A Metacognitive Model of Problem Drinking

Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. 16, 383393 (2009)

Published online 28 May 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.620
A Metacognitive Model of
Problem Drinking
Marcantonio M. Spada1* and Adrian Wells2,3
1
Roehampton University, London, UK

University of Manchester, Manchester, UK
3
Norwegian University of Science and Technology, Trondheim, Norway
2
Previous research has demonstrated signicant relationships between

metacognition and problem drinking. In this study, we aimed to
investigate further these relationships by testing the t of a metacognitive model of problem drinking in a sample of 174 problem
drinkers from a university student population. In the model presented, it is proposed that positive metacognitive beliefs about
alcohol use and negative affect lead to alcohol use as a means of
affect regulation. Positive metacognitive beliefs about alcohol use
are also associated with a reduction in metacognitive monitoring
which further contributes to alcohol use. Once alcohol use is initiated it brings a disruption in metacognitive monitoring leading to a
continuation in drinking. Following a drinking episode, alcohol use
is appraised as both uncontrollable and dangerous, which in turn
strengthens negative metacognitive beliefs about alcohol use. These
beliefs are associated with an escalation of negative affect, which acts
as a trigger for further drinking. The specied relationships among
these variables were examined by testing the t of a path model.
Results of this analysis indicated a good model t consistent with
predictions. The conceptual and clinical implications of these data
are discussed. Copyright 2009 John Wiley & Sons, Ltd.
Key Practitioner Message:
A cognitive-attentional model that may aid assessment, conceptualization and treatment for moderate or at risk problem drinkers.
Keywords: Alcohol Use, Attention, Metacognition, Metacognitive
Model, Negative Affect, Problem Drinking
INTRODUCTION
Many researchers argue that affect regulation is a
key motive for alcohol use (e.g., Khantzian, 1997;
Wills & Shiffman, 1985; for a review, see Backer,
Piper, McCarthy, Majeskie, & Fiore, 2004). Research
has abundantly documented the link between negative affect and drinking behaviour (e.g., Frone,
* Correspondence to: Marcantonio M. Spada, School of

Human and Life Sciences, Roehampton University, Whitelands College, Holybourne Avenue, London SW15 4JD,
UK.
E-mail M.Spada@roehampton.ac.uk
Copyright 2009 John Wiley & Sons, Ltd.
Cooper, & Russell, 1994; Kushner, Sher, Wood, &

Wood, 1994; Stephens & Curtin, 1995) as well as
demonstrated that negative affect is a frequent antecedent of alcohol use (e.g., Hussong, Hicks, Levy,
& Curran, 2001). For example, previous research
has revealed that the induction of negative mood
strengthens the urge to drink alcohol (e.g., Cooney,
Litt, Morse, Bauer, & Gaupp, 1997; Willner, Field,
Pitts, & Reeve, 1998) and that problem drinkers
retrospectively report using alcohol to cope with
negative affect (e.g., Zack, Toneatto, & MacLeod,
2002). The motivation to drink in order to reduce
negative affect is incorporated in prominent psychological theories of substance abuse (e.g., tension
384
reduction, motivational and expectancy models:
Cappell & Herman, 1972; Levenson, Sher, Grossman, Newman, & Newlin, 1980; Young, Oei, &
Knight, 1990). Alcohol-related cognition has been
proposed to play an important role in the development and maintenance of problem drinking. In
expectancy models of problem drinking, affective
states are believed to facilitate the activation of
expectancies concerning the reinforcing effects of
alcohol. For example, depressed mood is assumed
to trigger the anticipation of mood-enhancing
alcohol effects. By and large, the models based on
these constructs work well in accounting for variability in alcohol consumption (e.g., Goldman &
Darkes, 2004; Goldman, Del Boca, & Darkes, 1999;
Wiers, Hoogeeven, Sergeant, & Gunning, 1997). A
limitation of these models, however, is that they
do not explicitly address the role of cognitive
processes (such as attention) in the initiation and
maintenance of problematic alcohol use.
It is widely accepted that alcohol impacts cognitive processes. In particular, the impairment of
attentional functioning appears to play a fundamental role in determining alcohol effects. For example,
Steele and Josephs (1990) have argued that alcohols pharmacological properties disrupt attentional
processes (through the narrowing of perception to
immediate cues and reduction of cognitive abstracting capacity), and Hull (1981) has advocated that
alcohol use reduces self-awareness (corresponding to the encoding of information in term of selfrelevance). Both these processes are likely to play
a crucial role in the effective monitoring of internal
states during a drinking episode (Spada & Wells,
2006; Spada, Zandvoort, & Wells, 2007). The disruption of this monitoring process (termed metacognitive monitoring; Spada & Wells, 2006) is likely to
lead to a continuation in drinking because information on emotional change (e.g., feeling relaxed)
and proximity to goals of drinking (e.g., achieving
a greater degree of relaxation) is not attended to.
Indeed, evidence suggests that alcohol intoxication impairs neurological systems that underlie
meta-level processing (Nelson et al., 1998). Reductions in metacognitive monitoring can also contribute to alcohol use. Research has demonstrated
that problem drinkers have attentional biases for
alcohol-related stimuli, which reect their preoccupation with drinking alcohol (e.g., Bauer & Cox,
1998; Stormark, Laberg, Nordby, & Hugdahl, 2000).
Attentional orientation to alcohol-related cues, and
associated instrumental behaviours aimed at attaining and using alcohol, may also play a role in limiting resources available for monitoring internal
M. M. Spada and A. Wells

