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Maintenance of weight loss : the role of self-efficacy and coping strategies in relapse prevention 1990

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MAINTENANCE OF WEIGHT LOSS': THE ROLE OF SELF-EFFICACY AND COPING STRATEGIES IN RELAPSE PREVENTION by Kathleen F. Tees B.A., U n i v e r s i t y of B r i t i s h Columbia, 1980 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n The F a c u l t y of Graduate Stud i e s (Department of C o u n s e l l i n g Psychology) We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1990 (c) Kathleen F e l i c i a Tees, 1990 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department Of P n n n g p l l i n i ] Pgyr-hr.1r.gy The University of British Columbia Vancouver, Canada Date September 25. 1990 DE-6 (2/88) ABSTRACT Because t h e r e can be s e r i o u s h e a l t h and s o c i a l consequences t o o b e s i t y , the need f o r e f f e c t i v e treatment programs i s g r e a t . So f a r r e s e a r c h e r s i n the f i e l d have been more s u c c e s s f u l i n improving the s h o r t - t e r m e f f e c t i v e n e s s of treatment programs f o r weight l o s s t han the l i k e l i h o o d of long-term maintenance. T h i s study i n v e s t i g a t e d the e f f e c t s of a 4-week no n - d i e t maintenance i n t e r v e n t i o n program f o r 59 female p a r t i c i p a n t s who had s u c c e s s f u l l y reached a t a r g e t g o a l weight, m a i n t a i n e d t h e i r l o s s f o r a t l e a s t s i x months, and had moderately h i g h l e v e l s of c oncern about f u t u r e maintenance. Two treatment c o n d i t i o n s were compared, a maintenance i n t e r v e n t i o n (MI) and a r e l a p s e p r e v e n t i o n i n t e r v e n t i o n (RPI) w i t h a w a i t i n g l i s t s e r v i n g as a c o n t r o l group. Measures of s e l f - e f f i c a c y and c o p i n g were taken b e f o r e and a f t e r treatment, and by m a i l a t a 6-week follo w - u p f o r the 2 treatment c o n d i t i o n s ; t h e w a i t i n g l i s t was t e s t e d a t c o r r e s p o n d i n g time i n t e r v a l s w i t h o u t i n t e r v e n i n g treatment. I t was expected t h a t l e v e l s of s e l f - e f f i c a c y and the r e l a t i v e use of problem-focused c o p i n g would i n c r e a s e from p r e t e s t t o p o s t t e s t f o r both treatment c o n d i t i o n s compared wi t h the w a i t i n g l i s t and t h a t o n l y t h e r e l a p s e p r e v e n t i o n i n t e r v e n t i o n group would m a i n t a i n these i n c r e a s e s from p o s t t e s t t o f o l l o w - u p . No such s i g n i f i c a n t d i f f e r e n c e s were found among the groups on the dependent measures, however, as hypothesized, problem- f o c u s e d c o p i n g a t p o s t t e s t was p o s i t i v e l y c o r r e l a t e d w i t h l e v e l s of s e l f - e f f i c a c y a t f o l l o w - u p . When c l i n i c a l s i g n i f i c a n c e was assessed, i n d i v i d u a l p a r t i c i p a n t s i n both treatment c o n d i t i o n s showed improvement i n s e l f - e f f i c a c y (MI, 36%; RPI, 28%), and r e l a t i v e use of problem-focused c o p i n g (MI, 22%; RPI, 33%). In a d d i t i o n , c o r r e l a t i o n a l f i n d i n g s were s i m i l a r t o those of o t h e r maintenance s t u d i e s ( i . e . , s m a l l e r weight r e g a i n s were a s s o c i a t e d w i t h h i g h e r l e v e l s of e x e r c i s e and r e g u l a r m o n i t o r i n g of w e i g h t ) . I t was c o n c l u d e d t h a t the r e l a p s e p r e v e n t i o n treatment had not produced th e d e s i r e d e f f e c t of r a i s i n g l e v e l s of s e l f - e f f i c a c y and i n c r e a s i n g the r e l a t i v e use of problem-focused c o p i n g , but a l s o t h a t the program's o b j e c t i v e s had been too a m b itious f o r a 4-week program. The r e l a t i o n s h i p between s e l f - e f f i c a c y and problem-focused co p i n g found i n t h i s study i n d i c a t e s t h a t t h i s i s a f r u i t f u l area f o r f u r t h e r i n v e s t i g a t i o n i n the development of e f f e c t i v e i n t e r v e n t i o n programs f o r s u c c e s s f u l d i e t e r s a t r i s k of r e l a p s e . i v TABLE OF CONTENTS page A b s t r a c t i i T a b l e of Contents i v L i s t o f T a b l e s v i i L i s t of F i g u r e s . ... v i i i Acknowledgements i x I n t r o d u c t i o n 1 O b e s i t y and Weight Loss Maintenance 1 Relapse P r e v e n t i o n 3 S e l f - E f f i c a c y i n Relapse P r e v e n t i o n 5 Coping i n Relapse P r e v e n t i o n 5 Relapse P r e v e n t i o n i n Weight Loss Treatments 7 G e n e r a l Hypotheses f o r the Study 8 L i t e r a t u r e Review 10 O b e s i t y and Treatments 10 C o r r e l a t e s of S u c c e s s f u l Maintenance 13 Understanding the Relapse Process 15 S e l f - E f f i c a c y and Coping i n Relapse P r e v e n t i o n .... 17 S e l f - E f f i c a c y i n Weight Loss and Maintenance 19 Coping i n Weight Loss and Maintenance 2 4 Relapse P r e v e n t i o n T r a i n i n g 29 Development of a Maintenance Treatment Program .... 32 E v a l u a t i n g a Maintenance Treatment Program 3 8 Purpose of the Study 41 Hypotheses 43 V Method 44 S u b j e c t s 44 Design and Procedure 47 Dependent Measures 51 E a t i n g S e l f - E f f i c a c y S c a l e 51 Ways of Coping C h e c k l i s t 53 A n c i l l a r y Measures 56 T h e r a p i s t Q u a l i f i c a t i o n s 56 Treatments 57 Data A n a l y s i s 58 R e s u l t s 60 Group C o m p a r a b i l i t y 60 A t t r i t i o n 62 P r e t e s t Dependent Measures 63 E x p e c t a t i o n s of Treatment E f f e c t i v e n e s s 67 Hy p o t h e s i z e d Treatment E f f e c t s 68 Dependent Measures: C o r r e l a t i o n s 7 2 C l i n i c a l S i g n i f i c a n c e 76 D i s c u s s i o n 81 Dependent Measures Hypothesized R e s u l t s 82 C o r r e l a t i o n s I n v o l v i n g S e l f - E f f i c a c y and Coping ... 90 C o r r e l a t i o n s I n v o l v i n g Maintenance S t r a t e g i e s and E x e r c i s e 91 C l i n i c a l S i g n i f i c a n c e 93 A n e c d o t a l Evidence f o r Treatment E f f e c t i v e n e s s .... 96 C o n c l u s i o n , L i m i t a t i o n s , Recommendations 98 References 102 v i Appendix A 107 Demographic P r o f i l e 108 Informed Consent . . . 110 A t t r i b u t i o n S c a l e I l l Appendix B 112 E a t i n g S e l f - E f f i c a c y S c a l e (ESES) 113 Ways of Coping C h e c k l i s t (WCCL) 115 R e l i a b i l i t y and V a l i d i t y f o r the WCCL 119 Appendix C 121 Expectancy S c a l e 122 P a r t i c i p a n t E v a l u a t i o n 12 3 Appendix D 124 M u l t i v a r i a t e and U n i v a r i a t e A n a l y s e s 125 v i i LIST OF TABLES page T a b l e 1. Means and Standard D e v i a t i o n s f o r D e s c r i p t i v e Data ..'61 T a b l e 2. Means and Standard D e v i a t i o n s f o r S e l f - E f f i c a c y f o r A l l Groups ... 64 T a b l e 3. Means and Standard D e v i a t i o n s f o r Percentage of Problem-Focused Coping f o r A l l Groups 65 T a b l e 4. C o r r e l a t i o n M a t r i x f o r Dependent Measures and Subscales a t P r e t e s t , P o s t t e s t , and Follow-up f o r Combined+ Treatment Groups, MI-G and RPI-C 70 T a b l e 5. C o r r e l a t i o n M a t r i x f o r Dependent Measures and Other V a r i a b l e s a t P r e t e s t f o r a l l P a r t i c i p a n t s 75 T a b l e 6. C l i n i c a l l y S i g n i f i c a n t Change W i t h i n Combined Treatment Groups 78 v i i i LIST OF FIGURES page F i g u r e 1. R e p r e s e n t a t i o n of the Relapse P r e v e n t i o n Model ( M a r l a t t and Gordon, 1980) as i t A p p l i e s t o Ov e r e a t i n g 4 F i g u r e 2. Time-span of Study and Group Formation 48 ix ACKNOWLEDGEMENTS F i r s t and foremost I would l i k e t o thank my a d v i s o r , Dr. B o n i t a Long, f o r her u n f a i l i n g p a t i e n c e and the encouragement she gave me from the b e g i n n i n g t o the completion o f t h i s p r o j e c t . Her a t t e n t i o n t o d e t a i l , her a b i l i t y t o h e l p me st a y focused on what was important, and her w i l l i n g n e s s t o make whatever time was needed a v a i l a b l e to me were a constant source of support. I a l s o wish t o thank the oth e r members of my committee, Dr. A n i t a DeLongis and Dr. R i c h a r d Young, f o r t h e i r review of my study and t h e i r i n s i g h t f u l comments and s u g g e s t i o n s . S p e c i a l thanks are due to C a r o l y n Tees who a s s i s t e d me i n the p r e l i m i n a r y s e s s i o n s and who was an i n v a l u a b l e p a r t of my support system. Throughout t h i s p r o j e c t I have been b l e s s e d w i t h a husband and f a m i l y who encouraged and s u s t a i n e d me and I am f o r e v e r g r a t e f u l t o them. F i n a l l y I wish t o thank the women who made t h i s study p o s s i b l e by v o l u n t e e r i n g t h e i r time and who braved deluge and b l i z z a r d c o n d i t i o n s t o a t t e n d the s e s s i o n s . T h e i r w i l l i n g n e s s t o e x p l o r e with me a d i f f e r e n t approach t o weight l o s s maintenance i s deeply a p p r e c i a t e d . 1 INTRODUCTION In a s o c i e t y t h a t i n c r e a s i n g l y v a l u e s a t r i m , y o u t h f u l appearance, overweight people can be engaged i n what seems l i k e an e n d l e s s b a t t l e of the bulge. Not everyone wants t o l o s e weight f o r cosmetic reasons; h e a l t h and l o n g e v i t y can a l s o be an i s s u e . Although commercial weight l o s s programs abound, a l l p r o m i s i n g l a s t i n g b e n e f i t s , most d i e t e r s e v e n t u a l l y r e g a i n not onl y the weight they managed t o l o s e but even more. The o n l y r e c o u r s e i s another w h i r l on t h e d i e t merry-go-round, w i t h a g r a d u a l l y f a d i n g hope of permanent s u c c e s s . Over time, f a i l u r e s t o m a i n t a i n weight l o s s e s can le a v e a person f e e l i n g inadequate and even s t u p i d f o r not ha v i n g p r o p e r l y " l e a r n e d " the l e s s o n s of weight management. T h i s study looked a t some u n d e r l y i n g f a c t o r s a s s o c i a t e d w i t h maintenance of weight l o s s and i n v e s t i g a t e d the e f f e c t s of an i n t e r v e n t i o n program wi t h a n o n - d i e t approach f o r women who had s u c c e s s f u l l y l o s t weight but were concerned about long-term maintenance. O b e s i t y has been c a l l e d "one of the most d i f f i c u l t m e d i c a l and p s y c h o l o g i c a l problems of modern s o c i e t y " by a renowned r e s e a r c h e r i n the f i e l d (Brownell, 1982, p.820). Bray (1987) reviewed the medical f i n d i n g s and r e p o r t e d t h a t body weights 20% above average are a s s o c i a t e d w i t h i n c r e a s e d death r a t e s from h e a r t d i s e a s e , h y p e r t e n s i o n , d i a b e t e s m e l l i t u s , and cancer. Wadden and Stunkard (1985) looked a t the s o c i a l and p s y c h o l o g i c a l consequences of o b e s i t y and concluded t h a t women, ado l e s c e n t g i r l s , and the m o r b i d l y 2 obese s u f f e r severe consequences from a c u l t u r a l contempt f o r the obese. Although a c o n s i d e r a b l e amount of r e s e a r c h has been done t o develop e f f e c t i v e treatment programs t o h e l p people l o s e weight, the g o a l of long-term maintenance remains d i s c o u r a g i n g l y remote. S e v e r a l decades ago, Stunkard and McLaren-Hume (1959) r e p o r t e d t h a t two y e a r s a f t e r treatment f o r o b e s i t y , o n l y 5% of 100 p a t i e n t s had ma i n t a i n e d a weight l o s s of 20 pounds or more. With the i n t r o d u c t i o n of b e h a v i o r a l i n t e r v e n t i o n s , weight l o s s t r eatments became more e f f e c t i v e i n terms of i n i t i a l s u c c e s s , but Stunkard and Penick (1979) reviewed the r e s u l t s of s e v e r a l s t u d i e s and concluded t h a t the o u t l o o k f o r l o n g - term maintenance had not improved. Although the search f o r more e f f e c t i v e w e i g h t - l o s s t r e a t m e n t s goes on, some i n v e s t i g a t o r s have t u r n e d t h e i r a t t e n t i o n t o maintenance i t s e l f . C o r r e l a t i o n a l s t u d i e s have shown t h a t e x e r c i s e , m o n i t o r i n g of body weight and food amounts, s e l f - a t t r i b u t i o n f o r success, and c o n t r o l of o v e r e a t i n g i n response t o ne g a t i v e a f f e c t a re important determinants of s u c c e s s f u l maintenance (Leon & Chamberlain, 1973; S t u a r t & G u i r e , 1978). Other r e s e a r c h has i d e n t i f i e d long-term maintenance of any behavior change as a s e p a r a t e problem from the i n t i a l change and one t h a t needs s e p a r a t e treatment ( M a r l a t t & George, 1984; M a r l a t t & Gordon, 1980). 3 Relapse P r e v e n t i o n Working i n the f i e l d of r e c o v e r y from a d d i c t i o n s t o c i g a r e t t e s , a l c o h o l , and drugs, M a r l a t t and h i s a s s o c i a t e s i d e n t i f i e d f a c t o r s i n v o l v e d i n r e l a p s e and developed a r e l a p s e p r e v e n t i o n model which i s r e p r e s e n t e d i n F i g u r e 1 ( M a r l a t t & Gordon, 1980). In the model, h i g h e r l e v e l s of s e l f - e f f i c a c y and e f f e c t i v e use of c o p i n g s t r a t e g i e s are important f a c t o r s i n p r e v e n t i n g r e l a p s e and they i n f l u e n c e each o t h e r . In a h i g h r i s k s i t u a t i o n , an i n d i v i d u a l who uses a c o p i n g s t r a t e g y t h a t r e s u l t s i n s u c c e s s f u l avoidance of a l a p s e w i l l have i n c r e a s e d s e l f - e f f i c a c y i n the f u t u r e . On the o t h e r hand, i f the c o p i n g s t r a t e g y used i s i n e f f e c t i v e i n r e d u c i n g the r i s k of a l a p s e , the i n d i v i d u a l e x periences a decrease i n s e l f - e f f i c a c y , i s more l i k e l y t o c o n c e n t r a t e on the p o s i t i v e outcomes a s s o c i a t e d w i t h the o l d behavior, and i s l i k e l y t o l a p s e i n t o o l d behavior. Increases or decreases i n s e l f - e f f i c a c y w i l l have an i n f l u e n c e on what c o p i n g e f f o r t s are made i n the next h i g h - r i s k s i t u a t i o n . Lapses i n t o o l d behavior r e s u l t i n the A b s t i n e n c e V i o l a t i o n E f f e c t (AVE), l e a d i n g to n e g a t i v e f e e l i n g s about one's a b i l i t y t o c o n t r o l the s i t u a t i o n . The l i k e l i h o o d of a f u l l - b l o w n r e l a p s e i s i n c r e a s e d even more when the i n d i v i d u a l a t t r i b u t e s the lapse to i n t e r n a l and s t a b l e d e f i c i t s , such as l a c k of willpower, and f e e l s h e l p l e s s t o r e g a i n c o n t r o l . T h i s f e e l i n g of h e l p l e s s n e s s i s r e l a t e d t o 4 ( E f f e c t i v e ) Coping Response Increased S e l f - E f f i c a c y " Decreased P r o b a b i l i t y of Relapse High R i s k ( f o r Overeating) S i t u a t i o n No vj ( E f f e c t i v e ) 7 " ^ Coping Response Decreased e l f - E f f i c a c y and A b s t i n e n c e V i o l a t i o n E f f e c t O v e r e a t i n g — ^ P o s i t i v e -*> Outcome — Expectancies ( f o r Overeating) and P e r c e i v e d ^ E f f e c t s of " c o n t i n u e d O v e r e a t i n g I n c r e a s e d P r o b a b i l i t y of Relapse F i g u r e 1. R e p r e s e n t a t i o n of the Relapse P r e v e n t i o n Model ( M a r l a t t & Gordon, 1980) as i t A p p l i e s t o O v e r e a t i n g . 5 d e c r e a s e d l e v e l s of s e l f - e f f i c a c y f o r coping e f f e c t i v e l y w i t h h i g h - r i s k s i t u a t i o n s . S e l f - E f f i c a c y i n Relapse P r e v e n t i o n The r o l e of s e l f - e f f i c a c y i n r e l a p s e p r e v e n t i o n i s based on Bandura's (1977) th e o r y t h a t b e h a v i o r change depends both on the i n d i v i d u a l ' s outcome e x p e c t a n c i e s t h a t c e r t a i n b e h a v i o r s w i l l r e s u l t i n d e s i r e d outcomes, and s e l f - e f f i c a c y e x p e c t a t i o n s t h a t he or she i s capable of those b e h a v i o r s . A person who has succeeded i n l o s i n g weight has no t r o u b l e b e l i e v i n g t h a t c o n t r o l l e d e a t i n g i s a s s o c i a t e d w i t h maintenance, but may have d i f f i c u l t y b e l i e v i n g he or she i s c a p a b l e of e x e r c i s i n g t h a t c o n t r o l , p a r t i c u l a r l y a f t e r a s e r i e s of l a p s e s . S e l f - e f f i c a c y has been i d e n t i f i e d as an important f a c t o r i n weight l o s s ( B e r n i e r & Avard, 1986; Weinberg, Hughes, C r i t e l l i , England, & Jackson, 1984). B e r n i e r and Avard (1986) found t h a t an i n c r e a s e i n s e l f - e f f i c a c y e x p e c t a t i o n s d u r i n g weight l o s s treatment was p o s i t i v e l y and s i g n i f i c a n t l y c o r r e l a t e d w i t h continued weight l o s s d u r i n g two f o l l o w - u p i n t e r v a l s . In Weinberg e t a l . ' s study, groups w i t h h i g h e r p r e e x i s t i n g and manipulated l e v e l s of s e l f - e f f i c a c y l o s t more weight than groups i n which th e s e l e v e l s were lower. Coping i n Relapse P r e v e n t i o n A d a p t i v e c o p i n g has a l s o r e c e i v e d a t t e n t i o n from i n v e s t i g a t o r s i n t h i s f i e l d . The use of b e h a v i o r a l and c o g n i t i v e coping responses by d i e t e r s i n h i g h r i s k 6 s i t u a t i o n s was shown t o be a s s o c i a t e d w i t h p o s i t i v e outcomes i n a r e c e n t study of r e l a p s e c r i s e s ( G r i l o , Sniffman, & Wing, 1989) . Rippetoe and Rogers (1987) found t h a t when s e l f - e f f i c a c y and outcome e x p e c t a n c i e s were manipulated, h i g h e r l e v e l s strengthened the use of a d a p t i v e c o p i n g i n i n d i v i d u a l s r e c e i v i n g i n f o r m a t i o n about b r e a s t cancer. A d a p t i v e c o p i n g was i d e n t i f i e d as those e f f o r t s made by the i n d i v i d u a l t o d e a l w i t h the r e a l i t y of the s i t u a t i o n , such as p e r f o r m i n g r e g u l a r b r e a s t s e l f - e x a m i n a t i o n or u s i n g r a t i o n a l p r o b l e m - s o l v i n g t o d e a l w i t h the h e a l t h - t h r e a t i s s u e . A problem a r i s e s when coping s t r a t e g i e s a re i d e n t i f i e d as a d a p t i v e or e f f e c t i v e . A c c o r d i n g t o the Lazarus and Folkman (1984) model of s t r e s s , a p p r a i s a l , and co p i n g , i t i s important not t o d e f i n e coping e f f o r t s as good or bad per se when what i s r e a l l y being d i s c u s s e d i s t h e i r l o n g e r - t e r m outcome or consequences. The i n d i v i d u a l who o v e r e a t s t o reduce s t r e s s a s s o c i a t e d w i t h n e g a t i v e f e e l i n g s and then f e e l s b e t t e r , however momentarily, has i n some r e s p e c t s coped s u c c e s s f u l l y w i t h the s i t u a t i o n . However, i f t h i s i n d i v i d u a l i s a l s o t r y i n g t o eat moderately i n o r d e r t o m a i n t a i n a weight l o s s , o v e r e a t i n g i n response t o n e g a t i v e a f f e c t i s not an e f f e c t i v e s t r a t e g y s i n c e i t i s l i k e l y t o l e a d t o f u r t h e r n e g a t i v e f e e l i n g s of g u i l t and f a i l u r e . Thus d e s c r i b i n g c o p i n g e f f o r t s as a d a p t i v e or maladaptive i n terms of t h e i r long-term e f f e c t seems warranted i n t h i s s i t u a t i o n . 7 I d e n t i f y i n g a d a p t i v e coping s t r a t e g i e s f o r maintenance can be done by i n f e r e n c e . The G r i l o e t a l . (1989) study which i n v e s t i g a t e d coping responses of d i e t e r s a t h i g h r i s k f o r l a p s e d i d not s p e c i f y which s t r a t e g i e s r e s u l t e d i n p o s i t i v e outcomes beyond l a b e l l i n g them as c o g n i t i v e and b e h a v i o r a l . The Rippetoe and Rogers (1987) study was more s p e c i f i c , however, i n d e f i n i n g as a d a p t i v e those s t r a t e g i e s which were problem-focused and d e a l t w i t h the r e a l i t y of t h e s i t u a t i o n . C o r r e l a t i o n a l s t u d i e s have i d e n t i f i e d f a c t o r s a s s o c i a t e d w i t h s u c c e s s f u l maintenance as those which i n v o l v e d e a l i n g w i t h the t h r e a t of r e l a p s e i n a problem- f o c u s e d manner, such as m o n i t o r i n g weight r e g u l a r l y , e x e r c i s i n g , and r e v e r s i n g s m a l l g a i n s q u i c k l y (Leon & Chamberlain, 1973; S t u a r t & G u i r e , 1978). I t thus seems a p p r o p r i a t e t o make problem-focused coping e f f o r t s a f o c a l p o i n t of i n t e r e s t i n a maintenance study. Relapse P r e v e n t i o n T r a i n i n g i n Weight Loss Treatments Another important focus f o r maintenance of weight l o s s r e s e a r c h i s the s p e c i f i c i n t e r v e n t i o n s t r a t e g i e s f o r r e l a p s e p r e v e n t i o n t h a t M a r l a t t and h i s a s s o c i a t e s developed through t h e i r work on r e l a p s e p r e v e n t i o n ( M a r l a t t & George, 1984). B r o a d l y , these s t r a t e g i e s i n v o l v e s k i l l t r a i n i n g , c o g n i t i v e r e f r a m i n g , and l i f e s t y l e i n t e r v e n t i o n which can be i n c o r p o r a t e d i n t o an i n d i v i d u a l i z e d program f o r a person t r y i n g t o m a i n t a i n behavior changes. Relapse p r e v e n t i o n t r a i n i n g has been used w i t h some succ e s s i n weight l o s s programs. A group of d i e t e r s who 8 were taught r e l a p s e p r e v e n t i o n and other maintenance s k i l l s f o l l o w i n g a w o r k s i t e weight l o s s program showed b e t t e r maintenance of t h e i r l o s s e s a t a 6-month f o l l o w - u p than the group t h a t d i d not r e c e i v e t h i s t r a i n i n g (Abrams & F o l l i c k , 1983) . S t e r n b e r g (1985) found s i m i l a r r e s u l t s w i t h groups of d i e t e r s on a b e h a v i o r a l weight l o s s program. The group whose treatment i n c l u d e d a r e l a p s e p r e v e n t i o n component had s i g n i f i c a n t l y b e t t e r weight l o s s e s a t a 60-day f o l l o w - u p than the comparison group. In another study which e v a l u a t e d the long-term e f f e c t i v e n e s s of s e v e r a l m o d i f i c a t i o n s of a treatment program, on l y the group t h a t had r e c e i v e d a combination of behavior therapy, r e l a p s e p r e v e n t i o n t r a i n i n g , and posttreatment c o n t a c t had maintained l o s s e s a t a 10-month fo l l o w - u p ( P e r r i , Shapiro, Ludwig, Twentyman, & McAdoo, 1984). In the above s t u d i e s r e l a p s e p r e v e n t i o n t r a i n i n g took p l a c e d u r i n g or immediately f o l l o w i n g weight l o s s . Whether or not i t would be e f f e c t i v e f o r o n c e - s u c c e s s f u l m a i n t a i n e r s i n the p r o c e s s of r e l a p s e has y e t t o be demonstrated. T h i s study i n v e s t i g a t e d the e f f e c t s of a s e l f - e f f i c a c y enhancement maintenance i n t e r v e n t i o n program w i t h and w i t h o u t a r e l a p s e p r e v e n t i o n component on s u c c e s s f u l d i e t e r s a t r i s k of r e l a p s e or a l r e a d y i n v o l v e d i n the p r o c e s s . Changes i n l e v e l s of s e l f - e f f i c a c y and coping s t r a t e g i e s used i n response t o n e g a t i v e a f f e c t a s s o c i a t e d w i t h o v e r e a t i n g were s t u d i e d . The g e n e r a l hypotheses were t h a t 9 l e v e l s of s e l f - e f f i c a c y and the use of problem-focused c o p i n g would i n c r e a s e from p r e t e s t t o p o s t t e s t f o r both treatment groups, but not f o r a c o n t r o l group, and t h a t t h i s i n c r e a s e would be b e t t e r maintained a t a f o l l o w - u p by t h e r e l a p s e p r e v e n t i o n component group. In a d d i t i o n , a r e l a t i o n s h i p between s e l f - e f f i c a c y and c o p i n g s t r a t e g i e s was expected t o be demonstrated, w i t h a g r e a t e r use of problem- f o c u s e d c o p i n g a t posttreatment being a s s o c i a t e d w i t h h i g h e r s e l f - e f f i c a c y a t f o l l o w - u p . 