Addictive Behaviors 48 (2015) 30–35
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Addictive Behaviors
Difficulties in emotion regulation and problem drinking in young women: The mediating effect of metacognitions about alcohol use Małgorzata Dragan ⁎ Faculty of Psychology, University of Warsaw, ul. Stawki 5/7, 00-183 Warsaw, Poland
H I G H L I G H T S • • • •
Emotion dysregulation, metacognitions and alcohol use in young women were examined. Metacognition may be a mediator between emotion dysregulation and problem drinking. Positive metacognitions fully mediate between emotion dysregulation and drinking. Drinking in young people relates to positive expectation concerning self-regulation.
a r t i c l e
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Available online 22 April 2015 Keywords: Alcohol abuse Emotion dysregulation Metacognitions about alcohol use Problem drinking Structural equation modeling
a b s t r a c t Introduction: The aim of the current study was to examine, in a sample of women aged 18 25, the association between difficulties in emotion regulation, metacognitions about alcohol use and problem drinking. According to metacognitive model of problem drinking, it was assumed that metacognitions are potential mediators in the relationship between emotional dysregulation and problem drinking. Methods: A total sample of 502 women was recruited. They were administered a questionnaire identifying problem drinking (AUDIT), the Difficulties in Emotion Regulation Scale (DERS) and two scales measuring metacognitions about alcohol use: the Positive Alcohol Metacognitions Scale (PAMS) and the Negative Alcohol Metacognitions Scale (NAMS). A structural equation model of the relationships between emotional dysregulation and problem drinking – including a mediating role of metacognitions concerning alcohol use – was tested. Results: No direct association between emotional dysregulation and problem drinking was observed. A relationship between those variables became apparent once metacognitions were considered as a mediator; however, only positive metacognitions about alcohol use emerged as a significant predictor of drinking behavior, and as a full mediator of the relationship between emotion dysregulation and problem drinking. Conclusions: The results provide evidence for a metacognitive conceptualization of problem drinking. They emphasize the role of positive metacognitions about alcohol use. However, this result could be age-specific; it confirms previous findings that, in samples of young people, drinking is primarily related to positive metacognitions concerning cognitive emotional self-regulation. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction 1.1. Alcohol use and emotion regulation Many researchers state that emotions and their regulation are central to human life (Philippot & Feldman, 2013). This notion applies also to problem drinking and, more broadly, to the phenomenon of substance use. It is often underlined that the majority of theories of drinking behavior and alcohol problems accord an important, even central, role to emotional factors, and that understanding the relationship between the emotions and alcohol use is a fundamental theoretical issue (Lang, ⁎ Tel.: +48 225549761. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.addbeh.2015.04.008 0306-4603/© 2015 Elsevier Ltd. All rights reserved.
Patrick, & Stritzke, 1999). It is thought that while not all consumption of alcohol is prompted by exclusively emotional motives, the desire to regulate both positive and negative emotions is a major motivation. Apart from enhancing positive emotions, alcohol is very often used to alter negative emotions; however, its emotional impact is diffuse and nonselective. Thus, it is assumed that alcohol is one of the psychoactive substances which can be used to regulate emotion, and that the drinking of alcohol with the aim of influencing emotional state may be perceived as a strategy of emotion regulation. Emotion regulation is a complex construct for which no commonly acclaimed definition nor consensus upon its core features exists (Thompson, Lewis, & Calkins, 2008). Gross (1998) relates this concept to the intrinsic and extrinsic processes by which people influence which emotions they have, when they have them, and how they
M. Dragan / Addictive Behaviors 48 (2015) 30–35
experience and express them. Within the field of clinical psychology, the discussion focuses on core aspects of emotion regulation, seen as a potentially unifying function of diverse symptom presentations and maladaptive behaviors. Gratz and Roemer (2004) reviewed the literature on conceptualizations of emotion regulation, and noticed that while some of them emphasize the control of emotional experience and expression along with the reduction of emotional arousal, others underline the primarily functional nature of emotions. According to this second group of conceptualizations, emotion regulation is not a synonym for emotional control and is not necessarily associated with immediate reduction of negative affect. The authors have proposed their own conceptualization of the core aspects of emotion regulation, including: (a) awareness and understanding of emotions, (b) acceptance of emotions, (c) ability to control impulsive behaviors and to behave in accordance with desired goals when experiencing negative emotions, and (d) ability to make flexible use of situationally appropriate emotion regulation strategies, with the aim of modulating emotional responses. According to this multidimensional model, emotional dysregulation, or difficulties in emotion regulation, are related to the absence of any or all of these abilities. The model describes processes engaged in the general ability to regulate emotions, not specifically within the context of alcohol use. However, research confirms that difficulties in emotion regulation are broadly associated not only with the symptoms of emotional disorder but also with the problematic use of alcohol and with alcoholrelated consequences (Berking et al., 2011; Dvorak et al., 2014). 1.2. Alcohol use and metacognitively directed cognitive–emotional regulation Recent conceptualizations of alcohol use in terms of cognitive– emotional regulation emphasize the role of metacognition (Spada, Caselli, & Wells, 2013; Spada & Wells, 2005, 2009). The concept of metacognition refers to the aspect of cognitive processing being responsible for the monitoring, evaluation, interpretation and regulation of the content of cognitions, and also for its own organization (Moses & Biard, 1999). It is assumed that since metacognition fulfills an executive function with regard to cognitive processing, it also plays a contributory role in emotion regulation (Wells, 2000). From this standpoint, the role of metacognitive beliefs is central to the development and persistence of emotional dysfunction. Spada and co-authors, in several publications (e.g. Spada, Caselli, Nikčević, & Wells, 2015; Spada et al., 2013; Spada & Wells, 2005, 2009), conceptualized the role of metacognition in problematic alcohol use and other addictive behaviors. The authors identified specific metacognitions about alcohol use and examined their association with drinking behavior (e.g. Spada, Zandvoort, & Wells, 2007). Such beliefs are thought to play a central role in motivating individuals to engage in alcohol use as a means of