states (and consequently progress towards affect
regulation), contributing the perseveration of drinking behaviour (Spada, 2006).
The self-regulatory executive function (S-REF;
Wells & Matthews, 1994, 1996) theory was the rst
to conceptualize the role of multiple components
of cognition (e.g., belief systems and attention) in
the aetiology and maintenance of psychological
disturbance. In this theory, Wells and Matthews
(1994, 1996) argue that a common style of thinking
across psychological disorders leads to dysfunction. They propose that psychological disturbance
is maintained by a combination of perseverative
thinking styles, maladaptive attentional routines
and dysfunctional behaviours that constitute
a cognitive attentional syndrome (CAS; Wells,
2000). The CAS is derived from an individuals
set of metacognitive beliefs, which are activated
in problematic situations and drive coping (e.g.,
alcohol use) (Wells, 2000; Wells & Matthews, 1994,
1996). Metacognitive beliefs (Flavell, 1979; Moses
& Baird, 1999; Wells, 2000; Yussen, 1985) refer to
knowledge individuals hold about their internal
states and about coping strategies that impact on
them (Wells, 2000). Examples may include beliefs
concerning the signicance of particular types
of thoughts (e.g., having thought X means I am
weak) and emotions (e.g., I need to control my
anxiety at all times), and beliefs about other cognitive phenomena such as memory and judgement
(e.g., I do not trust my problem-solving capabilities). Examples of metacognitive beliefs individuals hold about their own coping strategies that
impact on internal states may include positive
beliefs such as ruminating will help me nd a
solution or negative beliefs such as my checking
behaviour will make me lose my mind. Metacognitive beliefs have been found to be associated with
depression (Papageorgiou & Wells, 2003), hypochondriasis (Bouman & Meijer, 1999), obsessive
compulsive symptoms (Emmelkamp & Aardema,
1999; Myers & Wells, 2005; Wells & Papageorgiou,
1998), pathological procrastination (Spada, Hiou,
& Nikcevic, 2006), pathological worry (Wells &
Papageorgiou, 1998), perceived stress (Spada,
Nikcevic, Moneta, & Wells, 2008), post-traumatic
stress disorder (PTSD) (Roussis & Wells, 2006),
predisposition to auditory hallucinations (Morrison, Wells, & Nothard, 2000), psychosis (Morrison, French, & Wells, 2007), smoking dependence
(Nikcevic & Spada, 2008; Spada, Nikcevic, Moneta,
& Wells, 2007) and test anxiety (Matthews, Hillyard, & Campbell, 1999; Spada, Nikcevic, Moneta,
& Ireson, 2006).
DOI: 10.1002/cpp
A Metacognitive Model of Problem Drinking

