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Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20
Health Locus of Control in a Primary Care Sample of Alcoholics and Nonalcoholics a
Dr Michael F. Fleming MD, MPH & Dr Kristen L. Barry PhD
a
a
Department of Family Medicine , University of Wisconsin , Madison, USA Published online: 09 Jul 2010.
To cite this article: Dr Michael F. Fleming MD, MPH & Dr Kristen L. Barry PhD (1991) Health Locus of Control in a Primary Care Sample of Alcoholics and Nonalcoholics, Behavioral Medicine, 17:1, 25-30, DOI: 10.1080/08964289.1991.9937549 To link to this article: http://dx.doi.org/10.1080/08964289.1991.9937549
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Health Locus of Control in a Primary Care Sample of Alcoholics and Nonalcoholics
Downloaded by [University of Victoria] at 00:23 19 November 2014
Michael F. Fleming, MD,MPH, and Kristen L. Barry, PhD
This study examined differencesbetween alcoholics and nonalcoholics in a primary care population on the internal, chance, and powet$ul others subscales of the Multidimensional Health Locus of Control Scale (MHLC). Two hundred eighty subjects were divided into four groups (alcoholics with a family history of alcoholism, alcoholics with no family history of alcoholism, nonalcoholics with a family history of alcoholism, and nonalcoholics with no family history of the diwaw) based on DSM-III criteriafor alcoholism and a family history of alcoholism. There were no differences between groups on the internal and powet$ul others scales. Nonalcoholics with a family history of alcoholism scored significant& lower on the chance scale than did alcoholics with a family history of the diwaw.
This study sought to determine whether there were differences in the health locus of control between alcoholics and nonalcoholics in a primary care population. Rotter’s’ locus of control construct identified the chronic propensity to place causality for events either in the self (internal) or in the environment (external). Rotter posited that people differ in the expectations they hold about the sources of positive and negative reinforcements for their behavior. “Internals” credit themselves with the ability to control the occurrence of reinforcing events. “Externals” perceive reinforcing events as under the control of forces external to themselves-luck, chance, or powerful other individuals. The unidimensional conception of the general locus of control construct was questioned by Levenson,’ who argued that internal beliefs are not only the opposite of external beliefs, but that understanding and prediction could be further improved by studying chance or fate expectations separately from external control by powerful others. Wallston c“t al’ expanded Levenson’s conceptuali-
Dr Fleming &an as&tant professor in the Department of Family Medicine at the University of Wkonsin, Madison, where Dr Barty is an mistant scientist.
zation to the health locus of control measure, developing the Multidimensional Health Locus of Control (MHLC) Scale. This scale included one internal control subscale and two external control subscales: powerful others, measuring the degree to which individuals feel health outcomes are dependent on the action of others; and the chance subscale, which is the degree to which individuals feel fate, chance, or luck determine their health. The majority of the general locus of control literature on alcoholism has focused, with disparate results, on Rotter’s original construct. The earlier studies hypothesized that alcoholics would have more external locus of control because they seem unable to control their drinking behavior or to cope effectively with other areas of living and tend to deny responsibility for their behavior.‘ Other data on the general locus of control construct indicated that alcoholics were more internal than external.>’ This fmding may reflect the treatment philosophy of taking responsibility for oneself through the treatment process. These studies, however, generally took place in alcohol treatment programs rather than in outpatient settings. The literature on alcoholism has also posited that gender and age are t’ alcohol abuse, with men and those in young-to-hddle adulthood reporting higher consumption and abuse”” than women and older adults.
25
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LOCUS OF CONTROL IN ALCOHOLICS
The locus of control in alcoholism literature has focused primarily on males in alcohol treatment settings and has not considered these potential covariates in a general medical ambulatory care setting. The MHLC has yet to be used extensively to study alcohol use and alcoholism. In one of the few studies of alcohol use and health locus of control, Carter et all' measured belief in internal health locus of control and intemperate use of alcohol with 791 high school students and found a significant relationship between external control and female students' alcohol use. The present study was part of a larger project to determine health behaviors of alcoholic and nonalcoholic patients in primary care setting^.'^." This section of the project was undertaken to determine whether the MHLC construct developed by Wallston could increase the understanding of how alcoholic and nonalcoholic patients in primary care settings attribute their health outcomes. The primary hypothesis was that alcoholics, when compared with nonalcoholics, would view their health as under the control of external forces, particularly chance or fate, and that they, therefore, would feel helpless to change. This would be especially true in the case of alcoholics with a family history of alcoholism.