10 LITERATURE REVIEW In a c u l t u r e where appearance i s of so much importance f o r s o c i a l and even c a r e e r success, the overweight person i s o f t e n i n v o l v e d i n what seems l i k e an en d l e s s s t r u g g l e t o l o s e weight. Although some people d i e t t o l o s e 10 t o 15 pounds merely f o r cosmetic reasons, o t h e r s have s e r i o u s h e a l t h concerns r e l a t e d t o o b e s i t y or f i n d t h a t b e i n g overweight i s keeping them from l i v i n g f u l l l i v e s . Commercial weight l o s s programs o f f e r h e l p t o those who f i n d i t d i f f i c u l t t o d i e t on t h e i r own, pr o m i s i n g t o t e a c h them a l l t h e s k i l l s n ecessary t o m a i n t a i n the l o s s . U n f o r t u n a t e l y , no matter how s u c c e s s f u l a d i e t e r i s i n l o s i n g weight, the long-term outcome i s poor, w i t h most people r e g a i n i n g the weight they l o s t and even more. The o n l y r e c o u r s e f o r the u n s u c c e s s f u l m a i n t a i n e r i s another d i e t , w i t h the sad p r o s p e c t of another e v e n t u a l f a i l u r e . While r e s e a r c h c o n t i n u e s t o i n v e s t i g a t e the causes and most e f f e c t i v e treatments f o r o b e s i t y , the i s s u e o f why so many weight l o s s treatment successes become maintenance f a i l u r e s deserves equal a t t e n t i o n . T h i s review f o c u s e s on some of the u n d e r l y i n g f a c t o r s i n v o l v e d i n weight l o s s maintenance and the e f f e c t s of a non-diet i n t e r v e n t i o n program f o r women concerned about t h e i r a b i l i t y t o m a i n t a i n p r e v i o u s l y a c hieved weight l o s s e s . O b e s i t y has been c a l l e d a s e r i o u s , p r e v a l e n t , and r e f r a c t o r y d i s o r d e r by one of the l e a d i n g r e s e a r c h e r s i n the f i e l d (Brownell, 1982, p.820). C o n s i d e r a b l e r e s e a r c h has 11 been done on the causes of o b e s i t y with a ve r y r e c e n t f o c u s on t h e r o l e of h e r e d i t y i n a p r e d i s p o s i t i o n t o be overweight. Stunkard, H a r r i s , Pedersen, and McClearn (199 0) reviewed d a t a on 247 i d e n t i c a l and 426 f r a t e r n a l p a i r s o f twins, r e a r e d t o g e t h e r or ap a r t , and found t h a t the g e n e t i c i n f l u e n c e s - on body-mass index were s u b s t a n t i a l , a c c o u n t i n g f o r as much as 70% of the v a r i a n c e . In another study, when 12 p a i r s of young a d u l t male monozygotic twins were s y s t e m a t i c a l l y o v e r f e d by 1000 k c a l per day f o r 84 days d u r i n g a 100 day p e r i o d , the w i t h i n - p a i r s i m i l a r i t y of weight g a i n and f a t i n c r e a s e i n response t o o v e r f e e d i n g was s i g n i f i c a n t (p <.05) (Bouchard e t a l . , 1990). The r e s e a r c h e r s concluded t h a t g e n e t i c f a c t o r s may govern the tendency t o s t o r e energy as e i t h e r l e a n o r f a t t i s s u e , t h e r e b y d i s p o s i n g some i n d i v i d u a l s t o g a i n weight more e a s i l y than o t h e r s . Although t h i s r e c e n t r e s e a r c h argues f o r a s t r o n g g e n e t i c component i n the development of o b e s i t y , the s e a r c h f o r a s o l u t i o n t o the problem goes on. There are s e r i o u s h e a l t h r i s k s a s s o c i a t e d w i t h o b e s i t y . Bray (1987) reviewed a s e r i e s of s t u d i e s t h a t have a s s o c i a t e d being overweight (body mass index of 25-30 kg/m2) or obese (BMI of 30 kg/m2) w i t h an i n c r e a s e d m o r t a l i t y r a t e , c a r d i o v a s c u l a r d i s e a s e , h y p e r t e n s i o n , impaired pulmonary f u n c t i o n , d i a b e t e s , g a l l b l a d d e r d i s e a s e , and some types of cancer. A d d i t i o n a l l y , t h e r e are s o c i a l and p s y c h o l o g i c a l consequences of o b e s i t y . Wadden and Stunkard (1985) 12 reviewed a s e r i e s of s t u d i e s which found s t r o n g p r e j u d i c e a g a i n s t the obese among c h i l d r e n as young as 6, a d u l t s of every socioeconomic category, and h e a l t h c a r e p r a c t i t i o n e r s . The obese were seen as l a z y , weak-willed, u n a t t r a c t i v e , and s e l f - i n d u l g e n t and the tendency t o view o b e s i t y as a moral f a i l i n g c o n t r i b u t e d t o job and s o c i a l d i s c r i m i n a t i o n . The aut h o r s concluded t h a t women, a d o l e s c e n t g i r l s , and the m o r b i d l y obese are the common v i c t i m s of t h i s c u l t u r a l contempt f o r the overweight. Thus, d e v e l o p i n g a treatment t h a t r e s u l t s i n permanent weight l o s s has been an ongoing concern f o r r e s e a r c h e r s i n t h i s f i e l d . Yet permanent weight l o s s remains an e l u s i v e g o a l . Some years ago, Stunkard and McLaren-Hume (1959) r e p o r t e d t h a t two years a f t e r treatment f o r o b e s i t y , o n l y 5% of 100 p a t i e n t s had maintained a weight l o s s of 2 0 l b s or more. With the development of behavior therapy treatment programs, weight l o s s d u r i n g treatment improved, but when Stunkard and Penick (1979) reviewed the r e s u l t s of such programs, they concluded t h a t the ou t l o o k f o r long-term maintenance had not improved. In t h e i r own study, a t a 1- year f o l l o w - u p a f t e r e i t h e r a b e h a v i o r a l or a s t a n d a r d m e d i c a l treatment f o r o b e s i t y , 17 of the 28 p a t i e n t s weighed l e s s than they had a t the end of treatment. At a 5-year f o l l o w - u p , however, on l y 7 p a t i e n t s s t i l l weighed l e s s than a t p o s ttreatment, 3 of whom had been i n the b e h a v i o r t h e r a p y group. 13 C o r r e l a t e s o f S u c c e s s f u l Maintenance Although the sea r c h f o r more l a s t i n g l y e f f e c t i v e weight l o s s t reatments c o n t i n u e s , some r e s e a r c h e r s have begun t o t u r n t h e i r a t t e n t i o n t o maintenance i t s e l f . One approach has been t o i d e n t i f y c o g n i t i o n s and be h a v i o r s t h a t a re a s s o c i a t e d w i t h s u c c e s s f u l maintenance. I n c r e a s e d e x e r c i s e , f o r example, was i d e n t i f i e d as an important f a c t o r by 41 women and 13 men who had l o s t a t l e a s t 2 0% of t h e i r body weight and maintained t h a t l o s s f o r a t l e a s t two ye a r s ( C o l v i n & Olson, 1983). In another c o r r e l a t i o n a l study, data were c o l l e c t e d from 721 women 15 months a f t e r they had reached t h e i r t a r g e t g o a l weights f o l l o w i n g a commercial weight l o s s program ( S t u a r t & G u i r e , 1978). T h i s study found t h a t those who remained p h y s i c a l l y i n a c t i v e or r e v e r t e d t o t h i s s t a t e a f t e r weight l o s s were an average of 13.7 l b s above g o a l , w h i l e t h ose who had h i g h e r l e v e l s of a c t i v i t y were an average of on l y 5.1 l b s above g o a l . In a d d i t i o n t o e x e r c i s e , r e g u l a r m o n i t o r i n g of weight, f e e l i n g p e r s o n a l l y r e s p o n s i b l e f o r s u c c e s s f u l weight l o s s , and f e e l i n g i n c o n t r o l of o v e r e a t i n g i n response t o n e g a t i v e a f f e c t were among s e v e r a l f a c t o r s r e l a t e d t o s u c c e s s f u l maintenance i n c o r r e l a t i o n a l s t u d i e s ( C o l v i n & Olson, 1983; Leon & Chamberlain, 1973; S t u a r t & Guire, 1978). I n v e s t i g a t i n g the r o l e of continued use of s p e c i f i c b e h a v i o r a l s t r a t e g i e s i n weight l o s s maintenance, S t a l o n a s , P e r r i , and Kerzner (1984) looked a t the long-term 14 e f f e c t i v e n e s s of t h e i r 10-week b e h a v i o r a l treatment program f o r o b e s i t y f o r 44 predominantly female p a r t i c i p a n t s . The average weight l o s s a t posttreatment was 10.7 l b s , and a t the 3-month foll o w - u p , 12.5 l b s . However, when the r e s e a r c h e r s were a b l e t o c o n t a c t 3 6 of the 44 p a r t i c i p a n t s f i v e y e a r s l a t e r , 86% of them had gained weight, w i t h t h e average r e g a i n being 16.3 l b s . They a l s o found t h a t t h e number of b e h a v i o r a l techniques p a r t i c i p a n t s used and the months o f c o n s c i e n t i o u s use of these t e c h n i q u e s were each s i g n i f i c a n t l y and n e g a t i v e l y c o r r e l a t e d w i t h p o s t t r e a t m e n t weight g a i n s (r = -.54, p_<.01, and r = -.48, p_<.05, r e s p e c t i v e l y ) . The f o r e g o i n g study supports the i d e a t h a t c o n t i n u e d use of s t r a t e g i e s a s s o c i a t e d with weight l o s s are important, y e t the m a j o r i t y of s u c c e s s f u l d i e t e r s appear t o abandon them pos t t r e a t m e n t , something t h a t p u z z l e s r e s e a r c h e r s . Stunkard and Penick (1979) argue t h a t the i n d i v i d u a l who i s t r y i n g t o m a i n t a i n a weight l o s s f a c e s a unique and u n u s u a l l y d i f f i c u l t c h a l l e n g e . U n l i k e someone who has r e c o v e r e d from an a d d i c t i o n t o a l c o h o l or tobacco, the s u c c e s s f u l d i e t e r must continue t o use, i n c a r e f u l moderation, the substance which proved so d i f f i c u l t t o c o n t r o l i n the p a s t . Added t o t h a t i s the f a c t t h a t a g e n e t i c p r e d i s p o s i t i o n t o be overweight may make c o n t r o l of c a l o r i c i n t a k e extremely important f o r s u c c e s s f u l weight l o s s maintenance. A t h i r d c o m p l i c a t i o n i s t h a t t h e r e i s some evidence from the l i t e r a t u r e on r e s t r a i n t t h a t d i e t i n g , 15 or c a r e f u l l y c o n t r o l l i n g c a l o r i c i n t a k e , makes an i n d i v i d u a l v u l n e r a b l e t o o v e r e a t i n g once the c o n t r o l i s r e l a x e d ( P o l i v y & Herman, 1985). Understanding the Relapse Process A l though the c h a l l e n g e of moderate use i s d i f f e r e n t from t h a t of a b s t i n e n c e , work done by r e s e a r c h e r s i n the f i e l d of r e c o v e r y from a d d i c t i o n s o f f e r s some e x p l a n a t i o n f o r what happens d u r i n g r e l a p s e and suggests a new d i r e c t i o n f o r i n t e r v e n t i o n ( M a r l a t t & George, 1984: M a r l a t t & Gordon, 1980). Viewing r e l a p s e as a process w i t h d i s c r e t e s e q u e n t i a l s t e p s , r a t h e r than as one a b s t i n e n c e - nonabstinence event, M a r l a t t and h i s a s s o c i a t e s d e v i s e d a c o g n i t i v e b e h a v i o r a l model f o r r e l a p s e p r e v e n t i o n (see F i g u r e 1). In the model, l e v e l s of s e l f - e f f i c a c y and the use of c o p i n g s t r a t e g i e s are i d e n t i f i e d as two important f a c t o r s i n the r e l a p s e p r o c e s s . A h i g h - r i s k s i t u a t i o n i s one i n which the i n d i v i d u a l i s tempted t o use (or overuse, i n the case of food) the substance t o be avoided. When no c o p i n g response t h a t r e s u l t s i n mastery of the s i t u a t i o n i s made, s e l f - e f f i c a c y decreases and the remembered p l e a s u r a b l e outcome of u s i n g the substance becomes s a l i e n t , l e a d i n g t o a l a p s e , or s l i p back i n t o o l d behavior. The i n d i v i d u a l ' s c o g n i t i v e and a f f e c t i v e responses t o t h i s l apse are c a l l e d the A b s t i n e n c e V i o l a t i o n E f f e c t (AVE) i n the model. The AVE has two components: (a) c o g n i t i v e dissonance, and (b) p e r s o n a l a t t r i b u t i o n . 16 The c o g n i t i v e dissonance component i s based on F e s t i n g e r ' s (1964) the o r y t h a t c o g n i t i v e d i s s o n a n c e d e v e l o p s when t h e r e i s a d i s p a r i t y between the i n d i v i d u a l ' s view of h i m s e l f (e.g., as a moderate eater) and b e h a v i o r t h a t i s i n c o n g r u e n t w i t h t h a t view (e.g., o v e r e a t i n g ) . T h i s i n t e r n a l c o n f l i c t motivates the i n d i v i d u a l t o reduce t h i s d i s s o n a n c e e i t h e r by doing something t o cope w i t h the d i s s o n a n t f e e l i n g s of g u i l t , t e n s i o n , and a n x i e t y (e.g., c o n t i n u i n g t o eat, i f t h a t has been a c o p i n g response t o d e a l w i t h s t r e s s i n the p a s t ) , or by changing h i s or her s e l f - i m a g e t o one more congruent wi t h the b e h a v i o r (e.g., s e e i n g o n e s e l f as someone who cannot c o n t r o l o v e r e a t i n g ) . The s e l f - a t t r i b u t i o n component of the AVE can thus l e a d the i n d i v i d u a l t o see the l a p s e as the r e s u l t of p e r s o n a l weakness or f a i l u r e r a t h e r than as a response t o the e x t e r n a l s i t u a t i o n (e.g., "I have no w i l l p o w e r , " i n s t e a d of, "I wasn't prepared t o handle t h a t s i t u a t i o n w e l l . " ) . T h i s would l e a d t o decreased s e l f - e f f i c a c y i n subsequent h i g h - r i s k s i t u a t i o n s because t h e r e would be an g e n e r a l i z e d e x p e c t a t i o n of f a i l u r e . Another element i n t h i s r e l a p s e process i s t h a t the o l d b e h a v i o r , such as o v e r e a t i n g , has probably been used i n the p a s t as a means of d e a l i n g with n e g a t i v e f e e l i n g s , and thus f u r t h e r o v e r e a t i n g seems a t t r a c t i v e as a way of c o p i n g w i t h the n e g a t i v e f e e l i n g s a s s o c i a t e d w i t h the AVE. As one l a p s e f o l l o w s another, the l i k e l i h o o d of f u l l - b l o w n r e l a p s e i s i n c r e a s e d . 17 The r e l a p s e p r e v e n t i o n model shows what an i n d i v i d u a l does i n a h i g h - r i s k s i t u a t i o n has important consequences f o r r e l a p s e . Every temptation t o overeat i s not a h i g h - r i s k s i t u a t i o n , however. What matters i s how s t r o n g the t e m p t a t i o n i s and whether the i n d i v i d u a l f e e l s c a p a b l e of r e s i s t i n g the temptation, or even wants t o . M a r l a t t and h i s a s s o c i a t e s have i d e n t i f i e d f a c t o r s t h a t can l e a d up t o h i g h - r i s k s i t u a t i o n s , p o i n t i n g out how l i f e s t y l e imbalances can l e a d t o a d e s i r e f o r indulgence and c o n t r i b u t e t o the l i k e l i h o o d of a l a p s e . The R o l e s of S e l f - E f f i c a c y and Coping i n Relapse P r e v e n t i o n S e l f - e f f i c a c y i n the r e l a p s e p r e v e n t i o n (RP) model i s based on Bandura's (1977) theory t h a t s u c c e s s f u l b e h a v i o r change depends not j u s t on an i n d i v i d u a l ' s b e l i e f t h a t c e r t a i n b e h a v i o r s w i l l produce the d e s i r e d outcome (outcome e x p e c t a n c i e s ) , but t h a t he or she w i l l be capable of e x e c u t i n g those b e h a v i o r s ( s e l f - e f f i c a c y e x p e c t a n c i e s ) . I t i s t h e s e s e l f - e f f i c a c y e x p e c t a n c i e s t h a t are damaged when l a p s e s occur. The r o l e o f co p i n g and i t s e f f e c t on s e l f - e f f i c a c y and s u c c e s s f u l outcomes i n hi g h r i s k s i t u a t i o n s i s c l e a r l y d e f i n e d i n the RP model, y e t the s u g g e s t i o n t h a t no c o p i n g e f f o r t s a re made when la p s e s occur i s i m p r e c i s e . A c c o r d i n g t o the Lazarus and Folkman (1984, p.141) d e f i n i t i o n i n t h e i r model of s t r e s s , a p p r a i s a l , and coping, c o p i n g r e f e r s t o " c o n s t a n t l y changing c o g n i t i v e and b e h a v i o r a l e f f o r t s t o manage s p e c i f i c e x t e r n a l and/or i n t e r n a l demands t h a t are 18 a p p r a i s e d as t a x i n g or exceeding the r e s o u r c e s of the person." Thus, whatever an i n d i v i d u a l t h i n k s or does i n a h i g h r i s k s i t u a t i o n i s coping of some nature, whether or not a l a p s e o c c u r s as a consequence. Choosing t o eat, f o r example, i s a c o p i n g s t r a t e g y t h a t has been i d e n t i f i e d by Lazarus and Folkman (1984) i n t h e i r Ways of Coping C h e c k l i s t and by Latack (1986) as a symptom management s t r a t e g y f o r j o b - r e l a t e d s t r e s s . L a zarus and Folkman suggest t h a t too o f t e n c o p i n g e f f o r t s are confounded w i t h coping outcomes, so t h a t a person i s s a i d t o have coped with a s i t u a t i o n o n l y i f the l o n g e r - t e r m outcome i s s u c c e s s f u l . The d e v e l o p e r s of the RP model are c l e a r l y d i s c u s s i n g coping i n terms of outcome when they d e s c r i b e c o p i n g e f f o r t s as " a d a p t i v e " i f they r e s u l t i n mastery of the source of p o t e n t i a l danger (Cummings, Gordon, & M a r l a t t , 1980, p. 297). There i s a p o t e n t i a l r i s k a s s o c i a t e d w i t h t h i s i n t h a t the coping s t r a t e g i e s t h a t r e s u l t i n p o s i t i v e outcomes may be seen as good or bad i n themselves. Although i t may not be a p p r o p r i a t e t o c a t e g o r i z e s p e c i f i c c o p i n g s t r a t e g i e s t h i s way, i d e n t i f y i n g those which a r e a d a p t i v e or maladaptive i n terms of outcome may be important i n r e l a p s e p r e v e n t i o n . For example, i f someone who i s concerned about g a i n i n g weight eats a b i g bowl of ice-cream when f e e l i n g sad or l o n e l y , the outcome might be a d a p t i v e i n terms of improving mood t e m p o r a r i l y , but maladaptive over the longer-term w i t h r e s p e c t t o weight 19 c o n t r o l . R e a l i z i n g t h a t the e x t r a c a l o r i e s a re l i k e l y t o show up as a weight g a i n i n the f u t u r e , the i n d i v i d u a l might f e e l i n c r e a s e d s t r e s s . In a l o n g i t u d i n a l study o f s t r e s s , r e s e a r c h e r s found t h a t major l i f e events d i d not account f o r as much of the v a r i a n c e i n p s y c h o l o g i c a l symptoms as d i d the minor ones, or d a i l y h a s s l e s (Kanner, Coyne, Schaefer, & Laza r u s , 1981). Concern about weight was the h a s s l e most f r e q u e n t l y r e p o r t e d by t h e i r 100 s u b j e c t s (52 women, 48 men, aged 45-64 y e a r s ) . To a p p r e c i a t e the importance of s e l f - e f f i c a c y and c o p i n g s t r a t e g i e s i n maintenance and r e l a p s e p r e v e n t i o n , i t w i l l be h e l p f u l t o look a t weight l o s s r e s e a r c h on these f a c t o r s . S e l f - E f f i c a c y i n Weight Loss and Maintenance. The r o l e of s e l f - e f f i c a c y i n weight l o s s s u c c e s s has r e c e i v e d c o n s i d e r a b l e a t t e n t i o n ( B e r n i e r & Avard, 1986; E d e l l , Edington, Herd, O'Brien, & W i t k i n , 1987; M i t c h e l l & S t u a r t , 1984; Weinberg e t a l . , 1984). In a study i n v o l v i n g 62 overweight women who v o l u n t e e r e d f o r a 10-week b e h a v i o r a l l y o r i e n t e d weight r e d u c t i o n program, B e r n i e r and Avard found a s i g n i f i c a n t r e l a t i o n s h i p between weight change and s e l f - e f f i c a c y d u r i n g the 6 week and 6-month f o l l o w - u p i n t e r v a l s . Posttreatment weight l o s s was not found t o be r e l a t e d t o l a t e r outcome, however. The authors f e l t t h a t t h e r e were d i f f i c u l t i e s i n v o l v e d i n measuring s e l f - e f f i c a c y l e v e l s f o r f u t u r e b e h a v i o r s . When they a s s e s s e d an i n d i v i d u a l ' s c o n f i d e n c e t h a t she would be a b l e t o perform 20 the c o g n i t i v e - b e h a v i o r a l s t r a t e g i e s i n t h e i r treatment package, or t o a v o i d e a t i n g i n h i g h - r i s k s i t u a t i o n s , t h e r e was no immediate demand f o r t h a t behavior, so B e r n i e r and Avard wondered i f they might have simply measured a g e n e r a l sense of s e l f - e f f i c a c y . E d e l l e t a l . (1987) conducted a r e t r o s p e c t i v e study of 52 men and 95 women t o determine whether s e l f - e f f i c a c y and s e l f - m o t i v a t i o n measured bef o r e and d u r i n g treatment p r e d i c t e d outcome i n a weight l o s s program. They found t h a t s e l f - e f f i c a c y measures c o r r e l a t e d s i g n i f i c a n t l y w i t h weight l o s s e s and suggested t h a t t h i s was a u s e f u l p r e d i c t o r of weight l o s s s u c c e s s . The measure of s e l f - e f f i c a c y used was v a g u e l y d e s c r i b e d as c o n f i d e n c e i n t e r v a l s and outcome e x p e c t a n c i e s , so i t may be g e n e r a l s e l f - e f f i c a c y t h a t was i n v o l v e d . M i t c h e l l and S t u a r t (1984) looked f o r a l i n k between w e i g h t - c o n t r o l s e l f - e f f i c a c y and the dropout r a t e f o r 414 p a r t i c i p a n t s i n a l a r g e - s c a l e b e h a v i o r a l program. They found t h a t dropouts were s i g n i f i c a n t l y more l i k e l y than those who c o n t i n u e d p a r t i c i p a t i o n t o r e p o r t low s e l f - e f f i c a c y a t the b e g i n n i n g of t h e i r membership. I n t e r e s t i n g l y , they a l s o found t h a t dropouts were s i g n i f i c a n t l y l e s s l i k e l y t o f e e l s u c c e s s f u l i n weight c o n t r o l and behavior change, even though t h e i r r a t e s of weight l o s s d i d not d i f f e r s i g n i f i c a n t l y from those who c o n t i n u e d t o be members. 21 Weinberg e t a l . (1984) i n v e s t i g a t e d the e f f e c t s of p r e e x i s t i n g and manipulated s e l f - e f f i c a c y on weight l o s s on 28 women and 4 men v o l u n t e e r s f o r a s e l f - c o n t r o l program. P r e e x i s t i n g s e l f - e f f i c a c y was measured as the l e v e l of c o n f i d e n c e p a r t i c i p a n t s expressed i n t h e i r a b i l i t y t o l o s e the weight they p r e d i c t e d was p o s s i b l e f o r them on the 2- month program. S e l f - e f f i c a c y was manipulated i n 2 of the 4 treatment groups by i n f o r m i n g p a r t i c i p a n t s t h a t t h e i r i n i t i a l s c r e e n i n g p s y c h o l o g i c a l t e s t s had i n d i c a t e d they would do w e l l i n a s e l f - c o n t r o l weight l o s s program and r e i n f o r c i n g t h i s i d e a a t every s e s s i o n . S i g n i f i c a n t i n t e r a c t i o n s were found. P a r t i c i p a n t s w i t h h i g h p r e e x i s t i n g s e l f - e f f i c a c y l o s t more weight over time (M = 8 l b s ) than those w i t h low l e v e l s a t p r e t e s t (M = 3 l b s ) . P a r t i c i p a n t s i n the 2 manipulated s e l f - e f f i c a c y groups l o s t more weight over time (M = 7 lbs) than those i n the non-manipulated c o n d i t i o n (M = 2 l b s ) . The number of p a r t i c i p a n t s w i t h h i g h or low p r e e x i s t i n g s e l f - e f f i c a c y and the number i n each treatment group were not s t a t e d i n the Weinberg e t a l . study. The s m a l l sample s i z e (N = 32) and number of groups l i m i t e d group s i z e , and so r e s u l t s from t h i s study have l i m i t e d g e n e r a l i z a b i l i t y . What i s c l e a r from these s t u d i e s , however, i s t h a t s e l f - e f f i c a c y p l a y s an important r o l e i n s u c c e s s f u l weight l o s s . One p u z z l i n g f i n d i n g i n a few of these s t u d i e s i s t h a t weight l o s s does not n e c e s s a r i l y r e s u l t i n h i g h e r l e v e l s of s e l f - e f f i c a c y . From Bandura's (1977) t h e o r y of 22 s e l f - e f f i c a c y , e x p e r i e n c e s of mastery should r e s u l t i n enhanced s e l f - e f f i c a c y . Why t h i s does not n e c e s s a r i l y o c c u r w i t h weight l o s s may be r e l a t e d t o the i n d i v i d u a l ' s a p p r a i s a l of h i s or her achievement. Bandura suggests t h a t when suc c e s s has been achieved w i t h minimal e f f o r t , t h e i n d i v i d u a l i s l i k e l y t o a s c r i b e t h a t success t o a b i l i t y , and t h i s f o s t e r s a s t r o n g sense of s e l f - e f f i c a c y . By c o n t r a s t , someone who has worked hard f o r success i s l e s s l i k e l y t o f e e l i t was the r e s u l t of a b i l i t y , and thus s e l f - e f f i c a c y i s not strengthened. T h i s may be an important p o i n t when i n v e s t i g a t i n g maintenance d i f f i c u l t i e s . P e r s i s t i n g i n b e h a v i o r s l i k e c a r e f u l c h a r t i n g of food amounts and c a l o r i e s , weighing and measuring foods, and r e s i s t i n g temptations t o o v e r e a t , may seem l i k e hard work even i f i t r e s u l t s i n weight l o s s maintenance. Over time s e l f - e f f i c a c y may be s u b t l y undermined, w i t h the person f e e l i n g l i k e someone who has t o e x e r c i s e r i g i d c o n t r o l or f a c e the consequences of weight g a i n r a t h e r than someone who i s g e n e r a l l y i n c o n t r o l of o v e r e a t i n g . In terms of weight l o s s maintenance, s e l f - e f f i c a c y can be a g e n e r a l b e l i e f i n one's a b i l i t y t o s t a y a t a t a r g e t weight, o r a more s p e c i f i c c o n f i d e n c e i n doing what i s ne c e s s a r y t o achieve t h a t . M a i n t a i n i n g a weight l o s s i n v o l v e s a s e r i e s of behaviors, from c o n t r o l l i n g the amount of c a l o r i e s taken i n t o expending enough energy t o o f f s e t imbalances. S i n c e weight g a i n occurs when more c a l o r i e s a re 23 i n g e s t e d than the body needs f o r energy, h i g h l e v e l s of s e l f - e f f i c a c y t o c o n t r o l o v e r e a t i n g seem e s s e n t i a l f o r the s u c c e s s f u l m a i n t a i n e r . O v e r e a t i n g can be simply d e f i n e d as i n g e s t i n g more c a l o r i e s than are r e q u i r e d by a p a r t i c u l a r i n d i v i d u a l t o m a i n t a i n a t a r g e t weight. The p o i n t a t which e a t i n g becomes o v e r e a t i n g may not always be c l e a r . An e x t r a 120 k c a l a day, a p i e c e of bread and a s m a l l apple, f o r example, may not look l i k e o v e r e a t i n g but adds up t o 3600 k c a l i n a month, e q u i v a l e n t t o a g a i n of 1 l b . Over a year, t h i s c o u l d mean a 10-12 l b g a i n . Because c o n t r o l r a t h e r than a b s t i n e n c e i s i n v o l v e d , s u c c e s s f u l maintenance of weight l o s s i n v o l v e s ongoing d e c i s i o n s about what k i n d of food t o eat, what amount, and how o f t e n . L i k e almost everyone e l s e , the s u c c e s s f u l d i e t e r w i l l o c c a s i o n a l l y overeat, e i t h e r t h o u g h t l e s s l y or by d e l i b e r a t e c h o i c e . Unless t h e r e are s t r o n g AVE responses, the f i r s t few l a p s e s may have l i t t l e e f f e c t on s e l f - e f f i c a c y , e s p e c i a l l y i f the person g e t s r i g h t back on t r a c k . As time passes and the number of l a p s e s accumulates, weight g a i n s may occur. At t h i s p o i n t , the AVE i s l i k e l y t o be much s t r o n g e r and l e a d t o even more o v e r e a t i n g . S e l f - e f f i c a c y i s t h e r e f o r e more l i k e l y t o be a f f e c t e d by c o n t i n u i n g d i f f i c u l t i e s i n c o n t r o l l i n g o v e r e a t i n g , r a t h e r than by i s o l a t e d episodes. 24 Coping i n Weight Loss and Maintenance Coping s t r a t e g i e s important f o r weight l o s s have been s t u d i e d by G r i l o e t a l . (1989). These r e s e a r c h e r s a n a l y z e d p o s t t r e a t e m e n t i n t e r v i e w s w i t h 57 obese d i e t e r s (24 men and 33 women) f o r r e l a p s e c r i s i s s i t u a t i o n s i n which d i e t e r s had e i t h e r l a p s e d or had overcome the temptation t o o v e r e a t . They found t h a t c o p i n g was the s t r o n g e s t c o r r e l a t e of outcome w i t h the use of e i t h e r c o g n i t i v e or b e h a v i o r a l c o p i n g responses being a s s o c i a t e d with p o s i t i v e outcomes. U n f o r t u n a t e l y , these r e s e a r c h e r s d i d not s p e c i f i c a l l y i d e n t i f y the c o p i n g s t r a t e g i e s i n v o l v e d . I n t e r e s t i n g l y , u s i n g more than one b e h a v i o r a l coping response or more than one c o g n i t i v e response was not a s s o c i a t e d w i t h more p o s i t i v e outcomes i n r e s i s t i n g temptation, w h i l e u s i n g a combination of t h e two types was. C o n s i s t e n t w i t h the r e l a p s e p r e v e n t i o n model ( M a r l a t t & George, 1984), G r i l o and h i s a s s o c i a t e s found t h a t d i e t e r s who r e p o r t e d u s i n g no coping s t r a t e g i e s i n r e l a p s e c r i s i s s i t u a t i o n s i n e v i t a b l y experienced a l a p s e . Here c o p i n g i s c l e a r l y b e i n g confounded w i t h i t s outcome. I t might be more a p p r o p r i a t e t o say t h a t no coping s t r a t e g i e s d i r e c t e d a t a v o i d i n g o v e r e a t i n g were used. The i n d i v i d u a l who i s tempted t o eat i n a h i g h r i s k s i t u a t i o n may use emotion- f o c u s e d c o p i n g e f f o r t s t o r a t i o n a l i z e or f e e l b e t t e r about d o i n g something t h a t i s not c o n s i s t e n t w i t h s t a y i n g a t a t a r g e t weight. 