The S-REF theory has led to the development of
disorder-specic models of depression (Papageorgiou & Wells, 2003), generalized anxiety disorder
(GAD) (Wells, 2000; Wells & Matthews, 1994),
obsessivecompulsive disorder (OCD) (Wells,
2000; Wells & Matthews, 1994), PTSD (Wells,
2000) and social phobia (Clark & Wells, 1995).
Central to these models is the notion that positive metacognitive beliefs are involved in the activation of maladaptive coping (e.g., rumination,
worry) and that negative metacognitive beliefs
lead to a prolongation and escalation of dysfunction. Therefore, positive metacognitive beliefs are
conceptualized as antecedent to, and negative
metacognitive beliefs as consequent to, the initiation of maladaptive coping. The models also
highlight the crucial role of attentional processes
in the perseveration of dysfunction. Metacognitive
therapy or techniques based on such models have
been evaluated across a series of studies for GAD
(Wells & King, 2006), major depression (Papageorgiou & Wells, 2000), OCD (Fisher & Wells, 2005,
2008), PTSD (Wells & Sembi, 2004) and social
anxiety (Wells, 2000; Wells & Papageorgiou, 2001)
with promising results.
It has recently been suggested that metacognitive theory may advance our understanding of
problem drinking (Spada, 2006; Spada, Moneta,
et al., 2007; Spada & Wells, 2005, 2006, 2008; Spada,
et al., 2007). Indeed, several studies have tested
hypotheses derived from the S-REF theory in relation to problem drinking. In an initial test of the
hypothesis of whether metacognitive beliefs are
associated with drinking behaviour, Spada and
Wells (2005) found evidence, in a community
sample, of a positive correlation between beliefs
about the need to control thoughts and alcohol
use that is independent of anxiety. In a further
study, Spada, et al. (2007) found that these same
beliefs and beliefs relating to lack of cognitive
condence (the evaluation of ones own cognitive
functioning in the presence or absence of objective
cognitive decit) predicted category classication
as a problem drinker independently of negative
affect.
In a series of semi-structured interviews aimed
at exploring the nature of metacognitions in a
sample of problem drinkers, Spada and Wells
(2006) found that the main goal of alcohol use
was to improve affect, yet patients were often
unaware of whether they had achieved their goal.
The authors hypothesized that a dysfunction in
monitoring of emotional change and proximity
to goals as drinking proceeds (metacognitive
385
monitoring) may explain this nding. Consistent
with this explanation and in line with ndings
by other researchers (e.g., Hull, 1981), patients
reported reductions in self-consciousness during
a drinking episode. Patients in the same study
also reported that they held both positive and
negative metacognitive beliefs about alcohol use.
Positive metacognitive beliefs about alcohol use
(e.g., drinking helps me to control my thoughts)
can be conceptualized as a specic form of alcohol
outcome expectancy relating to the use of alcohol
as a means of controlling cognition and emotion
(Spada & Wells, 2008). From a metacognitive
standpoint, such beliefs are thought to play a
central role in motivating individuals to engage
in alcohol use as a means of affect regulation
(Spada & Wells, 2006). Negative metacognitive
beliefs about alcohol use concern the perception
of lack of executive control over alcohol use (e.g.,
my drinking persists no matter how I try to
control it) and the negative impact of alcohol use
on cognitive functioning (drinking will damage
my mind). These beliefs can be respectively
conceptualized as specic forms of cognitive selfefcacy and negative alcohol outcome expectancies (Spada & Wells, 2008). From a metacognitive
standpoint, such beliefs are thought to play a
crucial role in the perpetuation of alcohol use
by becoming activated during, and following a
drinking episode, and triggering negative emotional states that compel a person to drink more
(Spada & Wells, 2006).
Studies on monitoring internal states during
drinking episodes have used the Alcohol Metacognitive Monitoring Scale (AMMS; Spada, 2006).
Lower scores on this scale indicate lower levels of
monitoring of internal states (units to being drunk,
and attention to the effects of alcohol on emotion,
performance and thoughts). AMMS was found
to be negatively correlated with alcohol use and
problem drinking in both community and clinical
samples. These data support the assertion that the
less individuals monitor internal states, the more
they are likely to drink in general. More recently
Spada and Wells (2008) developed measures of
positive (Positive Alcohol Metacognitions Scale;
PAMS) and negative (Negative Alcohol Metacognitions Scale; NAMS) metacognitive beliefs about
alcohol use. Positive and negative metacognitive
beliefs were found to predict alcohol use and
problem drinking independently of negative affect
in both community and clinical samples (Spada &
Wells, 2008). Further research in a large community sample has also conrmed that both positive
DOI: 10.1002/cpp
386
and negative metacognitive beliefs about alcohol
use are constructs related to, but independent of,
alcohol outcome expectancies (Spada et al., 2007).
On the basis of these studies and the theoretical
framework of the S-REF theory, we put forward
a metacognitive model of problem drinking. The
salient feature of this model, which differentiates it from related expectancy and motivational
models that exclusively focus on belief systems, is
that it presents a combined cognitive attentional
conceptualization of problem drinking. In this
model, it is proposed that positive metacognitive
beliefs about alcohol use and negative affect lead
to alcohol use as a means of affect regulation. Positive metacognitive beliefs about alcohol use are
also associated with a reduction in metacognitive
monitoring which further contributes to alcohol
use. Once alcohol use is initiated, it leads to a disruption in metacognitive monitoring, leading to
a continuation in drinking. Following a drinking
episode, alcohol use is appraised as both uncontrollable and dangerous, which in turn strengthens
These beliefs are associated with an escalation of
negative affect, which acts as a trigger for further
drinking. Central to this model is the tenet that
a combination of the activation of positive metacognitive beliefs about alcohol use and reduced
metacognitive monitoring leads to a pattern of
behaviour that is difcult to regulate as the person
loses sight of their objective for drinking (i.e., regulating affect). While the activation of positive metacognitive beliefs about alcohol use may contribute
to triggering alcohol use, reduced metacognitive
monitoring may contribute to the prolongation of
a drinking episode.
In this study, we aimed to examine the relationships between negative affect, metacognitive beliefs
about alcohol use, metacognitive monitoring and
problem drinking by testing the statistical t of
our metacognitive model in a sample of problem
drinkers. Hypothesized relationships among the
variables were examined and the statistical t of
a path model was then tested. For the purposes
of this study, problem drinking was conceptualized as the harmful or hazardous use of alcohol
that excludes severe alcohol dependence. This is
in line with Sobell and Sobbells (1993) review of
the literature, suggesting that relative to severely
alcohol dependent individuals, problem drinkers
have a shorter drinking history, greater social and
economic stability, and greater personal resources.
They also account for the vast majority of individuals experiencing problems with alcohol use.
METHOD
Participants and Procedure
Convenience sampling was used for selecting participants, consisting of both undergraduate and
postgraduate university students recruited from
large metropolitan universities during classes. For
purposes of inclusion in this study, the participants were required to speak English, use alcohol
regularly (at least once per week) and be at least
18 years of age. Four hundred and twenty individuals participated in the study between 2003
and 2006. Participants were included in the study
if they scored 5 or above and less than 20 on
the Alcohol Use Disorders Identication Test
(AUDIT; Babor, de la Fuente, Saunders, & Grant,
1992). A score of 5 on AUDIT is considered the
lowest acceptable cutoff point for problem drinking (Gual, Segura, Contel, Heather, & Colom,
2002; Piccinelli et al., 1997). A score of 20 or above
is considered a cutoff point for severe alcohol
dependence that warrants further diagnostic
evaluation (Babor, Higgins-Biddle, Saunders, &
Monteiro, 2001).
One hundred and seventy four individuals (107
females, 67 males) met criteria for problem drinking. The racial breakdown of the sample was as
follows: White 78%, Black 10%, Asian 8%, and
other or non-disclosed 6%. All participants completed the Hospital Anxiety and Depression Scale
(HADS; Zigmond & Snaith, 1983), the PAMS
(Spada & Wells, 2008), the NAMS (Spada & Wells,
2008), the AMMS (Spada, 2006), the Quantity
Frequency Scale (QFS; Cahalan, Cisin, & Crossley,
1969) and the AUDIT (Babor et al., 1992). The mean
age for the study sample was 23.5 years (standard
deviation [SD] = 2.8 years) and the age range was
1928 years. The participants reported drinking a
mean number of 29.3 units per week (SD = 24.5),
with males consuming 24.3 units (SD = 20.7) and
females consuming 37.2 units (SD = 27.9). Participants had been drinking for a mean number of 4.8
years (SD = 4.0). Their mean score on the AUDIT
was 11.2 (SD = 4.9), indicating moderate levels of
problem drinking.
Participants were approached and asked if they
were willing to take part in a research project
investigating the nature of thoughts, emotion and
alcohol use in student drinkers. Participation in
the research project was entirely voluntary. The
questionnaires were administered in paper-andpencil format with instructions given in writing.
The participants completed the questionnaires
in group format. All participants were debriefed
DOI: 10.1002/cpp

following the completion of the questionnaires.
The study was ethically approved by a review
board at a London university.
Measures
387
independently of anxiety and depression in a clinical population (n = 80) (Spada & Wells, 2008). PAMS
factor 2 has been found to predict classication as
a problem drinker independently of emotion in a
mixed community and clinical population (n = 163)
(Spada & Wells, 2008).
The HADS (Zigmond & Snaith, 1983)

This scale consists of 14 items, seven assessing anxiety and seven assessing depression. The
anxiety subscale includes items such as: I get a
sort of frightened feeling as if something horrible is
about to happen. The depression subscale includes
items such as: I feel as if I am slowed down.
Higher scores represent higher levels of anxiety
and depression. The majority of studies examining
the factor structure of HADS in both clinical and
general populations have identied two dimensions (Mykletun, Stordal, & Dahl, 2001). The intercorrelation of the anxiety and depression subscales
has been reported to be in the range of 0.490.63,
with lower correlations reported in studies with
healthy samples (Mykletun et al., 2001). Overall,
the scale possesses good validity and reliability
(Herrmann, 1997; Mykletun et al., 2001; Zigmond
& Snaith, 1983).
The PAMS (Spada & Wells, 2008)

