Psychology of Addictive Behaviors2001, Vol. 15, No. 2, 89-96

Copyright 2001 by the Educational Publishing Foundation0893-164X/01/$5.00 DOI: 10.1037//0893-164X.15.2.89

Constructive Thinking in Adolescents With Substance Use Disorders

Robert T. AramermanChildren's Hospital Medical Center and University of Pittsburgh

School of Medicine

Kevin G. Lynch, John E. Donovan, andChristopher S. Martin

University of Pittsburgh School of Medicine

Stephen A. MaistoSyracuse University and University of Pittsburgh School of Medicine

This study examined the concurrent validity and clinical correlates of the Constructive ThinkingInventory (CTI), a measure of experiential coping, in 551 adolescents aged 14-18 years with and withoutDiagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association,1994) substance use disorders (SUDs). The CTI was correlated with depression, anxiety, and conductproblems. After controlling for demographics and comorbid lifetime psychiatric disorders, the CTI scalesof Behavioral Coping and Categorical Thinking distinguished adolescents with and without SUDs.Implications of these findings for assessment and treatment are discussed.

Coping can be defined as the cognitive and behavioral activitiesused to manage stressful events and the emotions generated bythem (D'Zurilla & Chang, 1995; Lazarus & Folkman, 1984; Wills& Filer, 1996). Failure to effectively adapt to stressors and controlnegative emotional states can lead to or exacerbate the effects ofdepression and anxiety, social ineffectiveness, health problems,and other types of maladjustment. In adolescents, deficiencies incoping have been conceptualized as general risk factors that aug-ment vulnerability for a number of psychiatric conditions, includ-ing depression and anxiety (Lewinsohn, Gotlib, & Seeley, 1995).

Coping is typically viewed as an active, purposeful, rational, andconscious process (e.g., Lazarus & Folkman, 1984). Yet there isalso considerable evidence forpre-conscious (i.e., not in consciousawareness), or automatic aspects of coping. According tocognitive-experiential self-theory (CEST; Epstein, 1991, 1998),coping is first manifested at the experiential level in response to astressful event. This level is characterized by immediate emotional

Robert T. Ammerman, Division of Psychology, Children's HospitalMedical Center, Cincinnati, Ohio, and Pittsburgh Adolescent AlcoholResearch Center (PAARC), Department of Psychiatry, University of Pitts-burgh School of Medicine; Kevin G. Lynch, John E. Donovan, and Chris-topher S. Martin, PAARC, Department of Psychiatry, University of Pitts-burgh School of Medicine; Stephen A. Maisto, Department of Psychology,Syracuse University, and PAARC, Department of Psychiatry, University ofPittsburgh School of Medicine.

Kevin G. Lynch is now at the Department of Psychiatry, University ofPennsylvania.

This research was supported by Grant P50 AA08746 awarded by theNational Institute on Alcohol Abuse and Alcoholism and K02 AA00249 toChristopher S. Martin. We thank Howard Moss, Duncan Clark, and NancyPollock for their helpful comments in preparing this article.

Correspondence concerning this article should be addressed to Robert T.Ammerman, Children's Hospital Medical Center, Division of Psychology,3333 Burnet Avenue, Cincinnati, Ohio 45229-3039. Electronic mail maybe sent to ammm9c@chmcc.org.

reactions, rapid processing, holistic and intuitive appraisals, and acrudely structured cognitive integration of experiences. On theother hand, rational coping (at the conscious level) is analytic,slower, logical, and more highly differentiated and integrated.Whereas rational coping is modifiable through reason and didacticprocesses, experiential coping changes slowly and primarily bymeans of experience. Rational coping is associated with intellec-tual ability, but experiential coping is not strongly related tointelligence. Constructive thinking is the phrase coined by Epsteinand Meier (1989) to describe the automatic thoughts that emanatefrom the experiential level and affect both the emotional reactionsand behavioral responses to stressors. The heuristic value of CESTis that it provides a conceptual link between the immediate emo-tional processing of stressful events and subsequent coping pro-cesses that are more deliberate and effortful (Epstein, 1994).

Good constructive thinking "facilitates coping with problems inliving in a manner that maximizes the likelihood of an effectivesolution at a minimum cost to stress to oneself and distress toothers" (Epstein, 1990, p. 174). On the other hand, poor construc-tive thinking leads to psychological distress and interferes withrational attempts to generate and implement problem-solving strat-egies. Patterns of constructive thinking are believed to emerge inchildhood and be relatively stable across time. A considerablebody of research has supported the distinction between experien-tial and rational coping processes (see Epstein & Pacini, 1999). Forexample, D'Zurilla and Chang (1995) found little associationbetween constructive thinking and a measure of rational coping(Social Problem-Solving Inventory—Revised) in college students,demonstrating the independence of these two aspects of coping.However, experiential coping was related to initially approachingproblems in a negative way (reflecting an immediate orientationtoward stressful events that is characteristic of constructive think-ing). Epstein, Pacini, Denes-Raj, and Heier (1996) found that goodconstructive thinkers tend to use analytic-rational approaches toproblem solving; that is, their initial reaction to stressors facilitates

