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. Author manuscript; available in PMC: 2024 Mar 5.
Published in final edited form as: Psychol Trauma. 2022 May 26;15(1):110–120. doi: 10.1037/tra0001278

An Event-Level Evaluation of Women’s Self-Medicated Drinking: The Role of Sexual Assault Severity, Affect, and Drinking Motives

Cynthia A Stappenbeck a, Anna E Jaffe b, Jessica A Blayney c, Mitchell Kirwan d, William H George e, Kelly Cue Davis d
PMCID: PMC10914019  NIHMSID: NIHMS1879037  PMID: 35617256

Abstract

Objective.

Women with sexual assault (SA) histories report heavier and more frequent drinking. Consistent with the motivational model of alcohol use, women with SA histories may consume alcohol to both down-regulate negative emotions and up-regulate positive ones. The present event-level study used a Bayesian multilevel moderated mediation approach to examine the extent to which women’s alcohol use and intoxication was influenced by coping and enhancement drinking motives to down-regulate or up-regulate affect, respectively.

Method.

Women ages 21–30 were recruited from the community to participate in a larger study that included a 32-day daily diary assessment of affect, drinking motives, and alcohol use.

Results.

We found consistent support for women’s tendencies to be motivated to drink to cope or enhance negative or positive affect, respectively, and those drinking motives were associated with indicators of increased drinking. Becoming intoxicated to down-regulate negative emotion was common and this pathway was particularly strong for women who reported more severe SA histories. Although women with more severe SA histories were generally more likely to drink more, they were not likely to do so as a way to enhance positive experiences.

Conclusions.

Alcohol interventions that provide adaptive regulatory strategies are needed for women who experience increased negative or positive affect, with a particular focus on self-medication for young women with more severe SA histories.

Keywords: Event-level, Sexual assault, Alcohol use, Drinking motives, Self-medication

Introduction

Sexual Assault and Alcohol Use

Sexual assault (SA) and heavy drinking are significant public health concerns. It is estimated that 12–17% of the general population has experienced SA victimization, defined here as any nonconsensual sexual experiences ranging from unwanted sexual contact to completed rape since the age of 14 (Tjaden & Thoennes, 2006). These SA prevalence rates are even higher for target subpopulations, including women who consume moderate amounts of alcohol (George et al., 2014), which is alarming given the sheer number of women who drink alcohol. Statistics from the National Institute of Alcohol Abuse and Alcoholism (NIAAA) indicate that 60% of women in the US have had at least one drink in the past year, 21% of these women averaged three or more drinks per day, and 14% averaged one monthly instance of heavy episodic drinking (i.e., consuming 4 or more drinks in two hours; NIAAA, 2004, 2015). Alcohol consumption, particularly heavy drinking that results in high levels of perceived intoxication, is a risk factor for SA (for review, see Lorenz & Ullman, 2016). A history of SA is associated with subsequent alcohol consumption, including heavier and more frequent drinking (Bryan et al., 2016; Najdowski & Ullman, 2009; Norris et al., 2019; Rhew et al., 2017). This increased drinking along with increased intoxication levels are problematic because they place women at increased risk for a range of negative sequealea including more severe SA (Testa et al.,, 2004) and revictimization (Norris et al., 2021). Women with SA histories may use alcohol as a way to self-medicate and reduce distress following SA (Fossos et al., 2011; Hawn et al., 2020), and thus may be motivated to consume alcohol to both down-regulate negative emotional states such as anxiety or depression and up-regulate positive emotional states. Motivations to drink to cope or enhance emotions, in turn, have been associated with increased alcohol consumption (Cook et al., 2020; Dvorak et al., 2014) and may help explain the positive association between SA histories and drinking. Thus, the current study evaluated the impact of SA on two pathways – drinking to cope with negative affect and drinking to enhance positive affect – in a sample of moderately drinking women.

Affect, Drinking Motives, and Alcohol use

Cooper and colleagues (1995) posited a motivational model of alcohol use whereby alcohol consumption regulates affect through two theoretically distinct internal pathways: drinking to cope and drinking to enhance. Drinking to cope is a reactive process; motivated by negative emotions, drinking serves the function of escape or avoidance of negative emotional states. Drinking to enhance is an appetitive process, one that could be motivated by positive emotions to maintain or increase positive emotional states, though this hypothesized pathway had less research support at model conceptualization and ultimately was not supported when empirically tested (Cooper et al., 1995). Within this model, drinking motives (i.e., specific reasons for drinking) are an important explanatory mechanism, because unlike alcohol expectancies (i.e., beliefs about how alcohol will make us feel or act), drinking motives are more proximally associated with alcohol use behaviors, and in other work, have been found to mediate the relationship between alcohol expectancies and alcohol use (e.g., Kuntsche et al., 2010). Understanding regulatory pathways is of critical importance for prevention and intervention efforts aimed at reducing problematic alcohol use.