PAMS is a 12-item measure developed to assess
positive metacognitive beliefs about alcohol use.
It consists of two factors: (1) positive metacognitive beliefs about emotional self-regulation; and
(2) positive metacognitive beliefs about cognitive
self-regulation. Examples of items relating to emotional self-regulation include: drinking reduces
my self-consciousness. Examples of items relating to cognitive self-regulation include: drinking
helps me to control my thoughts. The measure
is scored using a four-point Likert scale with the
end points of do not agree to agree very much.
Participants are asked to rate how much they agree
with the statements listed. Higher scores represent higher levels of positive metacognitive beliefs
about alcohol use. PAMS was initially constructed
and factor analysed in a community sample (n
= 261), and its factor structure was replicated in
a clinical sample (n = 80) (Spada & Wells, 2008).
Results from these studies suggest that PAMS
is dimensional and possesses good internal and
external reliability in both community and clinical
populations (Spada & Wells, 2008). PAMS factors
1 and 2 have been found to predict problem drinking independently of trait anxiety in a community
population (n = 138) (Spada & Wells, 2008). PAMS
factor 1 has been found to predict problem drinking
The NAMS (Spada & Wells, 2008)

NAMS is a six-item measure developed to assess
It consists of two factors: (1) negative metacognitive beliefs about uncontrollability; and (2) negative metacognitive beliefs about cognitive harm.
Items relating to uncontrollability include: my
drinking persists no matter how I try to control
it. Items relating to cognitive harm include:
drinking will damage my mind. The measure
is scored using a four-point Likert scale with the
end points of do not agree to agree very much.
Higher scores represent higher levels of negative
metacognitive beliefs about alcohol use. NAMS
was initially constructed and factor analysed in
a community sample (n = 261), and its factor
structure was replicated in a clinical sample (n
= 80) (Spada & Wells, 2008). Results from these
studies suggest that NAMS is dimensional and
possesses good internal and external reliability in
both community and clinical populations (Spada
& Wells, 2008). NAMS factor 1 has been found
to predict problem drinking independently of
trait anxiety in a community population (n = 138)
(Spada & Wells, 2008). NAMS factor 1 has been
found to predict problem drinking independently
of anxiety and depression in a clinical population
(n = 80) (Spada & Wells, 2008). NAMS factor 1 has
been found to predict classication as a problem
drinker independently of emotion in a mixed community and clinical population (n = 163) (Spada
& Wells, 2008).
The AMMS (Spada, 2006)

AMMS is a four-item measure developed to assess
levels of monitoring of internal states during drinking. It consists of a single factor. Participants are
asked to rate whether during a drinking episode,
they count the units they drink, and pay attention
to the effects of alcohol on emotion, performance
and thoughts. Higher scores represent higher levels
of metacognitive monitoring. AMMS was initially
constructed and factor analysed in a community
sample (n = 342), and its factor structure was replicated in a clinical sample (n = 67) (Spada, 2006).
Results from these studies suggest that AMMS
possesses good internal and external reliability in
DOI: 10.1002/cpp
388
both community and clinical populations (Spada,
2006). AMMS has been found to predict problem
drinking independently of positive and negative
metacognitive beliefs about alcohol use in a community sample (n = 342) (Spada, 2006).
The QFS (Cahalan et al., 1969)

QFS is a measure of alcohol consumption levels,
with items assessing the dimensions of quantity
and frequency of alcohol beverages consumed over
a period of 30 days. This measure consists of three
questions (have you been drinking any beer/wine/
spirits over the last 30 days? about how often do
you consume beer/wine/spirits? and about how
much beer/wine/spirits did you drink on a typical
day when you drink beer/wine/spirits?). These
are repeated for each of the major alcohol beverage categories (beer, wine and distilled spirits). The
total scores from the different alcohol beverage categories are then added together, and an estimated
daily (or weekly) level of alcohol consumption can
be computed. This instrument has been extensively
used and possesses good validity and reliability
(Hester & Miller, 1995).
The AUDIT (Babor et al., 1992)

AUDIT was developed as a screening tool by
the World Health Organization for early identication of problem drinkers. AUDIT consists of 10
questions regarding recent alcohol consumption,
alcohol dependence symptoms and alcohol-related
problems. Respondents are asked to choose one of
between three and ve statements (per question)
that most applies to their use of alcohol beverages
over the past year. Responses are scored from 0 to 4
in the direction of problem drinking. The summary
score for the total AUDIT ranges from 0, indicating no presence of problem drinking behaviour,
to 40, indicating marked levels of problem drinking behaviour and alcohol dependence. A score of
5 on AUDIT is considered the lowest acceptable
cutoff point for problem drinking (Gual et al., 2002;
Piccinelli et al., 1997). A score of 20 or above is
considered a cutoff point for severe alcohol dependence (Babor et al., 2001). This instrument has been
extensively used and possesses good validity and
reliability (Babor et al., 2001).
Analytic Approach
The software used to test the path model specied was PRELIS 2.30 and LISREL 8.8 (Jreskog
& Srbom, 1996a, 1996b). Lisrel 8.8 employs a
range of goodness of t indices to estimate the