89

90 AMMERMAN, LYNCH, DONOVAN, MARTIN, AND MAISTO

a positive, action-oriented, and flexible approach. Poor construc-tive thinkers, on the other hand, were more reliant on intuitivestrategies, reflecting initial reactions to stressors that restrict pro-active and more effective approaches. Poor constructive thinkersare also more likely to make rapid negative appraisals, which inturn leads to frequent use of cognitive distortions (e.g., overgen-eralization; Epstein, 1992). Katz and Epstein (1991) found thatindividuals categorized as poor constructive thinkers were morephysiologically reactive (relative to good constructive thinkers) tostressors administered in a laboratory setting, revealing their ten-dency to experience heightened emotional arousal in response tostress. Deficits in constructive thinking are associated with unhap-piness, anxiety and depression, somatic symptoms, social malad-justment, and work problems (Epstein & Katz, 1992; Epstein &Meier, 1989).

The Constructive Thinking Inventory (CTI; Epstein & Meier,1989) measures the automatic thought processes that characterizethe experiential coping system. Originally developed on the basisof college student populations, the CTI has undergone severalmodifications. The most recent version of the CTI comprises 108items that yield six primary scales reflecting dimensions of expe-riential coping: Emotional Coping, Behavioral Coping, Categori-cal Thinking, Personal Superstitious Thinking, Naive Optimism,and Esoteric Thinking. A Global scale is derived from 30 itemsdrawn from these primary scales. It is minimally associated withIQ and academic achievement (Epstein & Meier, 1989), under-scoring the nonintellective quality of constructive thinking. TheCTI has exhibited satisfactory psychometric properties in severalpopulations, including college students (D'Zurilla & Chang, 1995;Epstein & Meier, 1989) and middle-aged adults (Finke & Hurley,1995).

Inability to manage stress and negative emotions has beenstrongly implicated in adolescent substance use and associatedproblems (e.g., Wills, 1986). Substance use can be a copingbehavior (albeit a maladaptive one) in that the acute physiologicaleffects of substances may temporarily reduce anxiety, relievedepression, and enhance mood (Wills & Filer, 1996). Adolescentswho rely on substances as a coping mechanism may fail to developand refine more active, efficient, and successful coping abilities.Wills and his colleagues (Wills, 1986; Wills & Filer, 1996; Wills,McNamara, & Vaccaro, 1995) have demonstrated that adolescentswith substance use problems are more likely to exhibit deficits inrational coping and problem-solving skills. In another study, Lau-rent, Catanzaro, and Callan (1997) reported an association betweenavoidant coping styles and adolescent substance use andsubstance-related problems. Labouvie (1987) found that adoles-cent substance abusers, in contrast to nonsubstance abusing peers,were more likely to engage in emotion-focused coping and lesslikely to use active problem-solving strategies.

Impairments in constructive thinking, reflecting preconsciousprocesses that lead to negative emotional states, may be especiallyimportant to the development of substance use disorders (SUDs)among adolescents. However, little research has been conductedon the relation between constructive thinking and substance use ingeneral and SUDs in particular. Epstein and Katz (1992) foundsmall correlations between global CTI scores and drug use prob-lems in a college population. Mezzich, Tarter, Kirisci, Hsieh, andGrimm (1995) used the CTT to examine constructive thinking infemale adolescents with SUDs, 93% of whom had alcohol abuse or

dependence diagnoses. Maladaptive constructive thinking wasidentified in this clinical population relative to a group of adoles-cent females without a psychiatric disorder. Mezzich et al. thencompared participants with substance use disorders with theirpeers diagnosed with depression or conduct disorder (but notsubstance use disorders). No differences were found between thesegroups, although depressed and conduct-disordered females ob-tained lower CTI scores than the control group of nonpsychiatri-cally disordered females.

Although Mezzich et al. (1995) provided evidence for an asso-ciation between deficits in constructive thinking and SUDs inadolescents, a number of important issues have not yet beenexamined. These include explication of the concurrent validity ofthe CTI in adolescent clinical populations, the study of construc-tive thinking among male adolescents, and the relation betweenconstructive thinking and comorbid psychiatric disorders in ado-lescents with SUDs. Such information would be useful in identi-fying the possible role of constructive thinking in the developmentof substance use problems, determining the utility of the CTI as anassessment tool in adolescents with SUDs, and informing thedesign of treatments targeting dysfunctional experiential copingprocesses.

