In this secondary analysis, we found that while changes in coping did not differ significantly among women randomized to either single gender versus mixed gender SUD treatment, the relationship between changes in certain types of coping and treatment outcomes were dependent on treatment condition. We also replicated the findings of several other studies investigating the relationship between coping and substance use (e.g., 9, 14
). More specifically, we found that increases in social support were associated with improvements in two out of the three measurements of substance use during the study's 6 month follow-up period. Changes in wishful thinking were also associated with these two outcome measures. As expected, increased use of this coping strategy was correlated with increased substance use.
While these findings are generally consistent with the existing literature, the correlation between increases in problem focused coping and increases in drinking days found in the GDC group was unexpected. In the WRG group this association was in the expected direction with an increase in problem focused coping associated with a decrease in drinking days, but the magnitude of the association was smaller in WRG than GDC. The strengths of these associations are greater in GDC than in WRG for all three scales, suggesting that treatment condition may play an important role in the relationship between changes in coping style and treatment outcomes. Several perspectives on coping may help to explain both the differences in the strength of these associations across treatment condition, as well as the unexpected relationship found between problem focused coping and substance use outcomes.
Given the complex, multi-faceted nature of coping, the Ways of Coping Questionnaire specifically, and other coping inventories more generally, may not capture all possible coping mechanisms related to substance use and recovery. Researchers have argued that coping measures operationalize coping in a narrow way, and the structure of coping remains contested. 29, 30
While our results suggest multiple coping mechanisms are related to substance use outcomes following treatment, it is also important to examine related factors which may be influencing the relationship between changes in coping and treatment outcome.
Researchers have highlighted the importance of examining the events, cognitions, and behaviors leading up to a stressful event. 31-33
Whereas coping strategies have been conceptualized as deliberate actions taken amidst the stressful event, these anticipatory coping mechanisms are more likely to be automatically generated. Some individuals may have developed effective ways of managing the precursors of stressful situations, making conclusions drawn from the examination of effortful responses amidst a stressful episode potentially misleading. 30
Therefore, in the present study, the differences in the magnitude of the relationship between changes and coping and outcome found across treatment condition may be a result of differences or improvements in automatic or anticipatory coping patterns across groups. These potential differences were not adequately captured within the questionnaire.
Examining the timing and effectiveness of coping strategies is also important 30
, such as whether the strategy was used before or after stressor and which specific method or perspective was taken. Unfortunately, some questions from the inventory may also be too broad or ambiguous to capture these aspects of the coping process. For example, one checklist item asks the degree to which the respondent “analyzed the problem in order to understand it better.” The effectiveness of this approach depends on the specific target of the respondent's analysis, the strategy of analysis utilized, and the ability of the respondent to develop and carry out a plan of action following such analysis. While women in WRG and GDC may have both engaged in “analyzing the problem”, they may have been focusing on a different aspect of their substance use, using different tools or perspectives, and may have been more or less able to make changes as a result of their insights. Research in other fields supports this view, suggesting that situational and individual characteristics influence whether problem focused coping is a beneficial or harmful coping strategy.34, 35
Exploring these factors may help to explain the association between increased use of problem focused coping and increased substance use, which was found in the GDC but not WRG group.
Elements of treatment that differed between these two conditions may have also had important influences on the relevance or effectiveness of coping strategies. In addition to providing women-focused content, previous research suggests that the all women's composition of WRG was likely to increase comfort among group members.36
WRG also stressed the need for self-care including the importance of seeking appropriate care and treatment for any co-occurring psychiatric or medical disorders and the importance developing a network of those supportive of sobriety.37
These differences between the GDC and WRG atmosphere and composition could have enhanced the positive effects of changes in coping on treatment outcomes, or made the specific coping strategies less relevant if anticipatory coping processes were utilized.
For example, while both women in WRG and GDC may have sought out the social support of their fellow group members, the support provided in WRG may have been more relevant or effective than the support provided in GDC. In a study conducted by Litman and Stapleton,16
baseline scores on the Coping Behaviors Inventory were not predictive of post-treatment follow-up; however, scores on several scales of a measure which asks participants to indicate the degree to which the same coping behaviors have been effective were predictive. Differences in group atmosphere and composition may also have required GDC group members to actively seek out additional social supports outside of the group in order to successfully reduce their substance use.38, 39
When the Ways of Coping was first developed, Folkman and Lazarus25
highlighted the importance of examining coping over time, as they argued that coping is a dynamic process that is influenced by situational and personal characteristics. Our findings support this view, and also highlight the importance of examining treatment modality as one potential explanation for the differing findings across studies of coping among SUD populations. A recent review of the reliability of the Ways of Coping also underlines the importance of reporting reliability coefficients for individual subscales as well as the importance of examining reliability across certain populations such as women, both of which were addressed in the current study 21
The small sample size, particularly in GDC, is an obvious limitation of this study. However, several sources point to the value of conducting such analyses despite this limitation. The Institute of Medicine40
provides guidelines to maximize information from small trials in order to obtain more reliable and valid results. They recommend several statistical approaches including the use of repeated measures. When the within subject correlation is properly incorporated, the repeated measures analysis takes full advantage of all information obtained from each subject, thereby greatly increasing statistical power over methods that compare groups univariately.41
Additionally, Clarke and Wheaton42
showed that, when using repeated measures designs, only a small bias in estimates of standard errors when the number of participants per group is 5 or more. As a rule of thumb, Van Voorhis and Morgan43
recommend a minimum of 7 participants per group in the assessment of group differences, which matches with the number of participants in the smaller treatment condition (GDC). Finally, as previously reported we observed no substantial outliers or influential observations.
Our results reinforce the importance of treating coping as a multidimensional construct. They also suggest that coping may have an important interactive effect with treatment approach, where changes in coping may not vary based on treatment condition but the effect that changes in coping has on outcomes may be dependent on treatment condition. Overall, we found that changes in coping had less of an effect on outcome for women participating in a women's specific treatment for SUDs, indicating that such treatment may provide additional supports that make coping strategies more effective or less central to the recovery process. For women participating in mixed gender treatment, changes in certain types of coping, including wishful thinking and seeking social support, were associated with positive outcomes while changes in problem focused coping were not. This suggests that focus on changing coping strategies may be a more central benefit of the mixed gender treatment context, but that more attention should be paid to the specific strategies utilized by participants as well as their effectiveness. Taken together, further study of contextual factors that may influence the use and effectiveness of coping strategies is necessary, and should take into account treatment modality.