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CORK Bibliography: Alcoholics Anonymous (AA)

45 citations. January 2009 to present

Prepared: December 2011

Andreas JB; O'Farrell TJ. Alcoholics Anonymous attendance following 12-step treatment participation as a link between alcohol-dependent fathers' treatment involvement and their children's externalizing problems. Journal of Substance Abuse Treatment 36(1): 87-100, 2009. (55 refs.)

We investigated longitudinal associations between alcohol-dependent fathers' 12-step treatment involvement and their children's internalizing and externalizing problems (N = 125, M-age = 9.8 +/- 3.1), testing the hypotheses that fathers' greater treatment involvement would benefit later child behavior and that this effect would be mediated by fathers' posttreatment behaviors. The initial association was established between fathers' treatment involvement and children's externalizing problems only, whereas Structural Equation Modeling (SEM) results supported mediating hypotheses. Fathers' greater treatment involvement predicted children's lower externalizing problems 12 months later, and fathers' posttreatment behaviors mediated this association. Greater treatment involvement predicted greater posttreatment Alcoholics Anonymous attendance, which in turn predicted greater abstinence. Finally, fathers' abstinence was associated with lower externalizing problems in children. Theoretical and practical implications of these findings are discussed.

Bevacqua T; Hoffman E. William James's "Sick-Minded Soul" and the AA recovery paradigm: Time for a reappraisal26. Journal of Humanistic Psychology (4, special issue): 440-458, 2010. (26 refs.)

This article focuses on William James's influence on Alcoholics Anonymous (AA), which arose 25 years after his death to dominate alcoholism treatment ever since as a lay organization. With its early leaders admiringly referring to James as AA's "cofounder," AA and the numerous 12-step programs it has spawned have generally enjoyed a favorable reputation among humanistic psychologists. However, the authors regard this reputation as reflexive and largely undeserved, rather than critically generated. For essentially AA's originators selected and promulgated one particular paradigm in James's multiarrayed approach to alcoholism -- the " self-surrender of the sick-minded soul" -- to the exclusion of all others. In this paradigm, the addicted individual descends into a state of utter despair and then experiences an epiphany leading to self-transformation. However, James never regarded this state -- which Maslow later called the " nadir-experience"-- as the only means to addiction recovery, but rather advocated a diversity of paths, reflecting the variability of human personality. In celebrating this centennial year James's enduring legacy, it is time for humanistic clinicians to take the lead in moving beyond AA's outmoded, " one-size-fits-all" approach to addiction recovery.

Blonigen DM; Timko C; Moos BS; Moos RH. Treatment, Alcoholics Anonymous, and 16-year changes in impulsivity and legal problems among men and women with alcohol use disorders. Journal of Studies on Alcohol and Drugs 70(5): 714-725, 2009. (76 refs.)

Objective: The link between impulsive personality traits and alcohol use disorders (AUDs) is well established. No studies, however, have investigated whether receipt of help for AUDs predicts change in impulsivity or whether such change is associated with relevant outcomes such as legal problems. The present study examined predictive associations between the duration of help for AUDs (Alcoholics Anonymous [AA], professional treatment) and impulsivity and legal problems over 16 years in men and women with AUDs. Method: Participants who were initially untreated for their AUDs (n(men) = 332 n(women) = 296) completed follow-up telephone interviews at 1 and 16 years after their baseline assessment. Results: Impulsivity and legal problems declined between baseline and the I-year and 16-year follow-ups among both women and men. A longer duration of participation in AA predicted a decline in impulsivity at both follow-up assessments, and, in turn, a decline in impulsivity predicted a decline in legal problems at Years 1 and 16. In addition, a longer duration of participation in AA predicted fewer legal problems at Year 1, and this association was moderated by gender (significant in men) and impulsivity (significant for individuals with higher baseline scores). Conclusions: The results highlight the potential for AA and professional treatment to reduce the expression of impulsivity and related disinhibitory traits and legal problems in individuals with AUDs.

Chen G. The meaning of suffering in drug addiction and recovery from the perspective of Existentialism, Buddhism and the 12-Step Program. Journal of Psychoactive Drugs 42(3): 363-375, 2010. (102 refs.)

The aim of the current article was to examine the meaning of suffering in drug addiction and in the recovery process. Negative emotions may cause primary suffering that can drive an individual toward substance abuse. At the same time, drugs only provide temporary relief, and over time, the pathological effects of the addiction worsen causing secondary suffering, which is a motivation for treatment. The 12-Step program offers a practical way to cope with suffering through a process of surrender. The act of surrender sets in motion a conversion experience, which involves a self-change including reorganization of one's identity and meaning in life. This article is another step toward understanding one of the several factors that contribute to the addict's motivation for treatment. This knowledge may be helpful for tailoring treatment that addresses suffering as a factor that initiates treatment motivation and, in turn, treatment success.