Numerous studies have sought to test motivational models of alcohol use. However, a major limitation of this area is that drinking motives have been historically assessed as stable and trait-like (Cooper et al., 2016), when in reality, these processes may be more dynamic in nature. Findings from studies examining drinking motives as stable traits suggest that greater drinking to enhance motives are positively associated with drinking quantity and frequency, whereas drinking to cope motives are positively associated with drinking problems (for review, see Kuntsche et al., 2005). More recently, event-level studies (i.e., daily diary, ecological momentary assessment) have begun to examine how self-regulatory processes unfold proximally between individuals (i.e., average differences, between-person) and within situations (i.e., on a given day, within-person).

In a systematic review of event-level studies, Votaw and Witkiewitz (2021) concluded that findings have generally supported the premises of the motivational model of substance use. First, individuals with greater average levels of positive affect report greater drinking to enhance motives (i.e., a between-person effect at the individual level) and days with more positive affect than usual were associated with more drinking to enhance motives than usual (i.e., a within-person effect at the situational level). No associations were observed for negative affect on enhancement drinking motives. Further, increased drinking to enhance motives were subsequently associated with greater alcohol use. Second, parallel findings at both the individual and situational level were also supported for the association between greater levels of negative affect and greater drinking to cope motives. However, drinking to cope motives were not always associated with alcohol use. Third, only a handful of studies have examined the mediational role of drinking motives on affect and alcohol use (e.g., Dvorak et al., 2014; Stevenson et al., 2019) and the findings were conflicting. In one study, coping drinking motives were found to mediate the association between negative affect and alcohol use at the situational level but not the individual level (Dvorak et al., 2014), whereas another study found no support for mediation at either the situational or individual levels (Stevenson et al., 2019). Enhancement motives mediated the association between positive affect and alcohol use at both the situational and individual levels in one study (Stevenson et al., 2019); however, there was no effect of enhancement motives in another study (Dvorak et al., 2014).

Of note, additional related research has examined whether drinking motives moderated the associations between affect and alcohol use (Votaw & Witkiewitz, 2021), with some studies finding moderation for coping motives (for exception, see Hamilton et al., 2020). However, mixed findings have been noted for enhancement motives as a moderator (Votaw & Witkiewitz, 2021), though a potential buffering effect has been found such that positive affect may be associated with decreased drinking among individuals characterized as low enhancement-motivated drinkers (Gautreau et al., 2015). Together, these conflicting findings suggest that additional research is needed to gain clarity on how these regulatory processes unfold between individuals and within situations. We expand upon existing research in several key ways. First, we evaluate dynamic regulatory process and include a measure of perceived intoxication along with the standard outcome of drinks consumed. Perceived intoxication may reflect the desired state of coping or enhancement motivated drinking since the amount an individual can consume before feeling intoxicated is dependent on a number of factors that vary across individuals (e.g., weight) and situations (e.g., pace of drinking, type of alcohol consumed). Additionally, intoxication and drinks consumed may confer different levels of risk on subsequent factors not included here but ultimately of interest and importance such as sexual risk taking and revictimization (Davis et al., 2009). Secondly, we evaluate SA history as an individual difference factor that may influence the strength of the enhancement and coping pathways.

The Influence of SA History

Research and theory have linked SA with emotion regulation difficulties (Kirwan et al., 2021; Ullman et al., 2014), suggesting that individuals with SA histories may rely on maladaptive emotion regulation strategies – such as alcohol use – to manage strong emotions. Consistent with the self-medication model, SA histories were associated with greater psychological distress which contributed to alcohol consumption via negative reinforcement (Miranda et al., 2002). Additionally, recent SA was associated with coping motives after controlling for pre-SA coping motives, suggesting that coping motives for drinking may change following SA (Nelson & Fischer, 2021). As noted previously, drinking motives are associated with increased alcohol use and, when used to self-medicate following SA, are associated with an increased risk for alcohol problems. In this manner, motivations to drink to cope and enhance may be particularly likely to increase alcohol use and intoxication for individuals with more severe SA histories. In a longitudinal study, drinking to cope motives mediated the association between SA and problem drinking; however, no support was found for drinking to enhance motives as a longitudinal mediator of the association between SA and problem drinking (Lindgren et al., 2012).