The purpose of the current study was to examine the concurrentvalidity and clinical correlates of the CTI in male and femaleadolescents aged 14-18 years with and without SUDs. First, weexamined the concurrent validity of the CTI by correlating thismeasure with indexes of psychosocial maladjustment (e.g., depres-sion, conduct problems, emotional dysregulation). Given the im-portance of coping as a general risk factor for psychiatric distur-bance (Lewinsohn et al., 1995), we predicted that the CTI wouldbe strongly associated with psychosocial maladjustment in bothadolescents with and without SUDs. Second, we examined therelation between constructive thinking and SUDs. We hypothe-sized that deficiencies in constructive thinking would be associatedwith presence of an SUD, given that deficits in coping are thoughtto be instrumental in the development of substance use problems.

Method

Participants

Participants were 551 adolescents aged 14-18 inclusive years, dividedinto those with (SUD group, n — 304; 181 males, 123 females) and without(comparison group, n = 247; 115 males, 137 females) lifetime SUDs(substance abuse or dependence as determined using criteria from theDiagnostic and Statistical Manual of Mental Disorders [4th ed.; DSM-IV;American Psychiatric Association, 1994]). The large majority of adoles-cents in the SUD group (91%) had a current diagnosis of substance abuseor dependence (the remaining 17% manifested the condition within 3 yearsof the assessment). SUD participants were recruited from a variety ofsubstance abuse treatment programs and juvenile justice facilities (84% ofSUD participants came from these settings), advertisements, and targetedage directory telephone sampling. Comparison participants were recruitedby means of advertisements and targeted age directory telephone sampling.SUD participants from treatment programs were assessed within 3 weeksof discharge. About 72% of adolescents at clinical sites who agreed to becontacted participated in both an initial telephone screen and the assess-ment battery. Participants were not excluded if they had additional psy-chiatric diagnoses.

In Table 1 are presented the demographic characteristics of the sample,as well as a breakdown of psychiatric diagnoses identified in the two

CONSTRUCTIVE THINKING AND ADOLESCENT SUBSTANCE USE 91

Table 1Demographics and Other Psychiatric Disorders in the SUD(N = 304) and Comparison (N = 247) Groups

Characteristic SUD Comparison Contrast

Age (M/SD)SES (M/SD)Gender (nl%)

MaleFemale

Ethnicity (nl%)European AmericanAfrican American and other

Lifetime psychiatricdisorder (nl%)

ADHDOppositional defiant disorderConduct disorderAnxiety disordersDepression

16.7/1.338.5/14.1

181/60123/40

244/8060/20

70/2364/21

214/7094/31

139/46

16.3/1.343.5/14.3

115/45137/55

188/7659/24

13/523/944/1871/2948/19

3.9**4.2**

12.3**

1.4

33.6**14.1**

151.3**0.3

42.0**

Note. SUD = substance use disorder; SES = socioeconomic status;ADHD = attention-deficit/hyperactivity disorder.**p < .01.

groups with and without lifetime SUDs. Relative to the comparison group,the SUD group was slightly older and had a lower mean family socioeco-nomic status (SES), as measured with the methods of Hollingshead (1975).The comparison group had a greater proportion of females relative to theSUD group. Demographics were statistically controlled in all of the sub-sequent analyses. The SUD group exhibited high rates of lifetime comorbidpsychiatric disorders, particularly conduct disorder, depression, and anxi-ety disorders. Other studies of adolescents with SUDs have reported similarprevalence rates of comorbidity (e.g., Bukstein, Glancy, & Kaminer, 1992),despite variability in recruitment sites and methods used to obtain diag-noses. The comparison group also exhibited high rates of some psychiatricdisorders, somewhat higher than the general population. For example, inthe Methods for the Epidemiology of Child and Adolescent Mental Dis-orders study, Shaffer et al. (1996) reported prevalence rates (individualswho met diagnostic criteria in the previous 6 months) for 9- to 17-year-oldsof 13.0% for anxiety disorders, 10.3% for disruptive behavior disorders,and 6.2% for mood disorders. In contrast to the comparison group, the SUDgroup exhibited higher rates of psychiatric disorder, as reflected by higherproportions of lifetime diagnoses of attention-deficit/hyperactivity disor-der, oppositional defiant disorder, conduct disorder, and depression. Lo-gistic regression analysis (see the Results section) predicting SUD statuscontrolled for demographics as well as lifetime history of these psychiatricdisorders. In the SUD group, 269 (88.5%) had an alcohol use disorder, and225 (74%) had a cannabis use disorder.

Procedure

In the initial contact, participants were informed that the study concernedsubstance use, particularly alcohol, among adolescents. After a completedescription of the study was provided to adolescents and parents, writteninformed consent was obtained. Adolescents were remunerated $125 in theform of coupons to local stores for participation in the full PittsburghAdolescent Alcohol Research Center protocol. The University of Pitts-burgh's Institutional Review Board approved the study procedures.

