoughts and urges to drink was assessed on a 15-item scale drawn from
The Processes of Change questionnaire indicating the frequency with which they engaged in thoughts and
behaviors to stop themselves from drinking (alphas .69 to .82) (Prochaska, Velicer, DiClemente, & Fava,
1988). Examples of items included, “I tell myself I can choose to drink/use or not” and “I stay away from
people who remind me of drinking or using.” The items were rated on five-point scales ranging from
“1 = Never” to “5 = Often.” Alcohol-specific coping was also measured at the 1-year follow-up.

2.4.2. Confidence in abstinence

Patients rated their confidence in being completely abstinent one year from the initiation of the program
on a ten-point scale ranging from “Not confident at all” to “Extremely confident”. Previous research
 K. Forys et al. / Addictive Behaviors 32 (2007) 1669–1680 1673

indicates that this measure significantly predicts abstinence after SUD treatment (Ilgen, McKellar, &
Tiet, 2005).

2.5. Characteristics of treatment

2.5.1. Treatment orientation

To obtain information about the characteristics of the CRFs, we asked the manager of each facility to
complete the Drug and Alcohol Program Treatment Inventory (DAPTI) (Swindle, Peterson, Paradise, &
Moos, 1995). The DAPTI contains eight scales composed of eight 4-point items ranging from 0 (not like
our program) to 3 (major part of our program) that assess a program's main treatment orientation. The five
DAPTI scales used here have adequate reliabilities and assess: 12-step orientation (alpha = .93), cognitive
behavioral orientation (alpha = .81), therapeutic community orientation (alpha = .71), rehabilitation
orientation (alpha = .86), and psychodynamic orientation (alpha = .83) (Swindle et al., 1995). Based on
responses of the CRF program managers to the DAPTI, we defined four types of treatment programs in
terms of their standard scores on these scales: AA/12 step, cognitive–behavioral, therapeutic community,
or eclectic/undifferentiated (Moos, Moos, & Andrassy, 1999).

2.5.2. Treatment components rated at discharge

At discharge staff members rated patients' participation in several aspects of treatment on four-point
scales ranging from “1 = Not at all” to “4 = 11 or more times.” The validity of staff ratings of patients'
participation in treatment has been shown through positive correlations with patients' outcomes, such as
completion of the program, having a stable residence at discharge, and confidence in the patient's
recovery a year after discharge (Moos & King, 1997; Moos et al., 1997).

2.5.3. Mental health counseling (two items, alpha = .76)

The staff reported the frequency with which CRF residents participated in individual and group therapy
sessions.

2.5.4. Skill training (four items, alpha = .82)

Staff members indicated the frequency with which CRF residents engaged in social and daily living
skills, and in family, psychoeducational, and peer counseling.

2.5.5. Vocational counseling (two items, alpha = .87)

Staff rated the frequency with which residents participated in vocational counseling.

2.5.6. Social and recreational activities (eight items, alpha = .81)

A composite score was comprised of the sum of staff ratings of the frequency with which patients
attended social and recreational activities offered at the CRF (e.g., cards or other games).

2.5.7. Positive social relationships (alpha = .82)

A composite variable measuring positive social relationships was assessed by summing the staff member's
rating of the frequency with which residents engaged in six positive interactions with the other patients (e.g., the
resident could count on other residents for help when needed, the resident shared mutual interests and activities
with other residents). These items were rated on a five point scale ranging from “1 = Never” to “5 = Often.”
1674 K. Forys et al. / Addictive Behaviors 32 (2007) 1669–1680

2.5.8. Self-help group meetings

The frequency at AA/NA groups both at the facility and off-site and attendance at non-12-step self-help
meetings was each rated on a four point scale ranging from “1 = Not at all” to “4 = 11 or more times.”

2.6. Variables measured at one-year follow-up

In addition to alcohol-specific coping, we assessed general approach and avoidance coping and 1-year
alcohol consumption, drinking problems, and drug use.

2.6.1. Approach and avoidance coping responses

Four subscales of the Coping Responses Inventory (CRI) (Moos, 1993) were used to assess approach
and avoidance coping at the one-year follow-up. Each of the four dimensions was comprised of six items.
Patients identified a recent stressor and rated their reliance on each of the 48 coping items on four-point
scales ranging from “1 = Not at all” to “4 = Fairly often.” The approach coping scale (alpha = .77) was
comprised of positive reappraisal and problem solving and the avoidance coping scale (alpha = .72) was
comprised of cognitive avoidance and emotional discharge. The CRI approach coping scales have
stabilities of .48 over a 1-year interval (McKellar, Stewarat, & Humphreys, 2003).