cognitive–emotional regulation. Two types of metacognitions about alcohol use are distinguished: positive and negative. Positive metacognitions are conceptualized as a specific form of expectancy relating to the use of alcohol as a means of controlling and regulating cognition and emotion (e.g. “Drinking helps me to control my thoughts”, “Drinking reduces my anxious feelings”). Negative metacognitions concern the perception of lack of executive control over alcohol use (e.g. “My drinking persists no matter how I try to control it”). Positive metacognitions are thought to play a central role in motivating individuals to engage in alcohol use as a means of affect regulation, whereas negative beliefs play a crucial role in the perpetuation of alcohol use (Spada & Wells, 2006, 2009). Thus, positive metacognitions about alcohol use are considered to be particularly important in the developing phase of problematic alcohol use (Spada & Wells, 2010). However, regular alcohol use is also associated with the activation of negative beliefs during and following a drinking episode; furthermore, activated beliefs trigger negative emotional states that compel a person to drink more (Spada, Moneta, & Wells, 2007). Spada and Wells (2009) and Spada et al. (2013), in their metacognitive model of problem drinking emphasize that alcohol use,
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in problem drinking, is a metacognitive control strategy that becomes poorly regulated mainly due to activation of the set of symptoms termed cognitive–attentional syndrome (CAS). CAS is a style of managing thoughts and emotions, involving extended thinking (e.g. worry and rumination), threat monitoring, and such maladaptive coping strategies as avoidance and thought suppression. According to the metacognitive theory, CAS prolongs and intensifies negative emotional experience and is derived from underlying dysfunctional metacognition, being responsible for ineffective cognitive–emotional self-regulation. It is also seen as a “common core” of various categories of emotional disorder, and therefore a unifying construct describing the basic self-regulation mechanisms underlying various forms of psychopathology. Thus, general emotion dysregulation can be seen as a manifestation or consequence of CAS, and as reflecting underlying dysfunctional metacognition. In problem drinking, specific metacognitions about alcohol use and the way this substance is actually used are related to the general difficulties in emotion regulation, being a sign of impaired self-regulation (Spada & Wells, 2009). Namely, metacognitions about alcohol use provide the incentive for using alcohol as a specific strategy to cope with emotion and cognition (metacognitive positive beliefs about alcohol use), and, subsequently, for perpetuating this strategy (metacognitive negative beliefs about alcohol use), so giving rise to alcohol use problems. Therefore, the main goal of the current study was to examine a relatively simple model of the relationship between general emotional dysregulation and problem drinking, including the potentially mediating role of metacognitions about alcohol use. 2. Material and methods 2.1. Sample characteristics and procedure A study was conducted on the sample of young females, taking into account several aspects related to alcohol use patterns and emotion regulation. Research confirms consistent gender differences in patterns of alcohol use (Holmila & Raitasalo, 2005; Wilsnack et al., 2000). Young age is indicated as an important risk factor for alcohol-related problems, and the rates of alcohol misuse in samples of women in higher education are described as “alarmingly high”. Some researchers (e.g. Stappenbeck, Bedard-Gilligan, Lee, & Kaysen, 2013) emphasize that in order to develop prevention programs and appropriate interventions it is crucial to understand which women are at the highest risk of drinking to cope with negative emotions. This is particularly true in the light of the literature indicating that gender is also one of the factors potentially influencing emotion regulation. Research shows that this variable, along with age, affects the extent and the way in which emotions are regulated (Aldao & Nolen-Hoeksema, 2011); however, studies on gender-related differences in the use of specific emotion-regulation strategies are scarce (Kwon, Yoon, Joormann, & Kwon, 2013). Differences between men and women are also underexplored in studies on the role of metacognition in problematic alcohol use (Clark et al., 2012). Taking into account the context of research on gender-related and age-related differences in emotion regulation, and also patterns of alcohol use, the principal aim of current study was to test associations between emotional dysregulation and problem drinking among young women, including in the model metacognitions about alcohol use. A total sample of 502 young women were recruited, via advertisements distributed mainly at academic sites or (additionally) through a social networking service (Facebook sites of academic departments). An exclusion criterion was being a student of psychology; inclusion criteria were gender (female) and age (18–25 years). The mean age was M = 21.78 (SD = 1.84). The vast majority of the participants (99%) declared their nationality as Polish (the remaining 1% were Ukrainian or Swedish). Also, the vast majority (96%) were single (0.4% were married; the remaining marked the answer “other”). More than half the sample (54.6%) had received education to secondary level; 19.5% had a Bachelor's degree; 13.9% were enrolled in Master's degree
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M. Dragan / Addictive Behaviors 48 (2015) 30–35
programs; and 8.2% held a Master's degree. Participation in the study was voluntary; participants were informed of the objectives and procedure, and also gave their informed consent. They completed the questionnaires individually; following completion, they were paid the equivalent of US$10. The study was approved by the Research Ethics Committee at the Faculty of Psychology, University of Warsaw. 2.2. Measures In the course of psychological assessment, a battery of measures was administered to participants, including the following questionnaires. The Alcohol Use Disorders Identification Test (AUDIT). This popular and widely used instrument was developed as a screening tool by the World Health Organization (WHO) for early identification of problem drinkers (Babor, de la Fuente, Saunders, & Grant, 1992). It also possesses good psychometric properties (Hester & Miller, 1995). AUDIT consists of ten questions regarding recent alcohol consumption, alcohol dependence symptoms and alcohol-related problems. The summary score ranges from zero, indicating no presence of problem drinking behavior, to 40 indicating marked levels of problem drinking behavior. The threshold for indicating possible (moderate) drinking problems is a score of eight. Research show that this is a valid measure in identifying individuals with alcohol drinking problems (Clements, 1998). In the present investigation, the total AUDIT score was used to index alcohol use problems. Cronbach's alpha for the total AUDIT score was .81. The Difficulties in Emotion Regulation Scale (DERS) is a brief (36-item) self-report questionnaire, developed by Gratz and Roemer (2004) to assess multiple aspects of emotion dysregulation. DERS