METHOD Our study covered 280 subjects drawn from three primary care clinics located in south central Wisconsin. We asked all adult English-speaking patients with regularly scheduled appointments during a 1-month period in spring 1988 to participate. The clinics offer medical care for obstetrical, pediatric, and adult patients in a midwestern university community. Faculty and residents of the university's Department of Family Medicine provide medical services in these clinics. We called subjects 48 hours before their appointments to explain the study and request that they participate. Of the 291 eligible patients asked, 280 (97%) agreed to take part in the study, and all gave informed consent to their participation. We categorized subjects into groups based on their responses to the Diagnostic Interview Schedule (DIS)" and their reported family history (FH) of drinking problems. The DIS alcohol subscale is a set of 20 questions based primarily on the three sets of diagnostic items contained in the Diagnostic and Starktical Manual of Mental Disorders of the American Psychiatric Association (DSM-111). The DIS gives two criteria for abuse-a pattern of pathological use and impairment in social and occupational functioning-and one criterion for dependence based on tolerance and withdrawal symptoms. Individuals can
26
meet criteria for abuse without meeting criteria for dependence if they have a pattern of pathological use and have experienced social or family problems as the result of their drinking but do not report either tolerance or withdrawal symptoms. Conversely, it is possible to meet criteria for dependence without meeting criteria for abuse if a subject reports prolonged and increased heavy alcohol use (ie, at least 7 drinks a day for a 1-month period or more) or withdrawal symptoms (ie, shaking) but does not report any other social or personal consequences of alcohol misuse. In addition, subjects can meet criteria for both abuse and dependence. For the purposes of this study, subjects were classified as alcoholic if they met alcohol abuse and/or dependence criteria on the DIS. To determine a family history of problem drinking, we asked subjects whether anyone in their family had had a drinking problem. Subjects who responded in the a f f m tive were given a list of choices, including father, mother, brother, sister, husband, wife, son, daughter, grandmother, grandfather, and other, and were instructed to check all relatives with drinking problems. One hundred eight subjects reported a family history of alcoholism. Of those, 90% (n = 97) reported the primary alcoholic family member as a firstdegree relative (Sooro. fathers; 20V0, mothers; 15%. brothers; 5%. sisters). Many also reported a number of family members with drinking problems, including seconddegree relatives. Ten percent (n = 11) reported primary drinking problems in spouses (5%) and children (5%); 9 of these 11 subjects also reported multiple family members, including seconddegree relatives, with alcohol problems. Subjects were divided into the following four groups for analyses: group 1 (n = 39) were DSM-111 positive and reported having one or more alcoholic family members (Alc+FH+); group 2 (n = 43) had a positive score for alcohol abuse and/or dependence but reported having no alcoholics in their families (Alc+FH-); group 3 (n = 70) had a negative score for alcoholism but reported one or more alcoholic family members (Alc-FH+); and group 4 (n = 128) were nonalcoholics who reported no alcoholism in their families (Alc - FH - ). The MHLC consists of 18 items divided into three subscales and measured on a &point Likert-type scale (see Table 1). The three dimensions of the multidimensional construct are internal, powerful others, and chance. They are defined as follows: (1) internal, the extent to which individuals perceive their own behavior as responsible for the outcome of health; (2) powerful others, the extent to which individuals perceive powerful other people (friends, family, nurses, doctors) as responsible for their health; and (3) chance, the extent to which individuals perceive
Behavioral Medicine
FLEMING & BARRY
TABLE 1 Multidimensional Health Locus of Control (MHLO Put the number of the answer that most reflects how you feel about each statement in the blank space in front of each statement. Scale: I = strongly disagree; 2 = moderately disagree; 3 = slightly disagree; 4 = slightly agree; 5 = moderately agree; 6 = strongly agree. -1. If I become sick, I have the power to make myself well again.
2. Often 1 feel that no matter what I do, if I am going to get sick, I will get
sick. 3. If I see an excellent doctor regularly, I am less likely to have a health
Downloaded by [University of Victoria] at 00:23 19 November 2014
problem.
-4. It seems that my health is greatly influenced by accidental happening. -5. 1 can only maintain my health by consulting health professionals.
6. 1 am directly responsible for my health.
-7. Other people play a big part in whether 1 stay healthy or become sick. -8. Whatever goes wrong with my health is my own fault. -9. When I
am sick, 1 just have to let nature run its own course.
10. Health professionals keep me healthy. -11.
When I stay healthy, I’m just plain lucky. 12. My physical well-being depends on how well I take care of myself.
-13.
When I feel ill, 1 know it is because I have not been takiig care of myself properly.
-14.
The type of care I receive from other people is what is responsible for how well I recover from an illness.
-15.
Even when I take care of myself, it is easy to get sick.
-16.
When I become ill, it’s a matter of fate.
-17.
I can pretty much stay healthy by taking good care of myself.
-18.
Following doctor’s orders to the letter is the best way for me to stay healthy.
such factors as luck, fate. or chance as responsible for their health. The Internal Health Locus of Control subscale (IHLC) includes questions 1, 6. 8. 12, 13, and 17. Questions 3, 5 , 7, 10, 14, and 18 form the Powerful Others Health Locus of Control subscale (PHLC). Chance Health Locus of Control (CHLC) is measured by questions 2, 4, 9, 11, 15, and 16 (Figure I). The items are scored in a scale format with 1 to 6 points per question. Using analysis of variance procedure, we analyzed the differences between the four groups chosen for analysis
Spring 1991
(Alc+FH+, Alc+FH-, Alc-FH+, Alc-FH-) on the three subscales of the MHLC measure (internal, chance, powerful others).