Christensen P. Struggles with sobriety: Alcoholics Anonymous membership in Japan. Ethnology 49(1): 45-60, 2010. (25 refs.)

Membership in Alcoholics Anonymous (AA) in Japan results in societal disjunction, the divorcing of oneself from family, friends, co-workers, and others. AA meetings and meeting dialogues over the course of fieldwork highlight the social marginalization experienced by AA members of the Central Group in Tokyo. Members are thwarted by ideological frustrations with AA and an inability to consume alcohol that clashes with societal expectations and find expression in sobriety group meetings. They are caught between AA's advocacy of a new and "joyous" life devoid of alcohol that rarely matches their daily experiences of being viewed as bearers of a shameful esoteric instead of a bested personal struggle.

Cisler RA; Silverman BL; Gromov I; Gastfriend DR. Impact of treatment with intramuscular, injectable, extended-release naltrexone on counseling and support group participation in patients with alcohol dependence. Journal of Addiction Medicine 4(3): 181-185, 2010. (30 refs.)

Objectives: The impact of intramuscular, injectable, extended-release naltrexone (XR-NTX; Vivitrol) on counseling and support group participation was examined in a post hoc analysis of a 24-week, randomized, double-blind study in 624 alcohol-dependent adults, most of whom were nonabstinent at baseline. Methods: Patients were offered 6 monthly injections of XR-NTX 380 mg, XR-NTX 190 mg, or placebo (n = 205, 210, and 209, respectively) and 12 sessions of manualized brief counseling. Voluntary participation in extramural counseling (eg, couples or family therapy) and self-help support groups (eg, Alcoholics Anonymous) was permitted and assessed. Results: The proportion of patients attending all 12 Biopsychosocial, Report, Empathy, Needs, Direct advice, and Assessment sessions was nonsignificantly greater for XR-NTX 380 mg (45%) than for placebo (39%), as was the proportion attending extramural counseling (10% vs 7%) and support groups (13% vs 10%). Attendance rates were intermediate with XR-NTX 190-mg. Attending self-help groups was significantly (P = 0.04) related to reduced heavy drinking across all treatment groups. Conclusions: XR-NTX is compatible with counseling and support group participation in the treatment of alcohol dependence.

Detar DT. Alcoholics Anonymous and other twelve-step programs in recovery. Primary Care 38(1): 143+, 2011. (26 refs.)

Recovery is a new way of life for many patients; a life without substances to alter their moods but with a major change improving the physical, psychological, and emotional stability with improved overall health outcomes. The Twelve Steps of the Alcoholics Anonymous (AA) are the foundation of the AA, describing both the necessary actions and the spiritual basis for the recovery program of the AA. The Twelve Steps of the AA provide a structure for which a patient with alcoholism may turn for an answer to their problem of alcohol use, abuse, or dependence.

Doukas N; Cullen J. Recovered, in recovery or recovering from substance abuse? A question of identity. Journal of Psychoactive Drugs 41(4): 391-394, 2009. (26 refs.)

There has always been widespread debate on how people with past substance abuse problems choose to identify themselves with regards to their recovery and the terms used to associate with that identity. Most of the disagreement over these terms is rooted on whether recovery is seen as an ongoing process ("recovering" or "in recovery") or a life event that can be mastered ("recovered"). This article discusses these three controversial terms and attempts to make them available as terms that one can use or identify with by presenting different perspectives on the topic of recovery. Some of these perspectives may be unconventional when compared to traditional views of the recovery process, but they are the realities of many individuals who have had a past experience with substance abuse and may be confronted with prejudice when voicing their recovery in a past tense. The article makes comparisons between the DSM IV and the Big Book of AA and discusses identity vs labels and the influence of the medical community on this controversial topic.

Goebert D; Nishimura S. Comparison of substance abuse treatment utilization and preferences among Native Hawaiians, Asian Americans and Euro Americans. Journal of Substance Use 16(2): 161-170, 2011. (49 refs.)

Use and preferences for substance abuse treatment can vary by ethnicity. However, little is known about use and preferences among Native Hawaiians and Asian Americans. Interviews from 192 admitted multi-ethnic residents from two treatment facilities in Hawaii were conducted. More similarities than differences were found. The most utilized treatments were Alcoholics Anonymous and the emergency department, with no significant ethnic differences. However, Native Hawaiians and Asian Americans were significantly less likely to have spoken to a mental health provider about alcohol problems (32%%, 39%%, respectively vs. 69%% of Euro Americans) and to have seen a physician for a drinking-related problem (21%% of Native Hawaiians and 19%% of Asian Americans vs. 41%% of Euro Americans). Native Hawaiians were significantly more likely to consider marriage counselling to be an effective form of treatment (33%% vs. 11%% of Asian Americans and 9%% of Euro Americans). Implications for substance abuse treatment are discussed. The findings suggest that it is important to integrate the field of substance abuse in multiple systems; including substance abuse, medical, criminal, social service and community settings to ensure treatment preferences are met. Ethnic differences may also have implications for expanding and tailoring services.