Although no known study has investigated the effect of SA history on the proposed down-regulating and up-regulating pathways at the event-level, a few studies have examined the proximal impact of posttraumatic stress symptoms (which individuals may experience following SA) and drinking motives on alcohol consumption. In one such study, the positive association between posttraumatic stress symptom severity and alcohol consumption was stronger for those with greater coping drinking motives (Simpson et al., 2014). This study also concluded that although the association between posttraumatic stress symptom severity and alcohol consumption was consistent at high levels of enhancement drinking motives, greater drinking was observed on days of increased symptoms among individuals with low levels of enhancement drinking motives. Importantly, this study only assessed symptoms and drinking at the event-level and utilized a trait-like measure of drinking motives. In another recent event-level study of sexual minority women, increased posttraumatic stress symptoms were associated with increased alcohol use via stronger-than-normal coping drinking motives and not other motives (Dworkin et al., 2021). Although individuals with greater posttraumatic stress symptoms may also have higher negative affect (DiMauro et al., 2016), these studies did not specifically examine the influence of negative affect on coping drinking motives and subsequent drinking outcomes. Additionally, these studies included individuals with general trauma exposure, but not SA specifically, which may have implications for regulatory processes associated with drinking. Thus, the event-level influence of affect specifically on drinking motives and alcohol consumption and intoxication, particularly among individuals with SA histories, warrants further examination. Understanding how these proximal processes unfold and potentially vary within individuals over time can inform tailoring of alcohol and SA risk-reduction approaches for women with SA histories that are rooted in evidence-based skill sets applicable to proximal processes.

The Present Study

Informed by a motivational model framework (Cooper et al., 1995), the present study used a Bayesian multilevel moderated mediation approach to examine the extent to which women’s alcohol consumption and level of intoxication was influenced by motives to down-regulate or up-regulate affect both at the individual as well as the situational level. We also evaluated the role of SA severity on the individual-level associations. We hypothesized that greater daily negative affect would be positively associated with alcohol consumption and intoxication at both the between- and within-person level and that daily drinking to cope motives would mediate these associations. Similarly, we hypothesized that greater daily positive affect would be positively associated with alcohol consumption and intoxication at both the between- and within-person level and that daily drink to enhance motives would mediate these associations. Finally, we expected that the between-person pathways would be stronger for women with more severe SA histories.

Method

Procedures

Social drinking single women at elevated risk for sexually transmitted infections were recruited from the local community in a large northwestern city in the US as part of a larger study that involved three phases: an online background survey, 32 days of monitoring, and an in-lab session that involved completing additional questionnaires and alcohol administration. Both print and online advertisements were used to identify interested women who were instructed to call the lab to be screened over the phone. After the phone screen, eligible participants (n = 646) were emailed a link and given seven days to complete the online background survey that included demographics and questionnaires to characterize participants’ drinking and sexual history (not included in the present study). Participants who completed the background survey (n = 600) were then asked to complete 32 days of daily monitoring in which they were sent a link to a survey each morning to report their experiences the prior day, including positive and negative affect, motivations for drinking, and alcohol use. Finally, participants (n = 503) completed an in-lab session which consisted of online questionnaires including an assessment of their lifetime sexual assault history, and an alcohol administration component (not included in the present study). For the full study, participants could earn up to $320 ($20 for baseline, $5 per daily diary survey with a $20 bonus for completing at least 75% of surveys, and $15 per hour for the lab session). The university’s Institutional Review Board approved all procedures prior to data collection.

Participants

Eligibility criteria were determined based on the aims of the larger study and included women ages 21–30 who had consensual sex with a male partner without a condom at least once in the past year. Additionally, eligible women were required to report at least one other sexual risk indicator in the past year, such as a previous STI diagnosis, having a new male sexual partner, having two or more male sexual partners, or having a risky male sexual partner (i.e., knowing or suspecting that a male sexual partner had a concurrent sexual relationship, had an STI, had ever been incarcerated, had ever used intravenous drugs, or had a history of sex with other men). Eligible women were also required to have had sex and consumed alcohol at least two times in the past month and report at least three drinks per week in the past month. Finally, because data for the present study were taken from a larger study in which participants were administered alcohol, the NIAAA (2005) guidelines to ethical alcohol administration were also applied. As a result, participants who reported a history of problem drinking according to the Brief Michigan Alcoholism Screening Test (Pokorny et al., 1972), previous negative reactions to drinking, or a medical condition or medication which contraindicated alcohol consumption were excluded.

The present study focused on data from the 600 individuals who completed the daily diary portion of the larger study. Data from nine women were excluded because they did not report any instances of drinking during their daily diary assessments. Thus, the final sample was comprised of 591 participants (98.5%). On average, participants were 24.97 years old (SD = 2.69); 72.7% identified as White, 10.1% multiracial, 8.1% Asian, 4.5% Black/African American, 2.2% Native American/American Indian/Alaska Native, 0.2% Native Hawaiian/Pacific Islander, and 2.2% were another race. Regarding ethnicity, 9.1% identified as Hispanic or Latinx. Over a third (36.9%) were college students, and over half (54.0%) were college graduates. In addition, 59.8% reported an annual income of less than $31,000 and 79.8% lived in a rented or leased apartment or house.

Measures

Positive and Negative Affect.