25 The work done i n de v e l o p i n g behavior therapy f o r weight l o s s (e.g., S t u a r t , 1978) c l e a r l y i d e n t i f i e d the importance of u s i n g a v a r i e t y of coping s t r a t e g i e s i n h i g h r i s k s i t u a t i o n s , such as being a s s e r t i v e i n response t o s o c i a l p r e s s u r e s t o eat, f i n d i n g a l t e r n a t i v e s t o i n a p p r o p r i a t e e a t i n g , and d e c r e a s i n g the impact of food cues, i n a c h i e v i n g weight l o s s . The p o s s i b i l i t y e x i s t s t h a t the co p i n g s t r a t e g i e s necessary f o r weight l o s s are d i f f e r e n t from t h o s e n e c e s s a r y f o r maintenance. When S t u a r t and G u i r e (1978) surveyed 721 women who had been s u c c e s s f u l i n r e a c h i n g t h e i r g o a l weights on a behavior m o d i f i c a t i o n weight l o s s program, they found t h a t those women who were m a i n t a i n i n g l o s s e s a t 15 months posttreatment had s e v e r a l t h i n g s i n common. They had con f i d e n c e i n t h e i r a b i l i t y t o m a i n t a i n , r e v e r s e d s m a l l g a i n s q u i c k l y , were s t i l l a s s o c i a t e d w i t h the weight l o s s program, and c o n t i n u e d t o use s t r a t e g i e s such as e x e r c i s e , u s i n g s t i m u l u s - c o n t r o l t e c h n i q u e s t o a v o i d snacking, and managing moods e f f e c t i v e l y . C o l v i n and Olson's (1983) r e s e a r c h i n v o l v e d e x t e n s i v e i n t e r v i e w s w i t h 41 women and 13 men who had l o s t a t l e a s t 2 0% of t h e i r body weight and maintained t h a t l o s s f o r a t l e a s t 2 y e a r s . In c o n t r a s t t o S t u a r t and G u i r e ' s f i n d i n g s , the s u c c e s s f u l m a i n t a i n e r s i n t h e i r study were no lo n g e r a s s o c i a t e d w i t h commercial or medical weight l o s s programs, al t h o u g h 14 of the 41 women had used them t o l o s e weight, nor d i d any of these women f o l l o w a formal d i e t p l a n as 26 m a i n t a i n e r s . I n s t e a d of i d e n t i f y i n g s p e c i f i c s t r a t e g i e s they used f o r managing e a t i n g , the women i n C o l v i n and Olson's study r e p o r t e d t h a t a b e t t e r u n d e r s t a n d i n g of n u t r i t i o n , i n c r e a s e d e x e r c i s e , and m o n i t o r i n g t h e i r weight were important f o r t h e i r maintenance suc c e s s . These same f a c t o r s were i d e n t i f i e d i n J e f f r e y e t a l . ' s (1984) study of weight l o s s and maintenance i n a group of 89 middle-aged men. C o l v i n and Olson f e l t t h a t what was most important f o r t h e i r s u c c e s s f u l m a i n t a i n e r s was t h a t the women had taken r e s p o n s i b i l i t y f o r t h e i r own weight management and had developed i n d i v i d u a l e a t i n g and e x e r c i s e h a b i t s t h a t a l l o w e d them t o m a i n t a i n t h e i r l o s s e s . In a 5-year fol l o w - u p study of a b e h a v i o r a l treatment program f o r o b e s i t y , Stalonas e t a l . (1984) found t h a t o n l y 2 of the 13 b e h a v i o r a l s t r a t e g i e s taught d u r i n g treatment were s i g n i f i c a n t l y r e l a t e d t o the maintenance of weight l o s s . The s t r a t e g i e s i d e n t i f i e d were c h a r t i n g weight d a i l y and making e a t i n g a "pure" experience (not engaging i n o t h e r a c t i v i t i e s such as r e a d i n g or watching t e l e v i s i o n d u r i n g m e a l s ) . Of i n t e r e s t i s the f a c t t h a t e x e r c i s e was not one of t h e f a c t o r s a s s o c i a t e d with s u c c e s s f u l maintenance i n the S t a l o n a s e t a l . study. In most of these s t u d i e s , r e g u l a r weight m o n i t o r i n g and e x e r c i s e are c o r r e l a t e d with s u c c e s s f u l maintenance, but beyond t h i s , few s p e c i f i c s t r a t e g i e s f o r c o p i n g w i t h t e m p t a t i o n s t o overeat are i d e n t i f i e d . In oth e r words, the m a c r o s k i l l s necessary f o r maintenance are emerging i n these 27 s t u d i e s , but the m i c r o s k i l l s necessary f o r e a t i n g management may v a r y from person t o person. I n s t e a d of l o o k i n g a t one or two s p e c i f i c b e h a v i o r a l t e c h n i q u e s , i t might be more f r u i t f u l t o see i f c e r t a i n t y p e s of c o p i n g s t r a t e g i e s are a s s o c i a t e d w i t h s u c c e s s f u l weight l o s s maintenance. Although the i s s u e s are d i f f e r e n t , r e s e a r c h done on the e f f e c t of s e l f - e f f i c a c y on a d a p t i v e and maladaptive c o p i n g e f f o r t s i n response t o a h e a l t h t h r e a t may p r o v i d e some c l u e s . Rippetoe and Rogers (1987) i n v e s t i g a t e d the intended coping responses of 167 female undergraduate psychology students who were g i v e n i n f o r m a t i o n about b r e a s t cancer and whose l e v e l s of s e l f - e f f i c a c y and outcome e x p e c t a n c i e s f o r b r e a s t s e l f - e x a m i n a t i o n ware e x p e r i m e n t a l l y manipulated. A s i g n i f i c a n t i n t e r a c t i o n was found between s e l f - e f f i c a c y and coping and outcome e x p e c t a n c i e s and coping. Higher l e v e l s of s e l f - e f f i c a c y and outcome e x p e c t a n c i e s were a s s o c i a t e d w i t h s t r o n g e r i n t e n t i o n s t o perform b r e a s t s e l f - e x a m i n a t i o n and a s t r o n g e r b e l i e f i n a r a t i o n a l p r o b l e m - s o l v i n g approach t o the t h r e a t of b r e a s t cancer. These coping e f f o r t s were judged t o be a d a p t i v e because the i n d i v i d u a l was d e a l i n g w i t h the r e a l i t y of the s i t u a t i o n , the h e a l t h t h r e a t , and not a t t e m p t i n g t o deny or a v o i d i t . Thus, they can a l s o be c a l l e d problem- f o c u s e d . The t h r e a t of r e g a i n i n g l o s t weight i s a r e a l one f o r i n d i v i d u a l s who are t r y i n g t o m a i n t a i n . In a study of the c o p i n g responses of 85 married couples, r e s e a r c h e r s found 28 t h a t d i f f e r e n t types of coping were used depending on what was a t stake and what the coping o p t i o n s were (Folkman, La z a r u s , Dunkel-Schetter, DeLongis, & Gruen, 1986). When a s i t u a t i o n was a p p r a i s e d as changeable, more c o n f r o n t i v e c o p i n g , a c c e p t i n g r e s p o n s i b i l i t y , p l a n f u l p r o b l e m - s o l v i n g , and p o s i t i v e r e a p p r a i s a l were used. On the o t h e r hand, when the s i t u a t i o n was a p p r a i s e d as one t h a t had t o be accepted, p a r t i c i p a n t s used more d i s t a n c i n g and escape-avoidance c o p i n g . C l e a r l y the most a d a p t i v e c o p i n g s t r a t e g i e s f o r people t r y i n g t o m a i n t a i n a weight l o s s are those f o c u s e d on d e a l i n g w i t h the problem, not t r y i n g t o a v o i d i t . Someone t r y i n g t o c o n t r o l o v e r e a t i n g can not a f f o r d t o engage i n the r a t i o n a l i z a t i o n s or d e n i a l of f e e l i n g s which M a r l a t t (1985) i d e n t i f i e s as two of the c o g n i t i v e p i t f a l l s t h a t c o n t r i b u t e t o r e l a p s e . From the Folkman et a l . (1986) study, i t appears t h a t the i n d i v i d u a l who p e r c e i v e s the s i t u a t i o n as changeable w i l l use more problem-focused c o p i n g . T h i s suggests t h a t the person who a t t r i b u t e s the cause of o v e r e a t i n g t o something t h a t can be changed w i l l be more l i k e l y t o use c o p i n g responses t h a t are problem-focused and t h e r e f o r e a d a p t i v e i n a v o i d i n g r e l a p s e . Age may a l s o i n f l u e n c e the use of problem-focused coping. In a study t h a t i n v e s t i g a t e d r e l a t i v e use of d i f f e r e n t types of c o p i n g i n response t o d a i l y h a s s l e s among 85 younger m a r r i e d c o u p l e s and 161 o l d e r people, o l d e r p a r t i c i p a n t s were found t o use r e l a t i v e l y l e s s problem-focused coping than younger 29 p a r t i c i p a n t s , s u g g e s t i n g t h a t problem-focused c o p i n g d e c r e a s e s w i t h age (Folkman, Lazarus, Pimley, & Novacek, 1987) . The r e l a p s e p r e v e n t i o n model ( M a r l a t t & Gordon, 1980) f o c u s e s on an i n d i v i d u a l ' s coping response t o a h i g h r i s k s i t u a t i o n , but whatever t h a t person t h i n k s or does a f t e r a l a p s e may be e q u a l l y important. The model p r e d i c t s t h a t the i n d i v i d u a l who has l a p s e d i n t o o l d behavior w i l l e x p e r i e n c e an A b s t i n e n c e V i o l a t i o n E f f e c t (AVE). T h i s r e s u l t s i n n e g a t i v e a f f e c t and c o n t i n u i n g t o use the o l d b e h a v i o r may be seen as an a t t r a c t i v e means of d e a l i n g w i t h the s t r e s s a s s o c i a t e d w i t h t h a t a f f e c t . The consequences of t h i s are a g r e a t e r l i k e l i h o o d of f u l l r e l a p s e . The i n d i v i d u a l who uses o t h e r c o p i n g s t r a t e g i e s t h a t are more a d a p t i v e i n terms of outcome w i l l be t h e r e f o r e be more s u c c e s s f u l i n a v o i d i n g r e l a p s e . Relapse P r e v e n t i o n T r a i n i n g i n Weight Loss and Maintenance Based on t h e i r work on r e l a p s e p r e v e n t i o n , M a r l a t t and h i s a s s o c i a t e s ( M a r l a t t & George, 1984) developed an i n t e r v e n t i o n program t o teach s p e c i f i c s t r a t e g i e s t o i n d i v i d u a l s t r y i n g t o m a i n t a i n s i g n i f i c a n t b e h a v i o r changes. Through a t h e r a p e u t i c process i n which the i n d i v i d u a l works as a c o l l e a g u e w i t h the t h e r a p i s t , a l i f e s t y l e assessment i s done and c o p i n g s k i l l s and c o g n i t i v e r e f r a m i n g are developed which become i n t e g r a l p a r t s of an i n d i v i d u a l ' s r e l a p s e p r e v e n t i o n p l a n . 30 Most of the s t u d i e s done on r e l a p s e p r e v e n t i o n t r a i n i n g have been i n the areas of r e c o v e r y from a d d i c t i o n s t o a l c o h o l , tobacco, and i l l e g a l drugs, but i t s a p p l i c a t i o n t o weight l o s s maintenance has been noted. Abrams and F o l l i c k (1983) found t h a t 133 predominantly female s u b j e c t s , aged 20 t o 60 y e a r s , who had been taught r e l a p s e p r e v e n t i o n a l o n g w i t h o t h e r maintenance s k i l l s f o l l o w i n g a w o r k s i t e weight l o s s program, maintained t h e i r l o s s e s s i g n i f i c a n t l y b e t t e r a t a 6-month f o l l o w up than those who had been a s s i g n e d t o a maintenance c o n d i t i o n i n which no new s k i l l s were taught. S i n c e r e l a p s e p r e v e n t i o n was o n l y one of s e v e r a l maintenance s t r a t e g i e s t h a t were taught t o the more s u c c e s s f u l group, however, i t i s i m p o s s i b l e t o determine whether i t was an i n d i v i d u a l s t r a t e g y or the combination of them t h a t mattered. A d d i t i o n a l l y , the high a t t r i t i o n r a t e r e p o r t e d i n t h i s study, w i t h o n l y 24 of the o r i g i n a l 13 3 p a r t i c i p a n t s measured a t the 6-month follow-up, makes i t d i f f i c u l t t o g e n e r a l i z e the f i n d i n g s of t h i s study, s i n c e those who dropped out may have been people who were l e s s s u c c e s s f u l i n m a i n t a i n i n g t h e i r weight l o s s e s . In another i n v e s t i g a t i o n of r e l a p s e p r e v e n t i o n i n weight l o s s maintenance f o r 43 predominantly female d i e t e r s , S t e r n b e r g (1985) r e p o r t e d t h a t the group t h a t had been taug h t the p r i n c i p l e s of the r e l a p s e p r e v e n t i o n model d u r i n g a 9-week beh a v i o r therapy w e i g h t - r e d u c t i o n program showed s i g n i f i c a n t l y b e t t e r weight l o s s a t the 60-day f o l l o w - u p 31 than the group who had undergone i d e n t i c a l treatment w i t h o u t the r e l a p s e p r e v e n t i o n component. Although the groups d i d not d i f f e r i n weight change from pretreatment t o p o s t t r e a t m e n t , when 3 6 p a r t i c i p a n t s were c o n t a c t e d f o r the 60-day f o l l o w - u p , the r e l a p s e p r e v e n t i o n group (n = 22) had c o n t i n u e d t o l o s e weight, w h i l e the s t a n d a r d treatment group (n = 14) was b e g i n n i n g t o r e g a i n . A s i g n i f i c a n t d i f f e r e n c e was found i n the t o t a l amount of weight l o s t (RP group, M = -13.9 l b s ; s t a n d a r d treatment group, M = -8.7 l b s ; t(34) = 2 . 08 , p_< . 05) . A d d i t i o n a l l y , although 80% of the r e l a p s e p r e v e n t i o n group i n the above study r e p o r t e d e x p e r i e n c i n g l a p s e s d u r i n g the 60-day f o l l o w - u p p e r i o d (as compared t o 100% of the s t a n d a r d treatment group), they were more l i k e l y t o see t h e i r d e c i s i o n t o overeat as a d e l i b e r a t e one. The r e s e a r c h e r s suggested t h a t the r e l a p s e p r e v e n t i o n component had been e f f e c t i v e i n r e d u c i n g the number of l a p s e s an i n d i v i d u a l e x p e r i e n c e d and a l s o i n changing some of h i s or her p e r c e p t i o n s of those events. In another study of 129 predominantly female p a r t i c i p a n t s i n a 15-week b e h a v i o r a l or n o n b e h a v i o r a l weight l o s s treatment program, the b e n e f i t s from r e l a p s e p r e v e n t i o n t r a i n i n g were l e s s c l e a r ( P e r r i e t a l . , 1984). When the weight l o s s maintenance success of 93 remaining p a r t i c i p a n t s was measured a t a 12-month follow-up, o n l y the group (n = 17) t h a t had r e c e i v e d b e h a v i o r a l treatment, r e l a p s e p r e v e n t i o n t r a i n i n g , and g r a d u a l l y f a d i n g p o s t t r e a t m e n t 32 t h e r a p i s t c o n t a c t by m a i l and telephone had m a i n t a i n e d t h e i r l o s s e s . On the o t h e r hand, P e r r i e t a l . a l s o found t h a t the group (n = 15) t h a t had r e c e i v e d b e h a v i o r a l treatment and r e l a p s e p r e v e n t i o n t r a i n i n g but no p osttreatment c o n t a c t were the l e a s t s u c c e s s f u l of the 4 treatment groups i n m a i n t a i n i n g a l o s s of 20 l b s or more a t the 12-month f o l l o w - up. In a t tempting t o e x p l a i n t h i s f i n d i n g , the r e s e a r c h e r s wondered i f without f u r t h e r t h e r a p i s t c o n t a c t the 6 s e s s i o n s of r e l a p s e p r e v e n t i o n t r a i n i n g d u r i n g treatment had been s u f f i c i e n t t o t e a c h the c o g n i t i v e and b e h a v i o r a l s t r a t e g i e s i n v o l v e d . A f u r t h e r concern they had was t h a t w ithout t h e r a p i s t feedback, i n d i v i d u a l s might have misused some of the c o g n i t i v e c o p i n g procedures t o r a t i o n a l i z e l a p s e s w i t h o u t implementing the b e h a v i o r a l techniques important f o r g e t t i n g back on t r a c k . P e r r i e t a l . concluded t h a t the guidance of a t h e r a p i s t may be e s s e n t i a l i n h e l p i n g c l i e n t s use t h e r e l a p s e p r e v e n t i o n s t r a t e g i e s e f f e c t i v e l y . Development of a Maintenance Treatment Program The p r e c e d i n g s t u d i e s on the r o l e s of s e l f - e f f i c a c y and c o p i n g s t r a t e g i e s i n weight l o s s and maintenance and the e f f e c t i v e n e s s of r e l a p s e p r e v e n t i o n t r a i n i n g i n d i c a t e t h a t t h e s e are p r o d u c t i v e areas f o r f u r t h e r r e s e a r c h . One d i r e c t i o n suggested by Stalonas e t a l . (1984) i s t o a s s e s s the e f f e c t s of maintenance treatment programs t h a t take i n d i v i d u a l d i f f e r e n c e s and needs i n t o c o n s i d e r a t i o n , r a t h e r than d e l i v e r i n g prepared treatment components a t f i x e d 33 i n t e r v a l s . From the w e i g h t - l o s s s t u d i e s reviewed, i t appears t h a t as such programs are developed, i t w i l l be important t h a t they focus on i n c r e a s i n g s e l f - e f f i c a c y , e n couraging problem-focused coping, and t e a c h i n g the p r i n c i p l e s of r e l a p s e p r e v e n t i o n . The f i r s t i s s u e i s how such a program c o u l d i n c r e a s e s e l f - e f f i c a c y . A program with a focus on weight l o s s , one t h a t encouraged the use of s p e c i f i c b e h a v i o r a l s t r a t e g i e s l i k e c h a r t i n g c a l o r i e s consumed, u s i n g s t i m u l u s c o n t r o l t o a v o i d o v e r e a t i n g , and i n c r e a s i n g p h y s i c a l a c t i v i t y , might w e l l r e s u l t i n weight l o s s e s f o r those who used the s t r a t e g i e s . Weight l o s s d u r i n g treatment i s not n e c e s s a r i l y a s s o c i a t e d w i t h changes i n s e l f - e f f i c a c y , however. M i t c h e l l and S t u a r t (1984) found t h a t p a r t i c i p a n t s i n a commercial weight l o s s program who dropped out of treatment were l e s s l i k e l y t o have h i g h l e v e l s of s e l f - e f f i c a c y f o r weight c o n t r o l and behavior change than those who c o n t i n u e d i n treatment, even though the r a t e s of weight l o s s f o r the two groups d i d not d i f f e r . The r e s e a r c h e r s concluded t h a t p e r c e p t i o n of success was more important than a c t u a l s u c c e s s i n f e e l i n g s of s e l f - e f f i c a c y and h y p o t h e s i z e d t h a t t h o se w i t h lower l e v e l s of s e l f - e f f i c a c y even a f t e r weight l o s s might have s t r o n g c o n v i c t i o n s t h a t they cannot succeed. Perhaps t h i s i s r e l a t e d t o Bandura's (1977) i d e a t h a t s u c c e s s f u l performance does not n e c e s s a r i l y l e a d t o i n c r e a s e d s e l f - e f f i c a c y , e s p e c i a l l y when the i n d i v i d u a l 34 a t t r i b u t e s a p o s i t i v e outcome t o hard work r a t h e r than a b i l i t y . The e f f e c t of f a i l u r e t o m a i n t a i n weight l o s s on s e l f - e f f i c a c y i n f u t u r e weight management e f f o r t s must a l s o be c o n s i d e r e d . In an i n v e s t i g a t i o n of f a c t o r s a s s o c i a t e d w i t h weight l o s s and maintenance i n 89 middle-aged men, r e s e a r c h e r s found t h a t men with p r i o r d i e t f a i l u r e s had e x c e p t i o n a l l y poor long-term maintenance success a t the 2- year f o l l o w - u p ( J e f f r e y e t a l . , 1984). Although encouraging u n s u c c e s s f u l m a i n t a i n e r s t o undertake another d i e t i s an a t t r a c t i v e f o c u s f o r a maintenance i n t e r v e n t i o n , t h i s approach i g n o r e s the f a c t t h a t people who have r e g a i n e d weight are l i k e l y t o f e e l a p e r s o n a l sense c f f a i l u r e . B e f o r e they t r y t o l o s e weight again, they need t o f e e l s t r o n g l y c o n v i n c e d t h a t they w i l l be a b l e t o m a i n t a i n t h e i r l o s s t h i s time. Bandura (1982) d e s c r i b e s the s i t u a t i o n i n which people see themselves as i n e f f e c t u a l i n a c h i e v i n g outcomes which are p e r c e i v e d t o be a c h i e v a b l e by o t h e r s as one which l e a d s t o se l f - d i s p a r a g e m e n t and d e p r e s s i o n . S t a l o n a s e t a l . (1984) b r i e f l y reviewed the f i n d i n g s of t h e i r own and other s t u d i e s on the importance of the c o n t i n u e d use of b e h a v i o r a l s t r a t e g i e s l i k e m o n i t o r i n g of weight, making e a t i n g a "pure experience", e t c . , i n l o n g - term weight l o s s maintenance and concluded t h a t when these s t r a t e g i e s a re c o n s c i e n t i o u s l y used, s u c c e s s f u l weight management i s l i k e l y . What d i s c o u r a g e s r e s e a r c h e r s i s t h a t s u c c e s s f u l d i e t e r s do not continue t o use these t e c h n i q u e s . 35 T h i s i s the i s s u e an i n t e r v e n t i o n program sh o u l d a d d r e s s : why do people stop doing what works so e f f e c t i v e l y ? One p o s s i b i l i t y i s t h a t t h e i r l e v e l s of s e l f - e f f i c a c y have decreased. One f a c t o r i n t h i s decrease i s t h a t d u r i n g s u c c e s s f u l maintenance, u n l i k e d u r i n g weight l o s s , no r e a l p r o g r e s s i s made towards a g o a l ; the g o a l i s t o s t a y where one i s . Bandura (1977) suggests t h a t people who are s u c c e s s f u l but f e e l t h a t t h e i r performance has l e v e l l e d o f f compared t o an e a r l i e r r a t e of achievement have lower l e v e l s of p e r c e i v e d e f f i c a c y than those who have setbacks but see they are making some p r o g r e s s . The t a s k f o r a maintenance i n t e r v e n t i o n thus becomes one of i n s t i l l i n g or r e b u i l d i n g a s t r o n g b e l i e f i n p e r s o n a l s e l f - e f f i c a c y . As Stunkard and Penick (1979) have p o i n t e d out, the s u c c e s s f u l d i e t e r f a c e s a l i f e t i m e of c o n t r o l l e d use of the v e r y substance t h a t caused the problem w h i l e b e i n g c o n s t a n t l y tempted t o overeat by the easy a v a i l a b i l i t y of h i g h - c a l o r i e , g o o d - t a s t i n g foods. Food i s not o n l y nourishment, but a l s o p l a y s an important r o l e i n g a t h e r i n g s , c e l e b r a t i o n s , and s p e c i a l events where t h e r e can be s t r o n g s o c i a l p r e s s u r e t o i n d u l g e i n e x t r a c a l o r i e s . The p o i n t a t which e a t i n g becomes o v e r e a t i n g can become i n c r e a s i n g l y d i f f i c u l t t o determine over time as the s u c c e s s f u l d i e t e r b e g i n s t o r e l a x d i e t a r y r e s t r i c t i o n s . I n i t i a l e p i s o d es of o v e r e a t i n g may r e s u l t i n the AVE of the r e l a p s e p r e v e n t i o n model ( M a r l a t t & Gordon, 1980) and a q u i c k r e t u r n t o c o n t r o l l e d e a t i n g , but as l a p s e s accumulate f o r a l l but the 36 most d i s c i p l i n e d m a i n t a i n e r , g r a d u a l l y they may erode an i n d i v i d u a l ' s c o n f i d e n c e t h a t he or she can c o n t r o l o v e r e a t i n g . What might i n c r e a s e t h i s sense of c o n f i d e n c e , or s e l f - e f f i c a c y , i s a treatment i n t e r v e n t i o n t h a t h e l p s an i n d i v i d u a l r e c a l l the p e r i o d of s u c c e s s f u l weight l o s s maintenance. By remembering what be h a v i o r s , a c t i v i t y l e v e l s , and c o p i n g s t r a t e g i e s were used a t t h a t time, the i n d i v i d u a l becomes aware t h a t he or she was i n f a c t c a p a b l e of s u c c e s s f u l l y m a i n t a i n i n g a weight l o s s f o r however l i m i t e d a time and s p e c i f i c a l l y i d e n t i f i e s what was n e c e s s a r y f o r t h a t success. Bandura (1977) has i d e n t i f i e d f o u r major sources of i n f o r m a t i o n f o r e f f i c a c y e x p e c t a t i o n s : performance accomplishments, v i c a r i o u s e x p e r i e n c e , v e r b a l p e r s u a s i o n , and p h y s i o l o g i c a l s t a t e s . An i n t e r v e n t i o n program w i t h a support group format c o u l d p r o v i d e people w i t h t h r e e of these f o u r sources of i n f o r m a t i o n . They c o u l d r e c a l l and d i s c u s s t h e i r s u c c e s s f u l p a s t accomplishments of weight l o s s maintenance as w e l l as t h e i r c u r r e n t s u c c e s s e s i n r e v e r s i n g the g r a d u a l d e t e r i o r a t i o n of t h e i r weight management s k i l l s (performance accomplishments), hear the s u c c e s s s t o r i e s of o t h e r s ( v i c a r i o u s e x p e r i e n c e ) , and r e c e i v e encouragement, advice, and support from t h e i r peers i n t h e i r c u r r e n t weight management e f f o r t s ( v e r b a l p e r s u a s i o n ) . The second focus f o r a maintenance i n t e r v e n t i o n treatment program would be i d e n t i f y i n g types of c o p i n g 37 responses a s s o c i a t e d w i t h s u c c e s s f u l maintenance. One way t h i s c o u l d be done i s t o p r o v i d e p a r t i c i p a n t s w i t h i n f o r m a t i o n about the behaviors t h a t have found t o be a s s o c i a t e d w i t h maintenance i n c o r r e l a t i o n a l r e s e a r c h . These i n c l u d e r e g u l a r weight mo n i t o r i n g , e x e r c i s e , and c o n t i n u e d use of the s p e c i f i c s t r a t e g i e s the i n d i v i d u a l found h e l p f u l i n weight l o s s (Stalonas e t a l . , 1984; S t u a r t & G u i r e , 1978) . Another f a c t o r r e l a t e d t o s u c c e s s f u l weight l o s s maintenance was an i n d i v i d u a l ' s a b i l i t y t o c o n t r o l o v e r e a t i n g i n response t o n e g a t i v e a f f e c t (Leon & Chamberlain, 197 3). In a study of 66 predominantly female s u c c e s s f u l d i e t e r s and 39 c o n t r o l group (non-dieter) p a r t i c i p a n t s , the c o n t r o l group showed a s t r o n g a s s o c i a t i o n between e a t i n g and hunger, w h i l e the groups of r e g a i n e r s (a r e g a i n of more than 20% of t h e i r weight l o s s e s ) and m a i n t a i n e r s (a r e g a i n of l e s s than 20%) showed an a s s o c i a t i o n between e a t i n g and emotional a r o u s a l . Thus, h e l p i n g s t r u g g l i n g m a i n t a i n e r s t o develop c o p i n g s t r a t e g i e s o t h e r than e a t i n g f o r d e a l i n g w i t h n e g a t i v e a f f e c t may be an important focus f o r an i n t e r v e n t i o n program. The t h i r d focus f o r such a program i s r e l a p s e p r e v e n t i o n t r a i n i n g . M a r l a t t and George (1984) recommend an i n d i v i d u a l i z e d program of techniques which addresses the p a r t i c u l a r h i g h r i s k s i t u a t i o n s , l i f e s t y l e , and c o p i n g s k i l l s of each person. T h i s approach i s not s u i t a b l e f o r a support group format because i t i n v o l v e s time-consuming, 38 c a r e f u l work between a t h e r a p i s t and i n d i v i d u a l i n d e v e l o p i n g a p e r s o n a l r e l a p s e p r e v e n t i o n p l a n . As an a l t e r n a t i v e , p r o v i d i n g program p a r t i c i p a n t s w i t h i n f o r m a t i o n about r e l a p s e p r e v e n t i o n and how t o develop a p l a n might f o s t e r a sense of s e l f - r e s p o n s i b i l i t y . One f a c t o r t h a t C o l v i n and Olson (1983) i d e n t i f i e d as c h a r a c t e r i z i n g s u c c e s s f u l weight l o s s m a i n t a i n e r s was a s t r o n g sense of p e r s o n a l r e s p o n s i b i l i t y f o r weight management. P