2.6.2. Alcohol consumption

Patients were asked about the frequency and largest amount of beer, wine, and hard liquor they had
consumed on any given day during the prior three months. The product of the frequency and largest
amount of alcohol consumed was used to assess the quantity of consumption. This method was used to
capture the frequency of heavy drinking episodes, a potent predictor of alcohol-related morbidity (Rehm
et al., 2003). Participants are able to report these outcomes with relative accuracy (Babor, Steinberg,
Anton, & Del Boca, 2000).

2.6.3. Drinking problems

The Drinking Problems Index (alpha = .90, range = 0–72) (Ouimette, Gima, Moos, & Finney, 1993)
covers general problems due to drinking, such as being intoxicated or drunk, feeling confused after
drinking, and experiencing drinking-related problems at work or in relationships with family and friends.
Patients responded to 18 items on five-point scales ranging from “1 = Never” to “5 = Often” to indicate the
frequency with which they experienced each of the problems over the prior three months.

2.6.4. Drug use

Drug use was assessed by summing responses to 15 items (alpha = .69, range = 0–60) rated on five
point scales ranging from “Never” to “Every day” indicating the frequency with which patients used a
variety of drugs (e.g., heroin, opiates, marijuana, amphetamines, hallucinogens) over the previous three
months.

2.7. Data analytic strategy

To highlight the importance of coping skills in relation to SUD outcomes, we first calculated Pearson
correlations between 1-year alcohol-specific coping and general approach and avoidance coping and the
three outcome variables (alcohol consumption, drinking problems, drug use). Next, we tested whether
 K. Forys et al. / Addictive Behaviors 32 (2007) 1669–1680 1675

treatment orientation (AA/12 step, cognitive–behavioral, therapeutic community, or eclectic/undifferen-

tiated) differentially impacted level of coping by conducting three one-way ANOVAs with the four
treatment orientations as the grouping variables and alcohol-specific, approach, or avoidant coping as the
outcomes.
We then identified which aspects of treatment predicted coping styles. To accomplish this, we
calculated Pearson (partial) correlations to determine associations between staff-rated treatment
participation and the three coping indices at one year controlling for baseline alcohol-specific coping.
Finally, we conducted hierarchical multiple regression analyses, controlling for baseline coping, to
determine which baseline patient characteristics and staff-reported treatment participation variables
significantly predicted each of the three coping indices. Associations between treatment orientation of the
CRF and the services offered in the CRFs have been shown elsewhere (Moos et al., 1999).

3. Results

3.1. Preliminary analyses

As shown in Table 1, there were significant predicted relationships between coping styles and SUD
outcomes (all ps b .01). Alcohol-specific and general approach coping was associated with less alcohol
consumption and drug use and fewer drinking problems, whereas general avoidance coping was
associated with more alcohol and drug use and drinking problems.
Next, analysis of variance (ANOVAS) was used to determine whether treatment orientation was
differentially associated with any of the three indices of coping. There were no significant associations
between treatment orientation and alcohol-use specific coping [AA/12-step (M = 32.7; SD = 14.1), CBT
(M = 33.1; SD = 13.7), Therapeutic community (M = 32.7; SD = 14.3), and Eclectic/undifferentiated
(M = 32.8; SD = 14.1); F = .49; p N .05]. No significant associations were found for general approach
coping [AA/12-step (M = 24.5; SD = 8.2), CBT (M = 21.8; SD = 8.3), Therapeutic community (M = 21.6;
SD = 8.2), and Eclectic/undifferentiated (M = 22.8; SD = 8.4); F = 1.81; p N .05]. Similarly, no significant
associations were found for general avoidance coping [AA/12-step (M = 14.3; SD = 7.32), CBT (M = 15.2;
SD = 7.1), Therapeutic community (M = 15.1; SD = 6.7), and Eclectic/undifferentiated (M = 15.3;
SD = 7.8); F = 1.42; p N .05].

