Journal of Substance Use

ISSN: 1465-9891 (Print) 1475-9942 (Online) Journal homepage: http://www.tandfonline.com/loi/ijsu20

Social cognitive theory as a theoretical framework

to predict sustained abstinence 6 months after
substance use treatment

Ahmad Ali Eslami, Ensiyeh Norozi, Morteza Hajihosseini, Abbas Ali Ramazani
& Mohammad Reza Miri

To cite this article: Ahmad Ali Eslami, Ensiyeh Norozi, Morteza Hajihosseini, Abbas Ali Ramazani
& Mohammad Reza Miri (2017): Social cognitive theory as a theoretical framework to predict
sustained abstinence 6 months after substance use treatment, Journal of Substance Use, DOI:
10.1080/14659891.2017.1394382

To link to this article: https://doi.org/10.1080/14659891.2017.1394382

Published online: 31 Oct 2017.

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JOURNAL OF SUBSTANCE USE
https://doi.org/10.1080/14659891.2017.1394382

Social cognitive theory as a theoretical framework to predict sustained abstinence 6

months after substance use treatment
Ahmad Ali Eslamia, Ensiyeh Norozib, Morteza Hajihosseinic, Abbas Ali Ramazanid, and Mohammad Reza Mirib
a
Department of Health Education and Health Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran; bSocial
Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran; cAtherosclerosis and Coronary Artery Research Center,
Birjand University of Medical Sciences, Birjand, Iran; dSocial Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand,
Iran

ABSTRACT ARTICLE HISTORY

Backgrounds: A wide variety of factors such as individualistic and social/environmental factors appear to Received 26 March 2017
determine whether or not individuals can successfully quit substance use. In this study, Social Cognitive Revised 12 August 2017
Theory was used as a theoretical framework to predict substance use abstinence among a sample of Accepted 08 October 2017
Iranian substance users. KEYWORDS
Methods: Data from 269 male substance users undergoing residential treatment were analyzed using Social cognitive theory;
logistic regression to assess the effects of socio-cognitive factors (treatment motivation, perceived social abstinence; relapse;
support, drug avoidance self-efficacy, and drug quitting outcome expectations) and background charac- substance-related disorders
teristics measured at 5–7 days after admission on drug abstinence status measured at 6-month follow-up.
Results: Abstinence rate after 6-month follow-up was 48.6%. Perceived social support, treatment
motivation, prior substance use treatment, and age of onset of substance use were predictors of
abstinence. However, substance use treatment outcome was not influenced by drug avoidance self-
efficacy, drug quitting outcome expectations, and demographic variables.
Conclusion: Our findings do not support the notion that pretreatment drug avoidance self-efficacy and
drug quitting outcome expectancies are among the most consistent predictors of substance use
treatment outcome. Accordingly, future research is recommended to explore post-treatment levels of
these variables on treatment outcome.