items focus primarily on the regulation of negative emotional states. The measure yields a total score as well as scores on six subscales, ultimately derived via factor analysis: (1) non-acceptance of emotional responses (Nonacceptance), (2) difficulties engaging in goal directed behavior (Goals), (3) impulse control difficulties (Impulse), (4) lack of emotional awareness (Awareness), (5) limited access to emotion regulation strategies (Strategies), and (6) lack of emotional clarity (Clarity). Problems in any of these areas are indicative of emotion regulation difficulties. The findings suggest that the DERS has high internal consistency, good test–retest reliability and adequate construct and predictive validity (Gratz & Roemer, 2004). In the current study, the total score, together with the six subscales, were used to index difficulties in emotion regulation. Cronbach's alpha for the total DERS score was .93. The Positive Alcohol Metacognitions Scale (PAMS). PAMS is a 12-item measure developed to assess positive metacognitions about alcohol use (Spada & Wells, 2008). It consists of two factors: (1) positive metacognitions about emotional self-regulation through drinking, and (2) positive metacognitions about cognitive self-regulation through drinking. Results from validation studies (Spada & Wells, 2008; Spada et al., 2007) suggest that PAMS possesses good psychometric properties. In the current study, the total score was used as an index of positive metacognitions about alcohol use. Cronbach's alpha for the total PAMS score was .85. The Negative Alcohol Metacognitions Scale (NAMS). NAMS is a 6-item measure developed to assess negative metacognitions about alcohol use (Spada & Wells, 2008). It consists of two factors: (1) negative metacognitions about uncontrollability of drinking, and (2) negative metacognitions about cognitive harm due to drinking. Results from validation studies (Spada & Wells, 2008; Spada et al., 2007) suggest that NAMS possesses good psychometric properties. In the current study, the total score was used as an index of negative metacognitions about alcohol use. Cronbach's alpha for the total NAMS score was .67. 2.3. Statistical analyses Data analysis was performed using the PASW Statistics 21.0 (S.P.S.S. Inc., 2012) and AMOS 21.0 (Arbuckle, 2012) software packages. The missing data rate did not exceed 1%. In order to test the relationship between
difficulties in emotion regulation, metacognitions about alcohol use, and problem drinking, the structural equation modeling technique (SEM) was employed, using the maximum likelihood method. In SEM, the proposed hypothesized model is evaluated for goodness of fit with actual observations in the sample data (Byrne, 2010). Since experts recommend reporting a variety of fit indicators to permit the making of comparisons (Ullman, 2007), the following were used to evaluate the model: chisquare, chi-square/df ratio, comparative fit index (CFI), root mean square of approximation (RMSEA), generalized fit index (GFI). 3. Results Of the entire sample, 31.5% of participants (n = 158) had AUDIT scores greater than eight; 18.7% scored over ten. Two-tailed Pearson product–moment correlations showed that the scores on this scale correlated positively both with negative and with positive metacognitions about alcohol use. Problem drinking (AUDIT) was also positively correlated with all six dimensions of emotion dysregulation, however the size of coefficients was not large, ranging from .10 for Awareness to .25 for Clarity. Descriptive statistics for all study variables – including mean scores, standard deviations, and correlation coefficients – are shown in Table 1. Fig. 1 is a visualization of the structural model identified, resulting from SEM analysis. Standardized estimates are reported. Due to theoretical considerations, correlations were permitted between measurement errors for the emotional dysregulation subscales, as well as for the scales measuring metacognitions about alcohol use. Despite χ2 being statistically significant [χ2(24) = 43.52, p b .01], other fit values for the model fall within acceptable ranges, suggesting a good fit for the model: χ2/n = 1.81, CFI = .97; RMSEA = .05; GFI = .97. Difficulties in emotion regulation were significantly predictive for both positive and negative metacognitions about alcohol use. They accounted for 12% of the variance in positive metacognitions, and 2% of the variance in negative metacognitions. However, whereas positive metacognitions were significantly predictive for drinking behavior – accounting for 22% of total variance – no statistically significant association was observed between negative metacognitions and drinking behavior. Positive metacognitions therefore emerged as fully mediating the relationship between emotional deregulation and problem drinking. No direct association between the latter two variables was observed. Fig. 1 also depicts a unique contribution of individual subscales (dimensions) as indicators of the global factor of difficulties in emotion regulation. The respective significant standardized parameter estimates ranged from .16, p b .01 for Awareness to .86, p b .001 for Strategies, indicating that this last dimension is the largest contributor to the global factor. 4. Discussion The study aimed to test presumed associations among young women between: general difficulties in emotion regulation, metacognitions about alcohol use, and problem drinking. The theoretical assumptions for the proposed model referring to the concept of emotion self-regulation and the metacognitive formulation of problem drinking (Spada et al., 2013) included an assumption that emotional deregulation reflects the presence of CAS and dysfunctional metacognition, being the basis for the development of specific metacognitions about alcohol use, so leading to further growth in alcohol use problems. Interestingly, within the tested model no direct association between emotional dysregulation and drinking behavior was observed. A relationship between those two variables only became apparent once metacognitions were taken into consideration as a mediator. This result is in line with the metacognitive formulation of problem drinking, suggesting a crucial role for specific metacognitions about alcohol use. However, the identified model, while being generally well-fitting, differs from the presumed model, indicating a specific role for just one of
M. Dragan / Addictive Behaviors 48 (2015) 30–35
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Table 1 Means, standard deviations, and two-tailed Pearson correlations of the study variables. Variables
M
1
2
3
1. Problem drinking (AUDIT) 2. Positive metacognitions about alcohol use (PAMS) 3. Negative metacognitions about alcohol use (NAMS)
7.04 25.72 10.63
SD 4.63 6.62 3.35
– .47⁎⁎⁎ ns
– .24⁎⁎⁎
–
Difficulties in emotion regulation (DERS) 4. Non-acceptance 5. Goals 6. Impulse 7. Awareness 8. Strategies 9. Clarity 10. Total score
13.69 15.08 12.70 13.13 18.47 10.27 83.32
5.31 4.65 4.67 3.18 6.40 2.98 19.78
.16⁎⁎⁎ .12⁎⁎ .24⁎⁎⁎ .10⁎ .21⁎⁎⁎ .25⁎⁎⁎ .25⁎⁎⁎
.33⁎⁎⁎ .30⁎⁎⁎ .35⁎⁎⁎ ns .27⁎⁎⁎ .27⁎⁎⁎ .39⁎⁎⁎
.17⁎⁎⁎ .14⁎⁎ ns ns ns .08⁎ .14⁎⁎
4
5
6
7
8
9
– .43⁎⁎⁎ .47⁎⁎⁎ .15⁎⁎ .57⁎⁎⁎ .41⁎⁎⁎ .75⁎⁎⁎
– .60⁎⁎⁎ ns .61⁎⁎⁎ .34⁎⁎⁎ .75⁎⁎⁎
– .17⁎⁎ .62⁎⁎⁎ .40⁎⁎⁎ .79⁎⁎⁎
– .15⁎⁎ .35⁎⁎⁎ .35⁎⁎⁎
– .50⁎⁎⁎ .88⁎⁎⁎
– .65⁎⁎⁎
ns — non-significant. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.
