the relationship of self-esteem and self-efficacy to treatment outcomes of alcohol-dependent men and...

The Relationship of Self-Esteem and Self-Efficacy toTreatment Outcomes of Alcohol-Dependent Men and Women

Elisa M. Trucco, BA,1 Hilary Smith Connery, MD, PhD,1,2 Margaret L. Griffin, PhD,1,2

Shelly F. Greenfield, MD, MPH1,2

1McLean Hospital, Alcohol and Drug Abuse Treatment Program, Belmont, Massachusetts2Department of Psychiatry, Harvard Medical School, Boston, Massachusetts

This study investigates whether self-esteem is associatedwith clinical and demographic characteristics, self-efficacyexpectancies, and post-treatment drinking outcomes.Forty-one (40.6%) women and 60 (59.4%) men wererecruited during inpatient alcohol dependence treatment.At baseline, lower self-esteem was significantly associatedwith current depression and other psychiatric disorders.Self-esteem was not related to gender, relapse, other one-year drinking outcomes, or self-efficacy. Age and psychiatricdisorders were strong predictors of self-esteem at follow-up.This study suggests that different perceptions of the self haveunique roles in recovery from alcohol use disorders. (Am JAddict 2007;16:85–92)

INTRODUCTION

Considerable research has been directed toward under-standing the etiology of alcohol use disorders. Currentresearch has focused on individual attributes as predictorsof alcohol misuse and abuse.1–9 Self-esteem in particularhas been implicated in the development of alcohol use dis-orders,1–7 while an individual’s self-efficacy has beenimplicated in alcohol relapse and recovery.10–16 Descrip-tions of personal attributes of individuals with alcoholdependence often include low self-esteem.2,5–9 Many stu-dies report that self-esteem ratings are lower among alco-hol-abusing populations compared to non-alcohol-abusing samples.2,6–9 In a prospective study of collegefreshmen, Walitzer reports that low self-esteem at base-line predicted alcohol use disorders three years later inwomen, though not in men.1 Although self-esteem deficitshave been implicated in the development of alcohol use

disorders across genders,6,17,18 women with poor-selfesteem appear to be at greater risk for developing druguse disorders compared to men.1,2,5,7,12

Substance abuse treatment programs frequently focuson enhancing self-esteem. Several studies report increasedlevels of self-esteem after substance abuse treatment, com-pared to levels at the beginning of treatment.5,19,20 Otherstudies, however, report lower self-esteem post-treatmentamong those with alcohol use disorders compared to con-trol participants with alcohol use disorders not receivingtreatment.21 Despite a lack of consistent evidence for sub-stance abuse treatment effects on self-esteem enhance-ment, substance abuse treatment programs commonlydiscuss a ‘‘deficit model’’ of self-esteem and teach self-esteem enhancement skills.2–4,22,23 Moreover, althoughpoor self-esteem may contribute to the development ofalcohol use disorders, there is scarce evidence suggestingthat increasing self-esteem in alcohol-abusing populationswill affect treatment outcomes or reduce relapse ratespost-treatment.

Studies focusing on alcohol treatment outcomes andrelapse tend to focus on another aspect of self-perception,self-efficacy. Bandura defines self-efficacy as the beliefthat one has the ability to cope effectively with high-risksituations.24 The cognitive-behavioral theory10 posits thathigher confidence in the ability not to drink in a high-risksituation is associated with the effective use of copingstrategies and lower relapse rates. In fact, a growingnumber of studies have reported that self-efficacy expec-tancies regarding drinking may predict relapse or absti-nence following treatment in individuals with alcoholuse disorders.10–16 Studies indicate that individuals withhigher self-efficacy scores are less likely to relapse13,15

and more likely to remain abstinent up to six monthsfollowing treatment.11 Similarly, low self-efficacy expec-tancies as measured by the Situational Confidence Ques-tionnaire (SCQ)25 were predictive of relapse during the 12months following inpatient detoxification from alcohol.16

Received November 10, 2005; revised December 14, 2005;accepted January 13, 2006.

This article not subject to United States copyright law.Address correspondence to Dr. Greenfield, 115 Mill Street,

Belmont, MA 02478. E-mail: [email protected].