Introduction modalities. Depending on the theoretical background, a wide

variety of factors such as individualistic and social/environ-
Substance-related disorders still continue to pose a serious
mental factors have been investigated to understand and
social problem among Iranian adult population (ranged
predict relapse/abstinence among different groups of sub-
15–64 years old). Based on statistics of the United Nations
stance users (Chauchard et al., 2013; Cornelius et al., 2003;
Office on Drugs and Crime (2014), prevalence of opiate use
Ellis et al., 2004; Ibrahim & Kumar, 2009; Ilgen, McKellar, &
in Iran is among the highest globally (average of 1.5% of the
Tiet, 2005; Laudet & Stanick, 2010; Mohammadpoorasl,
adult population (United Nations Office On Drugs and
2012; Van Zundert, Nijhof, & Engels, 2009; Walton et al.,
Crime, 2014), with about 1 million and 200,000 substance
2003).
users in the country (Narenjiha et al., 2007). Additionally,
Social Cognitive Theory (SCT) is one of the most impor-
addiction after disasters has the highest burden of disease
tant theoretical frameworks that have been shown to be useful
among men in Iran (Narenjiha et al., 2007). Despite an
in understanding and explaining risk behaviors (Ten Wolde
estimated global average of one in six people who suffer
et al., 2008; Van Zundert et al., 2009). SCT offers an
from substance use and abuse receiving treatment each
important theoretical foundation for explaining how people
year (United Nations Office On Drugs and Crime, 2015), a
acquire and maintain certain behavioral patterns including
major problem in the treatment of addicts, even with pro-
addictive behaviors. SCT is based on the assumption that
longed abstinence period, is high rate of relapse (Yan &
social-cognitive determinants, such as self-efficacy, motiva-
Nabeshima, 2009). For example, 6-month relapse rates fol-
tion, outcome expectations and social support, serve as pre-
lowing various classes of substance use cessation attempts
dictors of behavior (Bandura, 1986). According to SCT, one’s
generally range from 45% to 65% (McLellan et al., 2005;
perceived self-efficacy has direct effects both on initiation of
Mohammadpoorasl, 2012). Therefore, there is a pressing
and persistence in behavior (Bandura, 1986). In the context of
need to improve short- and long-term treatment outcomes.
substance use treatment, self-efficacy can be defined as the
An understanding of factors that predict abstinence may
confidence to resist substance use across different high-risk
contribute to improved treatment. Indeed, identification of
situations. In this regard, results from some studies indicate
factors that predict treatment outcomes can provide gui-
that higher levels of perceived drug avoidance self-efficacy
dance in decisions related to assignment to initial treatment