the two types of metacognitions about alcohol use, having been linked by Spada and co-authors (Spada & Wells, 2006, 2009; Spada et al., 2013) to problem drinking. Only positive metacognitions about alcohol use turned out to be a significant predictor of drinking behavior and, moreover, a full mediator of the relationship between emotion dysregulation and problem drinking. According to the triphasic model (Spada et al., 2013), a crucial role in alcohol-use related problems belongs to the metacognitively directed dysfunctional process of self-regulation, manifesting as CAS. Positive metacognitions about alcohol use – constituting a specific type of expectancies relating to the psychological effects of alcohol – contribute to cognitive–emotional regulation (Spada et al., 2007), so motivating the individual to cope with negative affect by means of alcohol consumption. Therefore, the association of such beliefs with more general difficulties in emotion regulation is not surprising; this is in line with previous research by Spada and Wells (2009), and also accords with the results of research on deficits in emotion regulation and alcohol use (Berking et al., 2011; Dvorak et al., 2014). However, the second category of metacognitions – negative metacognitions about alcohol use – was not predictive for problem drinking in the studied sample. These beliefs refer to the negative impact of alcohol use, and are thought to play a crucial role in its perpetuation. Such a result may be explained by the fact that the study focused on drinking behavior in a specific group: young women. Research shows that, in Europe and North America at least, alcohol use in general, and heavy drinking in
particular, is highly prevalent among adolescents and young adults, including young females (Grant et al., 2004); the same reports show that it declines as individuals grow older and develop an increasing sense of social responsibility. Results from the current study confirm these findings. As defined by the AUDIT cut-off scores, a high prevalence of problem drinking is indicated: more than 30% of participants had a score of greater than eight, while almost 20% exceeded a score of ten. However, these results may also suggest that drinking at this age, independent of gender, is primary related to generally positive motivations, including positive expectations regarding cognitive–emotional selfregulation. From the metacognitive perspective, those having more positive beliefs about alcohol use are more prone to develop alcohol use problems. However, the crucial role in developing an alcohol use disorder belongs to negative beliefs, conceptualized also as a specific level of cognitive self-efficacy and negative alcohol expectancy (Spada & Wells, 2006, 2009). These beliefs may reflect the process of development of the disorder, since they refer to the perceived negative impact of alcohol consumption related to uncontrollability. Therefore in the current sample the effects related to negative metacognitions about alcohol use may, due to the young age of the participants, be as yet unobserved. It may be assumed that in some participants these processes escalate over time, most likely for those whose cognitive–emotional self-regulation is the most impaired. This supposition is in line with previous findings of Spada and Wells (2010), indicating that while both
.22**
e3
r1
e4
e2
PAMS Nonacceptance
Impulse
.71***
.64***
Goals
Emotional dysregulation Awareness
.16**
.47***
.35***
.69***
.14*
.56*** .86***
Problem drinking
.14* e1
e7
Clarity
Strategies NAMS
.26***
e6
e5
r2
Fig. 1. Standardized equation model of associations between difficulties in emotion regulation, metacognitions about alcohol use, and problem drinking in the sample of young women (N = 502). Note: *p b .05, **p b .01, ***p b .001; PAMS — positive metacognitions about alcohol use; NAMS — negative metacognitions about alcohol use; e and r enclosed in circles indicate error representing measurement error.
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M. Dragan / Addictive Behaviors 48 (2015) 30–35
problem drinkers and alcohol dependent drinkers score higher than non-drinkers on positive metacognitions about alcohol use, significant predictors of alcohol dependence are negative metacognitions about uncontrollability and depression. This is consistent with the recent formulation of problem drinking by Spada and Wells (2009) and Spada et al. (2013), who underline the primary role of CAS in the process of development and maintenance of problem drinking. According to this model, CAS and underlying positive metacognitions about extended thinking, triggered by alcohol-related stimuli, escalate negative affect and cravings, strengthening negative metacognitions about the need to control thoughts; the latter beliefs enhance the likelihood of further alcohol use. From among the six dimensions distinguished by Gratz and Roemer (2004), the largest contribution within the global factor of emotion dysregulation was observed for limited access to emotion regulation strategies (Fig. 1), followed by, in declining order: impulse control difficulties, difficulties engaging in goal-directed behavior, non-acceptance of emotional responses, and lack of emotional clarity. Lack of emotional awareness had the lowest contribution, indicating that this kind of difficulty is of low importance for self-regulation through drinking in the studied sample relative to, for example, non-acceptance of emotions, or else having a clear understanding of their nature. This pattern of difficulties in emotion regulation is similar to previous findings from a study on a large sample of college students, conducted using the same scale (DERS). Dvorak et al. (2014), among others, have shown that the number of alcohol-related consequences is positively associated with non-acceptance of emotional responses, impulse control difficulties, lack of emotional clarity, and difficulties engaging in goal-directed behavior. However, in the current study it emerged that it is the limited access to emotion regulation strategies which drives the motivation to cope through the use of alcohol. This suggests that alcohol use is primarily a substitute strategy, used for gaining temporary relief in face of aroused negative emotional states, should access to other strategies be limited. This is in line with previous findings exploring associations between negative affect and drinking, and also with such theories as the experiential avoidance model of deliberate self-harm by Chapman, Gratz, and Brown (2006), treating substance abuse as a maladaptive strategy of self-regulation, based on emotion avoidance. On the other hand, the relatively high contribution of ‘difficulties engaging in goaldirected behavior’ factor in the current study may be seen as being in line with results of studies on conscientiousness, one of ‘the Big 5’ factors. This factor has been consistently found to be associated with alcohol use and misuse; also Clark et al. (2012) confirm that conscientiousness, along with positive metacognitions about alcohol use, significantly predicts the level of alcohol consumption in male binge drinking students. According to the authors, conscientiousness relates to the awareness about personal goals, their planning, and the monitoring of their achievement, thus shares common ground with ‘metacognitive monitoring’, comprising of monitoring of cognitive– emotional change and proximity to goals as drinking proceeds. The identified model suggests that certain patterns of difficulties in emotion regulation – with the limited access to emotion regulation strategies as the strongest contributor, and the lack of emotional awareness as the weakest – are predictive for positive metacognitions about alcohol use, and, to the lesser extent, for negative metacognitions about alcohol use. It may be assumed that this pattern is specific for problem drinking in young adults; however, such a generalization must be heavily qualified, for the obvious reason that the current study included female participants only. Thus the observed associations may be gender-specific, or even dependent on both gender and cultural differences (Kwon et al., 2013). The fact that studies on gender differences in the use of specific emotion regulation strategies are generally scarce suggests that testing the hypothesized model on a sample of males in future research would be all the more worthwhile. In order to determine their relationship in the model with emotional dysregulation and specific metacognitions about alcohol use, it would also be
worth including measures strictly relating to the symptoms of cognitive–attentional syndrome and general maladaptive metacognition,. Finally, it must be underlined that the principal weakness of this study – one restricting the possibility of generalization and, in particular, the drawing of conclusions regarding causality – lies in the crosssectional nature of its design, and also the correlational nature of the examined model. However, the results, being in line with metacognitive formulation of problem drinking, may be seen as supporting the notion that interventions aimed at metacognitive change and extending the repertoire of strategies relating to cognitive–emotional regulation, such as verbal reattribution of metacognitions about alcohol use or Situational Attentional Refocusing (Wells, 2000), can be helpful in the process of treatment. 4.1. Conclusions The results of the present study provide evidence for the metacognitive conceptualization of problem drinking in a sample of young women. They show that metacognitions about alcohol use are predictive for problem drinking; however, a direct association between emotion dysregulation and problem drinking was not observed. In particular, the findings strengthen the validity of one category of such metacognitions: positive metacognitions about alcohol use. These turned out to be a full mediator of the relationship between emotion dysregulation and problem drinking. Difficulties in emotion regulation were in turn predictive of metacognitions about alcohol use, and had the strongest bearing on limited access to emotion regulation strategies. However, it may be that the results are not only gender-specific, but also age-specific, since negative metacognitions about alcohol use may become increasingly important over time in the development of alcohol use problems. Role of funding sources The study was supported by the Ministry of Science and Higher Education Iuventus Plus grant no. 0105/IP3/2011/71. Contributors The manuscript was written by the author. Conflict of interest There are no conflicts of interest to declare. Acknowledgments This study was supported by Ministry of Science and Higher Education Iuventus Plus grant no. 0105/IP3/2011/71.