Gross M. Alcoholics Anonymous: Still sober after 75 years. (editorial). American Journal of Public Health 100(12): 2361-2363, 2010. (18 refs.)

Hagarty DE; Clark DJ. Using imagery and storytelling to educate outpatients about 12-Step programs and improve their participation in community-based programs. Journal of Addictions Nursing 20(2): 86-92, 2009. (32 refs.)

The longer a patient remains engaged in recovery activities the greater the success of long-term abstinence. Self-help community programs that use the 12-steps such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are known in the addictions field to contribute to sustained abstinence. Connecting patients to 12-step programs in early stages of recovery increases the chance of prolonged involvement. A nurse working in an outpatient substance abuse clinic developed a unique method to inform and educate patients about the 12-step process. A story and image metaphorically describe this journey. The cleaning of a vessel and subsequent discovery of tools along the way provide an uncomplicated look at the 12-steps. Nurses can use the image and story to develop the necessary tools of honesty, open-mindedness, and willingness for patients to embrace the 12-step journey.

Jenkins COE; Tonigan JS. Attachment avoidance and anxiety as predictors of 12-Step group engagement. Journal of Studies on Alcohol and Drugs 72(5): 854-863, 2011. (69 refs.)

Objective: Twelve-step mutual help groups such as Alcoholics Anonymous (AA) rely heavily on social interactions and support to reduce drinking, but little is known about how individual differences in social behavior tendencies, such as adult attachment, affect 12-step group engagement and resulting benefits. This prospective study investigated relationships between the anxiety and avoidance dimensions of adult attachment and subsequent 12-step meeting attendance, program behaviors, sponsorship, and alcohol use. Method: Early 12-step group affiliates (N = 253) were recruited from community-based AA and from outpatient treatment. Participants completed baseline interviews that included the Relationship Questionnaire, measures of motivation and professional treatment, and measures of 12-step meeting attendance, practices, and sponsorship. Follow-up interviews were conducted at 3, 6, 9, 12, 18, and 24 months. Results: At baseline, participants reported elevated attachment anxiety relative to a college population. Lagged analyses demonstrated that, as predicted, high attachment avoidance was related to lower rates of 12-step meeting attendance, practice of behaviors prescribed by 12-step organizations, and lower probability of acquiring a sponsor. Attachment anxiety did not predict any of these aspects of subsequent 12-step group engagement. Contrary to predictions, baseline attachment avoidance did not moderate the relationship between early sponsorship and alcohol use. Conclusions: Findings support the hypothesis that social demands of behaviors prescribed by 12-step groups may deter high-avoidance individuals from fully engaging in them. Perhaps because of instability in attachment avoidance in this population, however, baseline attachment avoidance did not predict drinking outcomes or moderate sponsor benefits.

Kaskutas LA. Alcoholics Anonymous effectiveness: Faith meets science. Journal of Addictive Diseases 28(2): 145-157, 2009. (42 refs.)

Research on the effectiveness of Alcoholics Anonymous (AA) is controversial and subject to widely divergent interpretations. The goal of this article is to provide a focused review of the literature on AA effectiveness that will allow readers to judge the evidence effectiveness of AA for themselves. The review organizes the research on AA effectiveness according to six criterion required for establishing causation: (1) magnitude of effect; (2) dose response effect; (3) consistent effect; (4) temporally accurate effects; (5) specific effects; (6) plausibility. The evidence for criteria 1- 4 and 6 is strong: rates of abstinence are about twice as high among those who attend AA (criteria 1, magnitude); higher levels of attendance are related to higher rates of abstinence (criteria 2, dose-response); these relationships are found for different samples and follow-up periods (criteria 3, consistency); prior AA attendance is predictive of subsequent abstinence (criteria 4, temporal); and mechanisms of action predicted by theories of behavior change are present in AA (criteria 6, plausibility). However, rigorous experimental evidence establishing the specificity of an effect for AA or Twelve Step Facilitation/TSF (criteria 5) is mixed, with 2 trials finding a positive effect for AA, 1 trial finding a negative effect for AA, and 1 trial finding a null effect. Studies addressing specificity using statistical approaches have had two contradictory findings, and two that reported significant effects for AA after adjusting for potential confounders such as motivation to change.

Kaskutas LA; Bond J; Avalos LA. 7-year trajectories of Alcoholics Anonymous attendance and associations with treatment. Addictive Behaviors 34(12): 1029-1035, 2009. (42 refs.)