RESULTS ~ m o g r p p ~ The 280 subjects included 97 men and 187 women from the three ambulatory care clinics. They ranged in age from 18 to 75 years, with a mean age of 36,93% (n = 261) of the subjects were white. The educational level
27
LOCUS OF CONTROL IN ALCOHOLICS
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of the sample was high, with 40% (n = 112) of the subjects having attended college and 20% (n = 56) having attended graduate school. Because subjects in the samples from the three clinics were similar with respect to age, sex, education, and race, we combined the data into a total sample of 280 for subsequent analyses. The sampling procedure of selecting all available adults with regular appointments entering each of the clinics during the study period resulted in an uneven sex distribution in the total sample. This distribution was comparable to the sex ratio for the total number of visits to these clinics in 1987, as well as to the sex ratio characteristics of other ambulatory care clinics studied, in which women predominated as the identified patients.’”16 Prevalence of Alcoholism
Within the total sample of 280 subjects, 30% (n = 82) met minimum DSM-111 criteria for alcohol abuse and/or dependence. Twelve percent (n = 33) of the sample met criteria for abuse without meeting criteria for dependence, 4% (n = 10) met criteria for dependence without abuse, and 14% (n = 39) met criteria for both abuse and dependence. With respect to sex, 38% (n = 37) of the men and 25% (n = 45) of the women met criteria for abuse and/or dependence. Health Locus of Control and Alcoholism
We performed analysis of variance tests on the variables internal locus of control, chance, and powerful others by group membership (1 to 4). Age and sex were covariates in the analysis. Group membership had a significant main effect on chance, F(3) = 2.63;p < .05, but
had no main effects on the internal, F(3) = 2.40, p > .05, or powerful other subscales F(3) = 1.18, p > .05. Covariates of interest, sex, and age had no significant effect on either the internal scale, sex: F(1) = 24,p > .05; age: F(4) = 1.65, p > .05, or on the chance scale, sex: F(1) = .25; p > .05, age: F(4) = .39, p > .05. In addition, although sex was not a significant covariate on the powerful others scale, F(1) = 3.16, p > .05, age produced a significant effect on this subscale, F(4) = 5.30, p < .05. Older subjects appeared to be more likely to believe that their health was in the hands of powerful others than did younger subjects. A post hoc Scheffd test determined pairwise significant differences by group on the chance subscale (Table 2). Group 1 ( A l c + F H + ) had significantly higher chance scores (A4 = 19.07) than group 3 (Alc-FH+: M = 16.00). There were no significant pairwise comparisons with Group 2 (Alc+FH-) or group 4 (Alc-FH-). None of the scores on the chance scale was above 28.38 out of a possible 36 (see Table 2), and it cannot be inferred that alcoholics with a family history of alcoholism had a strong belief that chance influenced their health. Nonalcoholics with a family history of the disease, however, were the least likely to believe that chance determined their health. Their scores fell in the range of slight to moderate disagreement that chance influenced their health. All four groups in the study reported relatively high scores on the internal scale, with mean scores falling between slight to moderate agreement (see Table 1). The mean group scores on the powerful others scale for the groups were primarily between slight disagreement and slight agreement.
TABLE 2 Post Hoc Tests: MHLC scples by Group Membership Group 1 Alc+FH+t M Internal subscale Chance subxale Powerful others subscale
27.41 19.0’71 19.23
Group 2 Alc+FHM 28.30 17.85 19.40
Group 3 Alc-FH+ M 26.88 16.00 17.61
Group 4 Ak-FHM 28.38 17.74 19.52
tAlc = alcoholic; FH = family history of alcoholism. $Group I reported significantly. 0 3 ) = 2.63; p < .05. higher chance scores than Group 3.
28
Behavioral Medicine
FLEMING & BARRY
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DISCUSSION The primary hypothesis, that alcoholics with a family history of alcoholism viewed their health as under the control of external forces, particularly chance or fate, was only partly supported. We found a significant difference on the chance scale between the groups. Those subjects who met criteria for alcohol abuse and/or dependence who also had a family history of alcoholism were significantly more likely than nonalcoholics with a family history of alcoholism to believe their health was influenced by chance or fate. Because none of the mean scores on the chance scale was above 19.07 out of a possible 36 points (see Table 2). it cannot be inferred that alcoholics with a family history of alcoholism had a strong belief that chance influenced their health. It can be inferred, however, that nonalcoholics with a family history of the disease were the least likely to believe that chance determined their health. Their scores fell in the range of slight disagreement to moderate disagreement that chance influenced their health. Because family history may be a risk factor in the development of alcoholism, those who are nonalcoholics raised in alcoholic families may have overcome their vulnerability, whereas the alcoholics may have been more susceptible to the development of the illness because of intervening variables. The chance subscale scores of both groups were thus in line. All four groups (Alc+FH+; Alc+FH-; Alc-FH+; Alc - FH - ) received relatively high mean scores (26.88 to 28.38) on the internal scale and lower mean scores (17.61 to 19.52) on one of the external scales-powerful others. Mean scores on the chance scale, across groups, fell between moderate disagreement and slight agreement. Both alcoholic and nonalcoholic primary care patients, regardless of family history, perceived their health as under their own internal control and not under the control of powerful others. Although alcoholics with a family history of alcoholism scored significantly higher on the chance scale than nonalcoholics with a family history of alcoholism. their mean score was 19.07 out of a possible 36 points and could not be considered a positive response. This study provided an extension to the literature through the use of the MHLC construct in a primary care population screened for alcohol-related problems. Previous studies have reported conflicting results regarding the general locus of control of alcoholics. These studies have not used DSM-I11 criteria to determine the extent of primary alcohol problems in their subjects or differentiated between alcoholics and nonalcoholics on
Spring 1991
the basis of family history of alcoholism. Because the high rate of alcohol-related problems in this study may reflect regular users of medical care, the results may not be generalizable to populations that include underutilizers of the healthcare system, and those who would extrapolate the results to a general population should do so cautiously. The prevalence results, however, suggest a larger percentage of adult primary care patients than previously estimated may be presenting with a variety of physical symptoms that may be related to alcohol use. The results of this study indicate few differences in health locus of control between alcoholic and nonalcoholic patients in this primary care sample. Patients who met Lifetime criteria for alcoholism did not attribute their health outcomes differently from nonalcoholics, with one exception. The perception of nonalcoholics from alcoholic families that chance influenced personal health factors can point in one of two directions. Nonalcoholic adult children of alcoholics may assess the importance of maintaining control over health factors and believe that chance or fate is not the major determinant of their health behaviors and status. They, however, could also have an expectation that chance (ie, genetic factors, accidental occurrences, etc), can have little effect on health status, and they may have difficulty using healthcare professionals to their best advantage. Further work focusing attention on outcomes of adult children of alcoholics based on their perceptions of control of their health status may be one factor in developing programs to address effective models of medical intervention for families who live with alcoholism.