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Contents lists available at ScienceDirect
Addictive Behaviors
Difficulties in emotion regulation and problem drinking in young women: The mediating effect of metacognitions about alcohol use Małgorzata Dragan ⁎ Faculty of Psychology, University of Warsaw, ul. Stawki 5/7, 00-183 Warsaw, Poland
H I G H L I G H T S • • • •
Emotion dysregulation, metacognitions and alcohol use in young women were examined. Metacognition may be a mediator between emotion dysregulation and problem drinking. Positive metacognitions fully mediate between emotion dysregulation and drinking. Drinking in young people relates to positive expectation concerning self-regulation.
a r t i c l e
i n f o
Available online 22 April 2015 Keywords: Alcohol abuse Emotion dysregulation Metacognitions about alcohol use Problem drinking Structural equation modeling
a b s t r a c t Introduction: The aim of the current study was to examine, in a sample of women aged 18 25, the association between difficulties in emotion regulation, metacognitions about alcohol use and problem drinking. According to metacognitive model of problem drinking, it was assumed that metacognitions are potential mediators in the relationship between emotional dysregulation and problem drinking. Methods: A total sample of 502 women was recruited. They were administered a questionnaire identifying problem drinking (AUDIT), the Difficulties in Emotion Regulation Scale (DERS) and two scales measuring metacognitions about alcohol use: the Positive Alcohol Metacognitions Scale (PAMS) and the Negative Alcohol Metacognitions Scale (NAMS). A structural equation model of the relationships between emotional dysregulation and problem drinking – including a mediating role of metacognitions concerning alcohol use – was tested. Results: No direct association between emotional dysregulation and problem drinking was observed. A relationship between those variables became apparent once metacognitions were considered as a mediator; however, only positive metacognitions about alcohol use emerged as a significant predictor of drinking behavior, and as a full mediator of the relationship between emotion dysregulation and problem drinking. Conclusions: The results provide evidence for a metacognitive conceptualization of problem drinking. They emphasize the role of positive metacognitions about alcohol use. However, this result could be age-specific; it confirms previous findings that, in samples of young people, drinking is primarily related to positive metacognitions concerning cognitive emotional self-regulation. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction 1.1. Alcohol use and emotion regulation Many researchers state that emotions and their regulation are central to human life (Philippot & Feldman, 2013). This notion applies also to problem drinking and, more broadly, to the phenomenon of substance use. It is often underlined that the majority of theories of drinking behavior and alcohol problems accord an important, even central, role to emotional factors, and that understanding the relationship between the emotions and alcohol use is a fundamental theoretical issue (Lang, ⁎ Tel.: +48 225549761. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.addbeh.2015.04.008 0306-4603/© 2015 Elsevier Ltd. All rights reserved.
Patrick, & Stritzke, 1999). It is thought that while not all consumption of alcohol is prompted by exclusively emotional motives, the desire to regulate both positive and negative emotions is a major motivation. Apart from enhancing positive emotions, alcohol is very often used to alter negative emotions; however, its emotional impact is diffuse and nonselective. Thus, it is assumed that alcohol is one of the psychoactive substances which can be used to regulate emotion, and that the drinking of alcohol with the aim of influencing emotional state may be perceived as a strategy of emotion regulation. Emotion regulation is a complex construct for which no commonly acclaimed definition nor consensus upon its core features exists (Thompson, Lewis, & Calkins, 2008). Gross (1998) relates this concept to the intrinsic and extrinsic processes by which people influence which emotions they have, when they have them, and how they
M. Dragan / Addictive Behaviors 48 (2015) 30–35
experience and express them. Within the field of clinical psychology, the discussion focuses on core aspects of emotion regulation, seen as a potentially unifying function of diverse symptom presentations and maladaptive behaviors. Gratz and Roemer (2004) reviewed the literature on conceptualizations of emotion regulation, and noticed that while some of them emphasize the control of emotional experience and expression along with the reduction of emotional arousal, others underline the primarily functional nature of emotions. According to this second group of conceptualizations, emotion regulation is not a synonym for emotional control and is not necessarily associated with immediate reduction of negative affect. The authors have proposed their own conceptualization of the core aspects of emotion regulation, including: (a) awareness and understanding of emotions, (b) acceptance of emotions, (c) ability to control impulsive behaviors and to behave in accordance with desired goals when experiencing negative emotions, and (d) ability to make flexible use of situationally appropriate emotion regulation strategies, with the aim of modulating emotional responses. According to this multidimensional model, emotional dysregulation, or difficulties in emotion regulation, are related to the absence of any or all of these abilities. The model describes processes engaged in the general ability to regulate emotions, not specifically within the context of alcohol use. However, research confirms that difficulties in emotion regulation are broadly associated not only with the symptoms of emotional disorder but also with the problematic use of alcohol and with alcoholrelated consequences (Berking et al., 2011; Dvorak et al., 2014). 1.2. Alcohol use and metacognitively directed cognitive–emotional regulation Recent conceptualizations of alcohol use in terms of cognitive– emotional regulation emphasize the role of metacognition (Spada, Caselli, & Wells, 2013; Spada & Wells, 2005, 2009). The concept of metacognition refers to the aspect of cognitive processing being responsible for the monitoring, evaluation, interpretation and regulation of the content of cognitions, and also for its own organization (Moses & Biard, 1999). It is assumed that since metacognition fulfills an executive function with regard to cognitive processing, it also plays a contributory role in emotion regulation (Wells, 2000). From this standpoint, the role of metacognitive beliefs is central to the development and persistence of emotional dysfunction. Spada and co-authors, in several publications (e.g. Spada, Caselli, Nikčević, & Wells, 2015; Spada et al., 2013; Spada & Wells, 2005, 2009), conceptualized the role of metacognition in problematic alcohol use and other addictive behaviors. The authors identified specific metacognitions about alcohol use and examined their association with drinking behavior (e.g. Spada, Zandvoort, & Wells, 2007). Such beliefs are thought to play a central role in motivating individuals to engage in alcohol use as a means of cognitive–emotional regulation. Two