CONTACT Mohammad Reza Miri miri_moh2516@yahoo.com Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran.
© 2017 Taylor & Francis Group, LLC
2 A. A. ESLAMI ET AL.
typically predict better substance abuse treatment outcomes
(Ibrahim & Kumar, 2009; Ilgen et al., 2005; Van Zundert
et al., 2009). Based on SCT, another predictor of a person’s
behavior is outcome expectations, which is defined as a per-
son’s estimate that a certain behavior will lead to certain
positive or/and negative consequences (Bandura, 1986). In
the context of substance use treatment, outcome expectations
can be defined as advantages and disadvantages of substance
use treatment. A number of studies have emphasized the
importance of experiencing negative/positive consequences
of substance use treatment on treatment readiness and treat-
ment outcomes (Battjes et al., 2003; Boyle, Polinsky, & Hser,
2000; Chauchard et al., 2013; Jackson, Wernicke, & Haaga,
2003; Laudet & Stanick, 2010).
A person’s perceived social support is also a key element
in influencing treatment outcomes where studies indicate
that the social support available to substance users can have
an impact on treatment outcomes (Amit, Suneet, & Pankaj,
2012; Ellis et al., 2004; Ibrahim & Kumar, 2009; McKay
et al., 2013). Finally, based on SCT and most theoretical
perspectives on substance use treatment, motivation is a
central element in achieving successful long-term, post-
treatment outcomes because high levels of motivation are
necessary to enact coping behaviors during situations with
high risk for relapse (Marlatt & Donovan, 2005; Prochaska
& DiClemente, 1991). This idea has been confirmed by
some studies indicating low motivation to quit can predict
less treatment success (Austin, Wagner, & Morris, 2010;
Ball et al., 2006; Cornelius et al., 2003; Goodman,
Peterson-Badali, & Henderson, 2011; Laudet & Stanick,
2010; Mohammadpoorasl, 2012).
In addition to the influence of social-cognitive determi-
nants, the effect of background characteristics on treatment
outcomes has been taken into account. Results and conclu-
sions derived from several studies have shown association
between treatment outcome and demographic variables
(Adamson, Sellman, & Frampton, 2009; Amit et al., 2012;
McKay et al., 2013; Smit et al., 2014; Walton et al., 2003) as
well as substance use related variables (Adamson et al., 2009;
Witkiewitz, 2011). However, some of these variables showed
inconsistent relationships with treatment outcomes (Adamson
et al., 2009; Amit et al., 2012; Mohammadpoorasl, 2012; Smit
et al., 2014; Walton et al., 2003). Thus, results of studies about
effect of background characteristics on treatment outcomes
are not conclusive.
While the association between social-cognitive factors and
treatment outcomes is well documented, the impact of socio-
cognitive factors in the context of background characteristics,
particularly among treatment seeking substance-dependent
individuals in short-term residential settings, is less clear. In
this study, we examined predictive power of pretreatment
characteristics such as age, educational level, type of substance
used, etc., and social-cognitive factors on sustained abstinence
as a fundamental goal for the treatment of substance use
problems. It was hypothesized that higher levels of pretreat-
ment social-cognitive factors would positively correlate with
better treatment outcomes upon controlling background
characteristics.
Methods
Participants
Patients were recruited for participation in the study from five
short-term residential substance use treatment programs in
Southern Khorasan province via convenience sampling
method. Southern Khorasan is an eastern Iranian province
that borders with Afghanistan (the country with the greatest
poppy and natural drugs in the world). Treatment program
had a length of stay of 21–28 days and encouraged aftercare
attendance via referrals to Narcotics Anonymous (NA)-based
aftercare counseling. All patients seeking admission to treat-
ment between May 2013 and September 2014, who met study
eligibility criteria, were recruited to participate in the study.
Eligibility was based on the main and primary diagnosis of
substance dependency disorders according to diagnostic cri-
teria of DSM-IV-TR (American Psychiatric Association, 2000)
and completion of detoxification stage. Also, to facilitate fol-
low-up, participants had to be able to provide the names,
addresses, and telephone numbers of at least two contacts.
Regular use of anti-psychotic drugs and inability to answer
questions due to physical and psychological problems were
exclusion criteria. Women were excluded from the study
because of their small number. Of the 425 eligible patients
recruited for the study, 317 (74.5%) consented to participate.
The most common reasons for refusal were lack of willingness
to participate or disinterest in participation. Of the 317 parti-
cipants, 269 (84.85%) completed the 6-month follow-up
assessment, 35 (11.04%) refused the follow-up assessment,
and 13 (4.10%) could not be located at follow-up.
Procedures and ethical considerations
All procedures were approved by the Ethics Committee of
Isfahan University of Medical Sciences (Code No. 393198).
The study was described to patients and they were assured
that their participation was voluntary. Written informed con-
sent was provided by all participants. After detoxification was
complete (typically 5–7 days after admission), separate con-
fidential interviews were scheduled with each patient and
trained research assistants completed a series of baseline ques-
tionnaires requiring about 30-minute completion time.
Confidentiality was assured and no information from these
assessments was shared with clinical staff. Abstinence status
was determined 6 months after discharge by urine analysis. In
this study, a patient was categorized as abstinent if he pro-
vided a negative urine toxicology results and reported no
substance use since the baseline assessment.
Measures
All measures were self-reported and administered via a face-
to-face interview conducted by trained research interviewers
as part of the admission process.
Demographic characteristics measures consisted of age (in
years), marital status, educational level, and employment status.
Substance use history included type of substance used
(opiate (Opium and Heroin), stimulants, hallucinogens or