The American Journal on Addictions, 16: 85–92, 2007

ISSN: 1055-0496 print / 1521-0391 online

DOI: 10.1080/10550490601184183

85

Theoretical and methodological limitations must beacknowledged in the self-esteem and substance use litera-ture. Although current literature suggests that individualswith alcohol dependence tend to have lower self-esteemratings than those without the disorder, the relationshipbetween self-esteem and alcohol misuse or relapseremains unclear. Longitudinal studies examining the rolethat self-esteem plays in the return to drinking or absti-nence are lacking, as are controlled studies of drinkingoutcomes with self-esteem-enhancing treatment. Thepurpose of this study is to measure self-esteem and self-efficacy independently within the same cohort of alco-hol-dependent men and women. By analyzing these twoaspects of individual self-perception separately, informa-tion regarding their unique roles and the extent to whichthey relate to relapse following inpatient hospitalizationcan be examined. This study investigated the relationshipbetween self-esteem and treatment outcomes in 101 alco-hol-dependent men and women in the 12 months follow-ing discharge from inpatient alcohol treatment. Weexamined whether self-esteem is associated with specificdemographic and clinical characteristics during inpatientalcohol treatment, self-efficacy expectancies, and post-treatment drinking outcomes.

METHOD

Participants

Alcohol-dependent participants (N ¼ 101) were re-cruited from consecutive admissions to McLean Hospital’sAlcohol and Drug Abuse Treatment Program inpatientunit. The methods for this study have been described indetail elsewhere.16,26–28 Patients were asked to participatein a study evaluating gender differences in recovery fromalcohol dependence following inpatient treatment. Partici-pants were eligible for the study if they were 18 years ofage or older and met criteria for a current diagnosis of alco-hol dependence. Participants meeting criteria for other sub-stance use disorders were eligible as long as alcohol was theprimary substance of abuse; those with most other Axis Idiagnoses were also considered eligible. Exclusion criteriawere living too far away to complete follow-up assessmentsand cognitive or physical impairment that could interferewith participation in study protocol. The sociodemographiccharacteristics of the study sample are reported below.

Procedure

Participants were recruited during inpatient hospitali-zation for alcohol dependence. After detoxification, thoseparticipants who were eligible signed informed consent.Each participant completed two two-hour sessions, whichincluded structured interviews and self-report question-naires as described below. The mean (�SD) length ofinpatient hospitalization for participants eligible andenrolled in the study was 12.7� 5.5 days, and the rangewas 4–28 days.16

Measures

Self-Esteem

Self-esteem was measured using the Rosenberg Self-Esteem Scale (RSE).29 The Rosenberg Scale is a 10-itemquestionnaire with items answered on a four-point Likertscale. The questionnaire measures how strongly the parti-cipant agrees or disagrees with declarative statementsrelated to self-satisfaction (eg, ‘‘At times I think thatI am no good at all’’), with a total score ranging fromzero to six. On the RSE, a higher score represents worseself-esteem.

Self-Efficacy

Self-efficacy expectancies were measured using theSituational Confidence Questionnaire (SCQ).25 The SCQis a 39-item self-report questionnaire assessing how confi-dent the subject feels about not drinking in specified situa-tions (eg, unpleasant emotions, conflict with others, andsocial pressure to drink) on a scale ranging from 0%to 100%. On the SCQ, a higher score reflects a higherdegree of confidence in the ability to refrain from drinkingheavily in each situation. The SCQ was administered toeach subject during inpatient hospitalization but not atfollow-up assessments.

Alcohol Use and Drinking Outcomes

Alcohol dependence was measured using the Struc-tured Clinical Interview for DSM-III-R (SCID),30 a stan-dardized clinical interview that allows the interviewer tomake DSM-III-R diagnoses. Sociodemographic informa-tion and lifetime history of alcohol and drug use wereassessed using a revised version of the Drug and AlcoholUse Questionnaire,31 a 138-item self-report instrumentthat we have used extensively in substance abuse treat-ment studies.16,26–28 The Timeline Follow-Back (TLFB),32

a standardized interview, was used to record drinks perdrinking day for the 30 days prior to hospitalization, totalnumber of drinking days following hospitalization, timeto first relapse, and time to first drink. As described inprevious articles,16,26–28 we chose to use a conservativedefinition of relapse based on work33 demonstrating thatrisks of problematic alcohol consumption increasearound 60 grams per day for men and 40 grams per dayfor women. A standard drink is defined as 13.6 g of abso-lute alcohol.32 Therefore, relapse was defined as three ormore standard drinks on a drinking day for women,and five or more on a drinking day for men.33

Statistical Analysis

To compare gender by background variables, chi-square was used for categorical variables and indepen-dent t-tests for continuous variables. Self-efficacy andself-esteem were examined using independent t-tests fordichotomous variables and Pearson correlation coeffi-cients for continuous variables. For self-esteem scores

86 Self-Esteem and Alcohol Treatment Outcomes March–April 2007

only, tests were conducted at both baseline and at12-month follow-up. Participants who completed the12-month follow-up were compared to dropouts on back-ground variables using chi-square for categorical variablesand independent t-tests for continuous variables. Pairedt-tests were conducted to analyze changes in self-esteemscores from baseline to 12-month follow-up.

