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 and accomodative 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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