u t t i n g the onus on the i n t e r v e n t i o n program p a r t i c i p a n t s t o develop t h e i r own p l a n might thus c o n t r i b u t e t o f u t u r e s u c c e s s . A s s e s s i n g the E f f e c t i v e n e s s of a Maintenance I n t e r v e n t i o n Program The e f f e c t i v e n e s s of a program designed t o i n c r e a s e s e l f - e f f i c a c y and the use of problem-focused c o p i n g can be as s e s s e d by measuring changes i n these f a c t o r s over time. S e l f - e f f i c a c y c o u l d be measured as a i n d i v i d u a l ' s g e n e r a l b e l i e f he or she can ma i n t a i n a weight l o s s , but t h a t might not be as i n f o r m a t i v e as measuring c o n f i d e n c e i n a b i l i t y t o perform s p e c i f i c b e h a v i o r s . A person might express c o n f i d e n c e i n a c h i e v i n g a d e s i r e d outcome t h a t has more t o do w i t h w i s h f u l t h i n k i n g than r e a l i s t i c e x p e c t a t i o n s . When S t a l o n a s e t a l . (1984) i n t e r v i e w e d the 28 remaining p a r t i c i p a n t s ( o r i g i n a l n = 44) i n the 5-year f o l l o w - u p of a b e h a v i o r a l treatment f o r o b e s i t y , they found t h a t the average p a r t i c i p a n t had gained 11.94 l b s s i n c e treatment t e r m i n a t i o n and was 1.49 l b s h e a v i e r than a t pretreatment. D e s p i t e t h i s , 87% of these people expected t o l o s e weight or 39 m a i n t a i n t h e i r l o s s e s over the next 5 y e a r s , and t h e average expected l o s s was 13 l b s . A b e t t e r method of measuring s e l f - e f f i c a c y would be t o i d e n t i f y an important behavior i n weight management and measure an i n d i v i d u a l ' s c o n f i d e n c e i n p e r f o r m i n g t h a t b e h a v i o r . S i n c e s u c c e s s f u l weight management depends on e s t a b l i s h i n g an energy balance i n which the c a l o r i e s consumed are equal t o the energy expended, c o n f i d e n c e i n one's a b i l i t y t o c o n t r o l c a l o r i c i n t a k e appears t o be a good fo c u s f o r measuring s e l f - e f f i c a c y . Researchers have developed an E a t i n g S e l f - E f f i c a c y S c a l e t h a t measures an i n d i v i d u a l ' s l e v e l of c o n f i d e n c e t h a t he or she can c o n t r o l o v e r e a t i n g i n a v a r i e t y of s i t u a t i o n s (Glynn & Ruderiuan, 1984). T h i s s c a l e can thus be used t o measure changes i n s e l f - e f f i c a c y t h a t may occur as a r e s u l t of treatment. Some support e x i s t s f o r the i d e a t h a t l e v e l s of s e l f - e f f i c a c y a f f e c t c oping s t r a t e g i e s . Rippetoe and Rogers (1987) found t h a t h i g h e r l e v e l s of e i t h e r s e l f - e f f i c a c y or outcome e x p e c t a n c i e s , e x i s t i n g a t p r e t e s t or manipulated d u r i n g treatment, were a s s o c i a t e d w i t h g r e a t e r use of a d a p t i v e c o p i n g i n a study of coping response t o a h e a l t h t h r e a t ( b r e a s t c a n c e r ) . Adaptive coping was d e f i n e d as u s i n g s t r a t e g i e s t h a t were problem-focused and d e a l t w i t h the r e a l i t y of the s i t u a t i o n , such as p e r f o r m i n g b r e a s t s e l f - e x a m i n a t i o n . In another study, i n c r e a s e d l e v e l s of g e n e r a l s e l f - e f f i c a c y were not found t o be a s s o c i a t e d with changes i n 40 t h e i r c o p i n g s t r a t e g i e s , as measured on the two domains of t y p e s of c o p i n g s t r a t e g i e s (Long & Haney, 1988). T h i s study compared the e f f e c t s of two s t r e s s - r e d u c t i o n i n t e r v e n t i o n s on 61 sedentary working women. P a r t i c i p a n t s i n both programs s i g n i f i c a n t l y i n c r e a s e d g e n e r a l s e l f - e f f i c a c y , but a c t i v e and p a s s i v e coping d i d not s i g n i f i c a n t l y change from p r e t e s t t o p o s t t e s t . The Rippetoe and Rogers (1987) study i d e n t i f i e d one p a r t i c u l a r s t r e s s o r , the t h r e a t of g e t t i n g b r e a s t cancer. S e l f - e f f i c a c y was manipulated i n terms of how w e l l an i n d i v i d u a l c o u l d d e a l s u c c e s s f u l l y with t h a t p a r t i c u l a r s t r e s s o r and c o p i n g was assessed i n terms of response t o t h a t s t r e s s o r . R e p o r t i n g on the r e s u l t s of s e v e r a l comparative s t u d i e s by other authors, Bandura (198 6) s t a t e s t h a t p a r t i c u l a r i z e d measures of s e l f - e f f i c a c y s u rpass g l o b a l i z e d measures i n terms of e x p l a i n i n g and p r e d i c t i n g b e h a v i o r . Thus, the r e s u l t s of the Long and Haney (1988) study c o u l d be due t o the f a c t t h a t g e n e r a l measures of w o r k - r e l a t e d s t r e s s were used, r a t h e r than a s p e c i f i c one. In o r d e r t o examine changes i n coping over time which may r e s u l t from changes i n s e l f - e f f i c a c y l e v e l s , i t might be h e l p f u l t o i d e n t i f y a p a r t i c u l a r type of s t r e s s o r , r a t h e r than look a t c o p i n g responses to a v a r i e t y of s t r e s s o r s . In a r e c e n t study on c o n s i s t e n c y i n coping, moderate c o n s i s t e n c y i n response t o the same s t r e s s o r over time was found, but o n l y low c o n s i s t e n c y when two s t r e s s o r s were i d e n t i f i e d (Compas, Forsythe, & Wagner, 1988). 41 One p a r t i c u l a r s t r e s s o r t h a t can l e a d t o o v e r e a t i n g has been i d e n t i f i e d i n the r e l a p s e p r e v e n t i o n model as t h e n e g a t i v e a f f e c t r e s u l t i n g from the AVE ( M a r l a t t & Gordon, 1984). Negative a f f e c t has been a s s o c i a t e d w i t h e a t i n g (Leon & Chamberlain, 1973), and with r e l a p s e c r i s e s and c o p i n g among d i e t e r s ( G r i l o e t a l . , 1989). As has been e a r l i e r noted, problem-focused coping t h a t d e a l s w i t h the r e a l i t y of the s i t u a t i o n (e.g., acknowledging t h a t o v e r e a t i n g has o c c u r r e d but keeping the s i t u a t i o n i n p e r s p e c t i v e ) i s l e s s l i k e l y t o l e a d t o f u r t h e r o v e r e a t i n g than emotion-focused coping such as w i s h f u l t h i n k i n g or avoidance (e.g., w i s h i n g the o v e r e a t i n g hadn't o c c u r r e d or t r y i n g not t o t h i n k about i t ) r Coping with n e g a t i v e a f f e c t i n a problem-focused way can thus keep s e l f - e f f i c a c y l e v e l s from d e c r e a s i n g f u r t h e r . Purpose of the Study A review of the work done on d e v e l o p i n g e f f e c t i v e t reatment programs f o r o b e s i t y leads t o the c o n c l u s i o n t h a t programs have become i n c r e a s i n g l y s o p h i s t i c a t e d w i thout a l t e r i n g the f a c t t h a t something goes very wrong i n l o n g - term weight l o s s maintenance. Researchers add more and more components t o treatment programs i n the hope of f i n d i n g the m i s s i n g element t h a t makes s u c c e s s f u l treatment permanent. D i e t e r s who f a i t h f u l l y abide by treatment g u i d e l i n e s and l o s e weight, then f a i l t o m a i ntain t h e i r l o s s e s , are l i k e l y t o blame themselves and l o s e c o n f i d e n c e i n t h e i r a b i l i t y t o succeed. C l e a r l y i t i s time to approach the problem from 42 another d i r e c t i o n and see i f an y t h i n g can be done t o i n t e r r u p t the p r o c e s s of r e l a p s e once i t has begun. The expected e f f e c t of a maintenance i n t e r v e n t i o n program w i t h a focus on i n c r e a s i n g s e l f - e f f i c a c y and e x p l o r i n g i s s u e s r e l a t e d t o weight management would be t h a t p a r t i c i p a n t s ' l e v e l s of s e l f - e f f i c a c y and r e l a t i v e use of problem-focused co p i n g w i l l i n c r e a s e as they b e g i n t o s h i f t from s e l f - b l a m e t o s e l f - u n d e r s t a n d i n g i n response t o o v e r e a t i n g e p i s o d e s . Those p a r t i c i p a n t s who a l s o r e c e i v e i n f o r m a t i o n on the r e l a p s e p r e v e n t i o n model would be expected t o develop a f u l l e r understanding of the s i t u a t i o n a l nature of l a p s e s and thus be more l i k e l y t o p e r s e v e r e i n t a k i n g a problem-focused approach t o n e g a t i v e a f f e c t r e s u l t i n g from o v e r e a t i n g . 43 Hypotheses 1. S e l f - e f f i c a c y i n e a t i n g s i t u a t i o n s , measured by s c o r e s on the E a t i n g S e l f - e f f i c a c y S c a l e (ESES), i n c r e a s e s s i g n i f i c a n t l y more from p r e t e s t t o p o s t t e s t f o r both t h e RPI group and the MI group as compared wi t h the w a i t i n g l i s t (WL) group. 2. S e l f - e f f i c a c y , as measured above, i s ma i n t a i n e d a t p o s t t e s t l e v e l s f o r the RPI group from p o s t t e s t t o the 6- week f o l l o w - u p , and i s s i g n i f i c a n t l y g r e a t e r than l e v e l s f o r the MI group, which decrease from p o s t t e s t t o f o l l o w - u p . 3. The r e l a t i v e s c o r e f o r Problem-focused c o p i n g t o the o v e r a l l c o p i n g s c o r e on the V i t a l i a n o e t a l . (1985) r e v i s i o n of the Ways of Coping C h e c k l i s t (WCCL) i n c r e a s e s s i g n i f i c a n t l y more from p r e t e s t t o p o s t t e s t f o r both the RPI group and the MI group as compared with the WL group. 4. The r e l a t i v e s c o r e f o r Problem-focused c o p i n g s t r a t e g i e s t o the o v e r a l l coping s c o r e i s maintained by the RPI group from p o s t t e s t t o 6-week follow-up, and i s s i g n i f i c a n t l y g r e a t e r than t h a t of the MI group which d e c r e a s e s . 5. There i s a moderately s i g n i f i c a n t n e g a t i v e a s s o c i a t i o n between the r e l a t i v e s c o r e f o r Problem-focused c o p i n g s t r a t e g i e s a t p o s t t e s t and s e l f - e f f i c a c y s c o r e s a t the 6-week fo l l o w - u p f o r both the RPI and MI groups ( i . e . , g r e a t e r r e l a t i v e use of Problem-focused c o p i n g i s a s s o c i a t e d w i t h g r e a t e r s e l f - e f f i c a c y ) . 44 METHOD S u b j e c t s The o r i g i n a l sample c o n s i s t e d of 72 women who met s c r e e n i n g c r i t e r i a , however, a t o t a l of 59 women were r e t a i n e d f o r a n a l y s i s . I n d i v i d u a l s responded t o a r t i c l e s i n l o c a l newspapers and a s h o r t r a d i o i n t e r v i e w which b r i e f l y d e s c r i b e d a r e s e a r c h program f o r women who had s u c c e s s f u l l y l o s t weight but were having d i f f i c u l t y m a i n t a i n i n g t h a t l o s s . A l t o g e t h e r 152 women and 7 men c o n t a c t e d the experimenter, but o n l y 72 of them q u a l i f i e d f o r the program. The 7 men were thanked f o r t h e i r i n t e r e s t and t o l d t h a t t h e program was l i m i t e d t o women. Women who q u a l i f i e d f o r the study were those who answered "yes" t o the f o l l o w i n g q u e s t i o n s : (a) "Have you s u c c e s s f u l l y l o s t weight t o a t a r g e t or g o a l weight a t some time i n the p a s t ? " (b) "Were you a b l e t o m a i n t a i n t h a t l o s s w i t h i n 5 l b s f o r a t l e a s t 6 months?" and "no" t o the q u e s t i o n , (c) "Have you r e g a i n e d a l l t h e weight you l o s t ? " Those s t i l l q u a l i f i e d a t t h i s p o i n t were asked, "On a s c a l e of 1 t o 10, with 1 b e i n g no conc e r n and 10 be i n g very g r e a t concern, how would you r a t e your own l e v e l of concern about maintenance?" Only those who i n d i c a t e d a l e v e l of 6 or above were i n c l u d e d i n the study. In summary, p r o s p e c t i v e p a r t i c i p a n t s were d i s q u a l i f i e d f o r t he f o l l o w i n g reasons: 10 were t r y i n g t o l o s e weight and had not y e t reached t h e i r g o a l s ; 16 had not maint a i n e d f o r at l e a s t 6 months; 40 had reg a i n e d a l l of t h e i r l o s t weight; 45 1 r e p o r t e d a low l e v e l of concern about maintenance. A f u r t h e r 13 women s t a t e d they were unable t o a t t e n d any of the 4 p r e l i m i n a r y s e s s i o n s . The 72 women who q u a l i f i e d were asked t o a t t e n d 1 o f 4 p r e l i m i n a r y s e s s i o n s . An e f f o r t was made t o randomly a s s i g n them t o any one of the s e s s i o n s but i n many cases i n d i v i d u a l s had time or t r a n s p o r t a t i o n r e s t r i c t i o n s and t h i s d i c t a t e d which s e s s i o n they attended. Ten women f a i l e d t o a t t e n d t h e i r p r e l i m i n a r y s e s s i o n , 6 because of f a m i l y emergencies, t r a n s p o r t a t i o n d i f f i c u l t i e s , or weather c o n d i t i o n s , 4 f o r no s t a t e d reason. Of the 62 women who attended the p r e l i m i n a r y s e s s i o n s , two withdrew b e f o r e s i g n i n g consent forms o r f i l l i n g i n any q u e s t i o n n a i r e s , s t a t i n g the program as d e s c r i b e d was not o f i n t e r e s t t o them. One woman who p a r t i c i p a t e d i n the study was l a t e r d i s c o v e r e d t o have maintained her weight l o s s f o r c o n s i d e r a b l y l e s s than 6 months and consequently her dat a were not i n c l u d e d i n any a n a l y s i s . The 59 remaining p a r t i c i p a n t s ranged i n age from 18 t o 76, w i t h a mean age of 45.0 (SD = 10.1). The m a j o r i t y (64%) were m a r r i e d or i n long-term r e l a t i o n s h i p s , 12% were s i n g l e , and the remaining 24% were separated, d i v o r c e d , or widowed. Most (79.9%) were employed e i t h e r f u l l or p a r t time; the r e s t were r e t i r e d (6.7%), students (6.7%), or homemakers (6.7%). P a r t i c i p a n t s were a t an average weight of 149.6 l b s (range, 115-202, SD = 18.3), w h i l e t h e i r average t a r g e t 46 weight was 135.5 l b s (range 105-165, SD = 12.6). Less than 2 0% (n = 11) r e p o r t e d being no more than 5 l b s above t h e i r t a r g e t weights and of these o n l y 5 women were a t t h e i r g o a l or a few l b s below i t . The average weight l o s s b e f o r e any r e g a i n had been 33.2 l b s (range 11-120, SD = 19.7). A l t h o u g h a l l p a r t i c i p a n t s had maintained f o r a t l e a s t - 6 months, the range was from 6 months t o 10 y e a r s , w i t h an average of 17.9 months (SD = 1 7 . 9 ) . An even g r e a t e r range was found i n how long ago they had l o s t weight w i t h the range b e i n g from 6 months t o 24 years and an average of 49.6 months (SD = 58.4). The Demographic Q u e s t i o n n a i r e used t o o b t a i n t h i s i n f o r m a t i o n i s found i n Appendix A. E x e r c i s e s t a t u s and change. Of the 59 p a r t i c i p a n t s , almost 90% (n = 53) d e s c r i b e d themselves as moderately a c t i v e or a c t i v e . Twenty-two p e r c e n t were more a c t i v e (n = 13) than when they reached t h e i r g o a l , 37% were l e s s a c t i v e (n = 22), and the remaining 41% had not changed (n = 24). Walking or j o g g i n g or a combination of a c t i v i t i e s were f a v o r e d by 81% of p a r t i c i p a n t s (n = 48) and 78% e x e r c i s e d 3 or more times a week (n = 46) . Maintenance s t r a t e g i e s . Weekly or more f r e q u e n t weigh- i n s were the most f r e q u e n t l y used maintenance s t r a t e g y . S e v e n t y - f i v e p e r c e n t of the p a r t i c i p a n t s r e p o r t e d d o i n g t h i s o f t e n (n = 10) or always (n = 34). C h a r t i n g amounts of food eaten was used by 3 5% of the p a r t i c i p a n t s , e i t h e r o f t e n (n = 12) or always (n = 7). F i f t y - f o u r p e r c e n t of p a r t i c i p a n t s r e p o r t e d r e t u r n i n g t o a s t r i c t e r e a t i n g program 47 o f t e n (n = 14) or always (n = 12) i n response t o a weight g a i n , and 3-5 l b s was the g a i n s p e c i f i e d by 54% (n_ = 32) of those who used t h i s s t r a t e g y . Design and Procedure P a r t i c i p a n t s were i n v i t e d t o a t t e n d 1 of 4 p r e l i m i n a r y s e s s i o n s . Based on which one they attended, they were a s s i g n e d t o one of two experimental c o n d i t i o n s o r t o a w a i t i n g l i s t (WL) which served as a c o n t r o l group i n a q u a s i - e x p e r i m e n t a l , repeated measures d e s i g n . The two treatment c o n d i t i o n s were Maintenance I n t e r v e n t i o n (MI) and Relapse P r e v e n t i o n I n t e r v e n t i o n (RPI). A l l groups (MI, RPI, and WL) were t e s t e d on the dependent v a r i a b l e s of s e l f - e f f i c a c y and c o p i n g a t p r e t e s t , p o s t t e s t , and f o l l o w - u p . WL p a r t i c i p a n t s who were subsequently a s s i g n e d t o treatment groups (MI2 and RPI2) were f u r t h e r t e s t e d on the dependent v a r i a b l e s a t p r e t e s t , p o s t t e s t , and fo l l o w - u p f o r those groups. The fo l l o w - u p t e s t i n g f o r the WL group p r o v i d e d the p r e t e s t measure f o r those p a r t i c i p a n t s who became p a r t of the MI2 and RPI2 groups. The group f o r m a t i o n and t e s t i n g s c h e d u l e i s shown i n F i g u r e 2. F o l l o w i n g p r e l i m i n a r y analyses f o r group d i f f e r e n c e s , t h e two treatment groups f o r each c o n d i t i o n (MI and MI2; RPI and RPI2) were c o l l a p s e d f o r f u r t h e r a n a l y s i s i n t o MI-C and RPI-C. I n i t i a l groups. P r o s p e c t i v e p a r t i c i p a n t s , i n s m a l l groups of 14-18, were asked t o a t t e n d an 1-hour p r e l i m i n a r y s e s s i o n d u r i n g which the purpose of the r e s e a r c h study, the 43 P r e t e s t P o s t t e s t Follow-up Week 1 Week 3 Week 9 MI RPI WL 1 (n = 1 15) 1 (n = 1 14) 1 (n = 1 = 14) 1 (n = 1 13) 1 (n = 13)  (n = = 12) 1 (n = 29) 1 (Q = 24) (n = •- 17) P r e t e s t P o s t t e s t Follow-up Week 9 Week 12 Week 13 MI2 I | | (n = 10) (n = 8) (n = 8) RPI 2 (n = 10) (n = 10) (n = 9) F i g u r e 2. Time-span of Study and Group Formation (MI2 group i n c l u d e d 2 pre-screened and q u a l i f i e d p a r t i c i p a n t s who d i d not a t t e n d the o r i g i n a l p r e l i m i n a r y s e s s i o n s . RPI2 group i n c l u d e d 1 WL p a r t i c i p a n t who d i d not complete the WL p o s t t e s t q u e s t i o n n a i r e and so i s not i n c l u d e d i n the 17 WL p a r t i c i p a n t s t e s t e d at f o l i o w - u p ) . 49 maintenance program i t s e l f , and p a r t i c i p a t i o n requirements were o u t l i n e d . Once informed consent had been o b t a i n e d (see Appendix A), p a r t i c i p a n t s became p a r t of one of two treatment groups (MI or RPI) or the w a i t i n g l i s t (WL). True random assignment of s u b j e c t s was not p o s s i b l e because the f i r s t treatment s e s s i o n s took p l a c e immediately f o l l o w i n g two of the p r e l i m i n a r y s e s s i o n s . T h i s meant t h a t those who a t t e n d e d the morning p r e l i m i n a r y s e s s i o n were a s s i g n e d t o one treatment group and those i n the a f t e r n o o n s e s s i o n t o the o t h e r . P a r t i c i p a n t s who attended the two r e m a i n i n g p r e l i m i n a r y s e s s i o n s a u t o m a t i c a l l y became p a r t of the w a i t i n g l i s t , w i t h the understanding t h a t they would be o f f e r e d treatment 9 weeks l a t e r . By means of a c o i n t o s s b e f o r e the f i r s t t reatment s e s s i o n , the morning and a f t e r n o o n groups were randomly a s s i g n e d t o the maintenance i n t e r v e n t i o n (MI) or r e l a p s e p r e v e n t i o n i n t e r v e n t i o n (RPI) treatment. The number of s u b j e c t s i n each group was: MI = 15, RPI = 13, WL = 29. Second treatment groups. E i g h t e e n of these 29 WL p a r t i c i p a n t s were l a t e r a s s i g n e d t o the second treatment groups (MI2 and RPI2) (See F i g u r e 2 ). Of the o r i g i n a l 29 WL s u b j e c t s , "1 f a i l e d t o complete the s e l f - e f f i c a c y q u e s t i o n n a i r e a t p r e t e s t and was among 5 p a r t i c i p a n t s who d i d not r e t u r n t h e i r q u e s t i o n n a i r e s a t p o s t t e s t . When c o n t a c t e d as the second treatment groups were b e i n g formed, 7 more were no longer a v a i l a b l e , l e a v i n g 17 WL p a r t i c i p a n t s t o be a s s i g n e d t o treatment groups. 50 At t h i s p o i n t one of the 5 p a r t i c i p a n t s who had not completed the p o s t t e s t q u e s t i o n n a i r e s phoned the experimenter w i t h a c o n v i n c i n g excuse ( i l l n e s s i n t h e f a m i l y n e c e s s i t a t i n g an unplanned t r i p ) and asked t o be i n c l u d e d i n a treatment group. Consequently, two groups of 10 and 8 were formed, a c c o r d i n g t o p a r t i c i p a n t s ' a b i l i t y t o a t t e n d morning or a f t e r n o o n s e s s i o n s . In order t o i n c r e a s e the s i z e of the s m a l l e r group, 2 women who had been among the 13 p r o s p e c t i v e p a r t i c i p a n t s who were q u a l i f i e d but unable t o a t t e n d the p r e l i m i n a r y s e s s i o n s were c o n t a c t e d , a t t e n d e d a s e p a r a t e p r e l i m i n a r y s e s s i o n , and became p a r t of the group. There were thus 10 p a r t i c i p a n t s i n each of the MI2 and RPI2 groups. Once a g a i n the morning and a f t e r n o o n groups were a s s i g n e d t o treatment c o n d i t i o n by a c o i n t o s s . Combined treatment groups. A f t e r p r e l i m i n a r y a n a l y s i s f o r group d i f f e r e n c e s , the data f o r the two treatment c o n d i t i o n s (MI and MI2; RPI and RPI2) were c o l l a p s e d f o r f u r t h e r a n a l y s i s . The two r e s u l t i n g groups were MI-C w i t h 25 p a r t i c i p a n t s and RPI-C wi t h 23 p a r t i c i p a n t s . T e s t i n g . Dependent measures of s e l f - e f f i c a c y i n e a t i n g s i t u a t i o n s and c o p i n g i n response t o n e g a t i v e a f f e c t a f t e r o v e r e a t i n g were assessed a t the end of the p r e l i m i n a r y s e s s i o n ( p r e t e s t ) , a t the end of the f o u r t h treatment s e s s i o n ( p o s t t e s t ) , and by m a i l 6 weeks a f t e r w a r d s ( f o l l o w - up) f o r the two treatment groups, MI, and RPI. The WL group was a s s e s s e d a t the end of the p r e l i m i n a r y s e s s i o n ( p r e t e s t ) and 3 weeks l a t e r by m a i l ( p o s t t e s t ) . Only those WL 51 p a r t i c i p a n t s who c a r r i e d on i n t o the second treatment groups (MI2 and RPI2) were assessed a t f o l l o w - u p which o c c u r r e d a p p r o x i m a t e l y 9 weeks f o l l o w i n g t h e i r p r e t e s t and immediately p r i o r t o the f i r s t treatment s e s s i o n . The assessment thus a l s o served as the p r e t e s t measure f o r the MI2 and RPI2 groups. P o s t t e s t and f o l l o w - u p measures f o r MI2 and RPI2 were taken immediately f o l l o w i n g the f o u r t h treatment s e s s i o n and 6 weeks l a t e r by m a i l . Dependent Measures The E a t i n g S e l f - E f f i c a c y S c a l e (ESES). T h i s s c a l e , developed and v a l i d a t e d by Glynn and Ruderman (1986), i s a measure of s e l f - e f f i c a c y i n e a t i n g s i t u a t i o n s based on Bandura's (1977) th e o r y of s e l f - e f f i c a c y (see Appendix B). P e r m i s s i o n was r e c e i v e d from Dr. Audrey Ruderman d u r i n g p e r s o n a l telephone communication i n June, 1989 t o use t h e measure f o r t h i s study. The s c a l e c o n s i s t s of 25 q u e s t i o n s c o n c e r n i n g p e r c e i v e d c o n t r o l of e a t i n g i n a v a r i e t y of e a t i n g s i t u a t i o n s , some of which are mood-related, others of which i n v o l v e food cues or s o c i a l s i t u a t i o n s . L e v e l of c o n f i d e n c e i n c o n t r o l l i n g o v e r e a t i n g i s measured by a 7-point L i k e r t s c a l e w i t h 1 i n d i c a t i n g no d i f f i c u l t y c o n t r o l l i n g e a t i n g and 7 i n d i c a t i n g most d i f f i c u l t y c o n t r o l l i n g e a t i n g . The items i n the s c a l e p r o v i d e a s c o r e r a n g i n g from 25 t o 175, w i t h lower s c o r e s i n d i c a t i n g h i g h e r l e v e l s of s e l f - e f f i c a c y i n e a t i n g s i t u a t i o n s . The s c o r e can be s u b d i v i d e d i n t o two s u b s c a l e s c o r e s f o r Negative A f f e c t (NA, s c o r e 52 range, 15 t o 105) and S o c i a l l y A c c e p t a b l e Circumstances (SAC, s c o r e range, 10 t o 70). The advantage of u s i n g t h i s instrument was t h a t i t measured s e l f - e f f i c a c y as an e x p e c t a t i o n of c o n t r o l i n s p e c i f i c e a t i n g s i t u a t i o n s , r a t h e r than as a g e n e r a l e x p e c t a t i o n of weight c o n t r o l . Obviously, a b i l i t y t o c o n t r o l o v e r e a t i n g i n a v a r i e t y of s i t u a t i o n s i s a t t h e b a s i s of an a b i l i t y t o m a i n t a i n weight l o s s . A d d i t i o n a l l y , the a u t h o r s of t h i s s c a l e have proposed i t s use w i t h weight l o s s program p a r t i c i p a n t s t o t e s t Bandura's (1977) h y p o t h e s i s t h a t i n c r e a s e d s e l f - e f f i c a c y promotes i n c r e a s e d c o p i n g b e h a v i o r , and t h i s was a focus f o r the study. I n t e r n a l c o n s i s t e n c y r e l i a b i l i t y f o r the s c a l e has been demonstrated (Glynn & Ruderman, 1986). C o e f f i c i e n t a l p h a (Cronbach, 1951) was .92 f o r the e n t i r e ESES s c a l e , .94 f o r N e g a t i v e A f f e c t , and .85 f o r S o c i a l l y A c c e p t a b l e C i rcumstances. T e s t - r e t e s t r e l i a b i l i t y over a 7-week p e r i o d was r = .70, p <.001. C o n s t r u c t v a l i d i t y was demonstrated by the authors w h i l e d e v e l o p i n g the s c a l e i n two s t u d i e s . In one, ESES s c o r e s were compared t o other v a r i a b l e s w i t h which they were expected t o be r e l a t e d (Glynn & Ruderman, 1986) and s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n s were found between ESES s c o r e s and R e s t r a i n t S c a l e (Stunkard, 1981) s c o r e s (r = .47, p_ <.001). In the second, c o n s t r u c t v a l i d i t y was a g a i n demonstrated i n a study of gender d i f f e r e n c e s i n which p o s i t i v e c o r r e l a t i o n s were shown wit h t o t a l R e s t r a i n t S c a l e 53 s c o r e s ( r [ f e m a l e s ] = .52, p_ <.0001), the concern w i t h d i e t i n g s u b s c a l e of the R e s t r a i n t S c a l e ( r [ f e m a l e s ] = .54, p_ <.001), and the weight f l u c t u a t i o n s u b s c a l e of the R e s t r a i n t S c a l e ( r [ f e m a l e s ] = .39, p_ <.0001). The norms were e s t a b l i s h e d u s i n g 484 female undergraduate psychology