multiple drug); length of substance abuse (in years); prior
substance use treatment; smoking history; history of alcohol
use; and method of administration (e.g., smoked, injected,
ingested).
Drug Avoidance Self-Efficacy Scale (DASES) was used to
assess an abstinence self-efficacy across 16 different high-risk
situations. For each item, the participants rated their level of
confidence to resist drug use on a 7-point Likert scale (1 = cer-
tainly no; 7 = certainly yes) (Martin, Wilkinson, & Poulos, 1995).
In this study, a culturally adapted version of DASES was used to
assess abstinence self-efficacy across different high-risk situa-
tions. This version of DASES, with some modifications, was a
psychometrically sound and reliable measure (Cronbach’s
α = 0.809) and had a two-factor 14-item structure (Norozi
et al., 2016b). The range of possible scores is from 14 to 98
with higher scores denoting greater avoidance self-efficacy.
Drug quitting consequences was measured by a 23-item
researcher-made measure that assesses the costs and benefits of
quitting substance use. Response categories of the scale ranged
from 1 (Strongly disagree) to 5 (Strongly agree). The content
validity of the measure, via the content validity ratio (CVR) and
content validity index (CVI), was determined and approved by a
panel of experts consisting of 10 experts, four health educators,
four clinical psychologists, and two addiction treatment physi-
cians. To determine the reliability of the measure, the instrument
was completed by 20 substance users who were not included in
the sample. Results showed that this measure have a good internal
reliability (Cronbach’s α = 0.760). The range of possible scores is
between 23 and 115. Higher scores denote greater perceived
benefits of quitting substance use.
Treatment motivation was measured by Circumstances,
Motivation, and Readiness (CMR) scales. CMR is an 18-item
self-administered questionnaire that is designed to assess
motivation among abusers of illegal substances (De Leon
et al., 1994). For the present study, a culturally adapted ver-
sion of CMR was used to assess motivation. This version of
CMR, with some modifications, was a psychometrically sound
and reliable measure (Cronbach’s α = 0.840) (Norozi et al.,
2016a). This culturally adapted version of CMR has 13 items
on a 5-point Likert scale reflecting extent of agreement with
the respective items (1 = Strongly Disagree; 5 = Strongly
Agree). The range of possible scores is from 13 through 65.
Higher scores denote higher levels of motivation.
Multidimensional Scale of Perceived Social Support
(MSPSS) was used to measure perceived social support.
MSPSS is a 12-item measure that specifically addresses the
subjective assessment of social support adequacy from three
specific sources: family members, friends, and significant
others. Respondents are asked to rate each of the 12 items
on a 7-point Likert scale (1 = Strongly Disagree; 7 = Strongly
Agree) (Zimet et al., 1990). For the present study, a culturally
adapted version of MSPSS was used to assess motivation. This
version of MSPSS was a psychometrically sound and reliable
measure (Cronbach’s α = 0.83) (Nasr & Seraj, 2010). The
range of possible scores is between 12 and 84 where higher
scores reflect higher levels of perceived support.
Outcome variable of this study was sustained abstinence at the
