Self- and Group-Dynamics in Mutual Support Recovery

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Abstract
Self-efficacy in those attempting to recover from substance abuse disorders is believed to contribute to abstinence. Participation in mutual support groups is believed to reinforce self-efficacy by giving participants the opportunity to help others. Self-efficacy, as a component of the conceptual "system of self" works in conjunction with self-esteem to help goal achievement, or self-agency, which, for those with substance disorders, is abstinence. To reinforce research from previous largely qualitative studies, this study proposes to correlate self-efficacy and self-esteem as predictors of the rate of abstinence, or self-agency, of a group 30 men with a mean age of 30 who attend mutual support substance abuse programs. It is hypothesized that increases in self-efficacy and self-esteem will predict self-agency in terms of higher abstinence and lower drug craving, but that self-efficacy will be a greater predictor. The study also proposes to explore innovative data collection and statistical methodologies that leverage cell phones, the internet, and continuous online statistical analysis for the benefit of other researchers and those who want to manualize self-efficacy and self-esteem concepts in the group context for substance abuse recovery.

Introduction
Statement of Problem
Alcohol abuse, as an example of substance abuse, has a lifetime prevalence of 18% with current abuse highest among the young, implying that it is a growing problem (Hasin, et al., 2007). Less than a quarter of alcohol abusers are treated and treatment opportunities have declined. Drug abuse is also shown to be growing, and treatment is also believed to be declining especially for the young (Terry-McElrath, 2005). Recovery is difficult and relapse is common (DeFulio & Silverman, 2011).

Mutual support groups such as Alcoholics and Narcotics Anonymous provide effective support and are cost-effective as they are self-supporting. Non-abstinent substance abusers regularly experience high permanent recovery rates if they regularly attend group support meetings (Gossop, Stewart, & Marsden, 2008; Groh, et al. 2009). The reason given for high success rates is that the groups provide opportunities for those recovering from abuse to increase their self-efficacy (Stevens, et al., 2010).

This study proposes to quantify the relationships between the "self-system" components of self-efficacy and self-esteem as they help recovering abusers achieve the goal, or self-agency, of abstinence in the context of mutual support groups.

Literature Review
Self-efficacy
Self-efficacy is the perception of one's ability to reach goals, or self-agency, and, according to Bandura (1982), mediates the process of achieving goals. Related to self-efficacy and self-agency (as components of the "self-system") is self-esteem (Phan, 2010), which, as the perception of self-worth, is enhanced by peer appraisals and support (Bracke, Christiaens, & Verhaeghe, 2008).

Self-efficacy is also suggested as a mechanism that reduces the drug craving that leads to abstinence relapse (Matto, Strolin, & Mogro-Wilson, 2008).

Group process
Bracke, Christiaens, and Verhaeghe (2008) show that self-efficacy and related self-esteem can interrelate as mutual mediators among support groups of the mentally ill. Under some circumstances, they show that self-esteem can be detrimental to self-agency in the absence of self-efficacy (especially in men) as it signifies peer dependence rather than self-agency. Also, they specifically show that self-efficacy is achieved when group members take a leadership role by providing support to other members. This study shows increased self-efficacy in a therapeutic context, but, using a cross-sectional design, could not link self-efficacy to self-agency, which would be the patients' progress over time.

Truneckova, & Viney describe group process as the means by which groups provide members with self-system support (2008), and Bandura (1982) describes group efficacy as a group's perception of its ability to reach goals, or group agency. While group efficacy should predict self-agency among members, Groh, et al. (2009) show that recovering abusers who both attend support groups and get further support by living in support communities have the highest self-agency, or abstinence, rate of about 90%. This suggests that these multiple group members are doing something different than single-group members, and it may be that they are taking more supportive roles. Combining these ideas suggests recovering abusers who benefit the most from group support in terms of self-agency tend to do so because they provide support to others as well as benefit from the group's support in terms of self-esteem. Group support benefits members with self-esteem, but it is the individual effort of the participant that is the ultimate predictor of self-agency. Truneckova, & Viney (2008) demonstrated group process as being beneficial for members but failed to connect it to individual efficacy and agency (even though their results seemed to support it), and Groh, et al. (2009) showed self-efficacy, but not in the context of involvement in group process.

Hypotheses to be Tested
This study proposes to show that self-efficacy and self-esteem both directly contribute to self-agency, or abstinence, in the context of mutually supported substance abuse recovery, and that self-efficacy is more predictive of self-agency than self-esteem is. It also proposes to show that self-efficacy is indeed associated with lower drug craving, giving those who participate in groups a higher rate of abstinence.
1. Clients who participate in mutual support groups by contributing support and suggestions to other group participants (self-efficacy), and who receive this kind of support (self-esteem) will have abstinence rates that are higher than those who have low measures in these variables.
2. Clients who have high abstinence will show higher self-efficacy than self-esteem.
3. Clients with high self-efficacy will have lower cravings, which will correlate with higher abstinence (or self-agency).