INDEX TERMS h b d l a , b&b
lorus of control, p h u y a r e
NOTE Send requests for further information to Michael F. Fleming. MD. MPH, Department of Family Medicine, 777 South Mills, Madison, WI 53715.
ACKNOWLEDGMENTS This research was supported by the Family Hcalth Foundation and the Wisconsin Institute of Family Medicine.
REFERENCES I . Rotter J. Generalized expectancies for internal versus external control of reinforcement. Psychological Monogmphs. 1966.80: 1-28.
2. Levenson H. Activism and powerful others: Distinctions within
29
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LOCUS O F CONTROL IN ALCOHOLlCS
the concept of internal-external control. J Pets Asse.ss. 1974;38: 377-383. 3. Wallston K, Wallston B, DeVellis R. Development of the multidimensional health locus of control (MHLC) scales. Heulth Educ Monogrcrph. 1978;6: 160-170. 4. Butts S . Chotlos J. A comparison of alcoholics and nonalcoholics on perceived locus of control. Q J Stud Alcohol. 1973;34:13271332. 5 . Goss A, Morosko T. Relation between a dimension of internalexternal control and the MMPI with an alcoholic population. J COWlt k w h o l . 1970;34: 189-192. 6. Distefano D. Pryer M, Garrison J . lnternalsxternal control among alcoholics. J CIin Psycho/. 1972;28:36-38. 7. Costello R. Manders K. Locus of control and alcoholism. Br J Addict. 1974;69:1 I - 17. 8. Engs R. Drinking patterns and drinking problems of college students. J Sfud Alcohol. 1977;38:2144-2156. 9. Ratcliff K. Burkhart B. Sex differences in motivation for and effects of drinking among college students. J Sfud Alcohol. 1984; 45:2632.
10. Wilsnack S . Wilsnack R, Klassen A. Drinking and drinking prob-
lems among women in a US national survey. Alcohol Heulfh und Research World. 1985;9(2):3-13. I I. Carter J, Denton D, Randow H. Correlates of temperate and intemperate attitudes toward alcohol use. J Sch Heulfh. 1985;55(1): 27-29. 12. Bany K. Fleming M. Family cohesion. expressiveness, and conflict in alcoholic families. Br J Addicf. 1990,85:81-87. 13. Fleming M, Bany K. Health status in adult children of alcoholics. SubsfonceAbuse. 1990,11(1):3&39. 14. Robins L. Helzer J. Croughan J. Ratcliff K. National Institute of Mental Health diagnostic interview schedule. Arch Gen Psych& fry. I981;38:381-39O. IS. Nicol E, Ford M. Use of the Michigan Alcoholism Screening Test in general practice. J R Coll Gen Prucf. 1986;36:409-410. 16. Hotch D. Sherin K. Harding P, Zitter R. Use of the self-administered Michigan Alcoholism Screening Test in a family practice center. J Fum Prucf. 1983;17(6):1021-1026.
............. STATEMENT
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TWELFTH CAPE COD INSTITUTE PLANNED
The twelfth annual Cape Cod Institute will consist of a summer-long series of postgraduate courses for mental health and health science professionals. Topics include psychodynamic therapy, behavioral medicine, brief therapy, developmental therapy, Jungian therapy, religion, alcohol treatment, neuropsychology, family therapy, childhood and adolescence, adult development, and organization and management. The program is sponsored by the Department of Psychiatry of the Albert Einstein College of Medicine. Sessions will be held weekday mornings June 24August 30, 1991, from 9:OO until 12:15, leaving the afternoons free for leisure and study. Optional discussion groups and social gatherings will be arranged and institute staff members provide abundant information about activities on Cape Cod. Tuition is $385 for one program and $215 for each additional program attended. A student rate is available. For a complete course catalogue, write or call the Cape Cod Institute, Albert Einstein College of Medicine, 1303A Belfer Building, Bronx, New York, 10461. Telephone 212-43@2307.