end of 6-month follow-up. In this study, the patients were cate-
gorized as abstinent if they provided negative urine toxicology
JOURNAL OF SUBSTANCE USE 3
results and reported no substance use since the baseline assess-
ment. The probability of relapse in the post-discharge period was
modeled as a binary response (0 = relapse, 1 = no relapse).
Data analysis
After all the preparations were made and assurance was achieved
in terms of accuracy of data, descriptive information was
announced as count and percentage by SPSS (version 22).
Then, univariate and adjusted logistic regression models were
fitted by R software 3.2.2 using glm () function to assess crude
and adjusted associations with odds ratios and 95% confidence
intervals between the predictor and outcome variables. To con-
trol which predictor variables might confound the relation
between other variables and the outcome variable, significant
predictor variables in univariate logistic model entered the
adjusted logistic model. Inclusion of these confounding variables
allowed us to determine the effect of socio-cognitive factors at
discharge which was adjusted for confounding variables and to
assess the combined effect of socio-cognitive factors and other
characteristics of participants on the outcome variable. P values
smaller than 0.05 were considered statistically significant.
Results
Mean age of participants was 28.5 ± 0.4 years. Of the 269
participants, 49.8% were single, 44.2% married and 5.9% were
divorced. In addition, 40.9% had diploma degrees or higher,
58.0% had prior substance use treatment, 89.2% had a history
of smoking and 44.6% a history of alcohol abuse. Most of the
participants’ first and current substance was opiates (74.0%
and 65.1% respectively) and the majority of participants had
used opium since age 15–20 years.
Abstinence rate after 6-month follow-up was 48.6%. Table 1
shows characteristics of patients and results of predictors of
abstinence using univariate logistic regression model. Results
showed that abstinence chance is 2.05 (95%CI: 1.2–3.3,
P = 0.004) times for married individuals compared with singles.
Moreover, abstinence chance of subjects who had prior sub-
stance abuse treatment is 2.1 (95%CI: 1.2–3.4, P < 0.001) times
more than others. Compared with <15 years subjects, those who
use their first drugs in 20–25 years and 25–30 years had 3.4 (95%
CI: 1.4–8.1, P = 0.004) and 6.7 (95%CI: 2.3–19.6, P < 0.001) times
greater chance of abstinence, respectively. Logistic regression
modeling shows that with one unit increase in each variable
including age, perceived social support, treatment motivation,
drug avoidance self-efficacy and drug quitting outcome expec-
tancies, chance of abstinence increases 1.074 (95%CI: 1.03–1.1,
P < 0.001), 1.14 (95%CI: 1.1–1.2, P < 0.001), 1.14 (95%CI: 1.0–
1.1, P < 0.001), 1.04 (95%CI: 1.0–1.08, P < 0.001) and 1.04 (95%
CI: 1.0–1.04, P = 0.019) times, respectively.
Adjusted logistic regression model shows that subjects with
prior substance abuse treatment had 2.2 (95%CI: 1.1–4.6,
P = 0.024) times greater chance of abstinence than others.
Furthermore, compared with <15yr, those who were 20–25
years and 25–30 years had 4.2 (95%CI: 1.2–14.2, P = 0.018)
and 6.3 (95%CI: 1.3–30.1, P = 0.020) times more chance of
abstinence. Also, with one unit increase in scores of perceived
4 A. A. ESLAMI ET AL.