types of metacognitions about alcohol use are distinguished: positive and negative. Positive metacognitions are conceptualized as a specific form of expectancy relating to the use of alcohol as a means of controlling and regulating cognition and emotion (e.g. “Drinking helps me to control my thoughts”, “Drinking reduces my anxious feelings”). Negative metacognitions concern the perception of lack of executive control over alcohol use (e.g. “My drinking persists no matter how I try to control it”). Positive metacognitions are thought to play a central role in motivating individuals to engage in alcohol use as a means of affect regulation, whereas negative beliefs play a crucial role in the perpetuation of alcohol use (Spada & Wells, 2006, 2009). Thus, positive metacognitions about alcohol use are considered to be particularly important in the developing phase of problematic alcohol use (Spada & Wells, 2010). However, regular alcohol use is also associated with the activation of negative beliefs during and following a drinking episode; furthermore, activated beliefs trigger negative emotional states that compel a person to drink more (Spada, Moneta, & Wells, 2007). Spada and Wells (2009) and Spada et al. (2013), in their metacognitive model of problem drinking emphasize that alcohol use,
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in problem drinking, is a metacognitive control strategy that becomes poorly regulated mainly due to activation of the set of symptoms termed cognitive–attentional syndrome (CAS). CAS is a style of managing thoughts and emotions, involving extended thinking (e.g. worry and rumination), threat monitoring, and such maladaptive coping strategies as avoidance and thought suppression. According to the metacognitive theory, CAS prolongs and intensifies negative emotional experience and is derived from underlying dysfunctional metacognition, being responsible for ineffective cognitive–emotional self-regulation. It is also seen as a “common core” of various categories of emotional disorder, and therefore a unifying construct describing the basic self-regulation mechanisms underlying various forms of psychopathology. Thus, general emotion dysregulation can be seen as a manifestation or consequence of CAS, and as reflecting underlying dysfunctional metacognition. In problem drinking, specific metacognitions about alcohol use and the way this substance is actually used are related to the general difficulties in emotion regulation, being a sign of impaired self-regulation (Spada & Wells, 2009). Namely, metacognitions about alcohol use provide the incentive for using alcohol as a specific strategy to cope with emotion and cognition (metacognitive positive beliefs about alcohol use), and, subsequently, for perpetuating this strategy (metacognitive negative beliefs about alcohol use), so giving rise to alcohol use problems. Therefore, the main goal of the current study was to examine a relatively simple model of the relationship between general emotional dysregulation and problem drinking, including the potentially mediating role of metacognitions about alcohol use. 2. Material and methods 2.1. Sample characteristics and procedure A study was conducted on the sample of young females, taking into account several aspects related to alcohol use patterns and emotion regulation. Research confirms consistent gender differences in patterns of alcohol use (Holmila & Raitasalo, 2005; Wilsnack et al., 2000). Young age is indicated as an important risk factor for alcohol-related problems, and the rates of alcohol misuse in samples of women in higher education are described as “alarmingly high”. Some researchers (e.g. Stappenbeck, Bedard-Gilligan, Lee, & Kaysen, 2013) emphasize that in order to develop prevention programs and appropriate interventions it is crucial to understand which women are at the highest risk of drinking to cope with negative emotions. This is particularly true in the light of the literature indicating that gender is also one of the factors potentially influencing emotion regulation. Research shows that this variable, along with age, affects the extent and the way in which emotions are regulated (Aldao & Nolen-Hoeksema, 2011); however, studies on gender-related differences in the use of specific emotion-regulation strategies are scarce (Kwon, Yoon, Joormann, & Kwon, 2013). Differences between men and women are also underexplored in studies on the role of metacognition in problematic alcohol use (Clark et al., 2012). Taking into account the context of research on gender-related and age-related differences in emotion regulation, and also patterns of alcohol use, the principal aim of current study was to test associations between emotional dysregulation and problem drinking among young women, including in the model metacognitions about alcohol use. A total sample of 502 young women were recruited, via advertisements distributed mainly at academic sites or (additionally) through a social networking service (Facebook sites of academic departments). An exclusion criterion was being a student of psychology; inclusion criteria were gender (female) and age (18–25 years). The mean age was M = 21.78 (SD = 1.84). The vast majority of the participants (99%) declared their nationality as Polish (the remaining 1% were Ukrainian or Swedish). Also, the vast majority (96%) were single (0.4% were married; the remaining marked the answer “other”). More than half the sample (54.6%) had received education to secondary level; 19.5% had a Bachelor's degree; 13.9% were enrolled in Master's degree
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M. Dragan / Addictive Behaviors 48 (2015) 30–35
programs; and 8.2% held a Master's degree. Participation in the study was voluntary; participants were informed of the objectives and procedure, and also gave their informed consent. They completed the questionnaires individually; following completion, they were paid the equivalent of US$10. The study was approved by the Research Ethics Committee at the Faculty of Psychology, University of Warsaw. 2.2. Measures In the course of psychological assessment, a battery of measures was administered to participants, including the following questionnaires. The Alcohol Use Disorders Identification Test (AUDIT). This popular and widely used instrument was developed as a screening tool by the World Health Organization (WHO) for early identification of problem drinkers (Babor, de la Fuente, Saunders, & Grant, 1992). It also possesses good psychometric properties (Hester & Miller, 1995). AUDIT consists of ten questions regarding recent alcohol consumption, alcohol dependence symptoms and alcohol-related problems. The summary score ranges from zero, indicating no presence of problem drinking behavior, to 40 indicating marked levels of problem drinking behavior. The threshold for indicating possible (moderate) drinking problems is a score of eight. Research show that this is a valid measure in identifying individuals with alcohol drinking problems (Clements, 1998). In the present investigation, the total AUDIT score was used to index alcohol use problems. Cronbach's alpha for the total AUDIT score was .81. The Difficulties in Emotion Regulation Scale (DERS) is a brief (36-item) self-report questionnaire, developed by Gratz and Roemer (2004) to assess multiple aspects of emotion dysregulation. DERS items focus