Although many members of Alcoholics Anonymous (AA) are introduced to AA during treatment, the relationship between treatment and AA attendance over time is unknown. This paper describes four latent classes of AA attendance among 586 dependent alcoholics interviewed by telephone 1, 3, 5 and 7 years after baseline, and models the relationship between treatment exposure and AA attendance in each class. There was a low AA group (averaging fewer than 5 meetings at most follow-ups), a medium AA group (about 50 meetings a year at each follow-up), a descending AA group (about 150 meetings year 1, then decreasing steeply), and a high AA group (about 200 meetings at I year, then decreasing gradually by year 7). Declines in meeting attendance were not always accompanied by decreases in abstinence. After accounting for the effect of time on AA attendance (i.e., the "ups-and-downs" that occur over time), treatment exposure was minimally related to AA attendance in all but the descending AA group, where it was negatively associated (p<0.001). Considering AA patterns over time highlights a different role for treatment in AA attendance than what is gleaned from analyses at single timepoints.

Kelly JF; Dow SJ; Yeterian JD; Kahler CW. Can 12-step group participation strengthen and extend the benefits of adolescent addiction treatment? A prospective analysis. Drug and Alcohol Dependence 110(1-2): 117-125, 2010. (47 refs.)

Background: Despite advances in the development of treatments for adolescents with substance use disorders (SUD), relapse remains common following an index treatment episode. Community continuing care resources, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), have been shown to be helpful and cost-effective recovery resources among adults. However, little is known about the clinical utility and effectiveness of AA/NA for adolescents, despite widespread treatment referrals. Method: Adolescents (N=127; 24% female, 87% White, M age = 16.7 years) enrolled in a naturalistic, prospective study of community outpatient treatment were assessed at intake, and 3 and 6 months later using a battery of standardized and validated measures. Results: Just over one-quarter of youth attended AA/NA meetings during the first 3 months, which was predicted by a goal of abstinence, prior AA/NA attendance, and prior SOD treatment experiences. Controlled multiple regression analyses revealed an independent effect of AA/NA on abstinence, in both contemporaneous and lagged models, which persisted over and above the effects of pre-treatment AA/NA attendance, prior treatment, self-efficacy, abstinence goal, and concomitant outpatient treatment. Conclusions: Results suggest that, similar to findings comparing adult outpatients to inpatients, AA/NA participation is less common among less severe adolescent outpatients. Nonetheless, attendance appears to strengthen and extend the benefits of typical community outpatient treatment. Given the dramatic increase in rates of substance use among same-aged peers in the population at this life-stage, and the relative dearth of abstainers and recovery-specific supports, these resources may provide a concentrated cost-effective social recovery resource for young people.

Kelly JF; Dow SJ; Yeterian JD; Myers M. How safe are adolescents at Alcoholics Anonymous and Narcotics Anonymous meetings? A prospective investigation with outpatient youth. Journal of Substance Abuse Treatment 40(4): 419- 425, 2011. (25 refs.)

Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have proven to be cost-effective recovery resources for adults and also appear helpful for youth. However, anecdotal concerns about adolescents' safety at meetings have dampened enthusiasm regarding youth participation. Unfortunately, little information exists to evaluate such concerns. Outpatients (N = 127; 24% female) were assessed at intake and at 3, 6, and 12 months regarding perceived safety at AA/NA, experience of negative incidents, and reasons for nonattendance/discontinuation. By 12-month follow-up, 57.5% reported some AA/NA attendance with a combined lifetime exposure of 5,340 meetings. Of these, 21.9% reported at least one negative experience, which was more common among NA than AA attendees. Overall, youth reported feeling very safe at meetings, and ratings did not differ by age or gender. Reasons for discontinuation or nonattendance were unrelated to safety or negative incidents. Weighing risks against documented benefits, these preliminary findings suggest that referral to AA/NA should not be discouraged, but, similar to adults, youth experiences at meetings should be monitored.

Kelly JF; Kahler CW; Humphreys K. Assessing why substance use disorder patients drop out from or refuse to attend 12-step mutual-help groups: The "REASONS" questionnaire. Addiction Research & Theory 18(3): 316-325, 2010. (46 refs.)

Substance use disorder (SUD) patients who become involved in 12-step mutual-help groups (MHGs), such as Alcoholics Anonymous, experience better outcomes and have reduced healthcare costs. In spite of this, many do not attend at all and other initial attendees drop out. Reasons for non-attendance and dropout have not been systematically studied, yet such knowledge could enhance the efficiency of twelve-step facilitation (TSF) efforts or help clinicians decide which patients might prefer non-12-step MHGs (e.g., SMART Recovery). This study developed and tested a measure of reasons for non-participation and dropout from 12-step MHGs. Items were generated and clustered into eight domains using a rational keying approach. Male veterans (N = 60; M age = 49; 41% African American) undergoing SUD treatment were asked to complete a brief assessment about prior MHG experiences. Psychometric analyses produced a 24-item measure containing seven internally consistent, face-valid, subscales. Co-morbid psychiatric issues and, to a lesser degree, spiritual concerns, were found to be particularly important dimensions relating to this phenomenon. The measure could serve as a useful screening tool for barriers to 12-step participation and subsequently focus TSF efforts or inform referral to non-12 step MHGs.