Method
The two intended goals are to provide support for correlations between concepts of "system of self" through regression analysis of Likert-type self-report scales in relation to self-reports of abstinence, and to implement a flexible self-report and analysis system that can be expanded, or "scaled," either to increase the n-number as recruits are found, or to accommodate future research by enhancing the statistical software.

Participants
Participants will be drug abuse clients who are referred by probation officers or recruited from Narcotics Anonymous-type mutual support groups with the assistance of group leaders.
Leaders of the mutual support groups will act as facilitators by reporting the group attendance of the participants and also that the group is functioning moderately well. They have to be reliable and drug free.

Limiting the study to male clients will solve a control problem which is that women respond to self-esteem at a different rate than men (Bracke, Christiaens, & Verhaeghe, 2008). Participants also need to be frequent mutual support group attendees, and, for abstinence testing purposes, the substances for which they have been referred have to be reliably testable drugs such as cocaine, heroin or methedrine.

There will be no control group primarily because the study will assess for correlations between self-efficacy and abstinence in the participants.

Materials
Self-efficacy, self-esteem, and the group process will each be tested with a separate scale. Self-efficacy will be tested with a modified version of the Alcohol Abstinence Self-Efficacy Scale, and self-esteem will be measured with the Rosenberg Self-esteem Scale. Both these tests are well-studied and have shown reliability and validity adequate for this study (Bogenschutz, Tonigan, & Miller, 2006; Greenberger, Chen, Dmitrieva, & Farruggia, 2003).
Self-report and statistical analysis will be conducted by an information system. It will consist of a cell phone "app" for self-report system, which is a tiny web page that runs on a smart phone. An online server secured with 128 bit encryption and sophisticated password checking will collect the data and an attached statistical program will analyze it on a continual basis.
Restaurant coupons will be supplied to participants as a reward for honesty about abstinence and relapse self-reporting based on drug screens. The choice of restaurant coupons is to involve the community. It is perceived that the business community leaders will support a program that seeks to reduce a major problem cost-effectively, and will be able to convince restaurant owners to donate dinners.

Procedures
Participants and group leaders will register anonymously with the web server and be given the informed consent agreement form in a format that can easily be understood by them. When they have agreed to agreement's terms, they will be asked if they have concerns about the agreement (by the web server) to assure that they understood it.

Using a secret name or number, participants will be asked to access the server via a cell phone "app" after group support sessions and will be asked a few questions from the self-esteem and self-efficacy questionnaires. They will be also be asked to access the "app" if they feel craving, or relapse to drug use. They can also reach the research staff anonymously this way if they have concerns about their participation in the study.

Using the same method, group leaders will insert attendance information into the server database, and will be asked a few questions about the group process to assure that the group is functioning normally. This data is inclusion criteria and not intended to be experimental.
Participants will be given random drug screens solely for the purpose of confirming abstinence or relapse. The test will be kept confidential simply by identifying it with the secret cell phone "app" log-in ID. They will be only tested for "hard" drugs such as cocaine, methedrine, and heroin, as some other substances such as marijuana and alcohol will provide either overly-positive or overly-negative results (DuPont, 2005; Goldberg, 2010).

These sessions will take a few minutes, and the study period will be three months.

Proposed Statistics
The test measures are self-efficacy and self-esteem as independent/predictor variables; and abstinence and craving as dependent criteria. As the relationship between the variables is expected to be linear, multiple regressions will be used to create the "r" value that will indicate the level of association between variables (Meyers, 2006).
In the second hypothesis, the multiple regression analysis may not be able to determine whether self-efficacy or self-esteem are more correlated with abstinence if they are closely correlated to each other: the condition of multicollinearity (Berry, 1985). Solutions may include obtaining more data or implementing other statistical formulations.

Ethical Considerations
The informed consent agreement (Appendix A) has been developed to meet United States federal government and American Psychology Association ethical guidelines (Goodwin, 2010; Kitchener, 2000). It is in terms clients can understand, their privacy rights are fully protected, and their individual concerns will be solicited and accommodated. They will be informed about the content and purpose of the study, its duration, how confidentiality will be protected, that they are volunteers, there will be no consequences for withdrawing, how they can withdraw, and that there are no deceptions in this study.

Group leaders will likewise be given informed consent material with the addition that they agree to protect the privacy of the other participants, and that they agree to attempt to stay with the program as they are needed to monitor participant attendance and group process.