Primary Measures

SUDs were identified using a form of the Structured Clinical Interviewfor DSM (SCID; Spitzer, Williams, & Gibbon, 1987) modified for use inadolescents and to use DSM-IV criteria (Martin, Kaczynski, Maisto, Buk-

stein, & Moss, 1995). The SCID provides a decision tree structure forasking questions about psychiatric symptoms, although assessors mustprobe for additional information as needed to make a clinical judgmentregarding the presence of each symptom. Martin, Lynch, Pollock, andBukstein (2000) reported high interrater reliability for DSM-IV alcohol usediagnoses and alcohol symptoms using this interview. An expanded ver-sion of the Lifetime History of Alcohol Use Interview (Skinner, 1982) wasalso administered to supplement alcohol and drug use symptomatology. Toincrease the veridicality of report, adolescent responses regarding alcoholand other drug use were not shared with parents or other treatmentproviders (the project has a U.S. Department of Health and Human Ser-vices Certificate of Confidentiality). DSM-TV diagnoses were verified in ameeting of the interviewer with a clinically experienced faculty psychiatristor clinical psychologist. SUD participants were primarily recruited fromtreatment sites and had current SUD diagnoses.

The CTI (Epstein & Meier, 1989) is a self-report measure of experientialcoping that comprises 108 items that are endorsed using a 5-point Likertscale reflecting the degree to which the item is true for the respondent (1 =definitely false, 5 = definitely true). It yields six primary scales: EmotionalCoping, Behavioral Coping, Categorical Thinking, Personal SuperstitiousThinking, Naive Optimism, and Esoteric Thinking. Emotional Copingrefers to a tendency not to take things personally, not to be sensitive todisapproval, and not to worry excessively about failure. Behavioral Copingreflects thought processes that facilitate effective action to resolve prob-lems. Categorical Thinking encompasses thought processes that are rigid,extreme, and polarized. Personal Superstitious Thinking indicates adher-ence to superstitious beliefs. Naive Optimism denotes stereotyped andsimplistic beliefs about the likelihood of positive outcomes. EsotericThinking measures patterns of thinking that are distorted or irrational.(Higher scores on Emotional Coping and Behavioral Coping indicateincreased coping capacity; high scores on remaining scales reflect de-creased coping capacity.) In addition, a Global scale is derived from 30items drawn from these scales. Examples of items from each of the sixscales of the CTI include "The slightest indication of disapproval gets meupset" (Emotional Coping); "When I realize I have made a mistake, Iusually take immediate reaction to correct it" (Behavioral Coping); "Thereare two kinds of people in the world, winners and losers" (CategoricalThinking); "When I am faced with a new situation, I tend to think the worstpossible outcome will happen" (Personal Superstitious Thinking); "Whensomething good happens to me, I feel that more good things are likely tofollow" (Naive Optimism); and "I believe in good and bad omens" (Eso-teric Thinking).

Psychopathology and Adjustment Measures

The Beck Depression Inventory (BDI; Beck, Ward, & Mendelson, 1961)is a widely used self-report measure of depression. It consists of 21 itemsof depressive symptoms that are endorsed using a 4-point scale reflectingseverity. It yields a total score indicative of overall severity of depressivesymptomatology. The BDI has excellent psychometric properties and hasbeen used numerous times with adolescents (e.g., Renaud et al., 1998).

The Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983)is a parental report measure of emotional and behavioral problems inchildren. It contains 118 problem items that are rated by parents using a3-point scale reflecting frequency of occurrence. Mothers completed theCBCL. The Total Internalizing and Total Externalizing scale scores wereused in this study.

The Youth Self-Report Form (YSRF; Achenbach & Edelbrock, 1987) isa parallel version of the CBCL that was completed by the adolescents. TheTotal Internalizing and Total Externalizing scale scores were used in thisstudy.

The Multidimensional Personality Questionnaire (MPQ; Tellegen, 1982)is a factor-analytically derived self-report measure of stable personalitytraits. It comprises 300 true-false questions, and it yields standardized

92 AMMERMAN, LYNCH, DONOVAN, MARTIN, AND MAISTO

scores on 11 primary and 3 higher order personality dimensions. Forpurposes of this study, the 3 higher order scales (which reflect emotionalregulation) were used: Positive Affectivity, Negative Affectivity, and Con-straint. The MPQ is a widely used measure with good reliability andvalidity, and has been used with adolescents (Gjerde, Block, & Block,1988).

The Drug Use Screening Inventory—Adolescents (DUSI-A; Tarter,1990) is a 149-item self-report measure of psychosocial maladjustment,particularly related to alcohol and drug use, in adolescents. It yieldsstandardized scores for 10 problem domains. For purposes of this study, theTotal Problem Density score was used. Among adolescents, the DUSI-Aexhibits acceptable reliability and validity, and it is strongly related tosubstance use and negative consequences of substance abuse (Tarter,Mezzich, Kirisci, & Kaczynski, 1994). Example items include "Have youever had trouble getting along with any of your friends because of alcoholor drug use?", "Is it difficult to make friends in a new group?", and "Areyour grades in school worse than they used to be?"