Kelly JF; Magill M; Stout RL. How do people recover from alcohol dependence? A systematic review of the research on mechanisms of behavior change in Alcoholics Anonymous. (review). Addiction Research & Theory 17(3): 236-259, 2009. (133 refs.)

Rigorous reviews of the science on the effectiveness of Alcoholics Anonymous (AA) indicate that AA and related 12-step treatment are at least as helpful as other intervention approaches. Exactly how AA achieves these beneficial outcomes is less well understood, yet, greater elucidation of AA's mechanisms could inform our understanding of addiction recovery and the timing and content of alcohol-related interventions. Empirical studies examining AA's mechanisms were located from searches in Pubmed, Medline, PsycINFO, Social Service Abstracts and from published reference lists. Thirteen studies completed full mediational tests. A further six were included that had completed partial tests. Mechanisms examined fell into three domains: (1) Common processes; (2) AA-specific practices; and (3) Social and spiritual processes. Results suggest AA helps individuals recover through common process mechanisms associated with enhancing self-efficacy, coping skills, and motivation, and by facilitating adaptive social network changes. Little research or support was found for AA's specific practices or spiritual mechanisms. Conclusions are limited by between-study differences in sampling, measurement, and assessment time-points, and by insufficient theoretical elaboration of recovery-related change. Similar to the common finding that theoretically-distinct professional interventions do not result in differential patient outcomes, AA's effectiveness may not be due to its specific content or process. Rather, its chief strength may lie in its ability to provide free, long-term, easy access and exposure to recovery-related common therapeutic elements, the dose of which, can be adaptively self-regulated according to perceived need.

Kelly JF; Stout RL; Magill M; Tonigan JS; Pagano ME. Mechanisms of behavior change in Alcoholics Anonymous: Does Alcoholics Anonymous lead to better alcohol use outcomes by reducing depression symptoms? Addiction 105(4): 626-636, 2010. (64 refs.)

Rationale: Indices of negative affect, such as depression, have been implicated in stress-induced pathways to alcohol relapse. Empirically supported continuing care resources, such as Alcoholics Anonymous (AA), emphasize reducing negative affect to reduce relapse risk, but little research has been conducted to examine putative affective mechanisms of AA's effects. Methods: Using lagged, controlled, hierarchical linear modeling and mediational analyses this study investigated whether AA participation mobilized changes in depression symptoms and whether such changes explained subsequent reductions in alcohol use. Alcohol-dependent adults (n = 1706), receiving treatment as part of a clinical trial, were assessed at intake, 3, 6, 9, 12 and 15 months. Results: Findings revealed elevated levels of depression compared to the general population, which decreased during treatment and then remained stable over follow-up. Greater AA attendance was associated with better subsequent alcohol use outcomes and decreased depression. Greater depression was associated with heavier and more frequent drinking. Lagged mediation analyses revealed that the effects of AA on alcohol use was mediated partially by reductions in depression symptoms. However, this salutary effect on depression itself appeared to be explained by AA's proximal effect on reducing concurrent drinking. Conclusions: AA attendance was associated both concurrently and predictively with improved alcohol outcomes. Although AA attendance was associated additionally with subsequent improvements in depression, it did not predict such improvements over and above concurrent alcohol use. AA appears to lead both to improvements in alcohol use and psychological and emotional wellbeing which, in turn, may reinforce further abstinence and recovery-related change.

Kelly JF; Stout RL; Magill M; Tonigan JS; Pagano ME. Spirituality in recovery: A lagged mediational analysis of Alcoholics Anonymous' principal theoretical mechanism of behavior change. Alcoholism: Clinical and Experimental Research 35(3): 454-463, 2011. (77 refs.)