students, o n l y some of whom (n = 72) were overweight by s e l f - r e p o r t a c c o r d i n g t o M e t r o p o l i t a n L i f e Insurance Company norms (1959). Mean ESES s c o r e s d i d not d i f f e r among the overweight and normal weight s u b j e c t s , but t h e mean ESES s c o r e was s i g n i f i c a n t l y h i g h e r among s e l f - r e p o r t e d d i e t e r s (n = 217, M = 87.2, SD = 25.08, range 33- 148) than among n o n - d i e t e r s (n = 267, M = 74.1, SD = 27.3, range 25-155; t(391) = 4.96, p_< .0001). Ways of Coping C h e c k l i s t (WCCL). The Ways of Coping C h e c k l i s t i s based on the Lazarus and Folkman (1984, p. 141) d e f i n i t i o n o f copi n g as the c o g n i t i v e and b e h a v i o r a l e f f o r t s an i n d i v i d u a l makes t o manage s p e c i f i c e x t e r n a l and/or i n t e r n a l demands which are a p p r a i s e d as t a x i n g o r exceeding h i s o r her r e s o u r c e s . R e l i a b i l i t y and v a l i d i t y i n f o r m a t i o n c o n c e r n i n g the o r i g i n a l WCCL (Folkman & Lazarus, 1980) i s found i n Appendix B. The WCCL used i n t h i s study i s a r e v i s i o n by V i t a l i a n o , Russo, C a r r , Maiuro, and Becker (1985) of the 67-item v e r s i o n of the s c a l e by the develo p e r s , Lazarus and Folkman (1984). The V i t a l i a n o e t a l . r e v i s i o n shortened the s c a l e t o 42 items, reduced the number of s u b s c a l e s from 8 t o 5, and kept the 4-point s c o r i n g s c a l e . The f i v e s u b s c a l e s 54 V i t a l i a n o e t a l . i d e n t i f i e d are d e s i g n a t e d as Problem- foc u s e d , Seeks S o c i a l Support, Blamed S e l f , W i s h f u l T h i n k i n g , and Avoidance. The norms f o r the V i t a l i a n o e t a l . (1985) r e v i s e d WCCL were e s t a b l i s h e d w i t h samples of medical s t u d e n t s , A l z h e i m e r spouses, and p s y c h i a t r i c o u t p a t i e n t s . The r e s e a r c h e r s compared the i n t e r n a l c o n s i s t e n c y c o e f f i c i e n t s of the o r i g i n a l WCCL and t h e i r r e v i s i o n on t h e i r samples of 452 me d i c a l s t u d e n t s , 62 spouses of p a t i e n t s w i t h A l z h e i m e r ' s d i s e a s e , and 83 p s y c h i a t r i c o u t p a t i e n t s . They found c o e f f i c i e n t a l p h a s f o r each of t h e i r f i v e s u b s c a l e s t o be equ a l t o or b e t t e r than those found f o r the o r i g i n a l WCCL. In a d d i t i o n , they found t h a t t h e i r r e v i s e d s c a l e s had s u b s t a n t i a l l y l e s s o v e r l a p than the o r i g i n a l s c a l e s . In a s s e s s i n g c o n s t r u c t v a l i d i t y f o r t h e i r r e v i s i o n of the WCCL, V i t a l i a n o e t a l . (1985) looked f o r p a t t e r n s o f c o n s i s t e n c y i n how t h e i r s u b j e c t p o p u l a t i o n s a p p r a i s e d s i t u a t i o n s and the type of coping s t r a t e g y used, both i n the o r i g i n a l WCCL and i n t h e i r v e r s i o n . C r i t e r i o n - r e l a t e d v a l i d i t y was asses s e d u s i n g the medical student sample. S c o r i n g f o r the r e v i s e d WCCL i s done i n terms of frequenc y of use of s p e c i f i c coping s t r a t e g i e s . For each of the 42 items, the i n d i v i d u a l i n d i c a t e s on a 4-point L i k e r t - t ype s c a l e whether the s t r a t e g y i s not used (0), used somewhat (1), used q u i t e a b i t (2), or used a g r e a t d e a l (3). These item s c o r e s can be summed t o produce raw s c o r e s f o r each of the 5 s u b s c a l e s . The range of raw s c o r e s 55 p o s s i b l e f o r each s u b s c a l e are as f o l l o w s : Problem-focused, 0-45, Seeks S o c i a l Support, 0-18, Blamed S e l f , 0-9, W i s h f u l T h i n k i n g , 0-24, and Avoidance, 0-30. V i t a l i a n o , Maiuro, Russo, and Becker (1987) compared the use of raw and r e l a t i v e coping s c o r e s and found t h a t the r e l a t i v e s c o r e p r o v i d e d more i n f o r m a t i o n . I n s t e a d of measuring the amounts of d i f f e r e n t types of c o p i n g responses, they f e l t i t made more sense t o look a t what p r o p o r t i o n of t o t a l coping responses each type r e p r e s e n t e d . While two i n d i v i d u a l s might have the same raw s c o r e f o r P l a n f u l p r o b l e m - s o l v i n g , f o r example, t h a t s c o r e might r e p r e s e n t 10% of one person's o v e r a l l c o p i n g and 30% of ano t h e r ' s . When vaeasuring changes i n a p a r t i c u l a r type o f c o p i n g response, such as problem-focused coping, a c r o s s time, i n c r e a s e d o r decreased r e l a t i v e s c o r e s would be a b e t t e r i n d i c a t o r of change than a simple i n c r e a s e i n the amount of one or more types of coping. In the p r e s e n t study, the r e l a t i v e percentage of s u b s c a l e s t o t o t a l c o p i n g e f f o r t s was of i n t e r e s t , p a r t i c u l a r l y the s u b s c a l e o f Problem-focused coping. R e l a t i v e c o p i n g s c o r e s were computed by u s i n g V i t a l i a n o e t a l . ' s (1987) formula of (a) f i n d i n g the average item s c o r e f o r a g i v e n s u b s c a l e by d i v i d i n g the raw s c o r e f o r t h a t s c a l e by the number of items on i t , (b) c a l c u l a t i n g the sum o f the average item s c o r e s on a l l f i v e s u b s c a l e s , and (c) d i v i d i n g the average item score f o r a g i v e n s u b s c a l e by the sum of the average item s c o r e s on a l l f i v e s u b s c a l e s . 56 A n c i l l a r y Measures A 3-item expectancy s c a l e was used t o a s s e s s c l i e n t c r e d i b i l i t y i n treatment and expectancy f o r improvement (see Appendix C ) . T h i s was done so t h a t d i f f e r e n c e s i n outcome between the two i n t e r v e n t i o n groups c o u l d be p l a u s i b l y a t t r i b u t e d t o s p e c i f i c i n t e r v e n t i o n i n g r e d i e n t s and not t o d i f f e r e n c e s i n e x p e c t a n c i e s between the groups. As p a r t of the demographic q u e s t i o n n a i r e (see Appendix A), p a r t i c i p a n t s were asked to respond t o t h r e e q u e s t i o n s about c a u s a l a t t r i b u t i o n . These were taken from R u s s e l l ' s (1982) Causal Dimension S c a l e and r e l a t e t o l o c u s of c a u s a l i t y , s t a b i l i t y , and c o n t r o l l a b i l i t y . T h e r a p i s t Q u a l i f i c a t i o n s The i n t e r v e n t i o n s e s s i o n s were conducted by the experimenter, an M.A. student i n C o u n s e l l i n g Psychology. She has a background i n Psychology and has worked i n the f i e l d of weight management f o r seven y e a r s . To a s s e s s experimenter b i a s i n the p r e s e n t a t i o n of the MI and RPI i n t e r v e n t i o n s , a l l p a r t i c i p a n t s were asked t o complete a s h o r t e v a l u a t i v e q u e s t i o n n a i r e a f t e r each s e s s i o n (see Appendix C). At the p r e l i m i n a r y s e s s i o n s , the experimenter was a s s i s t e d by C a r o l y n Tees, B.A., Psychology, who remained i n the treatment room t o answer q u e s t i o n s and c o l l e c t completed q u e s t i o n n a i r e s w h i l e the experimenter s u p e r v i s e d p a r t i c i p a n t s ' weigh-ins. 57 Treatments The program f o r both treatment groups was as s i m i l a r as p o s s i b l e w i t h the same i n f o r m a t i o n g i v e n and t o p i c s i n t r o d u c e d i n a 1-hour group d i s c u s s i o n format. The o n l y d i f f e r e n c e was t h a t i n the RPI c o n d i t i o n , a p p r o x i m a t e l y 5-10 minutes of each s e s s i o n was r e s e r v e d f o r i n f o r m a t i o n about and d i s c u s s i o n of r e l a p s e p r e v e n t i o n . S u b j e c t s i n both treatment c o n d i t i o n s met i n groups f o r a s e r i e s of 4 1-hour s e s s i o n s . The main treatment components i n both the MI and the RPI groups were (a) s h o r t i n f o r m a t i o n segments on t o p i c s such as e f f e c t i v e maintenance s t r a t e g i e s , body image, emotional e a t i n g , e t c . , (b) group p a r t i c i p a t i o n i n d i s c u s s i o n s which the experimenter kept f o c u s e d on the t o p i c under d i s c u s s i o n or o t h e r maintenance- r e l a t e d i s s u e s as these emerged, and (c) suggested homework assignments g i v e n a t the end of each s e s s i o n . The format of t h e s e s s i o n s was i n f o r m a l ; s e m i - s t r u c t u r e d d i s c u s s i o n s took p l a c e i n an atmosphere of support where a l l o p i n i o n s expressed were r e s p e c t e d as v a l i d . C o n f i d e n t i a l i t y norms were d i s c u s s e d and agreed upon i n each group. P a r t i c i p a n t s weighed themselves i n a p r i v a t e a l c o v e . i n the experimenter's presence and recorded t h e i r weights b e f o r e S e s s i o n 1 and a t the end of S e s s i o n 4. The s c a l e was a v a i l a b l e a t o t h e r s e s s i o n s but no r e c o r d of weights was made. During S e s s i o n 1, each p a r t i c i p a n t was g i v e n a P a r t i c i p a n t Workbook which c o n s i s t e d of s e v e r a l sheets of 58 l o o s e l e a f paper f o r notes and 4 O v e r e a t i n g Logs i n a Duo- Tang b i n d e r . The Workbooks f o r the RPI groups a l s o c o n t a i n e d a r e p r e s e n t a t i o n of the Relapse P r e v e n t i o n Model (see F i g u r e 1 ) . A complete treatment manual i s a v a i l a b l e upon r e q u e s t from the experimenter. Data A n a l y s i s D e s c r i p t i v e s t a t i s t i c s were c a l c u l a t e d . P r e l i m i n a r y a n a l y s e s were conducted u s i n g a one-way m u l t i v a r i a t e a n a l y s i s o f v a r i a n c e (MANOVA) t o t e s t f o r p r e t r e a t m e n t d i f f e r e n c e s among the treatment c o n d i t i o n s and w a i t i n g l i s t groups (MI, RPI, WL; MI2, RPI2; MI-C, RPI-C) on the two dependent v a r i a b l e s ( s e l f - e f f i c a c y and r e l a t i v e use of problem-focused coping) and other d e s c r i p t i v e v a r i a b l e s . A two-way (Group x Time) repeated measures MANOVA,' w i t h two pre - p l a n n e d nonorthogonal c o n t r a s t s ( p r e t e s t t o p o s t t e s t ) ( p o s t t e s t t o follow-up) u s i n g Dunn's t e s t f o r s i g n i f i c a n c e a t .025, was performed f o r both dependent measures ( s e l f - e f f i c a c y and coping) t o t e s t the hypotheses o f group d i f f e r e n c e s (Hypotheses 1 t o 4). Three s e p a r a t e a n a l y s e s were performed. For the f i r s t a n a l y s i s , t he groups were RPI, MI and WL, and f o r the second, the groups were MI2 and RPI2. The combined groups, MI-C and RPI-C, were used f o r the f i n a l a n a l y s i s . A one-way ANOVA was c a l c u l a t e d f o r pre-measures of expectancy f o r change. A Pearson product-moment c o r r e l a t i o n m a t r i x was c a l c u l a t e d f o r p r e t e s t , p o s t t e s t , and f o l l o w - u p d a t a . H y p o t h e s i s 5 was t e s t e d w i t h a c o r r e l a t i o n c o e f f i c i e n t f o r the p o s t t e s t problem-focused c o p i n g and f o l l o w - u p s e l f - e f f i c a c y v a r i a b l e s . C l i n i c a l s i g n i f i c a n c e was a s s e s s e d u s i n g the method f o r e v a l u a t i n g change suggested by Jacobson and Revenstorf (1988) f o r t h i s purpose. 60 RESULTS Group C o m p a r a b i l i t y The means and standard d e v i a t i o n s of d e s c r i p t i v e v a r i a b l e s f o r a l l groups of p a r t i c i p a n t s are shown i n T a b l e 1. A p r e l i m i n a r y a n a l y s i s was done u s i n g a one-way m u l t i v a r i a t e a n a l y s i s of v a r i a n c e (MANOVA) t o t e s t f o r p r e t r e a t m e n t d i f f e r e n c e s among the two treatment c o n d i t i o n s , MI (n = 15), RPI (n = 13), and the w a i t i n g l i s t , WL (n = 29), on age, weight, t o t a l weight l o s s , l b s above t a r g e t weight, how long ago weight was l o s t , and how l o n g weight l o s s was m a i n t a i n e d w i t h i n 5 l b s . No s i g n i f i c a n t m u l t i v a r i a t e Group e f f e c t was found, F< 1. The same a n a l y s i s was done s e p a r a t e l y f o r d i f f e r e n c e s between the two Maintenance I n t e r v e n t i o n groups, MI (n = 15) and MI2 (n = 10) , and f o r d i f f e r e n c e s between the two Relapse P r e v e n t i o n I n t e r v e n t i o n groups RPI (n = 13) and RPI2 (n = 10). Again, no s i g n i f i c a n t m u l t i v a r i a t e Group e f f e c t was found, F< 1; and F(6,16) = 1.51, p = .24, r e s p e c t i v e l y . F i n a l l y , when the d a t a f o r the two s e t s of treatment groups were c o l l a p s e d , the same a n a l y s i s was done f o r pretreatment d i f f e r e n c e s between the MI-C (n = 25) and RPI-C (n = 23) groups. No s i g n i f i c a n t m u l t i v a r i a t e Group e f f e c t was found, F(6,41) = 1.00, p_ = .44. The 5 m a r i t a l s t a t u s c a t e g o r i e s i n the demographic q u e s t i o n n a i r e were reduced to 2 f o r a n a l y s i s : M a r r i e d , and S i n g l e , c o m p r i s i n g s i n g l e , widowed, separated, and d i v o r c e d . S i m i l a r l y , the 5 employment s t a t u s c a t e g o r i e s were reduced Table 1 Means and Standard Deviations for Descriptive Data I n i t i a l Groups MI RPI WL Maintenance Relapse Prevention Waiting Intervention Intervention L i s t (a = 15) (S = 13) (a = 29) a SD H IS M SD age 44.7 7.7 44.7 9.0 45. 5 12.1 weight 155.6 IS. 5 146.2 14.1 149. 5 19.5 target weight 138.5 10.a 135.8 14.3 134. 3 13.1 t o t a l l o s s 39.5 22.7 29.7 13.5 32. 0 20.8 amount of regain 17.1 14.4 10.3 6.3 15. 2 10.7 how long ago was wt. l o s t 72.1 86.5 41.3 37.0 42 . 9 48.5 how long was wt. lo s s maintained 24.1 24.9 12 . 0 11.3 17. 7 16.2 Combined Treatment Groups and A l l P a r t i c i p a n t s MI-C RPI-C A l l Maintenance Relapse Prevention P a r t i c i p a n t s Intervention Intervention (a = *s> (a = 23) (a = 59) U SB M SD M SD age 45.4 9.5 43.7 9.7 45.0 10.1 weight 152.5 20.9 149.1 15.4 149.6 18.3 target weight 134.8 11.3 137.2 13.8 135.5 12.6 t o t a l l o s s 37.6 19.2 33.7 22.4 33.2 19.7 amount of regain 17.7 15.5 11.9 5.9 1 4 . l 11.3 how long ago was W t . l o s t 69.4 78.7 38.0 34.5 49.6 58.4 how long was wt. lo s s maintained 21.2 20.1 15.1 14.3 18.0 17.9 Note. A l l weights are i n lbs and a l l times stated are i n months. 62 t o 2: Employed, comprising f u l l - t i m e and p a r t - t i m e employed, and Unemployed, comprising students, f u l l - t i m e housewives, and r e t i r e d p eople. The v a r i a b l e s of m a r i t a l s t a t u s and employment s t a t u s were then examined by s e p a r a t e c h i - s q u a r e t e s t s of independence f o r MI, RPI, and WL groups, then f o r MI-C and RPI-C groups. No s i g n i f i c a n t group d i f f e r e n c e s were found ( m a r i t a l s t a t u s , ^ (2, n = 57) = 3.73, p = .16, and (1, n = 48) = 2.02, p = .16, r e s p e c t i v e l y ; employment s t a t u s , ^ 2 (2, n = 57) = .04, p = .98, and X 2 C1/ n = 48) = .02, p = .89, r e s p e c t i v e l y ) . A t t r i t i o n One p a r t i c i p a n t dropped out of the MI group b e f o r e S e s s i o n 2 because of job r e s p o n s i b i l i t i e s . One p a r t i c i p a n t i n t h e RPI group f a i l e d t o r e t u r n the f o l l o w - u p q u e s t i o n n a i r e s even a f t e r being r e c o n t a c t e d . T h i s meant t h a t 14 out of the 15 MI p a r t i c i p a n t s completed the program, and 12 out of the 13 RPI p a r t i c i p a n t s d i d so. The drop-outs from the WL group are d i s c u s s e d under the heading of S u b j e c t s i n the Methods s e c t i o n and summarized here. At p o s t t e s t , 5 p a r t i c i p a n t s f a i l e d t o r e t u r n t h e i r q u e s t i o n n a i r e s . No follow-up had o r i g i n a l l y been planned f o r t h i s group but because the f i r s t treatment s e s s i o n f o r t h e s e p a r t i c i p a n t s c o i n c i d e d with the time-span f o r f o l l o w - up assessment, these data were c o l l e c t e d f o r the 17 WL p a r t i c i p a n t s ( o r i g i n a l n = 29) who c a r r i e d on i n t o treatment groups. 63 In the second treatment groups, of the 10 RPI2 p a r t i c i p a n t s , one d i d not r e t u r n her f o l l o w - u p q u e s t i o n n a i r e s even a f t e r being r e c o n t a c t e d and sent a replacement s e t . Of the 10 MI2 p a r t i c i p a n t s , two women f a i l e d t o a t t e n d 3 out of the 4 Saturday s e s s i o n s . One woman was unexpectedly c a l l e d away on b u s i n e s s f o r two weekends; the second missed one s e s s i o n due t o i l l n e s s and the l a s t s e s s i o n because of weather c o n d i t i o n s . Thus, 9 out of 10 RPI2 p a r t i c i p a n t s completed the study and 8 out of 10 MI2 p a r t i c i p a n t s d i d so. A f t e r t he p r e l i m i n a r y a n a l yses d e s c r i b e d above t o r u l e out s i g n i f i c a n t p r e t e s t d i f f e r e n c e s between the MI and the MI2 groups and between the RPI and RPI2 groups, t h e da t a were c o l l a p s e d f o r f u r t h e r a n a l y s i s . The combined treatment groups were renamed MI-C and RPI-C. MI-C had a t o t a l o f 25 p a r t i c i p a n t s , 22 of whom completed the study. RPI-C had a t o t a l o f 2 3 p a r t i c i p a n t s , 21 of whom completed the study. P r e t e s t Dependent Measures Examination o f the p r e t e s t means f o r the dependent measures of s e l f - e f f i c a c y and problem-focused c o p i n g suggests l a r g e d i f f e r e n c e s between a l l 3 groups of s u b j e c t s , MI, RPI, and WL (see Table 2 and Tabl e 3). Such d i f f e r e n c e s I c o u l d t h r e a t e n the i n t e r n a l v a l i d i t y of the study i f t h e r e was (a) a c e i l i n g or f l o o r e f f e c t , or (b) reason t o t h i n k t h a t t h e s e i n i t i a l d i f f e r e n c e s produced a d i f f e r e n t i a l i n t e r a c t i o n w i t h treatment. 64 T a b l e 2 Means and Standard D e v i a t i o n s f o r S e l f - E f f i c a c y f o r A l l Groups Group P r e t e s t P o s t t e s t Follow-up M SD M SD M SD MI (n = 14) . 100.4 29.9 101.1 25.8 94 . 9 22 . RPI (n = 12) 119.3 17.9 115.7 13.9 11.5.8 13 . WL (n = 17) 115. 2 30.4 112.8 29.1 115. 7 20. MI 2 (n = 8) 104.5 15.1 97.9 21.3 89 . 3 30. RPI 2 (n = 9) 129.2 25.8 105.4 34 . 1 103.0 25. MI-C (n = 22) 100.9 25.2 100.0 23.8 92 . 9 25. RPI-C (n = 21) 123 . 6 21.6 111. 3 24 . 5 110 . 3 20. Note. Group numbers are d i f f e r e n t from those of o r i g i n a l groups because o n l y the data of p a r t i c i p a n t s who were a s s e s s e d a t a l l 3 times of t e s t i n g are i n c l u d e d here. Lower s c o r e s f o r s e l f - e f f i c a c y = h i g h e r l e v e l s of s e l f - e f f i c a c y . T a b l e 3 Means and Standard D e v i a t i o n s f o r Percentage of Problem- f o c u s e d Coping f o r a l l Groups Group P r e t e s t P o s t t e s t Follow-up M SD M SD M SD MI .27 .12 .27 .10 .29 .11 (n = 14) RPI .19 .08 .23 .14 :27 .17 (n = 12) WL .19 .10 .20 .12 .21 .11 (n = 17) MI2 .25 .15 .30 .15 .32 .13 (n = 8) RPI2 .16 .09 .22 .18 .22 .11 (n = 9) MI-C .27 .13 .28. .12 .30 .11 (n = 2 2 ) RPI-C .18 .08 .22 .16 .25 .15 (n = 21) Note. Group numbers are d i f f e r e n t from those of o r i g i n a l groups because o n l y the data of p a r t i c i p a n t s who were a s s e s s e d a t a l l 3 times of t e s t i n g are i n c l u d e d here. 66 A p r e l i m i n a r y a n a l y s i s u s i n g a one-way MANOVA t o t e s t f o r p r e t r e a t m e n t d i f f e r e n c e s among the t h r e e groups (MI, RPI, and WL) on the two dependent measures r e v e a l e d a s i g n i f i c a n t Group e f f e c t , F(4,104) = 3.01, p_< .02. U n i v a r i a t e a n a l y s i s of v a r i a n c e (ANOVA) f o r each dependent measure r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e f o r s e l f - e f f i c a c y , F(2,53) = 2.70, p_ = .08, and a s i g n i f i c a n t d i f f e r e n c e f o r problem-focused coping, F(2,53) = 4.95, p_< .01. A MANOVA done t o t e s t f o r pretreatment d i f f e r e n c e between the second treatment groups (MI2 and RPI2) r e v e a l e d no s i g n i f i c a n t Group e f f e c t f o r the two dependent measures, F(2,17) = 2.96, p_ = .08. F i n a l l y , a MANOVA done t o t e s t f o r p r e t r e a t m e n t d i f f e r e n c e s between the combined treatment groups MI-C and RPI-C r e v e a l e d a s i g n i f i c a n t m u l t i v a r i a t e Group e f f e c t , F(2,45) = 7.04, p_< .002. Separate ANOVAs f o r the two dependent measures showed s i g n i f i c a n t Group e f f e c t s f o r s e l f - e f f i c a c y , F ( l , 4 6 ) = 11.40, p_< .002, and f o r problem-focused coping, F(l,46) = 8.96, p< .004. D e s p i t e i n i t i a l l y lower ESES s c o r e s ( i n d i c a t i n g h i g h e r l e v e l s of s e l f - e f f i c a c y ) and h i g h e r percentages of problem- f o c u s e d c o p i n g i n the MI and MI2 groups, a l l group means showed s i m i l a r and v a r i a b l e p a t t e r n s of change a c r o s s time as i s shown i n Ta b l e 2 and Tabl e 3. Again, d e s p i t e i n i t i a l l y b e t t e r s c o r e s on both dependent measures i n the MI and MI2 groups, no p a r t i c i p a n t i n these groups s c o r e d below 37 on the ESES (lowest p o s s i b l e s c o r e i s 25), or above 57% (of a p o s s i b l e 100%) f o r percentage of problem-focused c o p i n g . 67 E x p e c t a t i o n s of Treatment E f f e c t i v e n e s s and S e s s i o n E v a l u a t i o n s A n a l y s i s of v a r i a n c e f o r the i n i t i a l treatment groups, MI and RPI, on summed responses t o 3 q u e s t i o n s r e l a t i n g t o e x p e c t a t i o n s of treatment e f f e c t i v e n e s s (see Appendix C) a t p r e t e s t r e v e a l e d no s i g n i f i c a n t group d i f f e r e n c e , F ( l , 2 4 ) = 1.37, p_ = .25. The same a n a l y s i s f o r the second treatment groups, MI2 and RPI2, a t p r e t e s t r e v e a l e d no s i g n i f i c a n t group d i f f e r e n c e , F(l,14) = 1.95, p = .18. F i n a l l y , when the groups were combined as MI-C and RPI-C, the ANOVA on expectancy a t p r e t e s t showed no s i g n i f i c a n t group d i f f e r e n c e , F ( l , 4 0 ) = 2.65, p = .11. T h e r e f o r e , the treatment groups d i d not d i f f e r i n t h e i r i n i t i a l e x p e c t a t i o n s of treatment e f f e c t i v e n e s s . A n a l y s i s of v a r i a n c e f o r the i n i t i a l treatment groups, MI and RPI, on summed responses t o 4 q u e s t i o n s r e l a t i n g t o e v a l u a t i o n of treatment s e s s i o n s (see Appendix C) which were a d m i n i s t e r e d f o l l o w i n g the second and t h i r d s e s s i o n s r e v e a l e d no s i g n i f i c a n t group d i f f e r e n c e f o r the second s e s s i o n , F ( l , 1 9 ) = 2.73, p = .15, or f o r the t h i r d s e s s i o n , F< 1. The same a n a l y s i s f o r the second treatment groups, MI2 and RPI2, r e v e a l e d no s i g n i f i c a n t group d i f f e r e n c e f o r the second s e s s i o n , F< 1, or the t h i r d s e s s i o n , F ( l , 1 3 ) = 1.24, p = .29. T h e r e f o r e , the treatment groups d i d not d i f f e r i n t h e i r e v a l u a t i o n s of treatment s e s s i o n s . 68 Hypo t h e s i z e d Treatment E f f e c t s on Dependent Measures To t e s t hypotheses 1 t o 4, a two-way (Group x Time) r e p e a t e d measures MANOVA, wit h two preplanned nonorthogonal c o n t r a s t s ( p r e t e s t t o p o s t t e s t ) ( p o s t t e s t t o follow-up) u s i n g Dunn's t e s t f o r s i g n i f i c a n c e a t .025 was performed f o r the dependent measures of s e l f - e f f i c a c y and percentage of problem-focused c o p i n g f o r the o r i g i n a l treatment groups (MI and RPI) and the WL group. No s i g n i f i c a n t m u l t i v a r i a t e Group e f f e c t was found, F(4,78) = 1.95, p = .11. No s i g n i f i c a n t m u l t i v a r i a t e p r e t e s t t o p o s t t e s t Time e f f e c t , o r p o s t t e s t t o f o l l o w - u p Time e f f e c t was found, F< 1, and F(2,39) = 1.17, p = .32, r e s p e c t i v e l y . No s i g n i f i c a n t Group x Time i n t e r a c t i o n e f f e c t was found ( p r e t e s t t o p o s t t e s t , p o s t t e s t t o follow-up, both Fs< 1, r e s p e c t i v e l y ) . T h e r e f o r e the treatment groups d i d not show s i g n i f i c a n t d i f f e r e n t i a l change over time from the w a i t i n g l i s t group. The same a n a l y s i s was done f o r the second treatment groups, MI2 and RPI2, t h a t had been formed from the WL. No s i g n i f i c a n t Group e f f e c t was found, F(2,14) = 1.32, p = .30. No s i g n i f i c a n t Time e f f e c t was found f o r p r e t e s t t o p o s t t e s t , F(2,14) = 2.60, p = .11, nor was t h e r e a s i g n i f i c a n t Time e f f e c t f o r p o s t t e s t t o f o l l o w - u p , F< 1. No s i g n i f i c a n t Group x Time i n t e r a c t i o n e f f e c t was found a t p r e t e s t t o p o s t t e s t , or p o s t t e s t t o fol l o w - u p , both Fs< 1, r e s p e c t i v e l y . The same a n a l y s i s was done f o r the combined treatment groups, MI-C and RPI-C. The m u l t i v a r i a t e Group e f f e c t 69 approached s i g n i f i c a n c e , F(2,40) = 4.00, p_< .026. Because of t h i s , the u n i v a r i a t e Group e f f e c t was examined f o r s e l f - e f f i c a c y and found t o be s i g n i f i c a n t , F ( l , 4 1 ) = 7.22, p_< .01. Time e f f e c t s were not s i g n i f i c a n t a t p r e t e s t t o p o s t t e s t , F(2,40) = 2.62, p_ = .09, and a t p o s t t e s t t o f o l l o w - u p , F(2,40) = 2.64, p = .08. No s i g n i f i c a n t Group x Time i n t e r a c t i o n e f f e c t was found ( p r e t e s t t o p o s t t e s t , F(2,40) = 1.17, p_ = .32; p o s t t e s t t o f o l l o w - u p , F(2,40) = 1.43, p_ = .25). Although the m u l t i v a r i a t e Group e f f e c t o n l y approached s i g n i f i c a n c e , an examination of the means suggests t h a t o v e r a l l the MI-C group was h i g h e r than t h e RPI-C group on s e l f - e f f i c a c y . M u l t i v a r i a t e and u n i v a r i a t e a n a l y s e s r e s u l t s f o r each of t h e groups are found i n Appendix D. To t e s t h y p o t h e s i s 5, a Pearson product-moment c o r r e l a t i o n m a t r i x f o r p o s t t e s t and f o l l o w - u p was c a l c u l a t e d f o r t h e combined groups, MI-C and RPI-C (n = 48, t o t a l ) . The percentage of problem-focused coping a t p o s t t e s t had a s i g n i f i c a n t n e g a t i v e c o r r e l a t i o n with s e l f - e f f i c a c y (lower s c o r e s = h i g h e r s e l f - e f f i c a c y ) a t f o l l o w - u p f o r t h e s e groups (r = -.34, p_< .013) (see Table 4). T h e r e f o r e , g r e a t e r r e l a t i v e use of problem-focused coping a t p o s t t e s t p r e d i c t e d h i g h e r l e v e l s of s e l f - e f f i c a c y a t f o l l o w - u p f o r both treatment groups. Table 4 C o r r e l a t i o n Matrix f o r Dependent Measures and Subscales at P r e t e s t , P o s t t e s t , and Follow-up f o r Combined Treatment Groups, MI-C and RPI-C SELFEFF1 S E L F E F F 2 S E L F E F F 3 NEGAFF1 NEGAFF2 NEGAFF3 S0CSIT1 S E L F E F F 1 S E L F E F F 2 . 