Results

Preliminary Analyses

Validity scales. The CTI has 16 items that are designed toidentify biased or inattentive response patterns. They are dividedequally between a Validity scale (to identify careless responding)and a Lie scale (to identify a socially desirable response bias).Examination of the distribution of the Lie and Validity scales didnot reveal any participants who systematically responded in care-less or a socially desirable manner.

IQ. We examined the relation between the CTI and IQ becauseof the hypothesized lack of an association between the CTI andintelligence. IQ was measured through an extrapolation of scoresfrom the Vocabulary and Block Design subtests from the WechslerIntelligence Scale for Children—Third Editions (Wechsler, 1991)or the Wechsler Adult Intelligence Scale—Revised (Wechsler,1981). In our sample of adolescents, statistically significant (p <.05) but relatively modest correlations between -.27 and .21 werefound between the scales of the CTI and IQ. These findingsconfirm that constructive thinking is not strongly associated withintellectual capacity (Epstein & Meier, 1989).

Internal Consistency Reliabilities

To examine the internal consistency reliability of the CTI, wedetermined Cronbach's alpha reliabilities for each of the six pri-mary scales and the Global scale. For the full sample (n = 551),alphas ranged from .76 to .91. These values were very similar inthe SUD and comparison groups. Results indicated that the scalesexhibited acceptable levels of internal consistency and were gen-erally higher than those reported by Epstein and Meier (1989) intheir samples of college students.

In Table 2 are presented the partial intercorrelations among theseven scales for the full sample after controlling for age, gender,ethnicity, and SES. The Global, Emotional Coping, BehavioralCoping, Personal Superstitious Thinking, and Categorical Think-ing scales showed the highest degree of association. In contrast,the Esoteric Thinking and Naive Optimism scales were only mod-estly correlated with the five other primary scales. This pattern issimilar to that reported by Epstein and Meier (1989). In oursample, the Emotional Coping and Behavioral Coping scales weremost highly correlated (.89 and .78, respectively) with the Global

Table 2Partial Correlations Among the Seven Constructive ThinkingInventory Scales Using the Full Sample (N = 551) AfterControlling for Age, Gender, Ethnicity, andSocioeconomic Status

Scale 1

1. OS2. EC3. BC4. PST5. CT6. ET7. NO

_.89**.78**

-.66**-.51**-.22*

.22*

—.52**

-.62**-.41**-.24*

.02

—-.43**-.31**-.14*

.36**

—.46** —.37** .18** —

-.02 .05 .21* —

Note. GS = Global scale; EC = Emotional Coping; BC = BehavioralCoping; PST = Personal Superstitious Thinking; CT = Categorical Think-ing; ET = Esoteric Thinking; NO = Naive Optimism.* p < .05. ** p < .01.

scale. The very high correlation between Emotional Coping andBehavioral Coping with the Global scale led us to omit the latterscale from subsequent analyses.

Concurrent Validity of the CTI

Deficits in coping are usually viewed as a general risk factor forpsychopathology and psychological maladjustment. Examinationof the relation between constructive thinking and psychosocialmaladjustment provides information about the concurrent validityof the CTI and helps explicate the link between coping mecha-nisms and emotional and behavioral dysfunction. We correlatedthe six CTI scales with measures of internalizing behavior prob-lems, externalizing behavior problems, and emotional regulation(obtained from both self-report and maternal report). No differen-tial patterns (p > .05) in these correlations were found between theSUD and comparison groups, and between males and females, sothe combined sample was used. Partial correlations (controlling forage, gender, ethnicity, and SES) are presented in Table 3. Becauseof missing data on certain measures, the sample size was 551 forall variables except for maternal CBCL scale scores (n = 460).Results indicated moderate to high correlations among EmotionalCoping, Behavioral Coping, Constructive Thinking, and PersonalSuperstitious Thinking and psychopathology. It appeared thatEmotional Coping was more highly correlated with most domainsreflecting internalizing disorders yet had comparatively lower as-sociations with measures reflecting externalizing behavior prob-lems, compared to Behavioral Coping. However, with the excep-tion of the YSRF Total Internalizing scale, these correlationcontrasts were not significant at the p < .05 level. CategoricalThinking was strongly correlated with overall psychosocial mal-adjustment (as measured by the DUSI-A), self-reported external-izing problems, and negative affectivity (as measured by theMPQ). Personal Superstitious Thinking, on the other hand, re-vealed strong correlations with internalizing problems, overallpsychosocial maladjustment, and negative affectivity.