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Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20
Health Locus of Control in a Primary Care Sample of Alcoholics and Nonalcoholics a
Dr Michael F. Fleming MD, MPH & Dr Kristen L. Barry PhD
a
a
Department of Family Medicine , University of Wisconsin , Madison, USA Published online: 09 Jul 2010.
To cite this article: Dr Michael F. Fleming MD, MPH & Dr Kristen L. Barry PhD (1991) Health Locus of Control in a Primary Care Sample of Alcoholics and Nonalcoholics, Behavioral Medicine, 17:1, 25-30, DOI: 10.1080/08964289.1991.9937549 To link to this article: http://dx.doi.org/10.1080/08964289.1991.9937549
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Health Locus of Control in a Primary Care Sample of Alcoholics and Nonalcoholics
Downloaded by [University of Victoria] at 00:23 19 November 2014
Michael F. Fleming, MD,MPH, and Kristen L. Barry, PhD
This study examined differencesbetween alcoholics and nonalcoholics in a primary care population on the internal, chance, and powet$ul others subscales of the Multidimensional Health Locus of Control Scale (MHLC). Two hundred eighty subjects were divided into four groups (alcoholics with a family history of alcoholism, alcoholics with no family history of alcoholism, nonalcoholics with a family history of alcoholism, and nonalcoholics with no family history of the diwaw) based on DSM-III criteriafor alcoholism and a family history of alcoholism. There were no differences between groups on the internal and powet$ul others scales. Nonalcoholics with a family history of alcoholism scored significant& lower on the chance scale than did alcoholics with a family history of the diwaw.
This study sought to determine whether there were differences in the health locus of control between alcoholics and nonalcoholics in a primary care population. Rotter’s’ locus of control construct identified the chronic propensity to place causality for events either in the self (internal) or in the environment (external). Rotter posited that people differ in the expectations they hold about the sources of positive and negative reinforcements for their behavior. “Internals” credit themselves with the ability to control the occurrence of reinforcing events. “Externals” perceive reinforcing events as under the control of forces external to themselves-luck, chance, or powerful other individuals. The unidimensional conception of the general locus of control construct was questioned by Levenson,’ who argued that internal beliefs are not only the opposite of external beliefs, but that understanding and prediction could be further improved by studying chance or fate expectations separately from external control by powerful others. Wallston c“t al’ expanded Levenson’s conceptuali-
Dr Fleming &an as&tant professor in the Department of Family Medicine at the University of Wkonsin, Madison, where Dr Barty is an mistant scientist.
zation to the health locus of control measure, developing the Multidimensional Health Locus of Control (MHLC) Scale. This scale included one internal control subscale and two external control subscales: powerful others, measuring the degree to which individuals feel health outcomes are dependent on the action of others; and the chance subscale, which is the degree to which individuals feel fate, chance, or luck determine their health. The majority of the general locus of control literature on alcoholism has focused, with disparate results, on Rotter’s original construct. The earlier studies hypothesized that alcoholics would have more external locus of control because they seem unable to control their drinking behavior or to cope effectively with other areas of living and tend to deny responsibility for their behavior.‘ Other data on the general locus of control construct indicated that alcoholics were more internal than external.>’ This fmding may reflect the treatment philosophy of taking responsibility for oneself through the treatment process. These studies, however, generally took place in alcohol treatment programs rather than in outpatient settings. The literature on alcoholism has also posited that gender and age are t’ alcohol abuse, with men and those in young-to-hddle adulthood reporting higher consumption and abuse”” than women and older adults.
25
Downloaded by [University of Victoria] at 00:23 19 November 2014
LOCUS OF CONTROL IN ALCOHOLICS
The locus of control in alcoholism literature has focused primarily on males in alcohol treatment settings and has not considered these potential covariates in a general medical ambulatory care setting. The MHLC has yet to be used extensively to study alcohol use and alcoholism. In one of the few studies of alcohol use and health locus of control, Carter et all' measured belief in internal health locus of control and intemperate use of alcohol with 791 high school students and found a significant relationship between external control and female students' alcohol use. The present study was part of a larger project to determine health behaviors of alcoholic and nonalcoholic patients in primary care setting^.'^." This section of the project was undertaken to determine whether the MHLC construct developed by Wallston could increase the understanding of how alcoholic and nonalcoholic patients in primary care settings attribute their health outcomes. The primary hypothesis was that alcoholics, when compared with nonalcoholics, would view their health as under the control of external forces, particularly chance or fate, and that they, therefore, would feel helpless to change. This would be especially true in the case of alcoholics with a family history of alcoholism.