5 4 2 4 " S E L F E F F 3 . 636 1 * * . 87 1 2 " NEGAFF1 .9 1 4 4 " .5296* • .6502* * NEGAFF 2 .5115"* .9089* * .8394* * NEGAFF 3 .5785* * .7978* * . 9 1 2 7 " SOCSIT 1 . 54 1 7 " .2303 .2014 SOCSI72 . 2421 .5164* * . 3529 S0CSIT3 .3152 .4203* . 4 8 8 9 " PERCENT 1 - .5248* * - . 4 4 2 7 ' - . 5 2 6 9 * ' PERCENT2 - . 2 1 8 6 - . 3489* - . 3 4 0 2 PERCENT 3 - . 2 3 2 0 - . 2849 - . 3 7 8 4 * PCB1 .2183 . 1 140 .0972 PCB2 .0764 .07 14 - . 1 0 3 0 PCB3 .2709 . 1893 . 1 705 PCW1 . 2033 .2434 . 3451 PCW2 .0985 . 2440 . 2979 PCW3 - . 0 4 5 3 .0725 . 2026 PC A 1 .2101 .2944 . 3382 PCA2 .0928 .0873 .1123 PCA3 . 1 757 .2087 . 326 7 PCS 1 - . 0 6 0 6 - . 1579 • . 1734 PCS2 .0655 .1189 . 2068 PCS3 - 1272 - .0893 - . 1562 PERCENT 3 PCB1 PCB2 PCB1 . 3060 PCB2 - 0642 4893* * PCB3 - . 3170 .4252* . 5 0 9 8 ' ' PCW 1 - . 4963* • . 1294 - .0478 PCW2 - . 6 0 0 2 " . 1560 - .0325 PCW3 - .707 1 " . 1215 - . 1430 PCA1 - . 1056 - .2907 .0008 PCA2 - . 2834 - .2315 - .0283 PCA3 - . 4 8 9 9 * ' - .057 1 - . 1 9 3 7 PCS 1 . 2658 - . 5 0 0 2 * * - . 3 1 1 2 PCS2 .0195 - . 1965 - . 4 8 1 6 " * PCS3 14 30 - . 2 5 19 - . 3287 • - S IGNIF . LE .01 * * - SIGNIF LE .001 .6240* * . 7 0 4 1 " . 9 1 6 5 * ' . 1550 - . 0 3 6 7 - .0570 .0195 . 1 123 .0116 . 6 2 4 1 " .0816 .0895 .0897 . 6 1 2 4 " . 4 9 8 3 " - . 4 1 1 4 * - . 4 6 5 0 " - . 2 4 5 8 . 2747 - . 3 9 9 0 * - . 3 9 5 1 * .0319 . 3305 • . 3506 - . 4 2 8 4 * . 1252 . 1853 .1101 .0318 . 1480 .0012 - .0234 - . 206 1 . 1867 . 1 785 . 1 150 .0299 .2954 .2417 .2947 .3901 * - . 0 0 5 7 .2315 . 3410 .4086* - . 2339 . 1270 .1714 .3187 - . 3 8 3 4 " .2192 .3151 . 3440 .0575 . 1950 . 2684 . 3401 - . 1 7 3 3 . 3284 . 3605* . 4 9 7 2 " - . 2 6 12 .0920 - . 2541 - .2130 .0433 .0266 .0661 .1214 . 1039 .1547 - . 1 2 2 9 - . 1368 .0123 PCB3 PCW 1 PCW2 PCW3 . 1306 . 1342 . 7 2 9 6 " .1179 . 6 2 6 7 " . 8 1 1 7 " .3972* . 1729 - .0519 - . 1 6 0 0 . 1552 . 2228 . 3258 . 2543 . 3335 .4254* .6464* * .5100* * .5470* * - . 4344* - . 2627 - . 1098 .3638" - . 1 7 0 8 - 2076 - . 0 6 9 3 .5830"" - .4643* * - . 3054 - .2824 S0CSIT2 S0CSIT3 PERCENT 1 PERCENT2 .8352* * .2100 - .29 lb .0120 .0142 . 4007* .0451 - .0076 . 5 4 4 8 " .5840* * .0455 . 1689 - . 4 0 8 6 * - . 1965 .2182 . 1890 - . 2 0 8 6 - . 3 3 9 2 .2187 .3517 - . 4 3 5 4 ' .0769 .0252 .0084 - . 6 3 3 5 " - . 4 4 0 4 ' . 1 189 - . 1459 - . 4 1 8 4 * - . 6 5 8 0 * ' .1847 - . 1866 - . 3 3 2 9 - . 5 2 5 6 * * .0544 .0900 - . 4 2 3 7 * .0340 . 3431 - . 4521 * - . 1 4 2 4 - . 4 7 8 8 * * . 2938 .2651 - . 1 9 8 4 - . 5 9 6 2 " . 1455 .0322 . 3288 . 1 100 . 1476 . 2450 .14 16 - . 0 8 5 4 .0414 - . 0 8 8 7 . 3400 .06 19 PC A 1 PCA2 PCA3 PCS 1 . 2928 .0046 . 6 3 3 7 " 4054* - .0657 - . 0 5 9 0 . 2048 .3198 - . 0 4 0 2 . 4407* . 2298 - . 1121 .1097 . 5 5 0 7 " -vl ( 1 - TA ILED, " . " PRINTED IF A COEFFICIENT CANNOT BE COMPUTED) o 71 Key f o r T a b l e s 4 and 5 Numerals 1 = p r e t e s t , 2 = p o s t t e s t , 3 = f o l l o w - u p . SELFEFF E a t i n g S e l f - e f f i c a c y S c a l e (ESES). NEGAFF Negative A f f e c t (NA) s u b s c a l e of ESES. SCOSIT S o c i a l l y A c c e p t a b l e Circumstances (SAC) s u b s c a l e of ESES. PERCENT Percentage of Problem-focused c o p i n g . PCB Percentage of Blames S e l f c o p i n g . PCW Percentage of W i s h f u l T h i n k i n g c o p i n g . PCA Percentage of Avoidance co p i n g . PCS Percentage of Seeks S o c i a l Support c o p i n g . V4 Age. V6 Weight. V7 T a r g e t or g o a l weight. V8 T o t a l weight l o s t . V9 How long ago weight was l o s t . V10 How long weight l o s s was maintained w i t h i n 5 l b s EX1 E x e r c i s e s t a t u s : sedentary, mod. a c t i v e , a c t i v e . EX2 E x e r c i s e change: more a c t i v e , no change, l e s s a c t i v e . MN2 Weekly weigh-ins. MN5 More r e s t r i c t e d e a t i n g program a f t e r g a i n . DIFF1 Weight r e g a i n e d i n l b s . GAIN Weight r e g a i n e d as percentage of t o t a l l o s t . COPING Raw s c o r e of t o t a l c oping responses. M1C2 A t t r i b u t i o n s c a l e : c a u s a l i t y . M1C3 A t t r i b u t i o n s c a l e : c o n t r o l l a b i l i t y . M1C4 A t t r i b u t i o n s c a l e : permanence. 72 Dependent Measures: C o r r e l a t i o n s The c o r r e l a t i o n found between problem-focused c o p i n g and s e l f - e f f i c a c y r a i s e d the q u e s t i o n of whether o t h e r r e l a t i o n s h i p s might be found between the two dependent measures of c o p i n g and s e l f - e f f i c a c y . Any such r e l a t i o n s h i p s must be i n t e r p r e t e d w i t h caution- as t h e y were not h y p o t h e s i z e d and s i n c e a number of the c o r r e l a t e s a r e not independent, an a d j u s t e d l e v e l of alpha i s t h e r e f o r e r e q u i r e d . The c o p i n g s c a l e has 4 other s u b s c a l e s b e s i d e s problem- f o c u s e d c o p i n g (avoidance, w i s h f u l t h i n k i n g , s e l f - b l a m e , and s e e k i n g s o c i a l support) and the s e l f - e f f i c a c y s c a l e c o n t a i n s 2 s u b s c a l e s , Negative A f f e c t and S o c i a l l y A c c e p t a b l e Circumstances. I t was c o n s i d e r e d important t o look a t t h e s e s u b s c a l e s t o see i f t h e r e were a s s o c i a t i o n s between them. A Pearson product-moment c o r r e l a t i o n m a t r i x was c a l c u l a t e d f o r t h e combined treatment groups, MI-C and RPI-C, t o look a t t h e s e and o t h e r v a r i a b l e s of i n t e r e s t . The m a t r i x i s found i n T a b l e 4. S e l f - E f f i c a c y , coping, and coping s u b s c a l e s . The dependent measure of s e l f - e f f i c a c y (lower s c o r e s = h i g h e r s e l f - e f f i c a c y ) showed a n e g a t i v e c o r r e l a t i o n w i t h percentage of problem-focused (PF) coping a t p r e t e s t (r = -.52), p o s t t e s t (r = -.35), and follow-up (r = -.38) and a p o s i t i v e c o r r e l a t i o n . S e l f - e f f i c a c y was not a s s o c i a t e d w i t h any o t h e r c o p i n g s u b s c a l e except with avoidance a t f o l l o w - u p (r = .33) . 73 The Negative A f f e c t s u b s c a l e of the s e l f - e f f i c a c y s c o r e showed s i m i l a r n e g a t i v e c o r r e l a t i o n s with percentage o f PF c o p i n g a t a l l t h r e e times of t e s t i n g (see T a b l e 4 ) . The Nega t i v e A f f e c t s u b s c a l e had weak t o moderate p o s i t i v e c o r r e l a t i o n s w i t h r e l a t i v e use of avoidance and w i s h f u l t h i n k i n g c o p i n g a t p o s t t e s t and foll o w - u p , and w i t h w i s h f u l t h i n k i n g a t p r e t e s t as w e l l . Higher s c o r e s on the Neg a t i v e A f f e c t s u b s c a l e r e p r e s e n t lower l e v e l s of s e l f - e f f i c a c y f o r c o n t r o l l i n g o v e r e a t i n g i n response t o n e g a t i v e f e e l i n g s , so i t appears t h a t the r e l a t i v e use of avoidance and w i s h f u l t h i n k i n g c o p i n g are a l s o a s s o c i a t e d w i t h t h e s e f e e l i n g s when s e l f - e f f i c a c y l e v e l s are low. I n t e r r e l a t i o n s among the coping s u b s c a l e s . The r e l a t i v e use of problem-focused c o p i n g was n e g a t i v e l y c o r r e l a t e d w i t h the r e l a t i v e use of avoidance, w i s h f u l - t h i n k i n g , and s e l f - b l a m e coping responses a t p r e t e s t , p o s t t e s t , and fo l l o w - u p (see Tab l e 4 ) . At p r e t e s t o n l y , r e l a t i v e use of problem-focused coping had a p o s i t i v e c o r r e l a t i o n w i t h r e l a t i v e use of seeking s o c i a l s u p p ort c o p i n g (r = .33). R e l a t i v e use of s e l f - b l a m e c o p i n g was found t o have a n e g a t i v e c o r r e l a t i o n with problem-focused and s o c i a l support coping a t p r e t e s t , p o s t t e s t and f o l l o w - up, and w i t h avoidance coping a t p r e t e s t and f o l l o w - u p . R e l a t i v e use of avoidance and w i s h f u l - t h i n k i n g c o p i n g were found t o have a p o s i t i v e c o r r e l a t i o n a t p o s t t e s t and f o l l o w - up. From t h i s i t appears t h a t h i g h e r r e l a t i v e use of problem-focused c o p i n g i s a s s o c i a t e d with lower r e l a t i v e use 74 of a l l o t h e r types of coping except perhaps s e e k i n g s o c i a l s u pport, and h i g h e r r e l a t i v e use of s e l f - b l a m e i s not r e l a t e d t o h i g h e r use of any o t h e r type of c o p i n g . I t a l s o appears t h a t h i g h e r r e l a t i v e use of avoidance and w i s h f u l t h i n k i n g c o p i n g are l i k e l y t o occur t o g e t h e r . A d d i t i o n a l c o r r e l a t i o n s . Because s p e c i f i c maintenance s t r a t e g i e s have been a focus of i n t e r e s t i n o t h e r maintenance s t u d i e s and because other r e s e a r c h has found a r e l a t i o n s h i p between age and r e l a t i v e use of d i f f e r e n t t y p e s of c o p i n g (Folkman e t a l . , 1987), a Pearson product-moment c o r r e l a t i o n m a t r i x f o r a l l 59 p a r t i c i p a n t s i n the study was c a l c u l a t e d f o r p r e t e s t r e l a t i o n s h i p s between the dependent measures and some d e s c r i p t i v e v a r i a b l e s (see T a b l e 5 ) . There was a weak p o s i t i v e c o r r e l a t i o n between r e l a t i v e use of s e l f - b l a m e c o p i n g and age (r = .25) and a weak n e g a t i v e c o r r e l a t i o n between r e l a t i v e use of seeks s o c i a l support c o p i n g and age (r = -.31), i n d i c a t i n g t h a t o l d e r p a r t i c i p a n t s were more l i k e l y t o blame themselves f o r o v e r e a t i n g and younger ones t o seek support from o t h e r s . The maintenance s t r a t e g y of weekly m o n i t o r i n g of weight was found t o have a n e g a t i v e c o r r e l a t i o n w i t h the amount of weight r e g a i n e d (r = -.36), c u r r e n t weight (r = -.31), and t o t a l weight l o s s (r = -.22). T h i s i n d i c a t e s t h a t the p e r s o n who monitors weight r e g u l a r l y has r e g a i n e d l e s s weight, but a l s o had l o s t l e s s t o begin with. The maintenance s t r a t e g y which i n v o l v e d r e t u r n i n g t o a more r e s t r i c t e d e a t i n g program when weight was r e g a i n e d had Table 5 C o r r e l a t i o n Matrix f o r Dependent Measures and Other V a r i a b l e s at P r e t e s t f o r a l l P a r t i c i p a n t s V4 V6 V4 V6 .0250 V7 1679 7964- V8 .0065 .4937' V9 0807 .2323 V 10 • .0263 0482 EX 1 - 1472 0453 EX2 • . 1543 -.1178 MN2 - 034 1 -.3096* MN5 -.1276 -.1042 DIFF 1 •147 1 7368' GAIN - .0436 . 36 30- SELFEFF 1 -.0656 .066 1 NEGAFF 1 - .0240 . 1298 SOCSIT1 - 1057 - . 1047 COPING 1 .0286 - .0335 PERCENT 1 .009 3 -.0656 PCB1 .2537 .2278 PCW1 • 0159 .0977 PCA1 0499 - . 1243 PCS 1 •.3052* •19 12 M1C2 - . 1877 - . 1773 M1C3 .07 17 .1191 M1C4 .0652 - 2853 SELFEFF1 NEGAFF 1 SOCSIT 1 C0PING1 PERCENT 1 PCB1 PCW1 PCA 1 PCS1 M1C2 M1C3 M1C4 M1C4 GAIN - .0279 .1286 1918 • 0650 • .0499 .0902 -.0260 0216 - .0383 .0346 1269 -.1562 M1C3 04 1 1 SELFEFF 1 .906 3- 5332* 3963- 4073* 0468 .2018 1872 0693 .2257 1047 0997 V7 .3621' 0903 0049 . 2608 .0413 . 1298 . 1681 .1778 .0593 .0624 . 1395 . 1327 .0247 .0164 . 206 7 0555 . 1290 178 1 .2153 .0441 29 15 NEGAFF 1 1257 . 4260' . 4026' .0221 . 2544 . 2564 0012 . 2504 .16 10 .0450 V8 V9 V10 EX 1 EX2 MN2 MN5 DIFF 1 1442 3183* .6 1 10"* 1 164 .1363 008 1 i 0370 - . 2262 - .0989 . 1286 2183 - . 1401 - .0925 - .0384 -. 1046 0950 .0633 . 1531 .0237 -.0568 2579 3985" . 2770 .0839 -.2179 •.1455 -.3585" .0184 2883 . 1376 .1702 - 3235* - . 1503 -.1745 -.0955 .6570* 0497 - .027 1 - .0689 .0766 -.0609 - 0079 . 2 159 .0377 2240 .0321 .0162 .0069 - 0888 -.0624 .1791 .0552 3316- -. 1277 - . 1942 - . 1937 .0348 . 1064 - . 1483 - .0220 0436 •.0240 .2077 - 0443 . 2857 .0463 .0907 - .0270 1 149 .0711 .0503 .0866 .0472 .1917 . 3029 - .0886 0787 • .0580 0862 - 0435 - . 1080 - 0109 - .0775 . 1400 1572 .2396 .0519 - . 1476 -.0629 -.2400 - . 106 1 .097 1 0219 -.0223 - .0417 -. 1066 -.0429 .0535 -.2209 -.0583 0943 - . 2078 - . 1660 . 1570 . 1529 - 0053 0078 -.1123 09 1 1 .0181 -.047 1 0607 0101 2121 2032 - 04 79 07 18 .0613 .0893 .0574 - . 1 106 .1391 -.1032 . 1444 0954 - . 1443 .1125 .0567 .0305 0768 363 1 * - 1383 SOCSIT1 COPING 1 PERCENT 1 PCB1 PCW1 PCA 1 PCS 1 M1C2 0817 1525 .1488 0645 - .0381 - .5098"" 0314 .0014 - . 6644*• . 2062 0689 - .0514 - .4063-" - .0927 . 1497 1568 2254 3798* - 6996*' 5271•• . 2440 0288 - . 1740 . 2252 -.2754 .1110 .0711 1252 0765 .2740 .0036 0892 - .0389 .0867 .0742 270 1 1439 •.0008 1254 1323 .0056 .0437 .0158 1077 SIGNIF. LE .01 SIGNIF LE 001 ( 1 - TAILED. PRINTED IF A COEFFICIENT CANNOT BE COMPUTED) 76 a p o s i t i v e c o r r e l a t i o n w i t h r e l a t i v e use of problem-focused c o p i n g a t p r e t e s t (r = .31). Amount of r e g a i n was p o s i t i v e l y c o r r e l a t e d w i t h how l o n g ago weight was l o s t (r = .28). Amount and p e r c e n t of r e g a i n were n e g a t i v e l y a s s o c i a t e d w i t h e x e r c i s e (r = -.22; r = -.32, r e s p e c t i v e l y ) i n d i c a t i n g t h a t those who are more a c t i v e have r e g a i n e d a lower percentage of the weight they l o s t . C l i n i c a l S i g n i f i c a n c e U s i n g the formula d e s c r i b e d by Jacobson and R e v e n s t o r f (1988) f o r a s s e s s i n g the c l i n i c a l s i g n i f i c a n c e of treatment programs, i n d i v i d u a l p a r t i c i p a n t s ' s c o r e s on the two dependent measures of s e l f - e f f i c a c y and percentage of problem-focused coping were examined a t p o s t t e s t ( f o r change from p r e t e s t t o p o s t t e s t ) and a t f o l l o w - u p ( f o r change from p o s t t e s t t o f o l l o w - u p and from p r e t e s t t o f o l l o w - u p ) . The c u t - o f f p o i n t f o r each dependent measure was o b t a i n e d u s i n g the standard d e v i a t i o n and mean of the normative sample and the standard d e v i a t i o n and mean o f the sample used i n t h i s study. In the case of the E a t i n g S e l f - E f f i c a c y S c a l e , the normative sample used was the group c l a s s i f i e d as d i e t e r s by the developers of the s c a l e (Glynn & Ruderman, 1986). T h i s was done because t h i s group most resembled the p a r t i c i p a n t s i n the study i n terms of t h e i r c oncern w i t h weight s t a t u s . In the case of the r e v i s e d Ways of Coping C h e c k l i s t ( V i t a l i a n o e t a l . , 1985), the normative sample used was the 77 group of spouses of Alzheimer's d i s e a s e p a t i e n t s . A l t h o u g h t h i s group was o l d e r (M = 65.8, SD = 9.2) than the sample i n the p r e s e n t study, 63% of the p a r t i c i p a n t s were female, and of a l l 3 normative sample groups, t h i s was the one w i t h the h i g h e s t r e l a t i v e use of problem-focused c o p i n g (M = .26, SD = .11). Once the c u t - o f f p o i n t s had been e s t a b l i s h e d f o r each dependent measure, the i n d i v i d u a l s c o r e s of p a r t i c i p a n t s i n each of the groups were assessed f o r change from p r e t e s t t o p o s t t e s t and from p r e t e s t t o fol l o w - u p u s i n g t h i s c r i t e r i o n . F o l l o w i n g the recommendation of Jacobson and R e v e n s t o r f (1988) t h a t the magnitude of change should be s u f f i c i e n t t o render i t u n l i k e l y (p< .05) t h a t i t c o u l d ba an a r t i f a c t of measurement e r r o r , t h e i r formula f o r r e l i a b l e change index was used a l o n g w i t h the change p o i n t as a t w o - f o l d c r i t e r i o n f o r c l i n i c a l s i g n i f i c a n c e . See ^*-*»«^U . V V N v Yvev^. p<a_<-je . S e l f - e f f i c a c y . Table 6 shows the number and pe r c e n t a g e s of p a r t i c i p a n t s i n each group who a f t e r assessment by the c r i t e r i o n d e s c r i b e d showed c l i n i c a l l y s i g n i f i c a n t change on the two dependent measures. The c u t - o f f p o i n t f o r s e l f - e f f i c a c y s c o r e s was determined t o be 100 and the amount of change above the p r o b a b i l i t y l e v e l t o be 7.5. For the combined MI-C group (n = 22), t h e r e were p a r t i c i p a n t s who improved, got worse, or s t a y e d the same a c r o s s t e s t i n g times w i t h a f i n a l t o t a l from p r e t e s t t o f o l l o w - u p of 8 (36%) who improved, 1 (5%) who got worse, and 13 (59%) who showed no change. These r e s u l t s are m i s l e a d i n g Erratum: While the Jacobson and Revenstorf (1988) formula was used t o e s t a b l i s h the change p o i n t s core, a m o d i f i e d and l e s s c o n s e r v a t i v e formula was used f o r the r e l i a b l e change index, thus i n c r e a s i n g the p o s s i b i l i t y of r e p o r t i n g chance f i n d i n g s as s i g n i f i c a n t change. For t h i s reason, c l i n i c a l s i g n i f i c a n c e i s used i n t h i s study d e s c r i p t i v e l y t o examine the e f f e c t of the program on i n d i v i d u a l p a r t i c i p a n t s , r a t h e r than d e f i n i t i v e l y t o e v a l u a t e program e f f e c t i v e n e s s . 78 Table 6 C l i n i c a l l y S i g n i f i c a n t Change within Combined Treatment Groups S e l f - E f f i c a c y Number and parcantaga of p a r t i c i p a n t s Improved Got Worse stayed the Same Pretest to Posttest MI-C 4 (18%) 2 (9%) 16 (73%) (S a 22) RPI 4 (19%) 2 (10%) 15 (71%) (S = 2D Posttest to Follow-up MI-C 4 (18%) 0 (0%) 18 (82%) RPI-C 2 (10%) 0 (0%) 19 (90%) Pretest to Follow-up MI-C 8 (36%) 1 (S%) 13 (59%) RPI-C 6 (28%) 2 (10%) 13 (62%) Percentage of Problem-focused Coping Number and Percentage of Parti c i p a n t s Improved Got Worse Stayed the Same Pretest to Posttest MI-C 5 (23%) 2 (9%) 15 (68%) (n = 22) RPI-C 4 (19%) 2 (10%) 15 (71%) (n = 21) Posttest to Follow-up MI-C 4 (18%) 2 (9%) 16 (73%) RPI-C 2 (10%) 0 (0%) 19 (90%) Pretest to Follow-up MI-C 5 (22%) 1 (5%) 16 (73%) RPI-C 7 (33%) 2 (10%) 12 (57%) 79 s i n c e t h e r e were p a r t i c i p a n t s who improved s u b s t a n t i a l l y w i t h o u t r e a c h i n g the change scor e p o i n t and some who s t a r t e d below t h i s p o i n t and st a y e d the same or improved. Of i n t e r e s t i s the f a c t t h a t a t p r e t e s t , t h e r e were 7 (32%) p a r t i c i p a n t s who had s c o r e s a t or below the change p o i n t ; a t p o s t t e s t , t h e r e were 11 (50%), and a t f o l l o w - u p , 14 (64%) . For t h e RPI-C group (n = 21), from p r e t e s t t o f o l l o w - u p , 6 (28%) p a r t i c i p a n t s improved, 2 (10%) got worse, and 13 (62%) s t a y e d the same. Once again t h e r e were p a r t i c i p a n t s who improved without r e a c h i n g the change s c o r e p o i n t and a few who were below i t from the s t a r t . In t h i s group t h e r e were 2 (10%) p a r t i c i p a n t s a t or below the change s c o r e a t p r e t e s t , 5 (24%) a t p o s t t e s t / and 7 (33%) a t f o l l o w - u p . T h i s p a t t e r n of improvement i n both groups i n d i c a t e s a p o s s i b l e ongoing improvement, e s p e c i a l l y s i n c e i t i s m i r r o r e d i n the c l i n i c a l s i g n i f i c a n c e r e s u l t s f o r problem- f o c u s e d c o p i n g . Problem-focused coping. For the dependent measure of percentage of problem-focused coping, the c u t - o f f p o i n t was determined t o be .24 and the amount of change above the l e v e l of p r o b a b i l i t y t o be .04. For the combined MI-C group from p r e t e s t t o foll o w - u p 5 (22%) p a r t i c i p a n t s improved, 1 (5%) got worse, and 16 (73%) stayed the same, w i t h the same q u a l i f i c a t i o n s as t h e r e were f o r s e l f - e f f i c a c y . Almost h a l f (n = 10, 45%) of the p a r t i c i p a n t s had s c o r e s a t or above .24 a t p r e t e s t , w i t h 12 (55%) a t p o s t e s t , and 15 (68%) a t f o l l o w - u p who had s c o r e s a t or above the change p o i n t . 80 In the RPI-C group from p r e t e s t t o f o l l o w - u p , 7 (33%) p a r t i c i p a n t s improved, 2 (10%) got worse, and 12 (57%) s t a y e d the same, again with some improved s c o r e s t h a t d i d not r e a c h the change scor e p o i n t . At p r e t e s t , 7 (33%) p a r t i c i p a n t s were a t or above the change p o i n t , a t p o s t t e s t , 7 (33%), and a t follow-up, 10 (48%). 81 DISCUSSION T h i s study was undertaken t o i n v e s t i g a t e f a c t o r s i n v o l v e d i n the maintenance of weight l o s s and t o a s s e s s t h e e f f e c t i v e n e s s of a maintenance i n t e r v e n t i o n program f o r s u c c e s s f u l d i e t e r s a t r i s k of r e l a p s e . The o b j e c t i v e of the i n t e r v e n t i o n was t o i n c r e a s e the l i k e l i h o o d of weight l o s s maintenance by r a i s i n g p a r t i c i p a n t s ' l e v e l s of s e l f - e f f i c a c y i n e a t i n g s i t u a t i o n s and i n c r e a s i n g the r e l a t i v e use of problem-focused c o p i n g i n response t o n e g a t i v e a f f e c t a s s o c i a t e d w i t h o v e r e a t i n g . The r e s u l t s i n d i c a t e t h a t t h i s t y p e of maintenance i n t e r v e n t i o n treatment, w i t h or w i t h o u t a r e l a p s e p r e v e n t i o n component, does not appear t o have the d e s i r e d e f f e c t . Because t h i s i n t e r v e n t i o n program took a d i f f e r e n t approach t o the problem of maintenance f a i l u r e s , i t i s d i f f i c u l t t o compare the f i n d i n g s with those of o t h e r s t u d i e s . The t r a d i t i o n a l format of maintenance i n t e r v e n t i o n s has been booster s e s s i o n s designed t o r e i n f o r c e the use of b e h a v i o r a l s t r a t e g i e s and o f f e r e d as a c o n t i n u a t i o n of treatment. In the p r e s e n t study, the i n t e r v e n t i o n was not a follow-up of a p r e v i o u s treatment group but a s e p a r a t e program e n t i r e l y . P a r t i c i p a n t s who had r e g a i n e d some or even most of the weight they had l o s t were not seen as treatment f a i l u r e s but as o n c e - s u c c e s s f u l people who understood what they needed t o do f o r weight management but were having d i f f i c u l t y doing i t . The focus of the program was on i n c r e a s i n g t h e i r l e v e l s of s e l f - e f f i c a c y and 82 enhancing t h e i r r e l a t i v e use of problem-focused c o p i n g by t r e a t i n g them as capable people who fa c e d a s i g n i f i c a n t c h a l l e n g e t h a t they c o u l d best meet by g a i n i n g a b e t t e r u n d e r s t a n d i n g of the problem and of themselves. I t was h y p o t h e s i z e d t h a t from p r e t e s t t o p o s t t e s t , p a r t i c i p a n t s i n both treatment c o n d i t i o n s , w i t h or wi t h o u t a' r e l a p s e p r e v e n t i o n component, would show i n c r e a s e d l e v e l s of s e l f - e f f i c a c y and r e l a t i v e use of problem-focused c o p i n g when compared wi t h the c o n t r o l group. I t was f u r t h e r h y p o t h e s i z e d t h a t these i n c r e a s e s would be main t a i n e d from p o s t t e s t t o a 6-week follow-up f o r the treatment group w i t h t h e r e l a p s e p r e v e n t i o n component, but not f o r the o t h e r treatment c o n d i t i o n . These hypotheses were not supported by the r e s u l t s . A f i n a l h y p o t h e s i s , t h a t t h e r e would be a s i g n i f i c a n t c o r r e l a t i o n between percentage of problem- f o c u s e d c o p i n g a t p o s t t e s t and s e l f - e f f i c a c y a t f o l l o w - u p , was supported. In a d d i t i o n , i n an e x p l o r a t o r y f a s h i o n , s e v e r a l c o r r e l a t i o n s were examined between v a r i a b l e s and dependent measures and s u c c e s s f u l weight l o s s maintenance. Depandent Measures and Hypothesized R e s u l t s Although changes among groups over time on the dependent measures were n o n - s i g n i f i c a n t , an examination of the mean s c o r e s f o r the dependent measures i n d i c a t e s a tendency towards change i n the expected d i r e c t i o n (see T a b l e 2 ) . From p r e t e s t t o follow-up, the s e l f - e f f i c a c y mean s c o r e s o f the i n i t i a l treatment groups showed decr e a s e s (lower s c o r e s = h i g h e r s e l f - e f f i c a c y ) whereas t h a t of the 83 c o n t r o l group d i d not. S i m i l a r l y , r e l a t i v e use of problem- f o c u s e d c o p i n g i n c r e a s e d f o r a l l groups. The change i n p r e t e s t t o p o s t t e s t s c o r e s f o r the MI and WL groups r e q u i r e s some attempt a t e x p l a n a t i o n . One p o s s i b i l i t y f o r improved s e l f - e f f i c a c y i n the WL group may "be t h a t merely a t t e n d i n g a p r e l i m i n a r y s e s s i o n gave some i n d i v i d u a l s a sense of p e r c e i v e d c o n t r o l . Two WL p a r t i c i p a n t s wrote u n s o l i c i t e d comments on t h e i r p o s t t e s t q u e s t i o n n a i r e s t o the e f f e c t t h a t they had e x p e r i e n c e d l e s s d i f f i c u l t y c o n t r o l l i n g o v e r e a t i n g s i n c e the s e s s i o n , even though no treatment had been g i v e n . Another p o s s i b i l i t y i s t h a t f i l l i n g i n the q u e s t i o n n a i r e s gave some p a r t i c i p a n t s i n s i g h t i n t o what was l e a d i n g t o t h e i r o v e r e a t i n g problems and they began t o address those i s s u e s . By f o l l o w - u p , however, the s e i n f l u e n c e s had faded. The s m a l l i n c r e a s e i n the mean s e l f - e f f i c a c y s c o r e (lower s c o r e s = h i g h e r s e l f - e f f i c a c y ) i n the MI group i s l e s s e x p l a i n a b l e . An examination of the i n d i v i d u a l s c o r e s i n t h i s group r e v e a l s t h a t of the 4 p a r t i c i p a n t s whose s c o r e s i n c r e a s e d a t p o s t t e s t , 2 of the i n c r e a s e s were u n u s u a l l y l a r g e , 26 and 51 p o i n t s , and perhaps t h i s outweighed any improvements and r e s u l t e d i n the h i g h e r mean s c o r e . The f a i l u r e of the r e l a p s e p r e v e n t i o n component t o have the h y p o t h e s i z e d e f f e c t of producing more l a s t i n g changes i n the RP groups was l i k e l y due to a combination of f a c t o r s . By chance, both the RPI and RPI2 groups had s u b s t a n t i a l l y 84 lower s e l f - e f f i c a c y and used r e l a t i v e l y l e s s problem-focused c o p i n g than the MI and MI2 groups. Low s e l f - e f f i c a c y may have kept p a r t i c i p a n t s i n the RPI groups from u s i n g the i n f o r m a t i o n they r e c e i v e d about the r e l a p s e p r o c e s s t o develop a p l a n f o r r e l a p s e p r e v e n t i o n . A d d i t i o n a l l y , i t became