Substantially smaller correlations were found between EsotericThinking and Naive Optimism and these indexes of psychopathol-ogy and raise questions regarding the utility of these scales asindicators of clinically meaningful aspects of coping in our ado-

CONSTRUCTIVE THINKING AND ADOLESCENT SUBSTANCE USE 93

Table 3Partial Correlations Between Measures of PsychosocialFunctioning and Six Scales of the Constructive ThinkingInventory Corrected for Age, Gender, Ethnicity, andSocioeconomic Status

Measure EC BC CT PST ET NO

BDIDUSI-A:TPDYSRF-INTYSRF-EXTMPQ-PAMPQ-NAMPQ-CONCBCL-INTCBCL-EXT

-.52*-.46*-.55*-.34*

.17*-.52*

-.41**-.44**-.35**-.34**

.44**-.35**

-.06 .28**-.28** -.28**-.20** -.29**

.35**,44**.29**.41**

-.12**43**

-.12**.19**.21**

.50*

.50*

.48*

.37*-.17*

.48*-.09*

.26*

.25**

.27**

.25**

.28**

.08

.35**-.20**

.11**.26* .16**

-.13**-.11**-.03-.09*

.28**-.04

.20**-.10*-.11*

Note. N = 551 for all variables except the Child Behavior Checklist(CBCL). EC = Emotional Coping; BC = Behavioral Coping; CT =Constructive Thinking; PST = Personal Superstitious Thinking; ET =Esoteric Thinking; NO = Naive Optimism; BDI = Beck DepressionInventory; DUSI-A:TPD = Drug Use Screening Inventory—Adolescents(Total Problem Density); YSRF = Youth Self-Report Form; INT =Internalizing score; EXT = Externalizing score; MPQ = MultidimensionalPersonality Questionnaire; PA = Positive Affecu'vity; NA = NegativeAffectivity; CON = Constraint.*p<.05. **p<.01.

lescent population. It is noteworthy that other research has docu-mented weaker relations between psychosocial functioning and theEsoteric Thinking and Naive Optimism scales relative to the otherfour scales (D'Zurilla & Chang, 1995; Epstein & Meier, 1989).Accordingly, we decided to drop these two scales from furtheranalyses.

Constructive Thinking and SUDs

Means and standard deviations were derived in the SUD andcomparison groups, respectively, for Emotional Coping (77.0[15.7] vs. 81.0 [15.6]), Behavioral Coping (49.5 [8.8] vs. 53.5[8.8]), Personal Superstitious Thinking (20.6 [5.3] vs. 18.5 [5.5]),and Categorical Thinking (48.6 [8.7] vs. 43.4 [9.1]). These are notcorrected for demographics, as age, gender, ethnicity, and SES arecontrolled in the analyses described below. High scores on Emo-tional Coping and Behavioral Coping, and low scores on PersonalSuperstitious Thinking and Categorical Thinking, indicate goodconstructive thinking.

To examine the relation between SUDs and constructive think-ing, we conducted a hierarchical logistic regression predictingSUD status (SUD vs. comparison group). First, demographicswere entered together at the first step to control for their effects.Next, the presence of four lifetime psychiatric disorders was en-tered in a second step. Finally, four of the CTI scales (EmotionalCoping, Behavioral Coping, Personal Superstitious Thinking, andCategorical Thinking) were standardized and entered in a thirdstep. In Table 4 are presented entry chi-squares and full-modelodds ratios (ORs) and 95% confidence intervals for each variablein each of the three steps. White ethnicity and older age wererelated to having an SUD in the full model, as were conductdisorder and depression. Of the CTI scales, deficits in activeorientation (Behavioral Coping) and rigid thinking style (Categor-ical Thinking) were associated with an increased likelihood ofhaving an SUD diagnosis. Specifically, elevated CategoricalThinking led to a 48% increase (final OR = 1.48) in the odds ofhaving an SUD diagnosis, and high Behavioral Coping resulted ina 32% decrease (final OR = .68) in the odds of having an SUDdiagnosis. It was surprising that high Emotional Coping was pos-itively related to an SUD status in the full model when accounting

Table 4Hierarchical Logistic Regression Predicting SUD Status Using the CTI Scales of EmotionalCoping, Behavioral Coping, Personal Superstitious Thinking, and Categorical Thinking AfterControlling for Demographics and Lifetime Psychiatric Disorders

Step Entry Final model OR 95% Confidence interval

Step 1: Demographics 42.9**GenderEthnicityAgeSES

Step 2: Lifetimepsychiatric diagnoses 173.9**

ADHDConduct disorderAffective disordersOppositional defiant disorder

Step 3: CTI scales 21.8**Behavioral CopingEmotional CopingPersonal Superstitious ThinkingCategorical Thinking

1.102.13*1.59**0.93

2.36*7.58**2.40**1.61

0.68**1.55**1.111.48**

0.69-1.771.25-3.651.28-1.990.74-1.17

1.14-4.914.74-12.111.46-3.980.86-3.01

0.52-0.881.13-2.110.83-1.491.14-1.92

Note. Results presented are from the final model. Full Model: /(12) = 238.59, p < .001, R2 = .47. SUD =substance use disorder; CTI = Constructive Thinking Inventory; OR = odds ratio; SES = socioeconomic status;ADHD = attention-deficit/hyperactivity disorder.*p<.05. **/>< .01.