3.2. Prediction of alcohol-specific coping

Partial correlations controlling for baseline coping showed that patients who participated more in life
skills therapy, vocational counseling, therapy sessions, social-recreational activities, and 12-step groups

Table 1
Correlations between coping and 1-year substance use outcomes
Outcome variables Substance-specific coping General approach coping General avoidance coping
Alcohol consumption −.19⁎⁎⁎ − .25⁎⁎ .29⁎⁎
Drinking problems −.12⁎⁎ − .25⁎⁎ .37⁎⁎
Drug use frequency −.17⁎⁎ − .19⁎⁎ .18⁎⁎
Results reflect Pearson's correlations.
⁎p b .05 ⁎⁎p b .01.
1676 K. Forys et al. / Addictive Behaviors 32 (2007) 1669–1680

Table 2
Partial correlations between staff's ratings of residents' participation in treatment and coping at one year (baseline coping
controlled)
Staff-rated treatment related factor Substance-specific coping General approach coping General avoidance coping
Skill-related training
Life skills therapy .08⁎ .09⁎⁎ − .01
Vocational counseling .05⁎ .06⁎⁎ − .04⁎

Mental health
Therapy sessions .07⁎ .02 − .02

Social
Social and recreational activities .05⁎ .05⁎⁎ − .01
Positive social relationships .09⁎⁎ .05⁎⁎ − .08⁎⁎

Mutual help involvement

AA/NA or 12 step in Tx .01 − .030 − .08⁎⁎
AA/NA or 12 step outside of Tx .10⁎⁎ .047⁎ − .04⁎⁎
⁎p b .05 ⁎⁎p b .01.

outside of treatment, and who had more positive relationships with other residents, reported more alcohol-
specific coping (Table 2).
To identify independent predictors of alcohol-specific coping, we conducted multiple regression
analyses in which we entered significant baseline patient characteristics followed by the significant
treatment indices identified in Table 2. As shown in Table 3, baseline alcohol-specific coping and

Table 3
Personal characteristics at baseline and treatment-related predictors of coping at one year
Predictors Substance-specific coping General approach coping General avoidance coping
Beta
Baseline variables
Baseline coping .27⁎⁎⁎ .15⁎⁎ .10⁎⁎
Ethnicity (1 = African .08⁎⁎ .08⁎⁎ − .01
American, 0 = Caucasian)
Education .04 .02 − .07⁎⁎
Global confidence in abstinence .03 .09⁎⁎ − .11⁎⁎

Treatment-related factors
Life skills therapy .03 .07⁎⁎ .04
Positive social relationships .07⁎⁎ .02 − .05⁎
AA/NA or 12 step In Tx .04 .04 − .06⁎⁎
AA/NA or 12 step Outside of Tx .09⁎⁎ .03 .02

Constant
R2 .10⁎⁎ .06⁎⁎ .05⁎⁎
⁎p b .05 ⁎⁎p b .01.
 K. Forys et al. / Addictive Behaviors 32 (2007) 1669–1680 1677

ethnicity (African Americans higher than Caucasians), predicted more alcohol-specific coping at one year.
In addition, positive relationships with peers and more frequent attendance of 12-step meetings outside of
treatment predicted higher alcohol-specific coping.

3.3. Prediction of general approach coping

Partial correlations controlling for baseline coping showed that patients who participated more in life
skills therapy, vocational counseling, social-recreational activities, and 12-step groups outside of
treatment, and who had more positive relationships with other residents, relied more on approach coping
(Table 2). As shown in Table 3, African American ethnicity, confidence in abstinence, and baseline coping
predicted approach coping at one year. In addition, greater participation in life skills counseling predicted
more approach coping at one year.

3.4. Prediction of general avoidance coping

Partial correlations controlling for baseline coping showed that patients who participated in more
vocational counseling and self-help groups, and who had more positive relationships with other residents,
relied less on avoidance coping (Table 2). After entering the patient baseline characteristics that predicted
less avoidance coping (more education, confidence in abstinence, and baseline coping), more
involvement in 12-step groups during treatment and more positive relationships with other residents
predicted less reliance on avoidance coping at one year (Table 3).

4. Discussion

Rather than focusing solely on the influence of treatment orientation in improving coping in SUD
patients, the current study identifies specific components of treatment that enhance coping. CRFs' overall
treatment orientation (e.g., 12-step or CBT) did not differentially influence patients' coping skills.
However, after controlling for patients' characteristics at baseline, patients' level of participation in life
skills and vocational counseling, social recreational activities, and 12-step self-help groups outside of
treatment predicted more reliance on alcohol-specific coping and general approach coping one year after
treatment. Positive social relationships and participation in 12-step self-help groups in treatment predicted
less reliance on general avoidance coping one year after treatment. Importantly, more reliance on alcohol-
specific coping and general approach coping and less reliance on general avoidance coping was
associated with less 1-year alcohol consumption and drug use and fewer drinking problems.
In general, many of the same patient and treatment factors predicted more one-year alcohol-specific
and general approach coping. Compared to Caucasian patients, African–American patients reported more
reliance on both of these types of coping. In addition, confidence in abstinence was a strong predictor of
approach coping at one-year follow-up. Greater participation in life skills and vocational training
predicted more alcohol-specific and general approach coping at one year. The acquisition of useful skills
to confront and manage general life problems is important for enhancing an individual's coping related to
alcohol use. Life skills training programs may reduce alcohol use by increasing approach coping
(Hanewinkel & Asshauer, 2004).
Patients who developed better relationships with others in the CRF, and those who participated more in
12-step self-help groups outside of treatment, also relied more on alcohol specific and general approach
1678 K. Forys et al. / Addictive Behaviors 32 (2007) 1669–1680