During each daily survey, participants were asked to rate how “emotionally positive” and “emotionally negative” they felt at the present moment, using seven-point scales, from 0 “not at all” to 6 “extremely”.

Drinking Behaviors.

During each of the daily surveys, participants were asked to report the number of drinks they consumed the previous day on a scale ranging from “0 drinks” to “More than 25 drinks”. A drink was defined as being 4 oz. of wine, 1 wine cooler, 12 oz. of beer, or 1 cocktail with 1 oz. of hard liquor. Participants also reported their perceived intoxication level the previous day on a seven-point scale from 1 “not at all” to 7 “extremely”.

Drinking Motives.

For days in which participants reported drinking, they were asked to respond to three items characterizing their motivations to drink to enhance positive affect (e.g., “Because you wanted the pleasant feelings it gives you”) and three items regarding their motivations to cope with negative affect (e.g., “To cheer you up because you were in a bad mood”) from the Drinking Motives Measure (Cooper, 1994). These items were assessed on seven-point scales from 0 “not at all” to 6 “extremely”. Responses to the three items on each subscale were averaged to create a mean score. Within-person averages were computed for each of these items to determine their internal reliability (Simpson et al., 2014), which showed excellent reliability for the drinking to cope (α = .94) and acceptable reliability for the drinking to enhance (α = .72).

Sexual Assault Severity.

Nonconsensual sexual experiences since the age of 14 were assessed using the Revised Sexual Experiences Survey (RSES; Koss et al., 2007). Participants were asked about the number of times that a man used one or more of a variety of tactics, including verbal coercion, intoxication, and physical force, to obtain unwanted sexual behavior, such as sexual contact and attempted or completed oral, vaginal, or anal penetration. These items were each assessed on a four-point scale ranging from 0 “never” to 3 “3 or more times”. Scores of sexual assault severity were calculated by assigning each combination of tactics and unwanted sex with a severity rank (0 “none”, 1 “sexual contact by verbal coercion”, 2 “sexual contact by intoxication”, 3 “sexual contact by force”, 4 “attempted or completed rape by verbal coercion”, 5 “attempted or completed rape by intoxication”, 6 “attempted or completed rape by force”) and crossing this result by the frequency with which each combination occurred (Davis et al., 2014). The resulting score ranged from 0–63, with higher scores representing more severe vicitmization.

Data Analysis

Descriptive analyses were conducted to characterize the sample. Intraclass correlation coefficients (ICCs) were computed to represent the percent of variability due to between-person differences. ICCs, as well as within-person and between-person correlations, were computed in R version 3.6.3 (R Core Team, 2020) with the ‘psych’ package (Revelle, 2019).

For the primary analyses, drinking motives were expected to mediate the associations between affect and alcohol use and intoxication. Because drinking motives were only assessed for days in which drinking was reported, analyses were limited to drinking days. Higher negative and positive affect in the morning were expected to predict greater same day coping and enhancement drinking motives, respectively, as reported on the subsequent morning survey. In turn, higher drinking motives were expected to predict more drinks consumed and a higher perceived intoxication level on that day (as reported on the next morning survey). Lagged variables (using a lag of 1 day) were created for negative and positive affect so that they aligned with drinking motives and drinking behavior reported the next day. Affect, motives, and alcohol consumption and intoxication were all assessed daily, and thus, were disaggregated into a between-person component (Level 2; i.e., the average for each person) and a within-person component (Level 1; i.e., the deviation of each daily report from the person’s mean, representing higher or lower levels on a given day than their own average). Day in the study (i.e., a running count from 1 to 32 to indicate days since the diary procedures began) was included as a Level 1 covariate to control for any potential reactivity affects associated with repeated monitoring of alcohol behavior. A variable representing whether the day was a weekend (i.e., 1 = the drinking day was a Thursday, Friday, or Saturday; 0 = the drinking day was any other day) was also included as a Level 1 covariate to control for cyclical weekly patterns in young adult drinking (Huh et al., 2015). At Level 2, SA severity was included as a covariate. We also allowed for the Level 2 association between average affect and average drinking motives to vary by SA severity by including interactions in the model.

To simultaneously examine between- and within-person associations, SA severity as a moderator of the affect-motives associations, and motives as a mediator of the affect-drinking associations, all within a single model, we examined a multilevel moderated mediation model using a Bayesian structural equation modeling approach in Mplus version 8.6 (Muthén & Muthén, 2021). A Bayesian approach involves combinining observed data with prior knowledge and expectations, known as the prior distribution, to estimate a posterior distribution for each parameter. Because we had minimal knowledge about specific parameter estimates in advance, non-informative (i.e., diffuse) priors were utilized in current analyses. To implement Bayesian analyses, Mplus implements Markov chain Monte Carlo (MCMC) algorithms based on the Gibbs sampler (Asparouhov & Muthén, 2010) to iteratively estimate each model parameter.