primarily on the regulation of negative emotional states. The measure yields a total score as well as scores on six subscales, ultimately derived via factor analysis: (1) non-acceptance of emotional responses (Nonacceptance), (2) difficulties engaging in goal directed behavior (Goals), (3) impulse control difficulties (Impulse), (4) lack of emotional awareness (Awareness), (5) limited access to emotion regulation strategies (Strategies), and (6) lack of emotional clarity (Clarity). Problems in any of these areas are indicative of emotion regulation difficulties. The findings suggest that the DERS has high internal consistency, good test–retest reliability and adequate construct and predictive validity (Gratz & Roemer, 2004). In the current study, the total score, together with the six subscales, were used to index difficulties in emotion regulation. Cronbach's alpha for the total DERS score was .93. The Positive Alcohol Metacognitions Scale (PAMS). PAMS is a 12-item measure developed to assess positive metacognitions about alcohol use (Spada & Wells, 2008). It consists of two factors: (1) positive metacognitions about emotional self-regulation through drinking, and (2) positive metacognitions about cognitive self-regulation through drinking. Results from validation studies (Spada & Wells, 2008; Spada et al., 2007) suggest that PAMS possesses good psychometric properties. In the current study, the total score was used as an index of positive metacognitions about alcohol use. Cronbach's alpha for the total PAMS score was .85. The Negative Alcohol Metacognitions Scale (NAMS). NAMS is a 6-item measure developed to assess negative metacognitions about alcohol use (Spada & Wells, 2008). It consists of two factors: (1) negative metacognitions about uncontrollability of drinking, and (2) negative metacognitions about cognitive harm due to drinking. Results from validation studies (Spada & Wells, 2008; Spada et al., 2007) suggest that NAMS possesses good psychometric properties. In the current study, the total score was used as an index of negative metacognitions about alcohol use. Cronbach's alpha for the total NAMS score was .67. 2.3. Statistical analyses Data analysis was performed using the PASW Statistics 21.0 (S.P.S.S. Inc., 2012) and AMOS 21.0 (Arbuckle, 2012) software packages. The missing data rate did not exceed 1%. In order to test the relationship between
difficulties in emotion regulation, metacognitions about alcohol use, and problem drinking, the structural equation modeling technique (SEM) was employed, using the maximum likelihood method. In SEM, the proposed hypothesized model is evaluated for goodness of fit with actual observations in the sample data (Byrne, 2010). Since experts recommend reporting a variety of fit indicators to permit the making of comparisons (Ullman, 2007), the following were used to evaluate the model: chisquare, chi-square/df ratio, comparative fit index (CFI), root mean square of approximation (RMSEA), generalized fit index (GFI). 3. Results Of the entire sample, 31.5% of participants (n = 158) had AUDIT scores greater than eight; 18.7% scored over ten. Two-tailed Pearson product–moment correlations showed that the scores on this scale correlated positively both with negative and with positive metacognitions about alcohol use. Problem drinking (AUDIT) was also positively correlated with all six dimensions of emotion dysregulation, however the size of coefficients was not large, ranging from .10 for Awareness to .25 for Clarity. Descriptive statistics for all study variables – including mean scores, standard deviations, and correlation coefficients – are shown in Table 1. Fig. 1 is a visualization of the structural model identified, resulting from SEM analysis. Standardized estimates are reported. Due to theoretical considerations, correlations were permitted between measurement errors for the emotional dysregulation subscales, as well as for the scales measuring metacognitions about alcohol use. Despite χ2 being statistically significant [χ2(24) = 43.52, p b .01], other fit values for the model fall within acceptable ranges, suggesting a good fit for the model: χ2/n = 1.81, CFI = .97; RMSEA = .05; GFI = .97. Difficulties in emotion regulation were significantly predictive for both positive and negative metacognitions about alcohol use. They accounted for 12% of the variance in positive metacognitions, and 2% of the variance in negative metacognitions. However, whereas positive metacognitions were significantly predictive for drinking behavior – accounting for 22% of total variance – no statistically significant association was observed between negative metacognitions and drinking behavior. Positive metacognitions therefore emerged as fully mediating the relationship between emotional deregulation and problem drinking. No direct association between the latter two variables was observed. Fig. 1 also depicts a unique contribution of individual subscales (dimensions) as indicators of the global factor of difficulties in emotion regulation. The respective significant standardized parameter estimates ranged from .16, p b .01 for Awareness to .86, p b .001 for Strategies, indicating that this last dimension is the largest contributor to the global factor. 4. Discussion The study aimed to test presumed associations among young women between: general difficulties in emotion regulation, metacognitions about alcohol use, and problem drinking. The theoretical assumptions for the proposed model referring to the concept of emotion self-regulation and the metacognitive formulation of problem drinking (Spada et al., 2013) included an assumption that emotional deregulation reflects the presence of CAS and dysfunctional metacognition, being the basis for the development of specific metacognitions about alcohol use, so leading to further growth in alcohol use problems. Interestingly, within the tested model no direct association between emotional dysregulation and drinking behavior was observed. A relationship between those two variables only became apparent once metacognitions were taken into consideration as a mediator. This result is in line with the metacognitive formulation of problem drinking, suggesting a crucial role for specific metacognitions about alcohol use. However, the identified model, while being generally well-fitting, differs from the presumed model, indicating a specific role for just one of
M. Dragan / Addictive Behaviors 48 (2015) 30–35
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Table 1 Means, standard deviations, and two-tailed Pearson correlations of the study variables. Variables
M
1
2
3
1. Problem drinking (AUDIT) 2. Positive metacognitions about alcohol use (PAMS) 3. Negative metacognitions about alcohol use (NAMS)
7.04 25.72 10.63
SD 4.63 6.62 3.35
– .47⁎⁎⁎ ns
– .24⁎⁎⁎
–
Difficulties in emotion regulation (DERS) 4. Non-acceptance 5. Goals 6. Impulse 7. Awareness 8. Strategies 9. Clarity 10. Total score
13.69 15.08 12.70 13.13 18.47 10.27 83.32
5.31 4.65 4.67 3.18 6.40 2.98 19.78
.16⁎⁎⁎ .12⁎⁎ .24⁎⁎⁎ .10⁎ .21⁎⁎⁎ .25⁎⁎⁎ .25⁎⁎⁎
.33⁎⁎⁎ .30⁎⁎⁎ .35⁎⁎⁎ ns .27⁎⁎⁎ .27⁎⁎⁎ .39⁎⁎⁎
.17⁎⁎⁎ .14⁎⁎ ns ns ns .08⁎ .14⁎⁎
4
5
6
7
8
9
– .43⁎⁎⁎ .47⁎⁎⁎ .15⁎⁎ .57⁎⁎⁎ .41⁎⁎⁎ .75⁎⁎⁎
– .60⁎⁎⁎ ns .61⁎⁎⁎ .34⁎⁎⁎ .75⁎⁎⁎
– .17⁎⁎ .62⁎⁎⁎ .40⁎⁎⁎ .79⁎⁎⁎
– .15⁎⁎ .35⁎⁎⁎ .35⁎⁎⁎
– .50⁎⁎⁎ .88⁎⁎⁎
– .65⁎⁎⁎
ns — non-significant. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.