adequacy of the model under investigation. The
most common statistic test for the assessment
of the model t is the chi-square goodness of
t test (2). This test estimates the discrepancies
between the observed covariance matrices and
those implied by the model. A non-signicant
chi-square value indicates adequacy of a model.
The chi-square statistic assesses the absolute t of
the model to the data. However, it is sensitive to
sample size and often inates type 1 error (Bollen,
1989; Cohen, 1988). Therefore, it is necessary to
use additional indices to evaluate the model t.
Hu and Bentler (1999) have recommended the use
of the root mean square error of approximation
(RMSEA). The RMSEA indicates the closeness of
t and is sensitive to the mis-specication of the
measurement model. Cutoff values close to 0.08
demonstrate adequate t of the model, whereas
an RMSEA between 0 and 0.05 indicates a good t
(Browne & Cudeck, 1993; Hu & Bentler, 1999). The
goodness of t index (GFI), comparative t index
(CFI) and non-normed t index (NNFI) represent
incremental t indices (Bentler & Bonett, 1980;
McDonald & Marsh, 1990). They were selected on
the basis of performance in simulation studies (Hu
& Bentler, 1999; Marsh, Balla, & Hau, 1996). Minimally acceptable t is indicated by threshold GFI,
CFI and NNFI values of 0.90 (Bentler & Bonett,
1980; McDonald & Marsh, 1990). Values close
to 0.95 indicate a good model t (Hu & Bentler,
1999).
RESULTS
Descriptive statistics for all questionnaire variables
are shown in Table 1. Cronbachs alpha coefcients
for most of the study measures exceeded 0.7, were
satisfactory and in line with previous studies. The
Cronbachs alpha coefcient for negative metacognitive beliefs about alcohol use (NAMS) was lower,
but still acceptable in consideration of the small
number of items contributing to the scale scores.
Skewness coefcients indicated that all measures
were normally distributed with the exception of
alcohol use (QFS), which was skewed towards high
values. The square root transformation (Tabachnick & Fidell, 1996) of the alcohol use scores was
symmetrical and was consequently used in all the
analyses.
Initially, we computed Pearson product-moment
correlation analyses to examine the basic patterns
of relationships between the various measures
(see Table 2). Of particular relevance to the metacognitive model in question, these data show that
DOI: 10.1002/cpp

Table 1.
389
Descriptive data of the study variables
Hospital Anxiety and Depression Scale

Positive Alcohol Metacognitions Scale
Negative Alcohol Metacognitions Scale
Alcohol Metacognitive Monitoring Scale
Quantity Frequency Scale
Alcohol Use Disorders Identication Test
Mean
SD
Range
Alpha
11.1
27.3
8.9
8.7
29.3
11.2
6.7
6.3
3.0
2.9
24.6
4.9
036
1544
618
416
2118
520
0.83
0.80
0.62
0.81
n/a
0.78
Note: n = 174.
Alpha = Cronbachs alpha. SD = standard deviation.
Table 2.
1
2
3
4
5
6
Intercorrelations among the study variables
Hospital Anxiety and Depression Scale

Positive Alcohol Metacognitions Scale
Negative Alcohol Metacognitions Scale
Alcohol Metacognitive Monitoring Scale
Quantity Frequency Scale
Alcohol Use Disorders Identication Test
0.21**
0.37**
0.24**
0.00
0.32**
0.03
0.29**
0.45**
0.33**
0.30**
0.36**
0.42**
0.44**
0.24**
0.79**
Note: n = 174.
** p < 0.001.
alcohol use (QFS) was: (1) positively correlated

with negative affect (HADS), positive metacognitive beliefs about alcohol use (PAMS) and negative
metacognitive beliefs about alcohol use (NAMS);
and (2) negatively correlated with metacognitive
monitoring (AMMS). In addition, positive metacognitive beliefs about alcohol use (PAMS) were
negatively correlated with metacognitive monitoring (AMMS).
In this study, our principal question of interest
was whether or not the model specied was a good
t to the data. The hypothesized path model (see
Figure 1) showed the following t indices: 2 =
5.66, p = 0.13; RMSEA = 0.07; GFI = 0.99; CFI = 0.98;
NNFI = 0.93. The RMSEA is below the acceptable
cutoff point (0.08), and the GFI, CFI and NNFI are
above the acceptable cutoff point (0.95). Globally,
these t indices indicate that the path model is
acceptable. In this analysis, we also relied on the
LaGrange multiplier (LM) test (Bentler, 1995) to
determine additional paths, which might signicantly improve the t of the model. The LM test
did not suggest additional paths that could signicantly improve model.
DISCUSSION
The aim of this study was to test the statistical t
of a metacognitive model of problem drinking in
a sample of problem drinkers from a university

student population. Because of the samples low
average age and quantity of alcohol consumed, the
drinkers presented can be described as problematic or at risk (i.e., younger drinkers who may have
a moderate or developing problem with alcohol
use).
Our metacognitive model of problem drinking was grounded in Wells and Matthews S-REF
theory of emotional disorders (Wells & Matthews,
1994, 1996). According to this theory, psychological
disorders involve inexible perseveration of cognition and behaviour that impairs self-regulation
and control. This pattern is linked to maladaptive
metacognitive beliefs and attentional strategies.
Therefore, the model tested differs from existing
expectancy and motivational models, as it presents
a combined cognitive attentional conceptualization
of problem drinking.
In the hypothesized metacognitive model of
problem drinking, we proposed that positive metacognitive beliefs about alcohol use and negative
affect lead to alcohol use as a means of affect regulation. Positive metacognitive beliefs about alcohol
use are also associated with a reduction in metacognitive monitoring which further contributes to
alcohol use. Once alcohol use is initiated, it leads to
a disruption in metacognitive monitoring, leading
to a continuation in drinking. Following a drinking
DOI: 10.1002/cpp
390
Figure 1. A path analysis of a metacognitive model of problem drinking. Note: n = 174. Negative affect as measured
by the Hospital Anxiety and Depression Scale, positive beliefs (positive metacognitive beliefs about alcohol use) as
measured by the Positive Alcohol Metacognitions Scale, negative beliefs (negative metacognitive beliefs about alcohol
use) as measured by the Negative Alcohol Metacognitions Scale, metacognitive monitoring as measured by the
Alcohol Metacognitive Monitoring Scale and alcohol use as measured by the Quantity Frequency Scale. **p < 0.001
episode, alcohol use is appraised as both uncontrollable and dangerous, which in turn strengthens
These beliefs are associated with an escalation of
negative affect, which acts as a trigger for further
drinking. Hypothesized relationships between
these variables were found in the bivariate correlation analyses and were further examined by
testing the t of a path model. Results of the latter
analysis indicated a good model t consistent with
predictions. To determine additional paths which
could signicantly improve the t of the model,
we employed the LM test (Bentler, 1995). The LM
test did not suggest additional paths that could
signicantly improve the t of the model.
These ndings have a number of possible implications for the assessment, conceptualization and
interventions for moderate or at-risk problem
drinkers. In terms of assessment, information could