Multiple linear regression models were created relat-ing demographic, alcohol, diagnostic, and drinking out-come variables considered separately to self-efficacy atbaseline and self-esteem at both baseline and at12-month follow-up to control for confounding vari-ables. Independent variables were entered in blocks:demographic variables (including baseline self-esteemscores for self-efficacy and self-esteem at follow-up) wereadded first, followed by alcohol history variables, diag-nostic variables, and finally post-treatment drinking out-comes (for self-esteem at follow-up only). A secondregression model was created relating demographic,drinking history, diagnostic, and self-perception ratingvariables to post-treatment drinking outcomes so as tocontrol for confounding variables. Independent variableswere entered in blocks: demographic variables wereadded first, followed by drinking history variables, diag-nostic variables, and finally self-perception ratings (self-efficacy and self-esteem at baseline). Only independentvariables with p < .10 in the intermediate models wereincluded in the final models. All analyses used SPSS13.0 for Windows.

RESULTS

Sample Description

As previously reported,16,26–28 age, race, and maritalstatus did not differ significantly by gender (see Table 1).However, men did have significantly fewer years of educa-tion compared to women (v2(1) ¼ 5.1; p < .05). Men werealso significantly more likely to be employed full time(v2(3) ¼ 25.0; p < .001) outside the home. Participantsassessed at follow-up (n ¼ 71) were similar to dropouts(n ¼ 30) on all background variables.

Self-Efficacy by Background Characteristics

Baseline self-efficacy scores were obtained from 100participants (59.0% males). The mean (�SD) for all par-ticipants on the SCQ was 65.80� 25.67. Self-efficacy wasanalyzed by both background and clinical characteristics.Married participants reported a significantly higher over-all self-efficacy score at baseline (t(96.21)¼� 3.85;p < .001) than unmarried participants. There were nosignificant differences in self-efficacy expectancies acrossother background variables, alcohol history characteri-stics (eg, first drinking experience), or reporting anycurrent psychiatric diagnoses at baseline.

Self-Esteem by Background Characteristics

Baseline self-esteem scores were obtained from 101participants (59.4% male) and follow-up at monthtwelve from 71 participants (59.1% male, see Table 2).

TABLE 1. Comparison of women and men by background characteristics

Women (n ¼ 41) Men (n ¼ 60)

Background variablesAge (Mean� SD) 42.00� 11.18 44.20� 10.94Race n (%)

White 38 (92.7%) 57 (95.0%)Black 2 (4.9%) 1 (1.7%)Other 1 (2.4%) 2 (3.3%)

Education n (%)�

High school diploma or less 6 (14.6%) 15 (25.0%)Some college or more 35 (85.4%) 45 (75.0%)

Employment, n (%)y

Employed full-time 10 (24.4%) 32 (53.4%)Disabled or retired 6 (14.6%) 20 (32.8%)Unemployed 10 (24.4%) 5 (8.6%)Other 15 (36.5%) 3 (5.2%)

Married n (%) 18 (43.9%) 24 (40.0%)Diagnostic variablesComorbid psychiatric diagnoses n (%)

Depression 19 (46.3%) 19 (31.7%)Other mood disorder 7 (17.1%) 7 (11.7%)Substance use disorder other than alcohol 6 (14.6%) 6 (10.0%)

�p < 0.05,yp < 0.001.

Trucco et al. March–April 2007 87

The mean (�SD) overall self-esteem score for allparticipants at baseline was 3.4� 1.8. There were nosignificant differences between mean self-esteem scoresfor men and women; however, self-esteem was slightlylower overall among women. There were no significantdifferences in self-esteem across age, education, or cur-rent marital status. At baseline, participants with depres-sion had significantly lower self-esteem than thosewithout depression (t(99) ¼ 3.83; p < .001); however,there was not a significant difference at the 12-monthfollow-up assessment (see Table 2). Participants withpsychiatric diagnoses other than depression or substanceuse had significantly lower self-esteem scores than thosewith no other diagnoses at both baseline (t(99) ¼� 3.55;p < .001) and at month 12 (t(44.80) ¼� 3.07; p < .01).RSE scores were not related to baseline number ofdrinking days. Younger age at first drinking experience

(p < .05) and younger age at first treatment for a sub-stance use disorder (p < .001) were related to lowerself-esteem at baseline but not at follow-up.