Background: Evidence indicates Alcoholics Anonymous (AA) can play a valuable role in recovery from alcohol use disorder. While AA itself purports it aids recovery through "spiritual" practices and beliefs, this claim remains contentious and has been only rarely formally investigated. Using a lagged, mediational analysis, with a large, clinical sample of adults with alcohol use disorder, this study examined the relationships among AA, spirituality/religiousness, and alcohol use, and tested whether the observed relation between AA and better alcohol outcomes can be explained by spiritual changes. Method: Adults (N = 1,726) participating in a randomized controlled trial of psychosocial treatments for alcohol use disorder (Project MATCH) were assessed at treatment intake, and 3, 6, 9, 12, and 15 months on their AA attendance, spiritual/religious practices, and alcohol use outcomes using validated measures. General linear modeling (GLM) and controlled lagged mediational analyses were utilized to test for mediational effects. Results: Controlling for a variety of confounding variables, attending AA was associated with increases in spiritual practices, especially for those initially low on this measure at treatment intake. Results revealed AA was also consistently associated with better subsequent alcohol outcomes, which was partially mediated by increases in spirituality. This mediational effect was demonstrated across both outpatient and aftercare samples and both alcohol outcomes (proportion of abstinent days; drinks per drinking day). Conclusions: Findings suggest that AA leads to better alcohol use outcomes, in part, by enhancing individuals' spiritual practices and provides support for AA's own emphasis on increasing spiritual practices to facilitate recovery from alcohol use disorder.

Kelly JF; Stout RL; Magill M; Tonigan JS. The role of Alcoholics Anonymous in mobilizing adaptive social network changes: A prospective lagged mediational analysis. Drug and Alcohol Dependence 114(2-3): 119- 126, 2011. (61 refs.)

Objective: Many individuals entering treatment are involved in social networks and activities that heighten relapse risk. Consequently, treatment programs facilitate engagement in social recovery resources, such as Alcoholics Anonymous (AA), to provide a low risk network. While it is assumed that AA works partially through this social mechanism, research has been limited in rigor and scope. This study used lagged mediational methods to examine changes in pro-abstinent and pro-drinking network ties and activities. Method: Adults (N = 1726) participating ill a randomized controlled trial of alcohol use disorder treatment were assessed at intake, and 3, 9, and 15 months. Generalized linear modeling (Generalized linear modeling) tested whether changes in pro-abstinent and pro-drinking network ties and drinking and abstinent activities helped to explain AA's effects. Results: Greater AA attendance facilitated substantial decreases in pro-drinking social ties and significant, but less substantial increases in pro-abstinent ties. Also, AA attendance reduced engagement in drinking-related activities and increased engagement in abstinent activities. Lagged mediational analyses revealed that it was through reductions in pro-drinking network ties and, to a lesser degree, increases in pro-abstinent ties that AA exerted its salutary effect on abstinence, and to a lesser extent, on drinking intensity. Conclusions: AA appears to facilitate recovery by mobilizing adaptive changes in the social networks of individuals exhibiting a broad range of impairment. Specifically by reducing involvement with pro-drinking ties and increasing involvement with pro-abstinent ties. These changes may aid recovery by decreasing exposure to alcohol-related cues thereby reducing craving, while simultaneously increasing rewarding social relationships.

Kelly JF; Yeterian JD. The role of mutual-help groups in extending the framework of treatment. Alcohol Research & Health 33(4): 350-355, 2011. (46 refs.)

Alcohol use disorders (AUDs) are highly prevalent in the United States and often are chronic conditions that require ongoing episodes of care over many years to achieve full sustained remission. Despite substantial scientific advances in specialized care, professional resources alone have not been able to cope with the immense burden of disease attributable to alcohol Perhaps in tacit recognition of this, peer-run mutual-help groups (MHGs), such as Alcoholics Anonymous (AA), have emerged and proliferated in the past 75 years and continue to play an important role in recovery from AUDs. This article describes the nature and prevalence of MHGs, particularly AA, and reviews evidence for their effectiveness and cost-effectiveness and the mechanisms through which they may exert their effects. The article also provides details about how health care professionals can facilitate their alcohol-dependent patients' participation in such groups and reviews the evidence for the benefits of doing so.

Litt MD; Kadden RM; Kabela-Cormier E; Petry NM. Changing network support for drinking: Network support project 2-year follow-up. Journal of Consulting and Clinical Psychology 77(2): 229-242, 2009. (59 refs.)

Network Support Project was designed to determine whether a treatment could lead patients to change their social network from one that supports drinking to one that supports sobriety. This study reports 2-year posttreatment outcomes. Alcohol-dependent men and women (N = 210) were randomly assigned to 1 of 3 outpatient treatment conditions: network support (NS), network support + contingency management (NS + CM), or case management (CaseM, a control condition). Analysis of drinking rates indicated that the NS condition yielded up to 20% more days abstinent than the other conditions at 2 years posttreatment. NS treatment also resulted in greater increases at 15 months in social network support for abstinence, as well as in AA attendance and AA involvement than did the other conditions. Latent growth modeling suggested that social network changes were accompanied by increases in self-efficacy and coping that were strongly predictive of long-term drinking outcomes. The findings indicate that a network support treatment can effect long-term adaptive changes in drinkers' social networks and that these changes contribute to improved drinking outcomes in the long term.

Loder E. Medical Classics. Alcoholics Anonymous: "The Big Book" (editorial). British Medical Journal 339(b4387), 2009. (0 refs.)