be gathered not only in relation to the content of
alcohol-related thoughts, expectancies and other
cognitive constructs, but also metacognitive beliefs
about alcohol use and metacognitive monitoring
tendencies. The S-REF-based metacognitive model
of problem drinking could also be used to guide
the development of idiosyncratic case conceptualizations, as well as socialize problem drinkers to the
idea that both metacognitive beliefs about alcohol
use and reductions in metacognitive monitoring
may contribute to the escalation of their drinking behaviour. In case of relapse of problematic
drinking, it may be helpful to derive and illustrate
this model for each episode to demonstrate the
consistency in factors associated with onset and
perpetuation. The therapeutic implications of the
S-REF theory may provide a foundation for the
DOI: 10.1002/cpp

development of a metacognitive-focused intervention programme aimed at weakening the transition
from high risk to full blown clinical problems as
well as managing later stage problem drinking.
Such programme should bring alcohol use under
executive control, modify maladaptive metacognitive beliefs about alcohol use and provide greater
exibility in modes of processing, such as metacognitive monitoring (Wells & Matthews, 1994).
Specic strategies should aim to facilitate the
abandonment of problematic drinking and challenge metacognitive beliefs about this process. In
addition, interventions may focus on enhancing
metacognitive monitoring (Wells, 2000; Wells &
Matthews, 1994). This may be achieved through
practice of situational attentional refocusing
(Wells, 2000), where the patient could be asked
to focus on the impact of alcohol use on internal
states as a drinking episode unfolds. This should
provide a means of amplifying self-attention, thus
increasing the ow of goal progress information
into processing.
There are a number of limitations of this study.
First, classication as a problem drinker was established using a self-report questionnaire. This may
have inuenced the nature of participant selection,
and precludes generalizing to true clinical samples.
Second, the sample consisted of university students,
and potential confounders such as age, socio-economic status and education were not controlled
for. Third, given the cross-sectional nature of this
study, we cannot make any causal inferences on
the results. Future studies should therefore verify
the structure of the model in severe problem drinkers from a wider age range. This could be done by
using structured diagnostic interviews as well as
adopting a cutoff point of 7 on AUDIT (Babor et al.,
2001), as it is a more stringent criterion for problem
drinking. Research is also needed on: (1) prospective tests of the model (e.g., whether positive and
negative metacognitive beliefs predict drinking
over time); and (2) process tests of the model (e.g.,
experiments showing whether positive metacognitive beliefs are activated or more accessible when
experiencing negative affect, or whether alcohol
administration disrupts metacognitive monitoring). Finally, social desirability, self-report biases,
context effects and poor recall may have contributed to errors in self-report measurements.
Despite the above limitations, we believe that the
present ndings might provide a step forward in
a metacognitive conceptualization of the maintenance of problematic drinking behaviour that integrates belief systems with attentional processes.
391
REFERENCES
Babor, T.F., de la Fuente, J.R., Saunders, J.B., & Grant, M.
(1992). The alcohol use disorders identication test: Guidelines for use in primary healthcare. Geneva: World Health
Organization.
Babor, T.F., Higgins-Biddle, J.C., Saunders, J.B., & Monteiro, M.G. (2001). AUDIT: The alcohol use disorders identication test: Guidelines for use in primary care. Geneva,
Switzerland: World Health Organization.
Backer, T.B., Piper, M.E., McCarthy, D.E., Majeskie, M.R.,
& Fiore, M.C. (2004). Addiction motivation reformulated: An affective processing model of negative reinforcement. Psychological Review, 111, 3351.
Bauer, D., & Cox, W.M. (1998). Alcohol-related words are
distracting to both alcohol abusers and nonabusers in
the Stroop colour-naming task. Addiction, 93, 168180.
Bentler, P.M. (1995). EQS structural equations program
manual. Encino, CA: Multivariate Software, Inc.
Bentler, P.M., & Bonett, D.G. (1980). Signicance tests
and goodness of t in the analysis of covariance structures. Psychological Bulletin, 88, 588606.
Bollen, K.A. (1989). Structural equations with latent variables. New York: Wiley.
Bouman, T.K., & Meijer, K.J. (1999). A preliminary
study of worry and metacognitions in hypochondriasis. Clinical Psychology and Psychotherapy, 6, 96101.
Special issue, Metacognition and Cognitive Behaviour
Therapy. Chichester, UK: Wiley.
Browne, M.W., & Cudeck, R. (1993). Alternative ways
of assessing model t. In K.A. Bollen, & J.S. Long
(Eds), Testing structural equation models (pp. 136162).
Newbury Park, CA: Sage.
Cahalan, D., Cisin, I., & Crossley, H. (1969). American
drinking practices: A national survey of drinking behaviors
and attitudes. New Brunswick, NJ: Rutgers Center for
Alcohol Studies, Monograph no. 6.
Cappell, H., & Herman, C.P. (1972). Alcohol and tension
reduction: A review. Quarterly Journal of Studies on
Alcohol, 33, 3364.
Clark, D.M., & Wells, A. (1995). A cognitive model of
social phobia. In R. Heimber, M. Liebowitz, D.A.
Hope, & F.R. Schneier (Eds), Social phobia: Diagnosis,
assessment and treatment. New York: Guilford Press.
Cohen, J. (1988). Statistical power analysis for the behavioral
sciences. Mahwah, NJ: Lawrence Erlbaum.
Cooney, N.L., Litt, M.D., Morse, P.A., Bauer, L.O., &
Gaupp, L. (1997). Alcohol cue reactivity, negativemood reactivity, and relapse in treated alcoholic men.
Journal of Abnormal Psychology, 106, 243250.
Emmelkamp, P.M.G., & Aardema, A. (1999). Metacognitions, specic obsessive-compulsive beliefs and obsessive compulsive behaviour. Clinical Psychology and
Psychotherapy, 6, 139145. Special issue, Metacognition
and Cognitive Behaviour Therapy. Chichester, UK:
Wiley.
Fisher, P.L., & Wells, A. (2005). Experimental modication of beliefs in obsessive-compulsive disorder: A
test of the metacognitive model. Behaviour Research and
Therapy, 43, 821829.
Fisher, P.L., & Wells, A. (2008). Metacognitive therapy
for obsessive-compulsive disorder: A case series.