94 AMMERMAN, LYNCH, DONOVAN, MARTIN, AND MAISTO

for all of the other variables. The full model accounted for 47% ofthe variance and correctly classified 79% of participants.

Discussion

In this study we examined constructive thinking using the CTIin adolescents with and without SUDs. The goals of the investi-gation were to examine the concurrent validity of the measure in aclinical sample of adolescents and determine the relation betweenconstructive thinking and SUDs. Noteworthy methodologicalstrengths were the large sample size, inclusion of both males andfemales, and comprehensive assessment of psychosocial and psy-chiatric functioning.

Both the internal reliabilities and the intercorrelations betweenscales of the CTI were similar to those reported by Epstein andMeier (1989). These psychometric characteristics are, therefore,essentially equivalent in our sample of adolescents and their sam-ple of college students. Although the mean age difference betweenthe two samples is relatively small, our sample is composed ofadolescents (many of whom exhibit psychiatric disorders) who arein earlier stages of psychosocial development. The similarity inreliabilities adds support to the contention that the CTI is anappropriate instrument for adolescent samples.

In a different, smaller study, Mezzich et al. (1995) found di-minished constructive thinking in female adolescents with SUDs,conduct disorder, or depressive disorders, relative to nonpsychiat-rically disturbed peers. We sought to examine the relation betweenthe CTI and psychological disturbance by correlating the six CTIscales with measures of psychosocial adjustment, psychopathol-ogy, and personality. Four of the CTI scales (Emotional Coping,Behavioral Coping, Personal Superstitious Thinking, and Con-structive Thinking) were related to these indexes, paralleling re-sults reported by Epstein and Katz (1992), who studied nonclinicalsamples of college students. In fact, the strength of the relationswas somewhat more robust in our sample, possibly because oftheir greater variability in psychosocial adjustment. Moreover, thepattern of relations was similar in adolescents with and withoutSUDs, suggesting that the linkage between constructive thinkingand psychological functioning is evident in diverse populations ofadolescents. The four CTI scales were correlated with a variety ofareas of psychosocial maladjustment, underscoring the fact thatdeficits in constructive thinking (as reflected by the CTI), regard-less of the specific type of thinking style, are associated features ofsocial, emotional, and behavior dysfunction in general. The rela-tion between the CTI and psychosocial dysfunction further adds tothe evidence that the CTI is a meaningful instrument in adolescentswith and without SUDs.

Our findings indicate that poor constructive thinking, character-ized by constricted thinking styles and immediate negative reac-tivity to stressors, may be an important contributor to the emer-gence or manifestation of psychological disturbance. Researchstrongly suggests that ineffective rational coping leads to increasedvulnerability of psychosocial maladjustment (Newcomb & Har-low, 1986; Wills & Filer, 1996). Moreover, in the developingadolescent, this process may be particularly insidious in that themaladjustment emerging from coping deficiencies impedes theacquisition of more effective coping skills, which in turn furtherimpairs psychosocial functioning. To the extent that constructivethinking is an essential precursor to more active and rational

coping behaviors, deficits in this domain may predispose theadolescent to maladjustment and psychiatric disorder. Epstein(1998) argued that psychopathology develops, in part, from animbalance between reliance on experiential and rational processingsystems, with an increased focus on emotional reactivity occurringat the expense of more active coping responses. Maladaptivepreoccupation with negative emotional states is characteristic ofanxiety and depressive disorders, and it is possible that deficits inconstructive thinking play a role in their etiology.

The results suggest that constructive thinking, particularly arigid and polarized thinking style (Categorical Thinking) and de-creased orientation to active coping (Behavioral Coping), is pre-dictive of SUD status. After controlling for demographics andlifetime history of psychiatric disorders (which contributed signif-icantly to the regression equation), both of these scales addedunique variance to the prediction of SUDs. Cognitive distortionsand passive orientation to problems are well-documented featuresof adolescents with SUDs. Once again, these constructive-thinkingimpairments may be possible contributors to the development ofSUDs, or they may be exhibited concurrently. The contribution ofdeficient experiential coping to SUD diagnosis is consistent withthe use of substances to decrease affective distress and discomfort.Adolescents with SUDs who are ineffective in managing theirinternal state may use substances during times of stress, whennegative emotional reactions are most likely to occur. The polar-ized thinking style reflected by Categorical Thinking impedes thegeneration of effective coping responses and leads to emotionaldistress, perhaps further contributing to problematic substance use.Paradoxically, we also found that high Emotional Coping contrib-uted significantly to the prediction of SUDs, after taking intoaccount demographics and lifetime history of psychiatric disor-ders. This finding is not consistent with other analyses involvingthis subscale, in which Emotional Coping was (a) lower in SUDversus comparison participants (M = 77.5, SD = 16.0, vs. M =80.9, SD = 15.3), and (b) highly negatively correlated with psy-chopathology and psychosocial maladjustment. Because lifetimehistory of psychiatric diagnoses was entered first into the regres-sion equation predicting SUD status, it is possible that sharedvariance between psychiatric history and Emotional Coping wasallocated to psychiatric history, thereby leaving an idiosyncraticbut statistically significant relation between Emotional Coping andSUD status. Future research should focus particular attention onthis scale and its utility in clinical populations.