Table 1. Predictors of abstinence using univariate logistic regression model. a significant number of Iranian substance users presenting for
N = 269 95%CI for treatment receive short-term residential services (Narenjiha
Parameters (100%) COR COR P et al., 2007). An understanding of factors that predict absti-
Marital status nence may contribute to improved treatment. The present
Single 134 (49.8) 1.0 – –
Married 119 (44.2) 2.05* 1.2–3.3 0.004 study used SCT as a theoretical framework for understanding
Divorced 16 (5.9) 0.8 0.3–2.5 0.785 predictors of substance use abstinence 6 month following
Educational level
<Diploma 159 (59.1) 1.0 – – substance abuse treatment among a sample of Iranian sub-
Diploma and college 110 (40.9) 1.2 0.7–2.0 0.395 stance users. Of the examined factors, treatment motivation,
Primary substance used
Opiates 199 (74.0) 1.0 – –
perceived social support, prior substance abuse treatment, and
Hallucinogens 44 (16.4) 0.8 0.4–1.6 0.584 age of onset of substance use emerged as important predictors
Stimulants 16 (5.9) 1.4 0.5–3.9 0.514 of sustained abstinence among the sample of Iranian clients
Multiple use 10 (3.7) 4.3 0.9–21.1 0.066
Current substance used who abused a variety of substances. Below, we discussed in
Opiates 175 (65.1) 1.0 – – detail each of our main results.
Hallucinogens 6 (2.2) 0.5 0.09–3.0 0.484
Stimulants 35 (13.0) 0.8 0.40–1.6 0.578 The results of our study corroborate other research, indi-
Multiple use 53 (19.7) 1.4 0.7–2.6 0.274 cating that motivation is an important step toward behavior
Prior substance use treatment changes and motivational level influences achieving successful
No 113 (42.0) 1.0 – –
Yes 156 (58.0) 2.1* (1.2–3.4) <0.001 long-term, post-treatment outcomes (Austin et al., 2010;
Age at first use Cornelius et al., 2003; Goodman et al., 2011; Laudet &
<15 years 38 (14.1) 1.0 – –
15–20 years 136 (50.6) 1.9 0.8–4.2 0.095 Stanick, 2010; Mohammadpoorasl, 2012). For example,
20–25 years 65 (24.2) 3.4* 1.4–8.1 0.004 based on results of a systematic review that investigated
25–30 years 30 (11.2) 6.7* 2.3–19.6 <0.001 patient predictors of alcohol treatment outcomes, motivation
History of smoking
No 29 (10.8) 1.0 – – was one of the most consistent predictors of alcohol treatment
Yes 240 (89.2) 1.0 0.4–2.2 0.962 outcome (Adamson et al., 2009). In another study, remaining
History of alcohol
No 149 (55.4) 1.0 – – cocaine abstinent and transitioning from cocaine use to absti-
Yes 120 (44.6) 1.1 0.7–1.8 0.530 nence at the next follow-up was predicted by motivational
Continues parameters
Age 28.5 ± 0.4† 1.07* 1.03–1.1 <0.001
constructs such as commitment to abstinence and readiness to
Perceived social support 53.9 ± 0.7 1.1* 1.1–1.2 <0.001 change (McKay et al., 2013). The finding that motivation
Treatment motivation 51.7 ± 0.5 1.1* 1.0–1.1 <0.001 significantly predicted treatment outcome is understandable
Drug avoidance self-efficacy 57.1 ± 0.8 1.0* 1.0–1.08 <0.001
Drug quitting outcome 89.5 ± 0.8 1.0* 1.0–1.04 0.019 because research has shown that motivational level is a key
expectancies element in influencing substance abusers to seek, comply
*Significant (P < 0.05); † = mean±SE; COR = crude odds ratio. with, and complete treatment (Ball et al., 2006; Battjes et al.,
2003). For example, according to results of a study, motiva-
tional inconsistencies were the most common subjective rea-
Table 2. Predictors of abstinence using adjusted logistic regression model. sons of clients for dropping out from substance abuse
Parameters AOR 95%CI for AOR P treatment (Ball et al., 2006). Another explanation for this
Marital status may be that a person with high levels of motivation is more
Single 1.0 – –
Married 1.8 0.7–4.2 0.154
likely to generate multiple alternative solutions for resolving
Divorced 0.7 0.1–4.1 0.751 his/her problems. Indeed motivation allows patients to cope
Prior substance abuse treatment with stressful situations and enables them to approach treat-
No 1.0 – –
Yes 2.2* 1.1–4.6 0.024 ment goal (sustained abstinence) with more confidence and to
Age at first use sustain effort toward meeting their treatment goal.
<15 years 1.0 – –
15–20 years 1.7 0.6–5.1 0.290 The finding that perceived social support significantly
20–25 years 4.2* 1.2–14.2 0.018 predicted treatment outcome is in line with our own
25–30 years 6.3* 1.3–30.1 0.020 hypotheses as well as findings from several prior studies
Continues parameters
Age (continues) 1.0 0.9–1.0 0.858 (Amit et al., 2012; Ellis et al., 2004; Ibrahim & Kumar,
Perceived social support 1.1* 1.1–1.2 <0.001 2009; McKay et al., 2013), indicating the importance of
Treatment motivation 1.1* 1.0–1.1 <0.001
Drug avoidance self-efficacy 1.0 0.9–1.0 0.239 supportive social network (family members, friends and
Drug quitting outcome expectancies 1.0 0.9–1.0 0.106 significant others) on achieving better substance use treat-
*Significant (P < 0.05); AOR = adjusted odds ratio. ment outcomes. In contrast with our finding, based on
results of one study, there was no relationship between
perceived social support and substance use treatment out-
social support and treatment motivation, chance of abstinence comes (McMahon, Kouzekanani, & Malow, 1999), suggest-
increases as much as 1.1 (P < 0.001) (Table 2). ing that a general sense of social support is not always
enough to help patients in their effort to achieve and main-
tain abstinence. An important point that should be noted is
Discussion
that in this study we examined effect of pretreatment per-
There is a pressing need to improve long-term treatment ceived social support on treatment outcome. Hence, this
outcomes particularly in short-term residential settings since issue may limit comparisons between the results of our