Anticipated Results
It is expected that the three hypotheses will be confirmed, though the relationship between self-efficacy and self-esteem in terms of abstinence may need further statistical analysis to magnify the differences to show a relationship. Likewise the technical innovations are expected to produce data efficiently with little chance of response bias such as response acquiescence and social desirability, as the self-reports are anonymous and supplied to a device rather than a person.

Implications
The material provided can be directly applied by researchers interested in manualizing group support strategies that leverage "system of self" components as they are enhanced by the normal group process (Stevens, et al., 2010). The research material will be presented in such a way that it can be further analyzed with the online software with which it is presented.
The anticipated success of the technology innovations will encourage similar efforts. The system will not be "taken down," but will be made available to researchers who have participants willing to self-report with cell phones at a cost of pennies per transaction. Statistical software, which is already in the public domain, will be made available for modification.

Discussion
Summary
The study will provide needed evidence of the relationships between "systems of self" and the group process for the purposes of policy-making and future research. The technology experience will show that self-report effectiveness can be enhanced by many factors and that collected material and statistical services can be made universally available at little cost.

Conclusion
This study will help define and "tease apart" the different components of the structures of the "system of self" and use quantitative data to define them in the context of group experience in ways that have largely been qualitative, and hence conflicting and often ambiguous.
It shown that good group process, or group efficacy, will enhance self-efficacy and self-agency (Stevens, et al., 2010), but it is important to understand that the individual may benefit from the group process in ways that are independent of the group's goal-reaching success, or group-agency. Individuals do this by contributing to the group in a way that reinforces their self-system. Presumably all the group members will benefit (especially in terms of self-esteem), but not as much as individuals who actively contribute.

Limitations
This second hypothesis (which is that self-efficacy and self-esteem are important to self-agency, but self-efficacy is more important) presents a possible limitation in that there may be statistical difficulties if the self-efficacy and self-esteem variables are found to be too closely correlated (Berry, 1985; Meyers, 2006).

Perceived limitations also relate to relapse and abstinence. Self-reports for drug use have been shown to be inaccurate (Tourangeau & Yan, 2007), though measures are being implemented to control for this through drug screening and with rewards for honesty. The craving variable data may be used in the first and second hypotheses if abstinence self-reporting is too problematic. Another limitation may be the influence of drug screening as they have been shown to mediate abstinence (Sánchez-Hervás, et al., 2010). Assured privacy and the reward for honesty should minimize this effect. Ultimately, these potential problems would best be resolved in future research by developing other variables to use as measures of self-agency.

Future Research
An intuitive next step is to apply the study to women. It has been shown that women are motivated differently by self-esteem, self-efficacy, and also social cohesiveness in terms of group process and especially abstinence (Bracke, Christiaens, & Verhaeghe, 2008; Figueira-McDonough & Sarri, 2002). This research should provide better definitions for the "system of self" in terms of gender differences.

The strongest rationale for this study is the initiation of future research. Evidence is building in different areas for a self-system and group process model, but terminology is unclear (and often defined in the context of a single study), and only a small percentage of studies have been applied to major disorders (rather than, say, business dynamics), and often by the same researchers. Real world effectiveness needs to be shown in a variety of environments such as different countries to win general support.

With implementation of a cell phone "app" that operates at nearly no cost, technical focus should move towards the statistical services. While most researchers cite most commonly-used "self-system" tests as having high reliability and validity, many researchers criticize their use such as in multi-cultural contexts (Schmitt, & Allik, 2005). A general solution is to implement factor analysis software (which is also in the public domain) in place of regression software so that test questions can be used at random (within the scope of self-system and mutual group support) and then "clustered" using Likert-type scales into categories that will relate to components of the self-system (DeCoster, 1998; Hojat, 2007). Further, participants could be asked open-ended questions such as "how do you feel?" These responses could be converted into questions to be categorized.

This will create real-world connections to theoretical abstractions in much the way that the Five Factor Model has been developed. (A Five Factor Model project can supply much of the software and expertise (J. A. Johnson, personal communication, December 6, 2010)). Ultimately, the greatest benefit may be the ability to interrelate variables to predict the all-important abstinence, or self-agency, so that abstinence success can be used to load variables that simulate group process; these, in turn, can contribute to developing outcomes that can be used to formulate therapeutic strategies.

Future software should be developed to further resolve privacy issues by deleting personal data as it is processed, and hopefully accurately predict abstinence honesty (using self-system variables) so as to eliminate drug screening as a potential mediator, source of participant concern, and expense. Also, research should attempt to transcend the singular focus on the "system of self," to move towards a group-oriented agency model as group agency will presumably yield a greater volume of beneficial outcomes than individual agency.

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