The results from this study have several implications for clinicalpractice. The CTI was originally designed for research rather thanclinical assessment. However, experiential coping is thought to beimportant to the manifestation and treatment of psychiatric disor-ders. The CTI is the only extant measure specifically developed tomeasure this level of coping and, as such, it may be a usefuladjunct to a more standardized assessment protocol. For adoles-cents with SUDs, the Categorical Thinking and Behavioral Copingscales appear to be the most robust, and administration of thesescales in clinical practice may be sufficient to measure the mostimportant dimensions of constructive thinking. Categorical Think-ing and Behavioral Coping also reflect dimensions that are ame-nable to intervention. Categorical Thinking, for example, indicatesa polarized thinking style that interferes with the generation ofeffective solutions to problems. Inadequate behavioral coping re-flects difficulty in initiating and maintaining active coping strate-

CONSTRUCTIVE THINKING AND ADOLESCENT SUBSTANCE USE 95

gies. Both of these forms of coping are well represented in stan-dard treatment protocols, even though such programs typicallyemphasize the acquisition of specific problem-solving skills andonly tangentially address the contributions of experiential domainsto effective coping.

Didactic, skills-based approaches may be insufficient to bringabout substantial and lasting improvements in the absence ofattention to experiential processes. Indeed, the experiential systemis hypothesized to be relatively stable and resistant to change.However, it is probable that interventions affecting the experientialsystem have an increased likelihood for success relative to othertherapeutic approaches (Epstein, 1998). These include techniquesthat directly target experiential levels (e.g., exposure, imagery, roleplay), interventions that facilitate experiential processing (e.g.,homework directing clients to confront stressful stimuli), andcognitive approaches targeting management of emotional states.Of course, many empirically based treatments contain such com-ponents. However, few extant treatments primarily emphasizeexperiential interventions. Moreover, it is possible that the order inwhich intervention techniques are applied is important. For exam-ple, didactic strategies may be more effective if they are precededby treatments that seek to modify experiential processing.

The findings from this study must be considered within thecontext of methodological limitations. The comparison group ev-idenced higher rates of lifetime psychiatric disorders relative to thegeneral population of adolescents (Shaffer et al., 1996). The SUDparticipants were recruited from substance abuse clinics and juve-nile justice facilities. Although we sought to enroll participantsfrom a variety of settings, to avoid biases associated with anysingle site, it is possible that this sample has limited generalizabil-ity to adolescents with SUDs who do not present for treatment. Theprevalence rates and pattern of comorbid lifetime psychiatric dis-orders in our SUD sample are similar to those reported in otherinvestigations of treated adolescents (Bukstein et al., 1992), how-ever, thereby providing evidence that our sample is representativeof adolescents with SUDs recruited from treatment settings.

Several avenues for future research are suggested by this study.Of particular importance is examining whether the CTI addsanything to our understanding of coping in adolescents with SUDsover and above that provided by more frequently used measures ofactive, rational coping (e.g., Wills & Filer, 1996). Epstein and hiscolleagues (e.g., Epstein & Pacini, 1999) have conducted a pro-grammatic research effort devoted to the delineation of experien-tial coping as a distinct and independent process and one thatprecedes and influences rational coping. However, much of thisresearch has been conducted with nonclinical populations, raisingquestions about its applicability to adolescents with psychiatricdisorders. The results from this study support the utility of the CTIin adolescents with SUDs and suggest that it has considerablepotential as a research and clinical tool. However, a direct com-parison of the CTI with other measures of coping is needed tomore definitively establish its unique contribution. A second ques-tion pertains to the etiologic importance of constructive thinking toadolescent psychopathology in general and SUDs in particular.Because our study was cross-sectional, it is not possible to deter-mine the causal significance of constructive thinking to the emer-gence of SUDs. Disaggregating the relations between constructivethinking and psychiatric disorders and SUDs is also desirable.Such an analysis is complicated by the high degree of psychiatric

comorbidity in clinical samples of adolescents with SUDs. Inaddition, the results from this study to not permit investigation ofdifferential relations between constructive thinking and specificsubstances (e.g., alcohol vs. marijuana). However, there is notheoretical or practical reason to suspect such differential relations.Indeed, the high incidence of polydrug use in clinical samples ofadolescents with SUDs further complicates attempts to identifydifferential relations. A final area of research interest is whetherthe CTI has heuristic value as a predictor of clinical outcomes andas an index of treatment effectiveness.

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Received June 3, 1999Revision received March 17, 2000

Accepted June 8, 2000