Baseline self-efficacy scores were not correlated withself-esteem scores at either baseline or at the 12-monthfollow-up (see Table 2). Mean self-esteem scores (�SD)for participants completing baseline and follow-up assess-ments (n ¼ 71) were 3.59 (�1.68) at baseline and 2.06(�1.80) at the 12-month follow-up. Improvement inself-esteem between baseline and follow-up was signifi-cant (t(70) ¼ 5.96; p < .001).

Relationship of Self-Esteem Scores toDrinking Outcomes

The mean (�SD) self-esteem score for participants com-pleting the follow-up assessment was 2.06� 1.80 atmonth 12. Individuals who relapsed to alcohol (n ¼ 74)

TABLE 2. Relationship of background characteristics and post-treatment drinking outcomes to self-esteem at baseline and follow-up (means and

correlations)

Self-esteem scores

Baseline (n ¼ 101) Follow-up (n ¼ 71)

I. Background variablesGender (mean� SD)

Male 3.23 (� 1.83) 1.93 (� 1.91)Female 3.56 (� 1.70) 2.24 (� 1.64)

Age (r) � .055 � .381z

Education (r) � .080 � .212Married (mean� SD)

Yes 3.68 (� 1.91) 2.53 (� 1.90)No 3.14 (� 1.66) 1.73 (� 1.68)

Drinking historyAge of first drinking experience (r) � .216� .015Age of first substance use treatment (r) � .368

z � .155# of drinking days 30 days prior to treatment (r) .051 � .178Diagnostic variablesDepression (mean� SD)

Yes 4.18 (� 1.52)z

2.43 (� 1.85)No 2.87 (� 1.75) 1.78 (� 1.73)

Diagnoses other than depressionor substance use (mean� SD)Yes 4.10 (� 1.69)

z2.89 (� 1.95)

y

No 2.89 (� 1.67) 1.55 (� 1.50)Self-Efficacy at Baseline (r) .010 .044II. Post-treatment drinking outcomesRelapse to Alcohol (mean� SD)

Yes 3.28 (� 1.69) 2.15 (� 1.89)No 3.59 (� 2.00) 1.79 (� 1.51)Time to first-relapse (r) .008 � .169Time to first-drink (r) .049 � .155Number of drinking days (r) < .001 � .049

Higher self-esteem scores represent worse self-esteem.�p < 0.05,

yp < 0.01,

zp < 0.001.


during the year following hospital discharge had lowerself-esteem levels (ie, higher scores) at follow-up com-pared to participants who did not relapse; however, thisdifference was not statistically significant (see Table 2).Baseline and follow-up self-esteem scores were not relatedto total number of drinking days recorded during the fol-low-up. Analyses demonstrated that neither baseline norfollow-up self-esteem scores were related to any of thepost-treatment drinking outcomes.

Relationship of Demographic, Clinical, andPost-Treatment Drinking Outcome Characteristicsto Self-Efficacy and Self-Esteem

Using multiple linear regression analysis, we assessedvarious predictors of self-esteem and self-efficacy scores(see Table 3). In the final model for self-esteem at base-line, age of first substance use treatment and both diag-nostic variables (ie, current depression diagnosis andother psychiatric diagnoses) remained significant. Self-esteem scores at baseline were better for participantswho were older at their first substance abuse treatmentand did not have co-occurring psychiatric diagnoses. Allthree of these variables were of similar magnitude in thebaseline self-esteem prediction model. However, addingdiagnoses other than depression or substance use to thefinal model increased the explained variance by approxi-mately five percent (22.9% to 27.3%).