A Bayesian approach has several advantages for the current multilevel moderated mediation model. First, the current Bayesian approach is more robust than maximum likelihood estimation for two-level moderation models and can be extended to multilevel moderated mediation (Asparouhov & Muthén, 2021). Second, mediation involves testing indirect effects, which are not normally distributed. Within a Bayesian framework, a posterior distribution is estimated for each parameter, which means there are no assumptions of normality (Muthén & Asparouhov, 2012). Thus, when using a Bayesian approach, indirect effects can be simply computed as the product of a paths (affect to motives) and b paths (motives to drinking) using the MODEL CONSTRAINT command in Mplus. Finally, Bayesian analyses make it possible to estimate complex models efficiently. In the current analyses, exogenous variables with missing data in the Level 2 interactions (positive/negative affect by SA severity) were represented by first specifying each observed variable as a perfect indicator of a latent variable, and then specifying latent variable interactions using the XWITH command (Asparouhov & Muthén, 2021)1.

Within this Bayesian framework, MCMC iterations are conducted within chains, which can be compared and evaluated for convergence. Convergence was evaluated using procedures recommended by Depaoli and van de Schoot (2017); the number of iterations was increased to 100,000 (thinning = 20), at which point Potential Scale Reduction (PSR) values were consistently at or near 1 (e.g., 1.001) with no evidence of increasing, and the trace plots, posterior distributions, and autocorrelations between chains supported convergence (see Supplemental Materials for examples). In the findings below, we represent all estimated model parameters with the median and 95% credibility interval of each parameter’s posterior distribution. Credibility intervals not containing zero indicate there is a 95% probability that an effect is present (i.e., non-zero).

Results

Descriptive Statistics

See Table 1 for descriptive statistics for all study variables. Per the ICCs, between-person differences accounted for about a third of the variability in affect, nearly half of the variability in motives, and less than a quarter of the variability in drinking outcomes. All daily variables were correlated at the within-person level, and many were also associated at the between-person level.

Table 1.

Descriptive Statistics for 591 Participants Across 8381 Drinking Days

Variable Person-days M (SD) Range Correlation Matrix
1 2 3 4 5 6
1. Negative affect (lagged) 6781 1.55 (1.36) 0 to 6 .32 −.66* .20* −.10* −.07* −.06*
2. Positive affect (lagged) 6783 3.99 (1.27) 0 to 6 −.64* .27 −.19* .12* .08* .07*
3. Coping motives 8335 1.07 (1.43) 0 to 6 .54* −.28* .41 .08* .07* .12*
4. Enhance motives 8190 2.63 (1.55) 0 to 6 .09* .13* .40* .48 .54* .57*
5. Drinks 8381 3.32 (2.44) 0.5 to 25 .03 .05 .18* .35* .22 .79*
6. Intoxication 8367 2.98 (1.64) 1 to 7 .13* .06 .36* .52* .65* .16
N M (SD) Range
7. SA severity 500 4.35 (9.36) 0 to 55 .08 .02 .17* .10* .14* .12*
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Note. In the correlation matrix, values below the diagonal are between-person correlations; values above the diagonal are within-person correlations; bolded and shaded values along the diagonal are intraclass correlations. SA = sexual assault.

*

p < .05.

On average, participants completed 25.1 daily diaries (SD = 6.5, Range = 1–32), representing 14.2 drinking days (SD = 6.3, Range = 1–32) and 5.5 heavy drinking days with four or more drinks consumed (SD = 4.3, Range = 0–24). Although all available data were represented in analyses, note that complete data (including the lagged affect variables from the prior morning survey) were only available for an average of 11.2 drinking days (SD = 6.3, Range = 0–31).

Only 500 participants attended the laboratory session and completed the measure of SA severity. Women missing SA data (n = 91) completed fewer daily diaries than women with SA data (n = 500), t(98.2) = −7.6, p < .001. Otherwise, participants with and without SA data did not differ on baseline demographics (age, race, ethnicity, student status). Amongst those who provided SA data, 35.2% (n = 176) reported any lifetime history of SA, and the median severity score was 8. At the bivariate level (see Table 1), SA severity was associated with greater average coping and enhancement motives as well as more drinks and greater intoxication on a typical drinking day.

Multilevel Moderated Mediation Model

Between-person.

Results (Table 2, Figure 1) revealed that higher average negative affect was associated with higher average coping drinking motives, and this association was stronger for individuals with more severe SA histories (Figure 2). Higher average coping drinking motives were uniquely associated with more severe intoxication but were not uniquely associated with drinks consumed. SA severity was positively associated with drinks consumed, but not uniquely associated with intoxication or coping drinking motives. Although there was no direct effect of negative affect on either drinks consumed or intoxication after controlling for SA and motives, higher average negative affect was associated with higher average intoxication levels via coping drinking motives – regardless of SA severity. There were no such indirect effects of negative affect on drinks consumed via coping drinking motives regardless of SA severity.