This editorial is a response to the 60the anniversary of the Alcoholics Anonymous' classic publication, known as "The Big Book." The editor cites the initial response of the medical community to AA, as witnessed by the editorial in the Journal of the American Medical Association. The editorial in JAMA "dismissed the AA method as a 'curious combination of organizing propaganda and religious exhortation' and decried it as among the 'considerable number of other forms of quack treatment' that had 'sprung up' to treat alcoholism. " The JAMA reviewer opined that the one valid element "is the recognition of the seriousness of addiction to alcohol", but other than this the book was described as being of "no scientific interest." In this editorial it is noted that AA has become a commonly used treatment approach, and might well be seen as the a very early "lifestyle" intervention, meaning that changes in personal habits are advocated rather than procedures or drugs.

Majer JM; Jason LA; Ferrari JR; Miller SA. 12-Step involvement among a U.S. national sample of Oxford House residents. Journal of Substance Abuse Treatment 41(1): 37-44, 2011. (38 refs.)

A longitudinal analysis was conducted among a U.S. national sample of persons affiliated with Alcoholics Anonymous and Narcotics Anonymous living in self-run recovery homes (Oxford Houses). Categorical involvement in a set of 12-step activities (i.e., having a sponsor, reading 12-step literature, doing service mirk, and calling other members for help) and averaged summary scores of involvement were examined in relation to abstinence and sell-efficacy for abstinence. Participants who were categorically involved in all 12-step activities reported significantly higher levels of abstinence and self-efficacy for abstinence at 1 year compared with those who were less involved, whereas averaged summary scores of involvement were not a significant predictor of abstinence. Participants' number of days in Oxford Houses, but not rates of 12-step meeting attendance, was significantly related to increased abstinence. Findings suggest that categorical involvement in a number of 12-step activities equip persons with substance use disorders with resources for ongoing recovery.

McMenamin D; Warren M; Tyrfingsson P; Hansdottir I; Dermatis H; Galanter M et al. Alcoholics Anonymous and the Minnesota Model of treatment in Iceland. (editorial). Substance Abuse 32(1): 36-39, 2011. (5 refs.)

This study was undertaken to provide an initial characterization of the current status of patients admitted to an alcoholism treatment program in Iceland. Consistent with the Minnesota Model, 12-step facilitation has been a central component of the program since its inception. Of the 94 patients assessed in this study, 67% were male and 40% had attended over 90 AA meetings prior to admission. The mean number of drinking days during the month prior to admission was 15.51 days and the mean length of hospital stay was 12.32 days. At time of hospital discharge, 39% were referred to residential treatment. Significant predictors of referral to residential treatment included having attended less than 90 AA meetings prior to admission and length of stay.

Orwat J; Samet JH; Tompkins CP; Cheng DM; Dentato MP; Saitz R. Factors associated with attendance in 12-step groups (Alcoholics Anonymous/Narcotics Anonymous) among adults with alcohol problems living with HIV/AIDS. Drug and Alcohol Dependence 113(2-3): 165-171, 2011. (65 refs.)

Background: Despite the value of 12-step meetings, few studies have examined factors associated with attendance among those living with HIV/AIDS, such as the impact of HIV disease severity and demographics. Objective. This study examines predisposing characteristics, enabling resources and need on attendance at Alcoholic Anonymous (AA) and Narcotics Anonymous (NA) meetings among those living with HIV/AIDS and alcohol problems. Methods: Secondary analysis of prospective data from the HIV-Longitudinal Interrelationships of Viruses and Ethanol study, a cohort of 400 adults living with HIV/AIDS and alcohol problems. Factors associated with AA/NA attendance were identified using the Anderson model for vulnerable populations. Generalized estimating equation logistic regression models were fit to identify factors associated with self-reported AA/NA attendance. Results: At study entry, subjects were 75% male, 12% met diagnostic criteria for alcohol dependence, 43% had drug dependence and 56% reported attending one or more AA/NA meetings (past 6 months). In the adjusted model, female gender negatively associated with attendance, as were social support systems that use alcohol and/or drugs, while presence of HCV antibody, drug dependence diagnosis, and homelessness associated with higher odds of attendance. Conclusions: Non-substance abuse related barriers to AA/NA group attendance exist for those living with HIV/AIDS, including females and social support systems that use alcohol and/or drugs. Positive associations of homelessness, HCV infection and current drug dependence were identified. These findings provide implications for policy makers and treatment professionals who wish to encourage attendance at 12-step meetings for those living with HIV/AIDS and alcohol or other substance use problems.

Pagano ME; Zemore SE; Onder CC; Stout RL. Predictors of initial AA-related helping: Findings from Project MATCH. Journal of Studies on Alcohol and Drugs 70(1): 117-125, 2009. (58 refs.)