METHOD Our study covered 280 subjects drawn from three primary care clinics located in south central Wisconsin. We asked all adult English-speaking patients with regularly scheduled appointments during a 1-month period in spring 1988 to participate. The clinics offer medical care for obstetrical, pediatric, and adult patients in a midwestern university community. Faculty and residents of the university's Department of Family Medicine provide medical services in these clinics. We called subjects 48 hours before their appointments to explain the study and request that they participate. Of the 291 eligible patients asked, 280 (97%) agreed to take part in the study, and all gave informed consent to their participation. We categorized subjects into groups based on their responses to the Diagnostic Interview Schedule (DIS)" and their reported family history (FH) of drinking problems. The DIS alcohol subscale is a set of 20 questions based primarily on the three sets of diagnostic items contained in the Diagnostic and Starktical Manual of Mental Disorders of the American Psychiatric Association (DSM-111). The DIS gives two criteria for abuse-a pattern of pathological use and impairment in social and occupational functioning-and one criterion for dependence based on tolerance and withdrawal symptoms. Individuals can
26
meet criteria for abuse without meeting criteria for dependence if they have a pattern of pathological use and have experienced social or family problems as the result of their drinking but do not report either tolerance or withdrawal symptoms. Conversely, it is possible to meet criteria for dependence without meeting criteria for abuse if a subject reports prolonged and increased heavy alcohol use (ie, at least 7 drinks a day for a 1-month period or more) or withdrawal symptoms (ie, shaking) but does not report any other social or personal consequences of alcohol misuse. In addition, subjects can meet criteria for both abuse and dependence. For the purposes of this study, subjects were classified as alcoholic if they met alcohol abuse and/or dependence criteria on the DIS. To determine a family history of problem drinking, we asked subjects whether anyone in their family had had a drinking problem. Subjects who responded in the a f f m tive were given a list of choices, including father, mother, brother, sister, husband, wife, son, daughter, grandmother, grandfather, and other, and were instructed to check all relatives with drinking problems. One hundred eight subjects reported a family history of alcoholism. Of those, 90% (n = 97) reported the primary alcoholic family member as a firstdegree relative (Sooro. fathers; 20V0, mothers; 15%. brothers; 5%. sisters). Many also reported a number of family members with drinking problems, including seconddegree relatives. Ten percent (n = 11) reported primary drinking problems in spouses (5%) and children (5%); 9 of these 11 subjects also reported multiple family members, including seconddegree relatives, with alcohol problems. Subjects were divided into the following four groups for analyses: group 1 (n = 39) were DSM-111 positive and reported having one or more alcoholic family members (Alc+FH+); group 2 (n = 43) had a positive score for alcohol abuse and/or dependence but reported having no alcoholics in their families (Alc+FH-); group 3 (n = 70) had a negative score for alcoholism but reported one or more alcoholic family members (Alc-FH+); and group 4 (n = 128) were nonalcoholics who reported no alcoholism in their families (Alc - FH - ). The MHLC consists of 18 items divided into three subscales and measured on a &point Likert-type scale (see Table 1). The three dimensions of the multidimensional construct are internal, powerful others, and chance. They are defined as follows: (1) internal, the extent to which individuals perceive their own behavior as responsible for the outcome of health; (2) powerful others, the extent to which individuals perceive powerful other people (friends, family, nurses, doctors) as responsible for their health; and (3) chance, the extent to which individuals perceive
Behavioral Medicine
FLEMING & BARRY
TABLE 1 Multidimensional Health Locus of Control (MHLO Put the number of the answer that most reflects how you feel about each statement in the blank space in front of each statement. Scale: I = strongly disagree; 2 = moderately disagree; 3 = slightly disagree; 4 = slightly agree; 5 = moderately agree; 6 = strongly agree. -1. If I become sick, I have the power to make myself well again.
2. Often 1 feel that no matter what I do, if I am going to get sick, I will get
sick. 3. If I see an excellent doctor regularly, I am less likely to have a health
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problem.
-4. It seems that my health is greatly influenced by accidental happening. -5. 1 can only maintain my health by consulting health professionals.
6. 1 am directly responsible for my health.
-7. Other people play a big part in whether 1 stay healthy or become sick. -8. Whatever goes wrong with my health is my own fault. -9. When I
am sick, 1 just have to let nature run its own course.
10. Health professionals keep me healthy. -11.
When I stay healthy, I’m just plain lucky. 12. My physical well-being depends on how well I take care of myself.
-13.
When I feel ill, 1 know it is because I have not been takiig care of myself properly.
-14.
The type of care I receive from other people is what is responsible for how well I recover from an illness.
-15.
Even when I take care of myself, it is easy to get sick.
-16.
When I become ill, it’s a matter of fate.
-17.
I can pretty much stay healthy by taking good care of myself.
-18.
Following doctor’s orders to the letter is the best way for me to stay healthy.
such factors as luck, fate. or chance as responsible for their health. The Internal Health Locus of Control subscale (IHLC) includes questions 1, 6. 8. 12, 13, and 17. Questions 3, 5 , 7, 10, 14, and 18 form the Powerful Others Health Locus of Control subscale (PHLC). Chance Health Locus of Control (CHLC) is measured by questions 2, 4, 9, 11, 15, and 16 (Figure I). The items are scored in a scale format with 1 to 6 points per question. Using analysis of variance procedure, we analyzed the differences between the four groups chosen for analysis
Spring 1991
(Alc+FH+, Alc+FH-, Alc-FH+, Alc-FH-) on the three subscales of the MHLC measure (internal, chance, powerful others).