Table 2.

Multilevel Moderated Mediation Results

Path Within Person Between Person
Negative affect 🡢 Drinks −0.02 [−0.08, 0.03] −0.06 [−0.30, 0.19]
Negative affect 🡢 Intoxication −0.03 [−0.06, 0.01] 0.07 [−0.07, 0.20]
Negative affect 🡢 Coping motives 0.21 [0.18, 0.23]* 0.59 [0.48, 0.69]*
Coping motives 🡢 Drinks 0.06 [0.02, 0.09]* 0.07 [−0.11, 0.25]
Coping motives 🡢 Intoxication 0.11 [0.08, 0.13]* 0.14 [0.04, 0.24]*
Positive affect 🡢 Drinks 0.02 [−0.03, 0.08] −0.01 [−0.26, 0.25]
Positive affect 🡢 Intoxication 0.001 [−0.037, 0.039] 0.11 [−0.03, 0.25]
Positive affect 🡢 Enhance motives 0.13 [0.11, 0.16]* 0.20 [0.04, 0.37]*
Enhance motives 🡢 Drinks 1.00 [0.96, 1.03]* 0.32 [0.20, 0.44]*
Enhance motives 🡢 Intoxication 0.74 [0.71, 0.76]* 0.26 [0.20, 0.33]*
SA 🡢 Drinks 0.024 [0.004, 0.026]*
SA 🡢 Intoxication 0.004 [−0.002, 0.010]
SA 🡢 Coping motives −0.01 [−0.03, 0.01]
SA 🡢 Enhance motives 0.03 [−0.05, 0.10]
SA x Negative affect 🡢 Coping motives 0.012 [0.003, 0.022]*
SA x Positive affect 🡢 Enhance motives −0.004 [−0.023, 0.015]
Day 🡢 Drinks 0.005 [0.000, 0.009]
Day 🡢 Intoxication −0.001 [−0.004, 0.002]
Day 🡢 Coping motives 0.000 [−0.002, 0.003]
Day 🡢 Enhance motives 0.001 [−0.002, 0.004]
Weekend 🡢 Drinks 0.52 [0.43, 0.60]*
Weekend 🡢 Intoxication 0.26 [0.21, 0.32]*
Weekend 🡢 Coping motives 0.02 [−0.03, 0.06]
Weekend 🡢 Enhance motives 0.38 [0.33, 0.43]*
Covariances
Coping with Enhance motives 0.13 [0.11, 0.16]* 0.39 [0.31, 0.48]*
Drinks with Intoxication 1.51 [1.45, 1.57]* 0.34 [0.27, 0.43]*
Indirect Effects
Negative affect 🡢 Coping motives 🡢 Drinks 0.012 [0.004, 0.020]*
 - in those without SA 0.04 [−0.06, 0.15]
 - in those with SA 0.05 [−0.07, 0.18]
Negative affect 🡢 Coping motives 🡢 Intoxication 0.02 [0.02, 0.03]*
 - in those without SA 0.08 [0.02, 0.14]*
 - in those with SA 0.09 [0.02, 0.17]*
Positive affect 🡢 Enhance motives 🡢 Drinks 0.13 [0.11, 0.16]*
 - in those without SA 0.06 [0.01, 0.13]*
 - in those with SA 0.052 [−0.001, 0.118]
Positive affect 🡢 Enhance motives 🡢 Intoxication 0.10 [0.08, 0.12]*
 - in those without SA 0.05 [0.01, 0.10]*
 - in those with SA 0.044 [0.000, 0.094]
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Note. SA = sexual assault. Estimates are medians of the posterior distribution, with the 95% credibility intervals in brackets. Indirect effects for those with SA were estimated at the median SA severity for those with SA (a value of 8).

*

effects that are present, indicated by a credibility interval not containing zero.

Figure 1.

Figure 1

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Multilevel Moderated Mediation Model

Note. Model corresponds to results in Table 2. Covariances between exogenous variables were estimated, but are not represented for simplicity. Solid black lines represent non-zero paths (i.e., the credibility interval does not contain zero); dashed gray paths indicate associations for which the credibility interval does contain zero. All non-zero paths represent positive associations. SA = sexual assault.

Figure 2.

Figure 2

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Between-Person Differences in the Negative Affect to Coping Motives Paths by Sexual Assault History

Note. Model-predicted values for coping motives are shown as a function of negative affect and sexual assault (SA) history. Paths for SA were estimated at the median severity for those with SA (a value of 8), and the highest observed severity (a value of 55).

Between-person direct effects revealed that higher average positive affect was associated with greater average enhancement drinking motives. However, SA severity was not directly associated with enhancement drinking motives and did not interact with positive affect to predict enhancement motives. Higher enhancement drinking motives were uniquely associated with more drinks consumed and higher intoxication levels on average. Indirect effects revealed that higher average positive affect was associated with greater average drinks and intoxication via enhancement drinking motives, but only among individuals with less severe SA histories.