DOI: 10.1002/cpp
392
Journal of Behaviour Therapy and Experimental Psychiatry, 39, 177132.
Flavell, J.H. (1979). Metacognition and cognitive monitoring: A new area of cognitive-developmental inquiry.
American Psychologist, 34, 906911.
Frone, M.R., Cooper, M.L., & Russell, M. (1994). Stressful
life events, gender, and substance use: An application
of Tobit regression. Psychology of Addictive Behaviors,
8, 5969.
Goldman, M.S., & Darkes, J. (2004). Alcohol expectancy
multiaxial assessment: A memory network-based
approach. Psychological Assessment, 16, 415.
Goldman, M.S., Del Boca, F.K., & Darkes, J. (1999).
Alcohol expectancy theory: The application of cognitive neuroscience. In H. Blane, & K. Leonard (Eds),
Psychological theories of drinking and alcoholism (pp.
203246). New York: Guilford Press.
Gual, A., Segura, L., Contel, M., Heather, N., & Colom,
J. (2002). AUDIT-3 and AUDIT-4: Effectiveness of two
short forms of the Alcohol Use Disorders Identication
Test. Alcohol and Alcoholism, 37, 591596.
Herrmann, C. (1997). International experiences with the
Hospital Anxiety and Depression ScaleA review of
validation data and clinical results. Journal of Psychosomatic Research, 42, 1741.
Hester, R.K., & Miller, W.R. (1995). Handbook of alcoholism treatment approaches: Effective alternatives. Needham
Heights, MA: Allyn & Bacon.
Hu, L., & Bentler, P.M. (1999). Cutoff criteria for t
indices in covariance structure analysis: Conventional
versus new alternatives. Structural Equation Modeling,
6, 155.
Hull, J.G. (1981). A self-awareness model of the causes
and effects of alcohol assumption. Journal of Abnormal
Psychology, 90, 586600.
Hussong, A.M., Hicks, R.E., Levy, S.A., & Curran, P.J.
(2001). Specifying the relations between affect and
heavy alcohol use among young adults. Journal of
Abnormal Psychology, 110, 449461.
Jreskog, K.G., & Srbom, D. (1996a). LISREL 8: Users
reference guide. Chicago, IL: Scientic Software
International.
Jreskog, K.G., & Srbom, D. (1996b). PRELIS 2: Users
reference guide. Chicago, IL: Scientic Software
International.
Khantzian, E.J. (1997). The self-medication hypothesis of
substance use disorders: A reconsideration and recent
applications. Harvard Review of Psychiatry, 4, 231244.
Kushner, M.G., Sher, K.J., Wood, M.D., & Wood, P.K.
(1994). Anxiety and drinking behavior: Moderating
effects of tension-reduction alcohol outcome expectancies. Alcoholism: Clinical and Experimental Research,
18, 852860.
Levenson, R.W., Sher, K.J., Grossman, L.M., Newman,
J., & Newlin, D.B. (1980). Alcohol and stress response
dampening: Pharmacological effects, expectancy, and
tension reduction. Journal of Abnormal Psychology, 89,
528538.
Marsh, H.W., Balla, J.R., & Hau, K. (1996). An evaluation
of incremental t indices: A clarication of mathematical and empirical properties. In G.A. Marcoulides, &
R.E. Schumacker (Eds), Advanced structural equation

modeling: Issues and techniques (pp. 315353). Mahwah,
NJ: Erlbaum.
Matthews, G., Hillyard, E.J., & Campbell, S.E. (1999).
Metacognition and maladaptive coping as components
of test anxiety. Clinical Psychology and Psychotherapy,
6, 111125.
McDonald, R.P., & Marsh, H.W. (1990). Choosing a multivariate model: Noncentrality and goodness of t.
Psychological Bulletin, 107, 247255.
Morrison, A.P., Wells, A., & Nothard, S. (2000). Cognitive factors in predisposition to auditory and visual
hallucinations. British Journal of Clinical Psychology, 39,
6778.
Moses, L.J., & Baird, J.A. (1999). Metacognition. In R.A.
Wilson, & F.C. Keil (Eds), The MIT encyclopedia of the
cognitive sciences (pp. 533535). Cambridge, MA: The
MIT Press.
Myers, S.G., & Wells, A. (2005). Obsessive-compulsive
symptoms: The contribution of metacognitions and
responsibility. Journal of Anxiety Disorders, 19, 806
817.
Mykletun, A., Stordal, E., & Dahl, A.A. (2001). Hospital
Anxiety and Depression Scale: Factor structure, item
analyses and internal consistency. British Journal of Psychiatry, 179, 540544.
Nelson, T.O., Graf, A., Dunlosky, J., Marlatt, A., Walker,
D., & Luce, K. (1998). Effect of acute alcohol intoxication on recall and on judgments of learning during
the acquisition of new information. In G. Mazzoni, &
T.O. Nelson (Eds), Metacognition and cognitive neuropsychology, monitoring and control processes (pp. 161180).
Mahwah, NJ: LEA.
Nikc evic, A.V., & Spada, M.M. (2008). Metacognitions
across the continuum of smoking dependence. Behavioural and Cognitive Psychotherapy, 36, 333339.
Papageorgiou, C., & Wells, A. (2000). Treatment of
recurrent major depression with attention training.
Cognitive and Behavioral Practice, 7, 407413.
Papageorgiou, C., & Wells, A. (2003). An empirical test
of a clinical metacognitive model of rumination and
depression. Cognitive Therapy and Research, 27, 261
273.
Piccinelli, M., Tessari, E., Bortolomasi, M., Piasere, O.,
Semenzin, M., Garzotto, N., et al (1997). Efcacy of the
alcohol use disorders identication test as a screening
tool for hazardous alcohol intake and related disorders in primary care: A validity study. British Medical
Journal, 314, 420424.
Roussis, P., & Wells, A. (2006). Post-traumatic stress
symptoms: Tests of relationships with thought control
strategies and beliefs as predicted by the metacognitive model. Personality and Individual Differences, 40,
111122.
Sobell, M.B., & Sobbell, L.C. (1993). Problem drinkers: Guided self-change treatment. New York: Guilford
Press.
Spada, M.M. (2006). Metacognition and problem drinking.
Unpublished PhD thesis, University of Manchester,
UK.
Spada, M.M., Hiou, K., & Nikc evic, A.V. (2006). Metacognitions, emotions and procrastination. Journal of
Cognitive Psychotherapy, 20, 319326.