RESULTS ~ m o g r p p ~ The 280 subjects included 97 men and 187 women from the three ambulatory care clinics. They ranged in age from 18 to 75 years, with a mean age of 36,93% (n = 261) of the subjects were white. The educational level
27
LOCUS OF CONTROL IN ALCOHOLICS
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of the sample was high, with 40% (n = 112) of the subjects having attended college and 20% (n = 56) having attended graduate school. Because subjects in the samples from the three clinics were similar with respect to age, sex, education, and race, we combined the data into a total sample of 280 for subsequent analyses. The sampling procedure of selecting all available adults with regular appointments entering each of the clinics during the study period resulted in an uneven sex distribution in the total sample. This distribution was comparable to the sex ratio for the total number of visits to these clinics in 1987, as well as to the sex ratio characteristics of other ambulatory care clinics studied, in which women predominated as the identified patients.’”16 Prevalence of Alcoholism
Within the total sample of 280 subjects, 30% (n = 82) met minimum DSM-111 criteria for alcohol abuse and/or dependence. Twelve percent (n = 33) of the sample met criteria for abuse without meeting criteria for dependence, 4% (n = 10) met criteria for dependence without abuse, and 14% (n = 39) met criteria for both abuse and dependence. With respect to sex, 38% (n = 37) of the men and 25% (n = 45) of the women met criteria for abuse and/or dependence. Health Locus of Control and Alcoholism
We performed analysis of variance tests on the variables internal locus of control, chance, and powerful others by group membership (1 to 4). Age and sex were covariates in the analysis. Group membership had a significant main effect on chance, F(3) = 2.63;p < .05, but
had no main effects on the internal, F(3) = 2.40, p > .05, or powerful other subscales F(3) = 1.18, p > .05. Covariates of interest, sex, and age had no significant effect on either the internal scale, sex: F(1) = 24,p > .05; age: F(4) = 1.65, p > .05, or on the chance scale, sex: F(1) = .25; p > .05, age: F(4) = .39, p > .05. In addition, although sex was not a significant covariate on the powerful others scale, F(1) = 3.16, p > .05, age produced a significant effect on this subscale, F(4) = 5.30, p < .05. Older subjects appeared to be more likely to believe that their health was in the hands of powerful others than did younger subjects. A post hoc Scheffd test determined pairwise significant differences by group on the chance subscale (Table 2). Group 1 ( A l c + F H + ) had significantly higher chance scores (A4 = 19.07) than group 3 (Alc-FH+: M = 16.00). There were no significant pairwise comparisons with Group 2 (Alc+FH-) or group 4 (Alc-FH-). None of the scores on the chance scale was above 28.38 out of a possible 36 (see Table 2), and it cannot be inferred that alcoholics with a family history of alcoholism had a strong belief that chance influenced their health. Nonalcoholics with a family history of the disease, however, were the least likely to believe that chance determined their health. Their scores fell in the range of slight to moderate disagreement that chance influenced their health. All four groups in the study reported relatively high scores on the internal scale, with mean scores falling between slight to moderate agreement (see Table 1). The mean group scores on the powerful others scale for the groups were primarily between slight disagreement and slight agreement.
TABLE 2 Post Hoc Tests: MHLC scples by Group Membership Group 1 Alc+FH+t M Internal subscale Chance subxale Powerful others subscale
27.41 19.0’71 19.23
Group 2 Alc+FHM 28.30 17.85 19.40
Group 3 Alc-FH+ M 26.88 16.00 17.61
Group 4 Ak-FHM 28.38 17.74 19.52
tAlc = alcoholic; FH = family history of alcoholism. $Group I reported significantly. 0 3 ) = 2.63; p < .05. higher chance scores than Group 3.
28
Behavioral Medicine
FLEMING & BARRY
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DISCUSSION The primary hypothesis, that alcoholics with a family history of alcoholism viewed their health as under the control of external forces, particularly chance or fate, was only partly supported. We found a significant difference on the chance scale between the groups. Those subjects who met criteria for alcohol abuse and/or dependence who also had a family history of alcoholism were significantly more likely than nonalcoholics with a family history of alcoholism to believe their health was influenced by chance or fate. Because none of the mean scores on the chance scale was above 19.07 out of a possible 36 points (see Table 2). it cannot be inferred that alcoholics with a family history of alcoholism had a strong belief that chance influenced their health. It can be inferred, however, that nonalcoholics with a family history of the disease were the least likely to believe that chance determined their health. Their scores fell in the range of slight disagreement to moderate disagreement that chance influenced their health. Because family history may be a risk factor in the development of alcoholism, those who are nonalcoholics raised in alcoholic families may have overcome their vulnerability, whereas the alcoholics may have been more susceptible to the development of the illness because of intervening variables. The chance subscale scores of both groups were thus in line. All four groups (Alc+FH+; Alc+FH-; Alc-FH+; Alc - FH - ) received relatively high mean scores (26.88 to 28.38) on the internal scale and lower mean scores (17.61 to 19.52) on one of the external scales-powerful others. Mean scores on the chance scale, across groups, fell between moderate disagreement and slight agreement. Both alcoholic and nonalcoholic primary care patients, regardless of family history, perceived their health as under their own internal control and not under the control of powerful others. Although alcoholics with a family history of alcoholism scored significantly higher on the chance scale than nonalcoholics with a family history of alcoholism. their mean score was 19.07 out of a possible 36 points and could not be considered a positive response. This study provided an extension to the literature through the use of the MHLC construct in a primary care population screened for alcohol-related problems. Previous studies have reported conflicting results regarding the general locus of control of alcoholics. These studies have not used DSM-I11 criteria to determine the extent of primary alcohol problems in their subjects or differentiated between alcoholics and nonalcoholics on
Spring 1991
the basis of family history of alcoholism. Because the high rate of alcohol-related problems in this study may reflect regular users of medical care, the results may not be generalizable to populations that include underutilizers of the healthcare system, and those who would extrapolate the results to a general population should do so cautiously. The prevalence results, however, suggest a larger percentage of adult primary care patients than previously estimated may be presenting with a variety of physical symptoms that may be related to alcohol use. The results of this study indicate few differences in health locus of control between alcoholic and nonalcoholic patients in this primary care sample. Patients who met Lifetime criteria for alcoholism did not attribute their health outcomes differently from nonalcoholics, with one exception. The perception of nonalcoholics from alcoholic families that chance influenced personal health factors can point in one of two directions. Nonalcoholic adult children of alcoholics may assess the importance of maintaining control over health factors and believe that chance or fate is not the major determinant of their health behaviors and status. They, however, could also have an expectation that chance (ie, genetic factors, accidental occurrences, etc), can have little effect on health status, and they may have difficulty using healthcare professionals to their best advantage. Further work focusing attention on outcomes of adult children of alcoholics based on their perceptions of control of their health status may be one factor in developing programs to address effective models of medical intervention for families who live with alcoholism.