In the final model for self-esteem at follow-up, severaldemographic characteristics were significant: age, educa-tion, marital status, and diagnoses other than depressionor substance use. Self-esteem scores were better for parti-cipants who were older, unmarried, had more years ofeducation, and had no co-occurring psychiatric diag-noses. A post-hoc chi-square analysis was conducted to

investigate the relationship between marital status andliving with someone with a substance use problem; thisrelationship, however, was not significant. Older agewas the strongest predictor of higher levels of self-esteemat follow-up compared to other variables in the model,followed by having a diagnosis other than depression orsubstance use. Although this diagnostic variable did nothave strong significance (p < .10), adding it to the finalmodel increased the explained variance by five percent(27.8% to 32.4%). In these multivariate models, gender,age of first drinking experience, and all post-treatmentdrinking outcomes were not significant and thereforenot entered in the final regression models.

Using multiple linear regression analysis, we alsoassessed potential predictors of post-treatment drinkingoutcomes (see Table 4). In the final model for relapseentered as a dichotomous variable, only marital statusremained significant. In the final model for time to firstdrink, education, marital status, and self-efficacy wereof similar magnitude and remained significant. In all ofthe multivariate models for post-treatment drinking out-comes, gender, age, age of first substance use, numberof drinking days 30 days prior to treatment, diagnosticvariables, and self-esteem were not significant and notentered in the final regression models.

DISCUSSION

The current study used the Rosenberg Self-EsteemScale to examine the relationships of self-esteem to socio-demographic characteristics, psychiatric diagnoses, andpost-treatment drinking outcomes. There was no signifi-cant correlation between the number of drinking daysthirty days prior to treatment and self-esteem scores

TABLE 3. Final models for self-efficacy and self-esteem (standardized beta coefficients)

Self-efficacy Self-esteem Self-esteemBaseline (n ¼ 100) Baseline (n ¼ 101) Follow-up (n ¼ 71)

Demographic variablesAge NE NE � .405�

Education NE NE � .176y

Married .367� .005 .170y

Drinking historyAge of first substance use treatment � .101 � .287

zNE

Number of drinking days 30 days priorto treatment

NE NE � .089

Diagnostic variablesCurrent depression diagnosis NE .249

zNE

Diagnoses other than depression orsubstance use

NE .228z

.221y

R2 15.9% 27.3% 32.4%

Abbreviation: NE ¼ variables that are not significant at p < 0.10 in intermediate models and therefore not entered in final models. Higher scores on

self-efficacy represent higher confidence levels, while higher self-esteem scores represent worse self-esteem.�p < 0.001,

yp < 0.10,

zp < 0.01.


either at baseline or at follow-up. This suggests that arelationship does not exist between alcohol use severityand self-esteem in this population. Younger age of firstsubstance use treatment remained a strong predictor forlower self-esteem baseline scores even when controllingfor other variables. Older age was a strong predictor ofhigher self-esteem levels following treatment. This sug-gests that age may have a more long-term effect on self-esteem levels compared to other background variables.These data are consistent with the findings of Salsali8

and Silverstone9 demonstrating that self-esteem levelsincrease with age when controlling for other backgroundvariables. The data also demonstrate a trend consistentwith previous reports demonstrating that a direct associa-tion does not exist between self-esteem and gender.1,2,34

Contrary to other reports,2 married participants in thissample reported having lower self-esteem than unmarriedparticipants at baseline and follow-up. These relation-ships, however, were significant only in follow-up predic-tion models, suggesting that marital status, like age, mighthave a more long-term effect on self-esteem after treat-ment. Based on post-hoc exploratory analysis, marriedparticipants in this sample also reported a higher incidenceof living with someone, a spouse or unrelated person, witha substance abuse problem compared to unmarried parti-cipants. This difference, however, did not reach statisticalsignificance. Research suggests that married couples havesimilar drinking patterns.35,36 Lower self-esteem may beattributed to a couple’s combined substance-related losses(eg, employment, finances, family, social support system).Further investigation of the complex relationship betweendrinking patterns of spouses and self-esteem is needed.

Findings in this study also support previous reportsthat self-esteem levels are lower in depressed partici-pants8,9,37 and in participants with other psychiatric diag-noses.8,9 The increase in explained variance when addingdiagnoses other than depression and substance use to the

final self-esteem model for baseline and follow-upsuggests that psychiatric diagnoses uniquely contributeto lower self-esteem. However, overall self-esteem scoresdid not differ from other studies of non-alcohol-dependentpopulations where mean scores of 2 to 3 were reported.38–40

This study also found that baseline self-esteem scoresdid not predict future post-treatment drinking outcomes.There were no significant relationships between any ofthe drinking outcomes as measured by the TLFB and base-line or follow-up self-esteem scores. Even though post-treatment self-esteem increased between baseline andpost-treatment follow-up, self-esteem scores were not asso-ciated with drinking outcomes. Therefore, improvement inself-esteem following alcohol treatment does not neces-sarily correlate with drinking outcomes or prevent alcoholrelapse after treatment. These findings are consistent withprevious studies that reported no association between self-esteem and relapse or treatment success.19,41,42 Therefore,even if self-esteem has a prominent role in the developmentof alcohol dependence, in our population, high levels orimprovement in self-esteem are not necessarily protectivefactors against future relapse following treatment.