study with those of other studies that used post-treatment
perceived social support as outcome predictor variable.
Indeed, the effect of perceived social support on treatment
outcomes may differ before entry into substance abuse
treatment than during or after substance abuse treatment.
For example, based on the results of one study, post-treat-
ment perceived social support is vital to achieving better
treatment outcome but pretreatment social support failed to
bring about abstinence (Ellis et al., 2004). However, it is
obvious that supportive social network can influence treat-
ment outcomes by boosting psychological well-being, which
may in turn provide protection against relapse. It should
also be borne in mind that social support on its own is not
sufficient to bring about abstinence even though it is funda-
mental to sustaining it (Dodge & Potocky, 2000).
With regard to substance use related variables, only history of
prior substance abuse treatment and age of onset of substance
use predicted abstinence at 6-month follow-up. Consistent with
our study, a systematic review reported that treatment history
was a successful predictor of alcohol treatment outcome
(Adamson et al., 2009). However, in contrast with our finding,
results from Witkiewitz’s (2011) study showed that individuals
with a greater number of prior treatments displayed a poorer
treatment outcome if they had increased risk factors during the
follow-up (Witkiewitz, 2011). Also, in a meta-analysis of 69
studies predicting continued drug use by opioid treatment cli-
ents, Brewer et al. (1998) identified prior treatment for opioid
addiction as a significant predictor of future drug use (Brewer
et al., 1998). This inconsistency of the results may reflect meth-
odological differences of studies, for example, in terms of sample
characteristics, type of prior treatment, etc. However, this result
of our study can be understandable because based on our patient
opinions, their prior quit attempts was related to greater under-
standing of the severity of their substance abuse problem and
thus their perceived need for further attempt. As mentioned
above, age of onset of substance use was also related to outcome
and higher age of onset of substance use predicted better out-
come at 6-month follow-up. Contrary to our result, a systematic
review that investigated patient predictors of alcohol treatment
outcome reported that onset age of alcohol misuse was a poor
predictor of outcome (Adamson et al., 2009). An explanation for
our result may be that younger age of onset of substance use can
be a rough indicator of exposure to more high risk situations and
a variety of potential negative experiences leading to lower self-
confidence across high risk situations on the part of such abu-
sers. This could lead to the perception that it would be more
difficult for them to experience successful abstinence. Also, a
small number of individuals in the 25–30 year’s age group as a
first use age can be explained by the high amount of odds ratio
and wide confidence intervals. Thus, our result in this regard
would be unreliable with lack of power because of this limitation.
It is noteworthy that none of the three demographic variables
examined––age, marital status and educational level––were pre-
dictors of abstinence. Highly studied as they are, demographic
characteristics are variables most widely used as predictors in
many studies (Adamson et al., 2009). In line with results of our
study, results of a majority of studies indicate that age, marital
status and education were generally poor predictors of treatment
outcome (Adamson et al., 2009). However, based on the results
JOURNAL OF SUBSTANCE USE 5
of a few studies, older age, being married and higher educational
level served as a protective factor for post-treatment alcohol and
drug use (Amit et al., 2012; McKay et al., 2013; Smit et al., 2014;
Walton et al., 2003). So, future research is recommended to
explore associations between demographic variables and treat-
ment outcome.
Based on the results of other studies, drug avoidance self-
efficacy is generally one of the most consistent predictors of
substance abuse treatment outcome (Adamson et al., 2009;
Ibrahim & Kumar, 2009; Ilgen et al., 2005; McKay et al., 2013;
Smit et al., 2014). Nonetheless, abstinence in our sample did
not differ based on drug avoidance self-efficacy. Our result is
not surprising given that this measure reflected pretreatment
levels of drug avoidance self-efficacy. Indeed, we used pre-
treatment perceived self-efficacy as a predictor variable, while
most studies have taken perceived self-efficacy measured at
discharge or multiple follow-ups as a predictor of treatment
outcome (Ilgen et al., 2005; McKay et al., 2013). In fact, little