INDEX TERMS h b d l a , b&b
lorus of control, p h u y a r e
NOTE Send requests for further information to Michael F. Fleming. MD. MPH, Department of Family Medicine, 777 South Mills, Madison, WI 53715.
ACKNOWLEDGMENTS This research was supported by the Family Hcalth Foundation and the Wisconsin Institute of Family Medicine.
REFERENCES I . Rotter J. Generalized expectancies for internal versus external control of reinforcement. Psychological Monogmphs. 1966.80: 1-28.
2. Levenson H. Activism and powerful others: Distinctions within
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LOCUS O F CONTROL IN ALCOHOLlCS
the concept of internal-external control. J Pets Asse.ss. 1974;38: 377-383. 3. Wallston K, Wallston B, DeVellis R. Development of the multidimensional health locus of control (MHLC) scales. Heulth Educ Monogrcrph. 1978;6: 160-170. 4. Butts S . Chotlos J. A comparison of alcoholics and nonalcoholics on perceived locus of control. Q J Stud Alcohol. 1973;34:13271332. 5 . Goss A, Morosko T. Relation between a dimension of internalexternal control and the MMPI with an alcoholic population. J COWlt k w h o l . 1970;34: 189-192. 6. Distefano D. Pryer M, Garrison J . lnternalsxternal control among alcoholics. J CIin Psycho/. 1972;28:36-38. 7. Costello R. Manders K. Locus of control and alcoholism. Br J Addict. 1974;69:1 I - 17. 8. Engs R. Drinking patterns and drinking problems of college students. J Sfud Alcohol. 1977;38:2144-2156. 9. Ratcliff K. Burkhart B. Sex differences in motivation for and effects of drinking among college students. J Sfud Alcohol. 1984; 45:2632.
10. Wilsnack S . Wilsnack R, Klassen A. Drinking and drinking prob-
lems among women in a US national survey. Alcohol Heulfh und Research World. 1985;9(2):3-13. I I. Carter J, Denton D, Randow H. Correlates of temperate and intemperate attitudes toward alcohol use. J Sch Heulfh. 1985;55(1): 27-29. 12. Bany K. Fleming M. Family cohesion. expressiveness, and conflict in alcoholic families. Br J Addicf. 1990,85:81-87. 13. Fleming M, Bany K. Health status in adult children of alcoholics. SubsfonceAbuse. 1990,11(1):3&39. 14. Robins L. Helzer J. Croughan J. Ratcliff K. National Institute of Mental Health diagnostic interview schedule. Arch Gen Psych& fry. I981;38:381-39O. IS. Nicol E, Ford M. Use of the Michigan Alcoholism Screening Test in general practice. J R Coll Gen Prucf. 1986;36:409-410. 16. Hotch D. Sherin K. Harding P, Zitter R. Use of the self-administered Michigan Alcoholism Screening Test in a family practice center. J Fum Prucf. 1983;17(6):1021-1026.
............. STATEMENT
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TWELFTH CAPE COD INSTITUTE PLANNED
The twelfth annual Cape Cod Institute will consist of a summer-long series of postgraduate courses for mental health and health science professionals. Topics include psychodynamic therapy, behavioral medicine, brief therapy, developmental therapy, Jungian therapy, religion, alcohol treatment, neuropsychology, family therapy, childhood and adolescence, adult development, and organization and management. The program is sponsored by the Department of Psychiatry of the Albert Einstein College of Medicine. Sessions will be held weekday mornings June 24August 30, 1991, from 9:OO until 12:15, leaving the afternoons free for leisure and study. Optional discussion groups and social gatherings will be arranged and institute staff members provide abundant information about activities on Cape Cod. Tuition is $385 for one program and $215 for each additional program attended. A student rate is available. For a complete course catalogue, write or call the Cape Cod Institute, Albert Einstein College of Medicine, 1303A Belfer Building, Bronx, New York, 10461. Telephone 212-43@2307.
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