the two types of metacognitions about alcohol use, having been linked by Spada and co-authors (Spada & Wells, 2006, 2009; Spada et al., 2013) to problem drinking. Only positive metacognitions about alcohol use turned out to be a significant predictor of drinking behavior and, moreover, a full mediator of the relationship between emotion dysregulation and problem drinking. According to the triphasic model (Spada et al., 2013), a crucial role in alcohol-use related problems belongs to the metacognitively directed dysfunctional process of self-regulation, manifesting as CAS. Positive metacognitions about alcohol use – constituting a specific type of expectancies relating to the psychological effects of alcohol – contribute to cognitive–emotional regulation (Spada et al., 2007), so motivating the individual to cope with negative affect by means of alcohol consumption. Therefore, the association of such beliefs with more general difficulties in emotion regulation is not surprising; this is in line with previous research by Spada and Wells (2009), and also accords with the results of research on deficits in emotion regulation and alcohol use (Berking et al., 2011; Dvorak et al., 2014). However, the second category of metacognitions – negative metacognitions about alcohol use – was not predictive for problem drinking in the studied sample. These beliefs refer to the negative impact of alcohol use, and are thought to play a crucial role in its perpetuation. Such a result may be explained by the fact that the study focused on drinking behavior in a specific group: young women. Research shows that, in Europe and North America at least, alcohol use in general, and heavy drinking in
particular, is highly prevalent among adolescents and young adults, including young females (Grant et al., 2004); the same reports show that it declines as individuals grow older and develop an increasing sense of social responsibility. Results from the current study confirm these findings. As defined by the AUDIT cut-off scores, a high prevalence of problem drinking is indicated: more than 30% of participants had a score of greater than eight, while almost 20% exceeded a score of ten. However, these results may also suggest that drinking at this age, independent of gender, is primary related to generally positive motivations, including positive expectations regarding cognitive–emotional selfregulation. From the metacognitive perspective, those having more positive beliefs about alcohol use are more prone to develop alcohol use problems. However, the crucial role in developing an alcohol use disorder belongs to negative beliefs, conceptualized also as a specific level of cognitive self-efficacy and negative alcohol expectancy (Spada & Wells, 2006, 2009). These beliefs may reflect the process of development of the disorder, since they refer to the perceived negative impact of alcohol consumption related to uncontrollability. Therefore in the current sample the effects related to negative metacognitions about alcohol use may, due to the young age of the participants, be as yet unobserved. It may be assumed that in some participants these processes escalate over time, most likely for those whose cognitive–emotional self-regulation is the most impaired. This supposition is in line with previous findings of Spada and Wells (2010), indicating that while both
.22**
e3
r1
e4
e2
PAMS Nonacceptance
Impulse
.71***
.64***
Goals
Emotional dysregulation Awareness
.16**
.47***
.35***
.69***
.14*
.56*** .86***
Problem drinking
.14* e1
e7
Clarity
Strategies NAMS
.26***
e6
e5
r2
Fig. 1. Standardized equation model of associations between difficulties in emotion regulation, metacognitions about alcohol use, and problem drinking in the sample of young women (N = 502). Note: *p b .05, **p b .01, ***p b .001; PAMS — positive metacognitions about alcohol use; NAMS — negative metacognitions about alcohol use; e and r enclosed in circles indicate error representing measurement error.
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problem drinkers and alcohol dependent drinkers score higher than non-drinkers on positive metacognitions about alcohol use, significant predictors of alcohol dependence are negative metacognitions about uncontrollability and depression. This is consistent with the recent formulation of problem drinking by Spada and Wells (2009) and Spada et al. (2013), who underline the primary role of CAS in the process of development and maintenance of problem drinking. According to this model, CAS and underlying positive metacognitions about extended thinking, triggered by alcohol-related stimuli, escalate negative affect and cravings, strengthening negative metacognitions about the need to control thoughts; the latter beliefs enhance the likelihood of further alcohol use. From among the six dimensions distinguished by Gratz and Roemer (2004), the largest contribution within the global factor of emotion dysregulation was observed for limited access to emotion regulation strategies (Fig. 1), followed by, in declining order: impulse control difficulties, difficulties engaging in goal-directed behavior, non-acceptance of emotional responses, and lack of emotional clarity. Lack of emotional awareness had the lowest contribution, indicating that this kind of difficulty is of low importance for self-regulation through drinking in the studied sample relative to, for example, non-acceptance of emotions, or else having a clear understanding of their nature. This pattern of difficulties in emotion regulation is similar to previous findings from a study on a large sample of college students, conducted using the same scale (DERS). Dvorak et al. (2014), among others, have shown that the number of alcohol-related consequences is positively associated with non-acceptance of emotional responses, impulse control difficulties, lack of emotional clarity, and difficulties engaging in goal-directed behavior. However, in the current study it emerged that it is the limited access to emotion regulation strategies which drives the motivation to cope through the use of alcohol. This suggests that alcohol use is primarily a substitute strategy, used for gaining temporary relief in face of aroused negative emotional states, should access to other strategies be limited. This is in line with previous findings exploring associations between negative affect and drinking, and also with such theories as the experiential avoidance model of deliberate self-harm by Chapman, Gratz, and Brown (2006), treating substance abuse as a maladaptive strategy of self-regulation, based on emotion avoidance. On the other hand, the relatively high contribution of ‘difficulties engaging in goaldirected behavior’ factor in the current study may be seen as being in line with results of studies on conscientiousness, one of ‘the Big 5’ factors. This factor has been consistently found to be associated with alcohol use and misuse; also Clark et al. (2012) confirm that conscientiousness, along with positive metacognitions about alcohol use, significantly predicts the level of alcohol consumption in male binge drinking students. According to the authors, conscientiousness relates to the awareness about personal goals, their planning, and the monitoring of their achievement, thus shares common ground with ‘metacognitive monitoring’, comprising of monitoring of cognitive– emotional change and proximity to goals as drinking proceeds. The identified model suggests that certain patterns of difficulties in emotion regulation – with the limited access to emotion regulation strategies as the strongest contributor, and the lack of emotional awareness as the weakest – are predictive for positive metacognitions about alcohol use, and, to the lesser extent, for negative metacognitions about alcohol use. It may be assumed that this pattern is specific for problem drinking in young adults; however, such a generalization must be heavily qualified, for the obvious reason that the current study included female participants only. Thus the observed associations may be gender-specific, or even dependent on both gender and cultural differences (Kwon et al., 2013). The fact that studies on gender differences in the use of specific emotion regulation strategies are generally scarce suggests that testing the hypothesized model on a sample of males in future research would be all the more worthwhile. In order to determine their relationship in the model with emotional dysregulation and specific metacognitions about alcohol use, it would also be
worth including measures strictly relating to the symptoms of cognitive–attentional syndrome and general maladaptive metacognition,. Finally, it must be underlined that the principal weakness of this study – one restricting the possibility of generalization and, in particular, the drawing of conclusions regarding causality – lies in the crosssectional nature of its design, and also the correlational nature of the examined model. However, the results, being in line with metacognitive formulation of problem drinking, may be seen as supporting the notion that interventions aimed at metacognitive change and extending the repertoire of strategies relating to cognitive–emotional regulation, such as verbal reattribution of metacognitions about alcohol use or Situational Attentional Refocusing (Wells, 2000), can be helpful in the process of treatment. 4.1. Conclusions The results of the present study provide evidence for the metacognitive conceptualization of problem drinking in a sample of young women. They show that metacognitions about alcohol use are predictive for problem drinking; however, a direct association between emotion dysregulation and problem drinking was not observed. In particular, the findings strengthen the validity of one category of such metacognitions: positive metacognitions about alcohol use. These turned out to be a full mediator of the relationship between emotion dysregulation and problem drinking. Difficulties in emotion regulation were in turn predictive of metacognitions about alcohol use, and had the strongest bearing on limited access to emotion regulation strategies. However, it may be that the results are not only gender-specific, but also age-specific, since negative metacognitions about alcohol use may become increasingly important over time in the development of alcohol use problems. Role of funding sources The study was supported by the Ministry of Science and Higher Education Iuventus Plus grant no. 0105/IP3/2011/71. Contributors The manuscript was written by the author. Conflict of interest There are no conflicts of interest to declare. Acknowledgments This study was supported by Ministry of Science and Higher Education Iuventus Plus grant no. 0105/IP3/2011/71.
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