apparent t h a t 4 1-hour s e s s i o n s , mostly spent on o t h e r i s s u e s , were inadequate f o r the t a s k of g i v i n g much more than an overview of r e l a p s e p r e v e n t i o n . In o t h e r words, the r e l a p s e p r e v e n t i o n component r e c e i v e d s h o r t s h r i f t and the r e s u l t s of the study should not be i n t e r p r e t e d as a f a i l u r e of r e l a p s e p r e v e n t i o n t r a i n i n g t o enhance maintenance success. In d i s c u s s i n g t h e i r own study, P e r r i e t a l . (1984) suggested t h a t even 6 s e s s i o n s may not have been enough f o r r e l a p s e p r e v e n t i o n t r a i n i n g . S e l f - e f f i c a c y s c o r e s . S e v e r a l i n t e r p r e t a t i o n s a re p o s s i b l e f o r the l a c k of an i n c r e a s e i n s e l f - e f f i c a c y as the r e s u l t of treatment. Although changes were i n the expected d i r e c t i o n as T a b l e 2 i n d i c a t e s , they were r e l a t i v e l y s m a l l . Only when the i n i t i a l and second treatment groups were combined i n t o MI-C and RPI-C d i d the r e s u l t s approach s i g n i f i c a n c e . The E a t i n g S e l f - e f f i c a c y S c a l e (Glynn & Ruderman, 1984) which was used t o measure s e l f - e f f i c a c y i n e a t i n g s i t u a t i o n s , r e s u l t e d i n a g r e a t d e a l of v a r i a b i l i t y among s c o r e s . In the normative sample of 217 young women who r e p o r t e d they were t r y i n g t o l o s e weight, the range of 85 s c o r e s on the s c a l e was from 3 3 t o 148 (lower s c o r e s = h i g h e r s e l f - e f f i c a c y ) w i t h an average s c o r e of 87.2 (SD = 25.08). In the p r e s e n t study, s i m i l a r ranges and s t a n d a r d d e v i a t i o n s were found. The l a r g e amount of v a r i a n c e i n the s c o r e s would thus make s i g n i f i c a n t changes u n l i k e l y u n l e s s the s i z e of the change was l a r g e as w e l l . What i s i n t e r e s t i n g , however, i s the f a c t t h a t the i n i t i a l p r e t e s t average s e l f - e f f i c a c y s c o r e f o r t h e 59 p a r t i c i p a n t s i n t h i s study was 108.6 (SD = 28.1), c o n s i d e r a b l y h i g h e r than t h a t of the normative sample. The average age of the normative sample was not r e p o r t e d , but p a r t i c i p a n t s were d e s c r i b e d as undergraduate s t u d e n t s i n an i n t r o d u c t o r y psychology course, s u g g e s t i n g an average age of under 25 y e a r s . The average age of p a r t i c i p a n t s i n the p r e s e n t study was 45.0 years (SD = 10.1). T h i s r a i s e s the q u e s t i o n of whether l e v e l s of s e l f - e f f i c a c y i n e a t i n g s i t u a t i o n s are l i k e l y t o decrease w i t h age, perhaps because of accumulated f a i l u r e s t o c o n t r o l o v e r e a t i n g . Another p o s s i b i l i t y f o r the r e l a t i v e l y s m a l l amount of change observed i n average s e l f - e f f i c a c y s c o r e s f o r the treatment groups i s t h a t the h i g h l y s p e c i f i c measure of s e l f - e f f i c a c y i n e a t i n g s i t u a t i o n s has a b e h a v i o r a l b i a s . An i n t e r v e n t i o n focused on techniques s p e c i f i c a l l y d i r e c t e d a t a v o i d i n g o v e r e a t i n g (e.g., d e l a y i n g e a t i n g , changing b e h a v i o r s l i n k e d t o e a t i n g , l i k e watching t e l e v i s i o n , e t c . ) , might have s i g n i f i c a n t l y i n c r e a s e d t h i s aspect of s e l f - e f f i c a c y . However, t h i s approach would not have addressed 86 the b a s i c problem i d e n t i f i e d by S t a l o n a s e t a l . (1984) which i s t h a t a f t e r treatment ends, s u c c e s s f u l d i e t e r s g r a d u a l l y abandon the s t r a t e g i e s t h a t they have been taught. In t h i s study, i t was assumed t h a t women who had s u c c e s s f u l l y m a i n t a i n e d weight l o s s e s f o r a t l e a s t 6 months knew what b e h a v i o r a l t e c h n i q u e s worked f o r them; the c h a l l e n g e was t o encourage them t o use these s t r a t e g i e s permanently. Thus the f o c u s of the program was on d e v e l o p i n g the p e r s o n a l sense of r e s p o n s i b i l i t y and c o n t r o l i n weight management t h a t C o l v i n and Olson (1983) i d e n t i f i e d as an important c h a r a c t e r i s t i c of s u c c e s s f u l weight l o s s m a i n t a i n e r s . T h i s o b j e c t i v e may have been too ambitious f o r a 4-week i n t e r v e n t i o n program. Problem-focused coping. U n l i k e many s t u d i e s t h a t have examined c o p i n g s t r a t e g i e s i n response t o a v a r i e t y of s t r e s s o r s (Folkman e t a l . , 1986; Long & Haney, 1988), t h i s study attempted t o examine changes i n c o p i n g over time i n response t o 1 i d e n t i f i e d s t r e s s o r , the n e g a t i v e a f f e c t a s s o c i a t e d w i t h o v e r e a t i n g . Compas et a l . (1988) had found moderate c o n s i s t e n c y i n coping p a t t e r n s i n response t o the same s t r e s s o r , and the i n d i v i d u a l s c o r e s of p a r t i c i p a n t s i n t h i s study support t h i s f i n d i n g f o r the most p a r t . A few i n d i v i d u a l s ' s c o r e s f l u c t u a t e d g r e a t l y , however. S i x p a r t i c i p a n t s i n the combined MI-C group and 4 i n the RPI-C group had i n c r e a s e s or decreases of 20% or more a t d i f f e r e n t times of t e s t i n g . T h i s v a r i a b i l i t y may have made group changes d i f f i c u l t t o d e t e c t . 87 F a i l u r e t o f i n d s i g n i f i c a n t posttreatment i n c r e a s e s i n the r e l a t i v e use of problem-focused c o p i n g l e d t o an examination of an a n c i l l a r y measure of a t t r i b u t i o n . Three q u e s t i o n s were posed t h a t r e l a t e d t o the c a u s a l i t y , c h a n g e a b i l i t y , and c o n t r o l l a b i l i t y of what p a r t i c i p a n t s f e l t was t h e major cause of t h e i r o v e r e a t i n g . I t was expected t h a t d u r i n g the course of treatment p a r t i c i p a n t s ' a p p r a i s a l of t h i s major cause would s h i f t from one r e l a t e d t o p e r s o n a l d e f i c i e n c i e s and thus l i k e l y t o be permanent and l e s s c o n t r o l l a b l e , t o a view t h a t i t was r e l a t e d t o s i t u a t i o n s t h a t were more c o n t r o l l a b l e and temporary. In a study i n v e s t i g a t i n g c o p i n g s t r a t e g i e s used i n response t o how a s i t u a t i o n was a p p r a i s e d , r e s e a r c h e r s found t h a t when the s i t u a t i o n was seen as changeable, more c o n f r o n t i v e c o p i n g , a c c e p t i n g r e s p o n s i b i l i t y , p l a n f u l p r o b l e m - s o l v i n g , and p o s i t i v e r e a p p r a i s a l were used (Folkman e t a l . , 1986). Thus i t was expected t h a t the r e l a t i v e use of problem-focused c o p i n g would be r e l a t e d t o p a r t i c i p a n t s ' a p p r a i s a l of t h e i r s i t u a t i o n , and t h a t as t h i s changed d u r i n g the course of treatment, so would t h e i r r e l a t i v e c o p i n g change. S u r p r i s i n g l y , no c o r r e l a t i o n was found between any of the a t t r i b u t i o n s c a l e items and the r e l a t i v e use of any type of c o p i n g . An i n t e r e s t i n g f i n d i n g i s t h a t the average s c o r e f o r percentage of problem-focused coping was f a i r l y h i g h f o r the MI groups a t p r e t e s t and both MI and RPI groups a t f o l l o w - up. In the V i t a l i a n o e t a l . (1987) normative sample of 88 spouses of A l z h e i m e r ' s d i s e a s e p a t i e n t s , the average s c o r e was .26 (SD =,11), s l i g h t l y lower than the average s c o r e f o r the MI group (M = .27, SD = .12). Of the t h r e e normative sample groups V i t a l i a n o e t a l . used, the spouses o f A l z h e i m e r ' s d i s e a s e p a t i e n t s showed h i g h e r r e l a t i v e use of problem-focused c o p i n g than e i t h e r the p s y c h i a t r i c o u t p a t i e n t s (M = .21, SD = .09) or medical s t u d e n t s (M = .24, SD = .06). Although t h e r e i s no e s t a b l i s h e d c e i l i n g e f f e c t f o r r e l a t i v e use of t h i s type of coping, i t may have been unreasonable t o expect the average s c o r e t o i n c r e a s e v e r y much f o r the MI group s i n c e i t was a t a h i g h l e v e l t o s t a r t w i t h . The f o l l o w - u p average s c o r e s f o r the MI (M = .29, SD = .11) and the RPI (M = .27, SD = .17) look v e r y good compared t o the normative sample's s c o r e . While the WL group improved, i t s s c o r e was s t i l l f a r below t h a t of t h e normative group (M = .21, SD = .11), and t h e r e was no c o r r e s p o n d i n g decrease i n s e l f - e f f i c a c y s c o r e s . One p o s s i b l e c o n c l u s i o n i s t h a t i n order t o have h i g h l e v e l s of s e l f - e f f i c a c y , people wanting t o m a i n t a i n a weight l o s s have t o use h i g h e r than average r e l a t i v e amounts of problem-focused c o p i n g t o other types of c o p i n g . I f t h i s i s t r u e , i t may be t h a t the c h a l l e n g e of weight l o s s maintenance, i s one t h a t demands a l i f e t i m e of e x t r a o r d i n a r y e f f o r t and may e x p l a i n why so few people meet i t . Another p o s s i b i l i t y f o r the r e l a t i v e l y h i g h problem-focused c o p i n g s c o r e s c o u l d be t h a t t h a t the items i n t h i s s u b s c a l e o f the V i t a l i a n o e t a l . (1985) r e v i s e d WCCL were not s p e c i f i c 89 enough f o r i n d i v i d u a l s f o c u s i n g on the s p e c i f i c s t r e s s o r of n e g a t i v e a f f e c t r e l a t e d t o o v e r e a t i n g . The items on t h e s u b s c a l e have a p o s i t i v e and o p t i m i s t i c q u a l i t y t h a t may have been a t t r a c t i v e t o p a r t i c i p a n t s even i f they were not sure i t r e l a t e d t o t h e i r s i t u a t i o n . Problem-focused coping and s e l f - e f f i c a c y r e l a t i o n s h i p . The f i n a l h y p o t h e s i s f o r the study s t a t e d an expected r e l a t i o n s h i p would be found between s e l f - e f f i c a c y and percentage of problem-focused coping. The r e l a p s e p r e v e n t i o n model ( M a r l a t t & Gordon, 1980) i n d i c a t e s t h a t when an a d a p t i v e c o p i n g s t r a t e g y i s used i n a h i g h - r i s k s i t u a t i o n , s e l f - e f f i c a c y i s i n c r e a s e d . A d a p t i v e c o p i n g which r e s u l t s i n mastery of the h i g h - r i s k s i t u a t i o n (e.g., not e a t i n g or ove r e a t i n g ) i s l i k e l y t o be problem-focused, f o r example, u s i n g a b e h a v i o r a l s t r a t e g y l i k e moving away from the tempting food. Since i t was expected t h a t r e l a t i v e use of problem-focused coping would i n c r e a s e d u r i n g treatment, l e v e l s a t p o s t t e s t were expected t o be n e g a t i v e l y c o r r e l a t e d w i t h s e l f - e f f i c a c y s c o r e s a t f o l l o w - u p (lower s c o r e s = h i g h e r s e l f - e f f i c a c y ) . T h i s r e l a t i o n s h i p was supported as a s i g n i f i c a n t although low moderate c o r r e l a t i o n f o r t h e dependent measures a t p o s t t e s t and f o l l o w - u p f o r the combined treatment groups, MI-C and RPI-C, was r e v e a l e d (r = -.34, p< .013). Although t h i s r e l a t i o n s h i p was expected, both from the r e l a p s e p r e v e n t i o n model and from Bandura's (1977) a s s e r t i o n t h a t b e i n g a b l e t o make a coping response t h a t produces an 90 a d a p t i v e outcome c o n t r i b u t e s t o a sense of p e r s o n a l e f f i c a c y , t h e r e has been l i t t l e i n v e s t i g a t i o n of t h i s a s s o c i a t i o n i n weight l o s s s t u d i e s . The p r e s e n t study i n d i c a t e s t h a t i n weight l o s s maintenance u s i n g r e l a t i v e l y more problem-focused c o p i n g i n a h i g h - r i s k s i t u a t i o n i s a s s o c i a t e d w i t h h i g h e r l e v e l s of s e l f - e f f i c a c y i n e a t i n g s i t u a t i o n s 6 weeks l a t e r . C o r r e l a t i o n s I n v o l v i n g S e l f - E f f i c a c y and Coping When Pearson product-moment c o r r e l a t i o n s were c a l c u l a t e d f o r the combined treatment groups (MI-C and RPI-C) f o r a s s o c i a t i o n s between the two dependent measures of s e l f - e f f i c a c y , coping,, and t h e i r s u b s c a l e s , s e v e r a l i n t e r e s t i n g r e l a t i o n s h i p s were observed (see T a b l e 4 ) . These r e l a t i o n s h i p s must be i n t e r p r e t e d w i t h c a u t i o n because they were not hy p o t h e s i z e d and because a number of the c o r r e l a t e s a re not independent so an a d j u s t e d l e v e l of al p h a i s r e q u i r e d . Higher l e v e l s of s e l f - e f f i c a c y were a s s o c i a t e d w i t h h i g h e r r e l a t i v e use of problem-focused c o p i n g a t p r e t e s t , p o s t t e s t , and fo l l o w - u p . When i n t e r r e l a t i o n s among the c o p i n g s u b s c a l e s were examined, i t was found t h a t o n l y the s t r a t e g y of see k i n g s o c i a l support showed a p o s i t i v e r e l a t i o n s h i p w i t h problem-focused coping. S e l f - b l a m e had a n e g a t i v e r e l a t i o n s h i p with problem-focused coping, s u p p o r t i n g what the r e l a p s e p r e v e n t i o n model ( M a r l a t t & Gordon, 1980) p r e d i c t s , t h a t the i n d i v i d u a l who a t t r i b u t e s a l a p s e t o i n t e r n a l p e r s o n a l d e f i c i t s i s more l i k e l y t o c o n t i n u e u s i n g the o l d behavior and l e s s l i k e l y t o g e t back on c o u r s e . C o r r e l a t i o n s I n v o l v i n g Maintenance S t r a t e g i e s and E x e r c i s e C o r r e l a t i o n a l s t u d i e s have i d e n t i f i e d a s s o c i a t i o n s between e x e r c i s e and the use of s p e c i f i c maintenance s t r a t e g i e s w i t h s u c c e s s f u l maintenance ( C o l v i n & Olson, 1983; S t a l o n a s e t a l . , 1984; S t u a r t & G u i r e , 1978). When Pearson product-moment c o r r e l a t i o n s were c a l c u l a t e d f o r a l l 59 p a r t i c i p a n t s i n the study and p r e t e s t r e l a t i o n s h i p s between demographic and weight v a r i a b l e s , maintenance s t r a t e g i e s and e x e r c i s e , and the dependent measures and t h e i r s u b s c a l e s , s e v e r a l i n t e r e s t i n g r e l a t i o n s h i p s were observed (see T a b l e 5). A p o s i t i v e c o r r e l a t i o n was found between age and r e l a t i v e use of s e l f - b l a m e (r = .25), i n d i c a t i n g t h a t o l d e r p a r t i c i p a n t s were l i k e l y t o use r e l a t i v e l y h i g h e r amounts of t h i s type of c o p i n g . Although the s u b s c a l e s used were d i f f e r e n t from those i n t h i s study, other r e s e a r c h e r s a l s o found t h a t o l d e r p a r t i c i p a n t s used r e l a t i v e l y h i g h e r amounts of the s u b s c a l e c a l l e d Accept R e s p o n s i b i l i t y (Folkman, La z a r u s , Pimley, & Novacek, 1987). In the Folkman e t a l . study, younger p a r t i c i p a n t s were found t o use r e l a t i v e l y more P l a n f u l p r o b l e m - s o l v i n g and Seek s o c i a l support c o p i n g r e s p o n s e s . In the p r e s e n t study, r e l a t i v e use of problem- f o c u s e d c o p i n g was not found to be a s s o c i a t e d w i t h age, but a n e g a t i v e c o r r e l a t i o n was found between age and s e e k i n g 92 s o c i a l support (r = -.28), i n d i c a t i n g t h a t younger p a r t i c i p a n t s were more l i k e l y t o use t h i s s t r a t e g y . Weekly m o n i t o r i n g of weight was found t o have an a s s o c i a t i o n w i t h amount of weight r e g a i n e d by p a r t i c i p a n t s i n t h i s study. A n e g a t i v e c o r r e l a t i o n was found between m o n i t o r i n g and the amount of weight r e g a i n e d (r = -.36). T h i s s u p p o r t s the f i n d i n g s i n c o r r e l a t i o n a l s t u d i e s t h a t r e g u l a r weight m o n i t o r i n g i s a s s o c i a t e d w i t h s u c c e s s f u l maintenance. S i n c e m o n i t o r i n g of weight i s a s t r a t e g y t h a t i s problem-focused, a s i g n i f i c a n t c o r r e l a t i o n between i t and r e l a t i v e use of problem-focused coping might be expected. None was found, but the r e l a t i v e use of another c o p i n g s u b s c a l e , w i s h f u l t h i n k i n g , was found t o have a n e g a t i v e c o r r e l a t i o n w i t h r e g u l a r weight m o n i t o r i n g (r = -.24). Perhaps when an i n d i v i d u a l f e e l s unable t o do a n y t h i n g about weight g a i n , w i s h f u l t h i n k i n g allows some d i s t a n c i n g from t h e problem. D i s t a n c i n g i s one of the c o p i n g responses t h a t was found a s s o c i a t e d w i t h s i t u a t i o n s t h a t were a p p r a i s e d as unchangeable i n a coping study (Folkman e t a l . , 1986). A s p e c i f i c c o r r e l a t e of s u c c e s s f u l maintenance i d e n t i f i e d by S t u a r t and Guire (1978) was a q u i c k r e v e r s a l of s m a l l g a i n s . In the present study, r e t u r n t o a more c o n t r o l l e d e a t i n g program i n response t o weight g a i n was found t o have a weak ne g a t i v e c o r r e l a t i o n w i t h s e l f - e f f i c a c y s c o r e s (lower s c o r e s = h i g h e r s e l f - e f f i c a c y ) and a weak p o s i t i v e c o r r e l a t i o n w i t h r e l a t i v e use of problem-focused c o p i n g (r = -.22; and r = .30, r e s p e c t i v e l y ) . A d d i t i o n a l l y , 93 t h i s maintenance s t r a t e g y was found t o have a weak n e g a t i v e c o r r e l a t i o n w i t h the r e l a t i v e use of another type of c o p i n g response, t h a t of avoidance (r = -.22). What i s not c l e a r from t h i s f i n d i n g i s whether t h e r e i s a c a u s a l r e l a t i o n s h i p between t h e s e f a c t o r s , and i f so, i n which d i r e c t i o n . E x e r c i s e s t a t u s (sedentary, moderately a c t i v e , or a c t i v e ) was shown t o have an a s s o c i a t i o n w i t h the amount of weight r e g a i n e d . Higher l e v e l s of a c t i v i t y were found t o have a n e g a t i v e c o r r e l a t i o n w i t h amount r e g a i n e d (r = -.22), and w i t h percentage of weight r e g a i n e d (r = -.32). T h i s s u p p o r t s the f i n d i n g of other s t u d i e s t h a t r e g u l a r e x e r c i s e may c o n t r i b u t e t o s u c c e s s f u l weight l o s s maintenance. C l i n i c a l S i g n i f i c a n c e A l though t h e r e were few s t a t i s t i c a l l y s i g n i f i c a n t f i n d i n g s i n t h i s study, when c l i n i c a l s i g n i f i c a n c e was a s s e s s e d u s i n g Jacobson and R e v e n s t o r f ' s (1988) c o n s e r v a t i v e formula, a p a t t e r n of improvement i n the i n d i v i d u a l s i n the treatment groups was observed. For s e l f - e f f i c a c y , an examination of the number of p a r t i c i p a n t s i n each treatment c o n d i t i o n who improved, got worse, or s t a y e d the same i n d i c a t e s t h a t from p r e t e s t to p o s t t e s t 36% of the MI-C group (n = 22) and 28% of the RPI-C group (n = 21) improved, w i t h 5% and 10% r e s p e c t i v e l y g e t t i n g worse. From p r e t e s t t o f o l l o w - u p on percentage of problem-focused coping, 22% of the MI-C group improved, with 5% worsening, and 33% of the RPI-C group improved, with 10% g e t t i n g worse. 94 On the b a s i s of these f i g u r e s , i t would be f a i r t o say- t h a t fewer than 4 out of 10 people b e n e f i t t e d from the program, and as many as 1 out of 10 were made worse. However, t h e r e were people i n both groups who improved o r got worse beyond the chance measure without r e a c h i n g the change p o i n t , or who s t a r t e d a t a p o i n t above or below the change p o i n t , depending on the measure, and improved or got worse w i t h o u t c r o s s i n g the change sco r e p o i n t . When t h e s e s c o r e s a re i n c l u d e d , 57% of the RPI-C group improved i n s e l f - e f f i c a c y and 57% i n r e l a t i v e use of problem-focused c o p i n g , w h i l e the percentage of those who got worse f o r the second measure i n c r e a s e d t o 14%. A l e s s n o t i c e a b l e i n c r e a s e was observed i n percentages f o r the MI-C group w i t h improved s e l f - e f f i c a c y r i s i n g t o 50% and those who got worse i n c r e a s i n g t o 14%. For problem-focused coping, the improved r a t e was 41% f o r the MI-C group and the percentage who got worse i n c r e a s e d t o 10%. Another way of examining the s c o r e s i s t o see how many p a r t i c i p a n t s i n each group were below the change p o i n t s c o r e f o r s e l f - e f f i c a c y (lower s c o r e s = h i g h e r s e l f - e f f i c a c y ) o r above the change p o i n t f o r problem-focused c o p i n g a t each time o f t e s t i n g . In the MI-C group a t p r e t e s t , t h e r e were 7 (32%) p a r t i c i p a n t s who had sc o r e s a t or below the change p o i n t ; a t p o s t t e s t , t h e r e were 11 (50%), and a t f o l l o w - u p , 14 (64%). In the RPI-C group t h e r e were 2 (10%) p a r t i c i p a n t s a t or below the change sco r e a t p r e t e s t , 5 (24%) a t p o s t t e s t , and 7 (33%) a t follow-up. 95 A s i m i l a r p a t t e r n was demonstrated f o r percentage of problem-focused c o p i n g . In the MI-C group, almost h a l f (n = 10, 45%) of the p a r t i c i p a n t s had s c o r e s a t or above the change p o i n t a t p r e t e s t . There were 12 (55%) p a r t i c i p a n t s a t p o s t e s t , and 15 (68%) a t f o l l o w - u p who had s c o r e s a t or above the change p o i n t . In the RPI-C group, a t p r e t e s t , 7 (33%) p a r t i c i p a n t s were at or above the change p o i n t , a t p o s t t e s t , 7 (33%), and a t follow-up, 10 (48%). A l though i t i s important t h a t WL p a r t i c i p a n t s not be compared d i r e c t l y t o the MI-C and RPI-C groups because some of t h e p a r t i c i p a n t s i n those treatment groups were o r i g i n a l l y p a r t of the WL, i t i s i n t e r e s t i n g t o note t h a t no such p a t t e r n of change was observed i n WL p a r t i c i p a n t s . For s e l f - e f f i c a c y , the numbers a t or below the change p o i n t were 5 (29%) a t p r e t e s t , 6 (35%) a t p o s t t e s t , and 3 (18%) a t f o l l o w - u p . For problem-focused coping, t h e r e were 5 (29%) p a r t i c i p a n t s a t or above the change p o i n t a t p r e t e s t , 6 (35%) a t p o s t t e s t , and 5 (29%) a t f o l l o w - u p . A lthough any i n t e r p r e t a t i o n of t h i s p a t t e r n must be done w i t h c a u t i o n , the p o s s i b i l i t y e x i s t s t h a t treatment e f f e c t s were not immediate but took longer t o develop. A f u r t h e r f o l l o w - u p assessment would have g i v e n a b e t t e r i n d i c a t i o n of whether t h e r e were long-term b e n e f i t s of the i n t e r v e n t i o n . 96 A n e c d o t a l Evidence f o r Treatment E f f e c t i v e n e s s There was no attempt t o r e c o r d or q u a n t i f y p a r t i c i p a n t s ' comments and r e p o r t s of s u c c e s s f u l change beyond the t h e r a p i s t ' s n o t a t i o n f o l l o w i n g s e s s i o n s , but because c e r t a i n i s s u e s were seen as important by every group, they are mentioned b r i e f l y here. The main comment made by p a r t i c i p a n t s was t h a t the group d i s c u s s i o n s h e l p e d them t o f e e l l e s s alone and h e l p l e s s i n t h e i r s t r u g g l e s t o m a i n t a i n weight l o s s , and many expressed r e g r e t t h a t t h i s would end when the program d i d . The t h e r a p i s t encouraged i n t e r e s t e d p a r t i c i p a n t s t o form support groups on t h e i r own f o l l o w i n g the i n t e r v e n t i o n . Two such groups were s t a r t e d a f t e r the f o l l o w - u p assessment, one from the i n i t i a l groups and one from the second treatment groups and were c o n t i n u i n g t o meet when the t h e r a p i s t c o n t a c t e d the o r g a n i z e r s s e v e r a l months l a t e r . P a r t i c i p a n t s o f f e r e d d i f f e r e n t e x p l a n a t i o n s f o r t h e i r d i f f i c u l t y i n m a i n t a i n i n g t h e i r l o s s e s , from too much i n t e r e s t i n food, t o r e l a t i o n s h i p problems, t o i l l n e s s or change i n a c t i v i t y l e v e l . What emerged as an i s s u e t h a t many found f a m i l i a r , however, was a f e e l i n g o f resentment and weariness about having t o "work so hard" t o keep the weight o f f . R e l a t e d t o t h i s was a f e e l i n g t h a t few people w i t h o u t a weight problem themselves understood the d i f f i c u l t y i n v o l v e d i n m a i n t a i n i n g a weight l o s s . The p r e v a i l i n g a t t i t u d e of s o c i e t y seemed t o be t h a t the problem had been the e x t r a pounds and once they were gone, the 97 p erson was "cured." Although many women r e p o r t e d r e c e i v i n g a g r e a t d e a l o f support and r e c o g n i t i o n d u r i n g weight l o s s , t h i s had l a r g e l y d i s a p p e a r e d d u r i n g maintenance. P a r t i c i p a n t s g e n e r a l l y made l i t t l e use of the O v e r e a t i n g Logs as a guide t o understanding what l e d t o o v e r e a t i n g . Many s a i d they " a l r e a d y knew" what the cause was, r e l a t i n g i t t o work or f a m i l y s t r e s s , boredom, or some ot h e r n e g a t i v e f e e l i n g . They appeared t o have a d e f e a t e d a t t i t u d e t h a t t h e r e was l i t t l e they c o u l d do t o change the s i t u a t i o n . Others who used the Logs a f t e r the f i r s t few s e s s i o n s r e p o r t e d t h a t they were having fewer problems and so had stopped r e c o r d i n g . The r e l a p s e p r e v e n t i o n i n f o r m a t i o n was r e c e i v e d w i t h g r e a t i n t e r e s t by the RPI groups, who were immediately a b l e t o r e l a t e the pr o c e s s t o t h e i r own ex p e r i e n c e . Only a few p a r t i c i p a n t s formulated a r e l a p s e p r e v e n t i o n p l a n by the end of the i n t e r v e n t i o n , however. Many appeared t o have d i f f i c u l t y w i t h the i d e a of br e a k i n g down the l a r g e r concept of " g e t t i n g back on t r a c k " i n t o the i n d i v i d u a l b e h a v i o r s t h a t were ne c e s s a r y t o do t h a t . A few claime d t h a t they no l o n g e r needed a r e l a p s e p r e v e n t i o n p l a n because they were now "back on t r a c k " as the r e s u l t of the i n t e r v e n t i o n . I t was c l e a r t h a t p r e s e n t i n g r e l a p s e p r e v e n t i o n i n f o r m a t i o n i n a condensed form was not r e a l l y h e l p f u l t o the p a r t i c i p a n t s . F i n a l l y , what came acr o s s most s t r o n g l y i n a l l the groups was a sense of f r u s t r a t i o n and discouragement among those who had r e g a i n e d more than a few pounds. T h e i r 98 commitment t o b e i n g a t a t a r g e t weight was e v i d e n t i n t h e i r p a r t i c i p a t i o n i n the d i s c u s s i o n s and w i l l i n g n e s s t o examine t h e i r i s s u e s , but many expressed u n c e r t a i n t y about b e i n g a b l e t o m a i n t a i n , even i f they managed t o get back t o t h e i r g o a l s . C o n c l u s i o n , L i m i t a t i o n s , and Recommendations T h i s study i n v o l v e d a maintenance i n t e r v e n t i o n t h a t took an u n c o n v e n t i o n a l approach t o the problem of maintenance d i f f i c u l t i e s . Instead of a focus on s p e c i f i c s t r a t e g i e s f o r weight management, the program was p r e s e n t e d t o p a r t i c i p a n t s as one which might h e l p them t o take a s t e p back from the problem and see what oth e r i s s u e s might be g e t t i n g i n the way of t h e i r success. By t r e a t i n g p a r t i c i p a n t s i n the i n t e r v e n t i o n groups as s u c c e s s f u l d i e t e r s who had been a b l e t o m a i n t a i n f o r a t l e a s t s i x months and thus were capable of g e t t i n g back t o g o a l and s t a y i n g t h e r e , the t h e r a p i s t / e x p e r i m e n t e r hoped t o r a i s e p a r t i c i p a n t s ' l e v e l s of s e l f - e f f i c a c y i n e a t i n g s i t u a t i o n s and t o i n c r e a s e t h e i r use of problem-focused c o p i n g . From a s t a n d p o i n t of s t a t i s t i c a l s i g n i f i c a n c e , the i n t e r v e n t i o n produced no such r e s u l t . From the s t a n d p o i n t of c l i n i c a l s i g n i f i c a n c e , however, a case can be made f o r t h i s type of i n t e r v e n t i o n b e n e f i t t i n g a t l e a s t some women a t r i s k of r e l a p s e . S e v e r a l l i m i t a t i o n s of the g e n e r a l i z a b i l i t y of the r e s u l t s of t h i s study must be s t a t e d . The sample s i z e was r e l a t i v e l y s m a l l , r e s u l t i n g i n s m a l l treatment groups. 