Within-person.

After controlling for between-person differences, within-person results were examined (Table 2, Figure 1). Day in the study was not associated with any drinking motive or outcome, indicating that reports of drinking did not change systematically over the study period. Weekends were associated with greater than typical enhancement drinking motives, drinks consumed, and intoxication levels, but not coping drinking motives.

Higher than typical negative affect was associated with greater same-day coping drinking motives. In turn, greater same-day coping drinking motives were associated with more same-day drinks and higher intoxication levels. Although higher than typical negative affect was not directly associated with more same-day drinks and higher intoxication levels, they were indirectly associated through greater coping drinking motives.

Higher than typical positive affect was associated with greater same-day enhancement drinking motives. Greater same-day enhancement drinking motives were associated with more same-day drinks and higher intoxication levels. Although higher than typical positive affect was not directly associated with more same-day drinks and higher intoxication levels, they were indirectly associated through greater enhancement drinking motives.

Discussion

The current study provided support for motivations to drink to up-regulate positive affect and down-regulate negative affect both between individuals and within situations. Consistent with hypotheses, women with more severe SA histories reported greater average drinks consumed; however, SA severity was not directly associated with perceived intoxication. SA severity exerted an influence on the association between negative affect and coping motives but not the association between positive affect and enhancement motives, suggesting that being motivated to drink to up-regulate positive affect is common for all women; whereas being motivated to down-regulate negative affect is more prominent for women with more severe SA histories.

Coping Motives Pathway

Consistent with hypotheses, women who reported greater average negative affect also tended to report greater average coping drinking motives. This association was especially strong for women with more severe SA histories. Regardless of SA severity, there was evidence for an overall path supporting the down-regulation of negative affect through intoxication to cope. That is, individuals with higher average negative affect reported higher coping drinking motives and achieved higher levels of perceived intoxication when they consumed alcohol, on average.

The situation-level findings revealed a similar indirect effect of negative affect and intoxication through coping drinking motives. Women who experienced greater increases in negative affect on a given day reported increased motivations to drink to cope which was associated with increased drinking and intoxication that same day. Although average coping drinking motives were not uniquely associated with increased average alcohol use, the high correlation between intoxication and average drinks suggests that individuals with greater average negative affect consume higher levels of alcohol and thus achieve greater levels of intoxication than their counterparts with lower average negative affect. After controlling for drinking quantity, women who tend to respond to negative affect with more drinking to cope motives may drink in a way that leads to higher perceived intoxication, such as drinking faster or consuming shots.

Taken together, these results suggest that women with more severe SA histories experience increased levels of coping drinking motives in response to higher average negative affect, placing these women at increased risk for higher average levels of intoxication. This is consistent with prior research on self-medicated drinking among women with SA histories (Lindgren et al., 2012). Additionally, women who report greater average levels of negative affect regardless of SA history are also at increased risk for high average levels of intoxication through increased average coping drinking motives. This pattern was also evident at the situation-level such that experiencing higher than typical negative affect on a given day was associated with increased coping drinking motives and increased drinking and intoxication that same day. Although these findings are similar to those reported by Dvorak et al. (2014), they did not examine perceived intoxication, which may explain why we found an effect of coping drinking motives at the individual level and they did not.

Enhancement Motives Pathway

Consistent with hypotheses, greater average positive affect was associated with greater average enhancement drinking motives. However, contrary to hypotheses, SA severity did not exert an influence on this association between positive affect and enhancement motives. Findings show that greater average positive affect was only associated with greater average drinking and perceived intoxication by way of greater average enhancement drinking motives. Similarly at the situation level, higher than typical positive affect was only associated with more same-day drinks and perceived intoxidation through increased same-day enhancement drinking motives. This suggests that up-regulation of positive affect was a salient motivator for drinking in this sample of young adult women, consistent with prior research (Stevenson et al., 2019).

When considering the overall path, up-regulation only led to increased average drinking and intoxication among women with no or less severe SA histories. Among women with no or less severe SA histories, those who tended to report more positive affect also experienced greater enhancement drinking motives, which led to greater drinking and intoxication on average. Although women with more severe SA histories were generally likely to drink more, they were not likely to do so as a way to enhance positive experiences. Importantly, these effects were examined while controlling for negative affect and coping motives. Taken together, findings suggest that the pathway from affect to drinking is driven more by down-regulation of negative affect than up-regulation of positive affect among women with more severe SA histories.