DOI: 10.1002/cpp

Spada, M.M., Moneta, G.B., & Wells, A. (2007). The relative contribution of metacognitive beliefs and expectancies to drinking behaviour. Alcohol and Alcoholism,
42, 567574.
Spada, M.M., Nikc evic, A.V., Moneta, G.B., & Ireson, J.
(2006). Metacognition as a mediator of the effect of test
anxiety on surface approach to studying. Educational
Psychology, 26, 110.
Spada, M.M., Nikc evic, A.V., Moneta, G.B., & Wells, A.
(2007). Metacognition as a mediator of the relationship
between emotion and smoking dependence. Addictive
Behaviors, 32, 21202129.
Spada, M.M., Nikc evic, A.V., Moneta, G.B., & Wells,
A. (2008). Metacognition, perceived stress, and negative emotion. Personality and Individual Differences, 44,
11721181.
Spada, M.M., & Wells, A. (2005). Metacognitions, emotion
and alcohol use. Clinical Psychology and Psychotherapy,
12, 150155.
Spada, M.M., & Wells, A. (2006). Metacognitions about
alcohol use in problem drinkers. Clinical Psychology and
Psychotherapy, 13, 138143.
Spada, M.M., & Wells, A. (2008). Metacognitive beliefs
about alcohol use: Development and validation of two
self-report scales. Addictive Behaviors, 33, 515527.
Spada, M.M., Zandvoort, M., & Wells, A. (2007). Metacognitions in problem drinkers. Cognitive Therapy and
Research, 31, 709716.
Steele, C.M., & Josephs, R.A. (1990). Alcohol myopia, its
prized and dangerous effects. American Psychologist,
45, 921933.
Stephens, R.S., & Curtin, L. (1995). Alcohol and depression: Effects on mood and biased processing of selfrelevant information. Psychology of Addictive Behaviors,
9, 211222.
Stormark, K.L., Laberg, J.C., Nordby, H., & Hugdahl,
K. (2000). Alcoholics selective attention to alcohol
stimuli: Automated processing? Journal of Studies on
Alcohol, 61, 1823.
Tabachnick, B.G., & Fidell, L.S. (1996). Using multivariate
statistics. London, UK: Harper Collins Publishers.
Wells, A. (2000). Emotional disorders and metacognition:
Innovative cognitive therapy. Chichester, UK: Wiley.
Wells, A., & King, P. (2006). Metacognitive therapy for
generalized anxiety disorder: An open trial. Journal
393
of Behavior Therapy and Experimental Psychiatry, 37,
206212.
Wells, A., & Matthews, G. (1994). Attention and emotion.
A clinical perspective. Hove, UK: Erlbaum.
Wells, A., & Matthews, G. (1996). Modelling cognition
in emotional disorder: The S-REF model. Behaviour
Research and Therapy, 34, 881888.
Wells, A., & Papageorgiou, C. (1998). Relationships
between worry and obsessive-compulsive symptoms
and meta-cognitive beliefs. Behaviour Research and
Therapy, 36, 899913.
Wells, A., & Papageorgiou, C. (2001). Brief cognitive
therapy for social phobia: A case series. Behaviour
Research and Therapy, 39, 713720.
Wells, A., & Sembi, S. (2004). Metacognitive therapy
for PTSD: A preliminary investigation of a new brief
treatment. Journal of Behavior Therapy and Experimental
Psychiatry, 35, 207318.
Wiers, R.W., Hoogeeven, K.J., Sergeant, J.A., & Gunning,
W.B. (1997). High and low dose expectancies and the
differential associations with drinking in male and
female adolescents and young adults. Addiction, 92,
871888.
Willner, P.E., Field, M., Pitts, K., & Reeve, G. (1998).
Mood, cue and gender inuences on motivation,
craving and liking for alcohol in recreational drinkers.
Behavioural Pharmacology, 9, 631642.
Wills, T.A., & Shiffman, S. (1985). Coping and substance
abuse: A conceptual framework. In S. Shiffman, & T.A.
Wills (Eds), Coping and substance use (pp. 324). New
York: Academic Press.
Young, R.M., Oei, T.P., & Knight, R.S. (1990). The tension
reduction hypothesis revisited: An alcohol expectancy
perspective. British Journal of Addiction, 85, 3140.
Yussen, S.R. (1985). The role of metacognition in contemporary theories of cognitive development. In D.L.
Forrest-Presley, G.E. MacKinnon, & T.G. Waller (Eds),
Metacognition, cognition, and human performance (pp.
253283). New York: Academic Press.
Zack, M., Toneatto, T., & MacLeod, C.M. (2002). Anxiety
and explicit alcohol-related memory in problem drinkers. Addictive Behaviors, 27, 331343.
Zigmond, A.S., & Snaith, R.P. (1983). The Hospital
Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361370.

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Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 16, 383393 (2009)

Roehampton University, London, UK

Previous research has demonstrated signicant relationships between

* Correspondence to: Marcantonio M. Spada, School of

Copyright 2009 John Wiley & Sons, Ltd.

Cooper, & Russell, 1994; Kushner, Sher, Wood, &

M. M. Spada and A. Wells