research has been conducted on the relationship between self-
efficacy at treatment entry and treatment outcome.
Accordingly, it seems that baseline self-efficacy did not pre-
dict outcome, while improved self-efficacy over time and after
the treatment phase would be related to treatment outcomes.
Moreover, since in our study not every patient with high drug
avoidance self-efficacy was abstinent at 6-month follow-up,
considerable concern remains that high levels of abstinence
self-efficacy may represent overconfidence for a portion of the
sample and this may have influenced 6-month outcome.
Indeed, based on work of Burling et al. (1989), overconfident
on entering treatment entry predicted early treatment exit and
more discharges for “negative” reasons for a large alcohol and
drug treatment sample (Burling et al., 1989).
One of the most noteworthy findings that have emerged in
this study is insignificance of drug quitting outcome expec-
tancies as predictor of abstinence. This finding is not in
keeping with our hypothesis. Based on the SCT, a person’s
positive expectancy is one of the most important factors that
influences whether one takes action to make necessary
changes Bandura, 1986). In the general population of addicts,
some studies have reported that perceptions of substance
abusers about advantages and disadvantages of quitting can
predict their motivation for treatment (Battjes et al., 2003;
Boyle et al., 2000; Chauchard et al., 2013; Jackson et al.,
2003; Laudet & Stanick, 2010). However, results of other
studies show inconsistent relationships about the effect of
drug quitting outcome expectancies on treatment outcomes.
In one study, drug quitting failure was greater for patients
who reported fewer advantages for quitting (Macnee &
Talsma, 1995), but results of other study showed that pros
of quitting were not significantly related to any of the relapse
variables except for a marginal effect on abstinence at follow-
up (Ten Wolde et al., 2008).
Limitations
Several limitations to the study should be acknowledged. First,
the sample was composed solely of substance users referred to
short-term residential treatment programs. Severity of sub-
stance use disorders in this sample is relatively low. Thus,
6 A. A. ESLAMI ET AL.
results of this study should not be generalized to patients with
more severe disorders who are entering TC treatment.
Further, research should be conducted on other samples of
substance users of different treatment modality. Also, the
sample represented 63.29% of those actually eligible, due to
the fact that some did not have willingness to participate in
research and some failed to participate in the follow-up
assessment. The fact that virtually the entire sample was
male also limits its generalizability.
A further limitation relates to the fact that sustained abstinence
is increasingly recognized as a complex product of a dynamic
interaction between many more than those relatively few factors
considered by this study. Indeed, data on other Individualistic and
social/environmental variables of interest—such as craving, his-
tory of physical abuse, and family functioning—were not avail-
able. Also, the role that treatment might have played in the present
results is unknown at this time. In fact, we measured pretreatment
levels of predictor variables. Thus, it is possible that changes/
improvements in predictors following treatment would be related
to post-treatment outcome. Therefore, a longer follow-up period
utilizing multiple measurement points would be desirable. This
study is also limited by its convenience sampling method and by
its relatively short follow-up period.
Conclusion
Results of this study provide a clinically useful way to under-
stand the interactions between predictors of outcome and to
identify specific subgroups of patients who may be either more
or less likely to have positive outcomes following treatment. The
findings suggest that pretreatment motivation and perceived
social support are important variables affecting successful sub-
stance abuse treatment outcomes. In short-term residential
treatment programs, the management of treatment motivation
and perceived social support are not typically given primary
attention. Treatment approaches that address treatment moti-
vation and perceived social support are likely to enhance sub-
stance abuse treatment outcomes in real world clinical settings.
On the other hand, our findings do not support the notion that
pretreatment drug avoidance self-efficacy and drug quitting
outcome expectancies are among the most consistent predictors
of substance use treatment outcome. Consequently, future
research is recommended to explore post-treatment levels of
these variables on treatment outcome.
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