99 A l though data were c o l l e c t e d f o r 59 p a r t i c i p a n t s a t p r e t e s t , o n l y 4 3 were t e s t e d both f o r p r e t e s t and f o l l o w - u p . Thus, any f i n d i n g s must be c a u t i o u s l y i n t e r p r e t e d . The women who p a r t i c i p a t e d i n the study may not be h i g h l y r e p r e s e n t a t i v e of the g e n e r a l p o p u l a t i o n of s u c c e s s f u l d i e t e r s a t r i s k of r e l a p s e . Any i n t e r p r e t a t i o n of the r e s u l t s w i t h r e s p e c t t o the e f f e c t i v e n e s s of r e l a p s e p r e v e n t i o n t r a i n i n g would be m i s l e a d i n g . The time l i m i t a t i o n s of the i n t e r v e n t i o n a l l o w e d f o r such l i m i t e d p r e s e n t a t i o n of r e l a p s e p r e v e n t i o n m a t e r i a l t h a t even i f s i g n i f i c a n t d i f f e r e n c e s had been found between groups, i t would be d i f f i c u l t t o a t t r i b u t e them t o t h e r e l a p s e p r e v e n t i o n component. A t r u e i n v e s t i g a t i o n of the e f f e c t s of r e l a p s e p r e v e n t i o n i n f o r m a t i o n and t r a i n i n g on people having d i f f i c u l t y m a i n t a i n i n g a weight l o s s remains t o be done. Based on the s t a t i s t i c a l l y n o n s i g n i f i c a n t f i n d i n g s of t h i s study, f u r t h e r i n v e s t i g a t i o n of the type of i n t e r v e n t i o n t h a t was o f f e r e d might appear unwarranted. The more c o n v e n t i o n a l approach which t r i e s t o r e i n f o r c e the use of b e h a v i o r a l t e c h n i q u e s has a l s o had l i m i t e d s u c c e s s , however, otherwise the p r o s p e c t of m a i n t a i n i n g weight l o s s e s f o r more than a year would be b r i g h t e n i n g . The f o c u s of t h i s program on s e l f - u n d e r s t a n d i n g and s e l f - a c c e p t a n c e made i t one t h a t the p a r t i c i p a n t s almost unanimously d e s c r i b e d as b e i n g too s h o r t , both i n s e s s i o n l e n g t h and i n d u r a t i o n of the program. I t i s recommended t h a t f u t u r e r e s e a r c h on t h i s 100 type of program takes t h i s i n t o account. A program l a s t i n g 8 t o 12 weeks, w i t h s e s s i o n s 1 and a h a l f t o 2 hours l o n g seems b e t t e r s u i t e d t o the o b j e c t i v e s o u t l i n e d . A f u r t h e r recommendation f o r f u t u r e r e s e a r c h i n t h i s a rea i s t h a t o t h e r measures be developed or used which show l e s s s u s c e p t i b i l i t y t o dramatic change. In one or two cases i t was u n c l e a r whether an i n d i v i d u a l had r e a l l y had such l a r g e i n c r e a s e s i n s e l f - e f f i c a c y or had j u s t misunderstood the s c o r i n g method a t p r e t e s t . The Ways of Coping C h e c k l i s t proved d i f f i c u l t t o a d m i n i s t e r i n a group s e t t i n g . Some p a r t i c i p a n t s d i d not r e c o r d what n e g a t i v e a f f e c t they had e x p e r i e n c e d and t h i s made i t u n c l e a r whether they understood the v e r b a l i n s t r u c t i o n s and those p r i n t e d on the q u e s t i o n n a i r e . In other r e s e a r c h t h i s s c a l e has been a d m i n i s t e r e d f o l l o w i n g a p e r s o n a l i n t e r v i e w t o e s t a b l i s h t h a t the s t r e s s o r has been c l e a r l y i d e n t i f i e d (Folkman e t a l . , 1987). To use i t i n a group format, i t i s recommended t h a t the p r o c e s s of i d e n t i f y i n g the s t r e s s o r be c a r e f u l l y done b e f o r e the coping s c a l e i s used. M a i n t a i n i n g a weight l o s s i s a d i f f i c u l t g o a l , and one t h a t few s u c c e s s f u l d i e t e r s achieve. Even those people who make s i g n i f i c a n t l i f e s t y l e and food management changes i n t h e p r o c e s s of weight l o s s f ace a f o r m i d a b l e c h a l l e n g e f o r t h e r e s t of t h e i r l i v e s . Recent s t u d i e s on g e n e t i c p r e d i s p o s i t i o n t o o b e s i t y (Bouchard e t a l . , 1990; Stunkard e t a l . , 1990) c o n f i r m what some overweight people have long suspected, t h a t m a i n t a i n i n g an i d e a l body weight i s f a r more 1 0 1 d i f f i c u l t f o r some people than o t h e r s . The focus i n weight l o s s treatment programs on t e a c h i n g "good" e a t i n g h a b i t s i m p l i e s t h a t ignorance and c a r e l e s s n e s s are r e s p o n s i b l e f o r weight problems, and promises l a s t i n g success once new h a b i t s are i n p l a c e . C l e a r l y i t i s not t h a t s i m p l e . What i s needed i s more r e s e a r c h t h a t c a r r i e s on the work done on s e l f - e f f i c a c y and coping i n weight l o s s treatment and a p p l i e s i t t o weight l o s s maintenance t r e a t m e n t s . B e t t e r measurements of s e l f - e f f i c a c y and c o p i n g must be developed t h a t are more s p e c i f i c t o the problems f a c e d by people t r y i n g t o m a i n t a i n a weight l o s s . T h i s w i l l enable r e s e a r c h e r s t o l e a r n more about what happens when s u c c e s s f u l d i e t e r s begin t o r e l a p s e and e v e n t u a l l y develop treatments t h a t can r e v e r s e the p r o c e s s . E x p l o r a t o r y r e s e a r c h i s n e c e s s a r y because the problem i s one f o r which no s o l u t i o n has y e t been found. The more t h a t i s l e a r n e d about t h i s group of i n d i v i d u a l s , even i n the course of i n t e r v e n t i o n s t h a t have l i t t l e e f f e c t , the sooner the p r o c e s s of r e l a p s e can be understood and u l t i m a t e l y r e v e r s e d . 102 REFERENCES Abrams, D.A., & F o l l i c k , M. J . (1983). 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E f f e c t s of p r e e x i s t i n g and manipulated s e l f - e f f i c a c y on weight l o s s i n a s e l f - c o n t r o l program. J o u r n a l of Research i n P e r s o n a l i t y , 18, 352-358. Appendix A Demographic P r o f i l e Informed Consent Form A t t r i b u t i o n S c a l e 1 0 CODE DEMOGRAPHIC QUESTIONNAIRE P l e a s e answer a l l the f o l l o w i n g q u e s t i o n s as they are important f o r r e s e a r c h purposes. Your name w i l l not be a s s o c i a t e d w i t h any of t h i s i n f o r m a t i o n and i t w i l l be kept s t r i c t l y c o n f i d e n t i a l . M a r i t a l s t a t u s : Married/commonlaw r e l a t i o n s h i p S i n g l e D i v o r c e d / s e p a r a t e d Widowed Employment s t a t u s : Employed f u l l - t i m e ( f o r any employer or self-employed) P a r t - t i m e R e t i r e d : Student Age: (years) Height: (inches) Weight: ( l b s . ) T a r g e t weight: ( l b s . ) How much weight d i d you l o s e , from h i g h e s t weight t o t a r g e t weight (or below)? Weight l o s s ( l b s . ) How l o n g ago d i d you reach your goal? (months) How long d i d you ma i n t a i n your t a r g e t weight w i t h no more than a f i v e pound gain? (months) EXERCISE Would you r a t e y o u r s e l f as: (please check one) Sedentary Moderately A c t i v e A c t i v e (no e x e r c i s e ( o c c a s i o n a l walks, ( r e g u l a r planned beyond d a i l y moderate e x e r t i o n ) e x e r c i s e t h a t r o u t i n e ) r a i s e s a sweat) Has t h i s changed s i n c e you f i r s t reached your t a r g e t weight? In what way has i t changed? i09 I f you checked Moderately A c t i v e , or A c t i v e , p l e a s e l i s t which a c t i v i t i e s you do weekly. How many times weekly? How l o n g does a s e s s i o n l a s t ? (minutes) MAINTENANCE Which ( i f any) of the f o l l o w i n g maintenance t e c h n i q u e s do you use? P l e a s e c i r c l e the number u s i n g t h i s s c a l e t o i n d i c a t e how much or how l i t t l e you use each one: 0 1 2 3 4 not used seldom sometimes o f t e n always used used used used 1. Keeping t r a c k of food amounts or c a l o r i e s ? 0 1 2 3 4 2. Weighing y o u r s e l f once a week? 0 1 2 3 4 (Do you weigh i n more often? How often? (times weekly) 3. C o n t r o l l i n g amounts of food by weighing or measuring (ex., h a l f a cup of skim milk, 4 oz. of f i s h , e t c . ) 0 1 2 3 4 4. P u t t i n g y o u r s e l f on a more s t r u c t u r e d e a t i n g and/or e x e r c i s e p l a n a f t e r g a i n i n g a s p e c i f i e d number of pounds? 0 1 2 3 4 (What i s your s p e c i f i e d number of pounds? ) I l l ATTRIBUTION SCALE When you c o n s i d e r most of the o c c a s i o n s i n which you have eaten more than you should i f you want t o m a i n t a i n your weight l o s s , what do you f e e l was the major cause? W r i t e i t down i n t h e space p r o v i d e d i f you wish. Major Cause: Think about t h i s major cause, then look a t the items below. P l e a s e c i r c l e the number which i s c l o s e s t t o your o p i n i o n f o r each of the f o l l o w i n g s c a l e s . 1. I s the major cause something t h a t : R e f l e c t s an a s p e c t of y o u r s e l f R e f l e c t s an as p e c t of the s i t u a t i o n 2. I s the major cause: C o n t r o l l a b l e by you or o t h e r people U n c o n t r o l l a b l e by you or o t h e r people Is the major cause something t h a t i s : Permanent Temporary 1 2 3 4 5 6 7 8 9 APPENDIX B The E a t i n g S e l f - E f f i c a c y S c a l e (ESES) The Ways of Coping C h e c k l i s t (WCCL) E a t i n g S e l f - E f f i c a c y S c a l e For each of the s i t u a t i o n s below, p l e a s e r a t e the l i k e l i h o o d you would have d i f f i c u l t y c o n t r o l l i n g your e a t i n g , u s i n g t h i s s c a l e : 1 2 3 4 5 6 7 No Moderate Most D i f f i c u l t y D i f f i c u l t y D i f f i c u l t y C o n t r o l l i n g O v e r e a t i n g For example, i f you t h i n k you have g r e a t d i f f i c u l t y c o n t r o l l i n g o v e r e a t i n g when you are a t a p a r t y , you might complete an item s p e c i f y i n g p a r t i e s t h i s way: O v e r e a t i n g a t p a r t i e s 1 2 3 4 5 (6) 7 P l e a s e complete every item. How d i f f i c u l t i s i t t o c o n t r o l your .... 1. O v e r e a t i n g a f t e r work or school? 1 2 3 4 5 6 7 2 . O v e r e a t i n g when you f e e l r e s t l e s s ? 1 2 3 4 5 6 7 3 . O v e r e a t i n g around h o l i d a y time? 1 2 3 4 5 6 7 4 . O v e r e a t i n g when you f e e l upset? 1 2 3 4 5 6 7 5. O v e r e a t i n g when tense? 1 2 3 4 5 6 7 6. O v e r e a t i n g w i t h f r i e n d s ? 1 2 3 4 5 6 7 7. O v e r e a t i n g when p r e p a r i n g food? 1 2 3 4 5 6 7 8. O v e r e a t i n g when i r r i t a b l e ? 1 2 3 4 5 6 7 9 . O v e r e a t i n g as p a r t of a s o c i a l o c c a s i o n d e a l i n g with food — l i k e a t a r e s t a u r a n t or d i n n e r p a r t y ? 1 2 3 4 5 6 7 10 . O v e r e a t i n g w i t h f a m i l y members? 1 2 3 4 5 6 7 11 . O v e r e a t i n g when annoyed? 1 2 3 4 5 6 7 12 . O v e r e a t i n g when angry? 1 2 3 4 5 6 7 114 No Moderate Most D i f f i c u l t y D i f f i c u l t y D i f f i c u l t y C o n t r o l l i n g O v e r e a t i n g How d i f f i c u l t i s i t f o r you t o c o n t r o l your ... 13 . O v e r e a t i n g when you are angry a t y o u r s e l f ? 1 2 3 4 5 6 7 14 . O v e r e a t i n g when depressed? 1 2 3 4 5 6 7 15. O v e r e a t i n g when you f e e l i m p a t i e n t ? 1 2 3 4 5 6 7 16. O v e r e a t i n g when you want t o s i t back and enjoy some food? 1 2 3 4 5 6 7 17 . O v e r e a t i n g a f t e r an argument? 1 2 3 4 5 6 7 18 . O v e r e a t i n g when you f e e l f r u s t r a t e d ? 1 2 3 4 5 6 7 19. O v e r e a t i n g when tempting food i s i n f r o n t o f you? 1 2 3 4 5 6 7 20. O v e r e a t i n g when you want t o cheer up? 1 2 3 4 5 6 7 21. O v e r e a t i n g when th e r e i s a l o t of food a v a i l a b l e t o you? 1 2 3 4 5 6 7 22 . O v e r e a t i n g when you f e e l o v e r l y s e n s i t i v e ? 1 2 3 4 5 6 7 23 . O v e r e a t i n g when nervous? 1 2 3 4 5 6 7 24. O v e r e a t i n g when hungry? 1 2 3 4 5 6 7 25. O v e r e a t i n g when anxious or worried? 1 2 3 4 5 6 7 26. O v e r e a t i n g when 1 2 3 4 5 6 7 ( f i l l i n your own s i t u a t i o n i f you f e e l i t i s m i s s i n g from l i s t above). 115 WAYS OF COPING CHECKLIST P l e a s e take a few minutes t o t h i n k about a r e c e n t time ( w i t h i n t h e p a s t week or two i f p o s s i b l e ) when you a t e more than you knew was c o n s i s t e n t with m a i n t a i n i n g your g o a l weight and f e l t upset about i t . B r i e f l y d e s c r i b e the s i t u a t i o n i n the space below, paying a t t e n t i o n t o the c i r c u m s t a n c e s , i n c l u d i n g what l e d up t o i t , and j u s t how you f e l t a f t e r o v e r e a t i n g . Now, p l e a s e read each item below and i n d i c a t e , by c i r c l i n g t h e a p p r o p r i a t e category, t o what e x t e n t you used i t i n the s i t u a t i o n you have s e l e c t e d . Not Used Used Used a used some- q u i t e g r e a t what a b i t d e a l 1. Changed something so t h i n g s would t u r n out a l l r i g h t . 0 1 2 3 2. Thought about f a n t a s t i c or u n r e a l t h i n g s ( l i k e p e r f e c t revenge or f i n d i n g a m i l l i o n d o l l a r s ) t h a t made me f e e l b e t t e r . 0 1 2 3 3. T a l k e d t o someone t o f i n d out about the s i t u a t i o n . 0 1 2 3 4. Changed or grew as a person i n a good way. 0 1 2 3 5. T r i e d not t o a c t too h a s t i l y o r f o l l o w my own hunch. 0 1 2 3 6. Bargained or compromised t o g e t something p o s i t i v e from the s i t u a t i o n . 0 1 2 3 I knew what had to be done, so I doubled my e f f o r t s and t r i e d harder t o make t h i n g s work. 8. F e l t bad t h a t I c o u l d n ' t a v o i d the problem. 9. Refused t o b e l i e v e i t had happened. 10. Made a p l a n of a c t i o n — and f o l l o w e d i t . 11. T r i e d t o f o r g e t the whole t h i n g . 12. T r i e d t o make myself f e e l b e t t e r by e a t i n g , d r i n k i n g , smoking, t a k i n g m e d i c a t i o n s . 13. A ccepted sympathy and under- s t a n d i n g from someone. 14. T r i e d not to burn my b r i d g e s behind me, but l e f t t h i n g s open somewhat. 15. S l e p t more than u s u a l . 16. Daydreamed or imagined a b e t t e r time or p l a c e than the one I was i n . 17. T a l k e d t o someone who c o u l d something about the problem. 18. C o ncentrated on something good t h a t c o u l d come out of the whole t h i n g . 19. T a l k e d t o someone about how I was f e e l i n g . 20. Came up w i t h a couple of d i f f e r e n t s o l u t i o n s t o the problem. 21. Wished t h a t I c o u l d change what had happened. 116 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 22. Went on as i f n o t h i n g had happened. 23. Wished t h a t I c o u l d change the way I f e l t . 24. Stood my ground and fought f o r what I wanted. 25. Changed something about myself so I c o u l d d e a l w i t h the s i t u a t i o n b e t t e r . 26. Wished I was a s t r o n g e r person — more o p t i m i s t i c and f o r c e f u l . 27. Got mad a t the people or t h i n g s t h a t caused the problem. 28. R e a l i z e d I brought the problem on myself. 29. Wished the s i t u a t i o n would go away or somehow be f i n i s h e d . 30. J u s t took t h i n g s one step a t a time. 31. Got p r o f e s s i o n a l h e l p and d i d what was recommended. 32. Hoped a m i r a c l e would happen. 33. Asked someone I r e s p e c t e d f o r a d v i c e and f o l l o w e d i t . 34. Avoided being w i t h people i n g e n e r a l . 35. Came out of the experience b e t t e r than when I went i n . 36. Kept o t h e r s from knowing how bad t h i n g s were. 37. Had f a n t a s i e s or wishes about how t h i n g s might t u r n out. 38. Blamed myself. 1 1 7 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 . Accepted the s t r o n g f e e l i n g s , but d i d n ' t l e t them i n t e r f e r e w i t h o t h e r t h i n g s too much. Kept my f e e l i n g s t o myself. C r i t i c i z e d or l e c t u r e d myself. Accepted the next b e s t t h i n g t o what I wanted. 119 R e l i a b i l i t y and v a l i d i t y f o r the WCCL Because c o p i n g i s c o n c e p t u a l i z e d as a p r o c e s s t h a t changes over time, t e s t - r e t e s t r e l i a b i l i t y of the WCCL i s d i f f i c u l t t o measure. I n t e r n a l c o n s i s t e n c y of the s c a l e has been demonstrated by Folkman and Lazarus (1980). F i r s t , p r o j e c t members showed 91% agreement i n c l a s s i f y i n g items on the s c a l e as e i t h e r problem-focused or emotion-focused c o p i n g . In a study i n which t h r e e v i g n e t t e s d e s c r i b i n g s t r e s s f u l s i t u a t i o n s were presented t o undergraduate s t u d e n t s , items on the s c a l e were c l a s s i f i e d as problem- f o c u s e d o r emotion-focused coping, with 78% of the items i d e n t i f i e d as s e r v i n g the same f u n c t i o n s p e c i f i e d by p r o j e c t members. In an independent sample, the mean a l p h a (Cronbach, 1951) ac r o s s two a d m i n i s t r a t i o n s was .80 f o r the problem-focused s u b s c a l e and .81 f o r the emotion-focused s u b s c a l e . Only modest c o r r e l a t i o n s between the problem- f o c u s e d and emotion-focused s u b s c a l e s were found. C o n s t r u c t and concurrent v a l i d i t y have been demonstrated i n a s e r i e s of s t u d i e s , some of which a re r e p o r t e d here. Folkman and Lazarus (1980) found t h a t both problem- and emotion-focused coping were used i n 98% of the s t r e s s f u l encounters of a sample of 100 middle-aged community r e s i d e n t s whose s e l f - r e p o r t e d s t r e s s f u l events were s t u d i e d over the course of a year, and who completed the WCCL a t r e g u l a r i n t e r v a l s . T h i s r e s u l t was r e p l i c a t e d 120 i n a l a t e r study of the s t r a t e g i e s used by c o l l e g e s t u d e n t s t o cope w i t h a s i n g l e s t r e s s f u l event, an exam (Folkman & L a z a r u s , 1985). S e v e r a l s t u d i e s have i n v e s t i g a t e d the r e l a t i o n s h i p between c o p i n g and t h e o r e t i c a l l y r e l e v a n t p e r s o n a l i t y c h a r a c t e r i s t i c s . Heppner, Reeder, and Larson (1983) s t u d i e d the r e l a t i o n s h i p between p r o b l e m - s o l v i n g s k i l l and c o p i n g , f i n d i n g t h a t t h e i r 26 s e l f - a s c r i b e d e f f e c t i v e problem s o l v e r s used more problem-focused means of c o p i n g and were l e s s l i k e l y t o blame themselves than an equal number of s e l f - a s c r i b e d poor problem s o l v e r s . Parkes (1984) looked a t the r e l a t i o n s h i p between copinq and l o c u s of c o n t r o l i n a sample of 171 student nurses, f i n d i n g t h a t s t u d e n t s w i t h an i n t e r n a l c o n t r o l o r i e n t a t i o n seemed b e t t e r a b l e t o a s s e s s the s p e c i f i c demands of a s i t u a t i o n and thus t o s e l e c t more a p p r o p r i a t e c o p i n g s t r a t e g i e s . APPENDIX C Expectancy S c a l e P a r t i c i p a n t S e s s i o n E v a l u a t i o n 122 Expectancy S c a l e P l e a s e i n d i c a t e your response t o each q u e s t i o n by c i r c l i n g the number a t the p o i n t which i s c l o s e s t t o your f e e l i n g s . 1. How c o n f i d e n t are you t h a t t h i s program w i l l be s u c c e s s f u l i n improving your long-term a b i l i t y t o m a i n t a i n your weight l o s s ? 0 1 2 3 4 5 6 Not a t a l l Somewhat Very much so 2. How l o g i c a l does t h i s program seem t o you as one t h a t c o u l d i n c r e a s e the l i k e l i h o o d o f weight l o s s maintenance? 0 1 2 3 4 5 6 Not a t a l l Somewhat Very much so 3. How c o n f i d e n t would you be i n recommending t h i s program t o a f r i e n d who was having t r o u b l e w i t h weight l o s s maintenance? 0 1 2 3 4 5 6 Not a t a l l Somewhat Very much so 123 Se s s i o n E v a l u a t i o n 1. How p r o d u c t i v e or u s e f u l was today's s e s s i o n f o r you? 1. v e r y low 2. low 3. moderate 4. h i g h 5. v e r y h i g h 2. How important t o you were the problems or s i t u a t i o n s d i s c u s s e d i n the group today? 1. not a t a l l important; i r r e l e v a n t 2. somewhat unimportant 3. n e i t h e r important nor unimportant 4. somewhat important 5. v e r y important 3. How would you d e s c r i b e the i n f o r m a t i o n t h a t i s b e i n g presented? 1. something you a l r e a d y know and are not i n t e r e s t e d i n h e a r i n g more about 2. something you a l r e a d y know but are w i l l i n g t o hear more about 3. something you d i d n ' t know and are w i l l i n g t o hear about 4. something you d i d n ' t know but are not i n t e r e s t e d i n h e a r i n g about 4. How c o m f o r t a b l e are you with the way the i n f o r m a t i o n i s b e i n g p r e s e n t e d ( i . e . , group d i s c u s s i o n s , s h o r t p r e s e n t a t i o n s ? 1. v e r y uncomfortable 2. somewhat uncomfortable 3. n e i t h e r uncomfortable or comfo r t a b l e ; n e u t r a l 4. somewhat comfortable 5. v e r y comfortable 5. I f you wish t o add any comments, p l e a s e f e e l f r e e t o do so i n the space below or on the other s i d e of the page. APPENDIX D M u l t i v a r i a t e and U n i v a r i a t e Analys f o r Dependent Measures 125 M u l t i v a r i a t e and U n i v a r i a t e A n a l y s e s f o r S e l f - E f f i c a c y and Percentage of Problem-Focused Coping I n i t i a l Groups (MI. RPI , WL) F E df M u l t i v a r i a t e Group E f f e c t 1.95 . 11 4,78 U n i v a r i a t e s S e l f - E f f i c a c y 2.72 .08 2 , 40 % P-F Coping 2.55 .09 2 , 40 M u l t i v a r i a t e Time E f f e c t P r e t e s t t o P o s t t e s t <1 .51 2,39 U n i v a r i a t e s S e l f - E f f i c a c y <1 .49 1,40 % P-F Coping <1 . 38 1,40 M u l t i v a r i a t e Time E f f e c t P o s t t e s t t o F o l l o w -up 1. 17 . 32 2 , 39 U n i v a r i a t e s S e l f - E f f i c a c y <1 . 63 1,40 % P-F Coping 2.27 . 14 1,40 M u l t i v a r i a t e Group x Time E f f e c t P r e t e s t t o P o s t t e s t <1 .87 4,78 U n i v a r i a t e s S e l f E f f i c a c y <1 .77 2 , 40 % P-F Coping <1 .72 2 ,40 M u l t i v a r i a t e Group x Time E f f e c t P o s t t e s t t o Follow-up <1 .45 4,78 U n i v a r i a t e s S e l f - E f f i c a c y 1. 64 .21 2,40 % P-F Coping <1 .73 2 , 40 126 M u l t i v a r i a t e and U n i v a r i a t e A nalyses f o r S e l f - E f f i c a c y and Percentage of Problem-Focused Coping Second Treatment Groups (MI 2 and RPI2) F E df M u l t i v a r i a t e Group E f f e c t 1.32 .30 2 ,14 U n i v a r i a t e s S e l f - E f f i c a c y 1. 98 . 18 1,15 % P-F Coping 2.44 . 14 1, 15 M u l t i v a r i a t e Time E f f e c t P r e t e s t t o P o s t t e s t 2 . 60 • 11 2, 14 U n i v a r i a t e s S e l f - E f f i c a c y 4.66 . 05 1, 15 % P-F Coping 1.87 . 19 1, 15 M u l t i v a r i a t e Time E f f e c t P o s t t e s t t o F o l l o w -up <1 .40 2, 14 U n i v a r i a t e s S e l f - E f f i c a c y 2 . 12 . 17 1, 15 % P-F Coping <1 .68 1, 15 M u l t i v a r i a t e Group x Time E f f e c t P r e t e s t t o P o s t t e s t <1 . 52 2 ,14 U n i v a r i a t e s S e l f E f f i c a c y 1.48 .24 1,15 % P-F Coping <1 . 82 1, 15 M u l t i v a r i a t e Group x Time E f f e c t P o s t t e s t t o F o l l o w -up <1 .73 2 , 14 U n i v a r i a t e s S e l f - E f f i c a c y <1 .43 1, 15 % P-F Coping <1 .63 1, 15 127 M u l t i v a r i a t e and U n i v a r i a t e A n a l y s e s f o r S e l f - E f f i c a c y and Percentage of Problem-Focused Coping Combined Treatment Groups (MI-C and RPI-C) F P. df M u l t i v a r i a t e Group E f f e c t 4.00 . 026 2 , 40 U n i v a r i a t e s S e l f - E f f i c a c y 7.22 .01 1,41 % P-F Coping 4.23 . 05 1,41 M u l t i v a r i a t e Time E f f e c t P r e t e s t t o P o s t t e s t 2 . 62 . 09 2,40 U n i v a r i a t e s S e l f - E f f i c a c y 3.95 . 05 1,41 % P-F Coping 2 .16 . 15 1,41 M u l t i v a r i a t e Time E f f e c t P o s t t e s t t o Follow-up 2.64 . 08 2,40 U n i v a r i a t e s S e l f - E f f i c a c y 4 76 . 04 1,41 % P-F Coping 1.75 . 19 1,41 M u l t i v a r i a t e Group x Time E f f e c t P r e t e s t t o P o s t t e s t 1.17 . 32 2 ,40 U n i v a r i a t e s S e l f E f f i c a c y 2 . 11 . 15 1,41 % P-F Coping <1 .46 1,41 M u l t i v a r i a t e Group x Time E f f e c t P o s t t e s t t o Follow-up 1.43 .25 2 , 40 U n i v a r i a t e s S e l f - E f f i c a c y 2 .77 . 10 1,41 % P-F Coping <1 .98 1,41

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