Clinical Implications

Intervention approaches to reduce alcohol consumption and intoxication are needed to bolster acquisition and use of adaptive strategies to down-regulate negative affect and up-regulate positive affect for all young adult women with increased negative or positive affect. Additional research is needed to determine which emotion regulation strategies best reduce the reliance on alcohol use to regulate affect and whether the strategies would be the same for both positive and negative pathways. Importantly, these interventions should take special care to meet the needs of women with SA histories who may be especially motivated to drink to cope with negative affect (Stappenbeck et al., 2021) and yet particularly sensitive to messages to decrease their alcohol use that could be interpreted as judgemental or victim blaming (Jaffe et al., 2018; Gulati et al., 2021).

Strengths and Limitations

There are a number of strengths of the current study, including the daily assessment of drinking motives, which highlights the dynamic nature of motivations to consume alcohol and recognizes that these motivations are likely situation specific. An additional strength involved the use of a recently developed Bayesian approach to estimating multilevel moderated mediation (Asparouhov & Muthén, 2021). The MCMC algorithms used to estimate the model are efficient, robust, and make no assumptions of normality. Another advantage of this Bayesian approach is that results of current analyses (posterior distributions) can be used in future analyses (as priors), such that this framework can accommodate and adapt to evolving data and observations over time.

A number of limitations should also be noted. Due to the focus of the larger study from which these data were drawn including the inclusion/exlusion criteria necessitated by the alcohol administration component, only non-problem drinking women at elevated sexual risk who had sex with a man in the past year were included. Additionally, although consistent with the ethnic and racial makeup of the community from which the sample was drawn, the sample was predominantly White. Thus, there is limited generalizability of findings to women who are nondrinkers, problem drinkers, infrequent non-problem drinkers, at low or no sexual risk, do not have sex with men, and are non-White. Finally, there may be a volunteer bias associated with individuals willing to participate in a study that includes alcohol administration. These individuals may be willing to drink more frequently and in more situations than the average individual and thus may explain why we observed an indirect effect of negative affect on drinks through coping drinking motives regardless of SA severity. Other studies with broader inclusion/exclusion criteria should be conducted to evaluate these pathways to determine if this is indeed the case.

A single daily monitoring survey necessitated the assessment of daily drinking motives the next morning (e.g., “Yesterday, to what extent did you…”). Thus, reports may have been influenced by drinking outcomes. Future studies should examine these associations using multiple daily reports of drinking motives or ecological momentary assessments. Also, drinking motives were only assessed for days in which participants reported drinking despite the fact that women could be motivated to drink to cope or enhance but not end up drinking that day for a variety of reasons. An important future research endeavor would be to understand reasons individuals either do or do not consume alcohol even when they report being motivated to drink to cope with negative affect or enhance positive affect. Finally, we did not evaluate cross-level interactions to examine whether within-person associations differed based on SA severity. Future research should address this as additional advances in Bayesian approaches for multilevel moderated mediation become available.

Conclusion

The present study represents a methodologic and analytic advance using a Bayesian approach to evaluate a multilevel moderated mediation model of women’s individual and situational level tendencies to be motivated to drink to down-regulate negative emotion or up-regulate positive emotion, and the subsequent impact on alcohol use and perceived intoxication. Further, we examined the role of SA severity on individual level pathways and found consistent support for women’s tendencies to be motivated to drink to cope or enhance negative or positive affect, respectively, and those drinking motives being associated with indicators of increased drinking. That is, becoming intoxicated to down-regulate negative emotion was common and this pathway was particularly strong for women who reported severe SA histories, whereas drinking to up-regulate positive emotion was only supported for individuals with no or low-severity SA histories, and these relationships play out over daily timeframes. Alcohol interventions that provide adaptive regulatory strategies are needed for all women who experience increased negative or positive affect, with a particular focus on self-medication for women with severe SA histories.

Supplementary Material

Supplemental Material

Clinical Impact Statement:

Results of the present study suggest that becoming intoxicated to cope with negative emotion is common among women with severe sexual assault histories. Although women with more severe SA histories were generally more likely to drink more, they were not likely to do so as a way to enhance positive experiences. Interventions to reduce alcohol consumption and associated intoxication levels that provide adaptive regulatory strategies are needed for young adult women with increased negative or positive affect.

Acknowledgments

This research was funded by grants from the National Institute of Alcohol Abuse and Alcoholism (NIAAA): 2R01AA016281 (PIs: George & Davis), K08AA021745 (PI: Stappenbeck), T32AA007455 (PI: Larimer), K99AA028777 (PI: Blayney), and K08AA028546 (PI: Jaffe). This content is solely the responsibility of the authors, does not represent the official views of the NIAAA, and NIAAA had no other role in the research other than financial support. The authors report no real or perceived conflicts of interest, including financial, personal, or other.

Footnotes

1

Although model fit can be evaluated within Bayesian structural equation models using a posterior predictive p-value (Muthén & Asparouhov, 2012), no such fit statistics are currently available for Bayes models with interactions in Mplus (Asparouhov & Muthén, 2021).

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