Self-efficacy and self-esteem scores did not correlatesignificantly either at baseline or during follow-up, sug-gesting that self-esteem and self-efficacy are in fact dis-tinct constructs. Although the current data do notdemonstrate a significant relationship between self-esteemand drinking outcomes, there was a strong associationbetween self-efficacy and time to first drink. This finding,though seemingly contradictory, supports the premisethat different aspects of self-perceptions have distinctroles in the development of and recovery from alcoholuse disorders.43

Variations in defining self-esteem or collapsing distinctfacets of self-esteem into one global construct may contri-bute to the inconsistencies in the current self-esteem litera-ture. As suggested by Silverstone and Salsali,9 a significantdrawback in the self-esteem literature is the lack of a consis-tent and specific definition of self-esteem. Althoughresearchers have made an effort to define the self-esteemconstruct,29 without any agreement of definitions, it is verydifficult to compare results across various studies.43 Self-esteem is normally confounded or used interchangeablywith other terms such as self-efficacy and self-concept.

Other researchers suggest that a major drawback inthe self-esteem and substance use disorder literature isthe fact that only a very small percentage of variance indrug use can be explained by self-esteem, even across var-ious definitions.42,44–46 This may account for the lack ofconsistent findings in this literature and may lead to unre-liable and unsupported claims. Numerous authors havepromoted the idea that self-esteem enhancement is inte-gral to, and necessary for, achieving optimal results insubstance abuse prevention programs.43 As noted bySchroeder’s review article on the limitations of self-esteem research,43 most of these claims are based on weak

TABLE 4. Final models for post-treatment drinking (standardized

beta coefficients)

Relapse toalcohol

Time tofirst drink

Demographic variablesEducation NE .210�

Married � .240� .250�

Drinking historyAge of first substance

use treatment.140 NE

Self-perception ratingsSelf-efficacy at baseline � .121 .203�

R2 13.3% 21.6%

Abbreviation: NE ¼ variables that are not significant at p < 0.10 in

intermediate models and therefore not entered in final models. Higher

scores on self-efficacy represent higher confidence levels.�p < 0.05.


correlations and non-significant differences betweensubstance use and self-esteem. Moreover, there is littleevidence to suggest that prevention programs havedetectable effects on self-esteem2,3,47,48 or that improve-ment in self-esteem scores endures over time in thesepopulations.43 The results presented here suggest that tar-geting a more specific aspect of self-perception duringtreatment—self-efficacy expectancies—and not a moreglobal construct such as self-esteem may be moreeffective in preventing relapse rates following inpatienthospitalization.

The results extend previous work examining therelationship between self-esteem and drinking outcomesfollowing alcohol abuse treatment. This sample, however,had a high prevalence of co-occurring psychiatric comor-bidity and high severity of alcohol dependence, whichmay limit the generalizability of these findings. In addi-tion, this study has procedural limitations that shouldbe acknowledged. Self-esteem was only measured atintake and at 12 months following hospitalization. Self-esteem scores were not examined during early abstinence,and notable changes that may have occurred during earlyrecovery were therefore not captured. Also, the SCQwas only measured at baseline; therefore, changes inself-efficacy following inpatient hospitalization couldnot be assessed. In spite of these limitations, this studycontributes new information regarding the relationshipbetween self-esteem and alcohol dependence treatmentoutcomes and highlights the need for a re-examinationof self-esteem’s role in prevention efforts. Future studiesusing various methodologies may be more reliable atassessing the long-term relationship between perceptionsof the self and relapse rates following treatment in alco-hol-dependent men and women.

This research was supported by grants AA 09881 fromthe National Institute on Alcohol Abuse and Alcoholism,Bethesda, Md. (Dr. Greenfield); DA 09400, DA 07252,and DA 00407 from the National Institute on Drug Abuse,Bethesda, Md. (Dr. Greenfield); and the Dr. Ralph andMarian C. Falk Medical Research Trust, Chicago, Ill.(Dr. Greenfield).

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