coping at one year. Social support gained during treatment and attendance in 12-step groups might have
allowed participants to learn and model alcohol-specific coping successfully employed by 12-step group
members living in the community. This behavior may have facilitated behavioral transfer of coping skills
from the CRF program to the community.
Baseline and treatment factors also predicted level of general avoidance coping. Better educated
patients relied less on avoidance coping at one year, perhaps because they had learned that avoidance
strategies tend to be less effective ways of dealing with stressors. More confidence in abstinence was also
related to less avoidance coping at one year. Better relationships with peers and increased participation in
12-step groups predicted less avoidance coping at one year. These findings are consistent with the ideas
that social support reduces reliance on avoidance coping (McCrady et al., 2002) and that participation in
12-step groups reduces individuals' reliance on indirect ways of coping, such as the use of substances as a
coping strategy (Humphreys et al., 1999).
Overall, the findings suggest that several common components of SUD treatment in CRFs predict more
alcohol-specific and general approach coping and less general avoidance coping one year following
treatment. Life skills training and vocational training are likely to provide concrete strategies that increase
effective coping skills that patients can integrate into their daily life. While 12-step self-help participation
during treatment predicted reduced avoidance coping, it did not predict increased approach coping. It is
likely that in-treatment 12-step groups provide support and skills for reducing avoidance behaviors, but
that they are not structured to improve approach coping the way targeted skills training does. However,
these groups likely help model specific approach coping skills, especially when the models are
community members participating in 12-step groups off-site. The benefits of supportive abstinence-
oriented role models in 12-step self-help groups might counteract the negative behaviors and thoughts
previously used as primary coping strategies, reduce long-term avoidance coping, and enhance alcohol-
specific related coping skills.

4.1. Limitations and future directions

Some limitations of this work should be noted. The findings are applicable only to men who were
motivated to attend a CRF. Further research is needed to find out whether the findings apply to women or
to individuals in other treatment settings, such as outpatient care. CRF treatment is intensive, and future
research should assess whether life skills counseling, vocational training, and 12-step meeting attendance
would be as effective in shorter-term, less intensive settings. Although staff ratings at discharge from the
program are likely good indicators of patients' participation in treatment, they ideally should be compared
with patients' perceptions and objective indicators of participation. Aggregating ratings from several staff
members is one potential direction for future research. Another limitation is that our focus was on specific
treatment components and treatment orientation, and we did not have information about non-CRF
treatment, which could have influenced coping. Not withstanding these limitations, it is encouraging that
specific aspects of treatment are associated with improvement in coping one year following treatment.
The work presented here is exploratory, and the findings may lead to future work with more specific
hypotheses and more stringent statistical controls. In addition, given the generally limited prediction of
coping we were able to obtain, future research should identify other treatment- and personal-related
predictors of coping. More information is needed about the specific treatment processes underlying these
findings, and future research should further explore whether any specific treatment orientations are
associated with the specific services that facilitate coping.
 K. Forys et al. / Addictive Behaviors 32 (2007) 1669–1680 1679

4.2. Conclusions

This study identified specific components of treatment beyond patients' baseline characteristics that
predicted increases in alcohol-specific and general approach coping and reductions in general avoidance
coping over a one-year follow-up. Life skills training, 12-step self-help groups, and methods of enhancing
supportive relationships during CRF treatment for alcohol abuse appear to be effective ways to promote
healthy coping. Positive changes in alcohol use appear to be driven both by changes in alcohol-specific
coping and by changes in general approach and/or avoidance coping style.

Acknowledgments

The research was funded in part by the Department of Veterans Affairs Health Services Research and
Development Service and Mental Health and Strategic Health Care Group. The views expressed here are
the authors' and do not necessarily represent the views of the Department of Veterans Affairs.

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