Objective: The purpose of this article is to identify the factors that predict initial Alcoholics Anonymous (AA)-related helping following treatment admission. Method: Data were derived from Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), a longitudinal investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence. Cox proportional hazard regressions were performed to determine the extent to which demographic, clinical, belief, and AA factors predicted initial AA-related helping. Results: Demographic characteristics, drinking severity, antisocial personality, and purpose in life were not associated with initial AA-related helping. Increased self-efficacy, faith-based practices, meeting attendance, number of steps worked, having a sponsor, and length of sobriety predicted initial AA-related helping. Alcoholics reported elevated depressive symptoms before initial AA-related helping, lowered depressive symptoms at the start of AA-related helping, and similarly lowered depressive symptoms in the interval following initial AA-related helping. Conclusions: The profile of prospective helpers in AA is not limited to alcoholics from certain backgrounds or higher functioning in terms of drinking or clinical severity. To increase participation in AA-related helping, and hence outcomes, results suggest strengthening self-efficacy and progress in other AA programmatic components.

Reich MS; Dietrich MS; Martin PR. Temporal sequence of incident cigarette, coffee, and alcohol use among AA participants. (review). American Journal of Drug and Alcohol Abuse 37(1): 27-36, 2011. (48 refs.)

Background: Cigarettes and coffee are widely used psychoactive substances among alcoholics. Due to the devastating public health impact of alcohol use disorders, it is important to determine if using cigarettes or coffee may influence alcoholism. Previous studies indicate that cigarette smoking is associated with progression of alcohol dependence, but the effects of coffee drinking have yet to be investigated. Objectives: To retrospectively determine the temporal sequence of incident cigarette, coffee, and alcohol use and attributed subjective effects in AA participants. Methods: Volunteers at all Nashville open-AA meetings (n = 289 [126 women], completion rate = 94.1%) were administered a Lifetime Drinking History modified to also include lifetime cigarette and coffee consumption, as well as coffee consumption and effects questions, the Fagerstrom Test for Nicotine Dependence, and the Smoking Effects Questionnaire. Results: Average ages (years) at first regular use of alcohol, cigarettes, and coffee were 15.4 (IQR: 13.0-18.0), 16.7 (IQR: 13.0-18.5), and 18.5 (IQR: 14.0-23.5), respectively. In a subset who used all three substances (n = 236; 102 women) alcohol consumption preceded cigarette smoking (p < .001) and coffee drinking (p < .001), and cigarette smoking preceded coffee drinking (p < .001); these relationships did not differ by gender. Conclusions: Recovering alcoholics started regular alcohol consumption prior to cigarette smoking and coffee drinking. Scientific Significance: In AA participants, coffee does not precede initiation of regular smoking or alcohol drinking as might be anticipated for a gateway drug.

Robinson EAR; Krentzman AR; Webb JR; Brower KJ. Six-month changes in spirituality and religiousness in alcoholics predict drinking outcomes at nine months. Journal of Studies on Alcohol and Drugs 72(4): 660-668, 2011. (48 refs.)

Objective: Although spiritual change is hypothesized to contribute to recovery from alcohol dependence, few studies have used prospective data to investigate this hypothesis. Prior studies have also been limited to treatment-seeking and Alcoholics Anonymous (AA) samples. This study included alcohol-dependent individuals, both in treatment and not, to investigate the effect of spiritual and religious (SR) change on subsequent drinking outcomes, independent of AA involvement. Method: Alcoholics (N = 364) were recruited for a panel study from two abstinence-based treatment centers, a moderation drinking program, and untreated individuals from the local community. Quantitative measures of SR change between baseline and 6 months were used to predict 9-month drinking outcomes, controlling for baseline drinking and AA involvement. Results: Significant 6-month changes in 8 of 12 SR measures were found, which included private SR practices, beliefs, daily spiritual experiences, three measures of forgiveness, negative religious coping, and purpose in life. Increases in private SR practices and forgiveness of self were the strongest predictors of improvements in drinking outcomes. Changes in daily spiritual experiences, purpose in life, a general measure of forgiveness, and negative religious coping also predicted favorable drinking outcomes. Conclusions: SR change predicted good drinking outcomes in alcoholics, even when controlling for AA involvement. SR variables, broadly defined, deserve attention in fostering change even among those who do not affiliate with AA or religious institutions. Last, future research should include SR variables, particularly various types of forgiveness, given the strong effects found for forgiveness of self.

Schneider R; Timko C; Moos B; Moos R. Violence victimization, help-seeking, and one- and eight-year outcomes of individuals with alcohol use disorders. Addiction Research & Theory 19(1): 22-31, 2011. (61 refs.)

We examined the associations of recent victimization with subsequent participation in alcohol-related treatment and mutual help, and with short- and long-term drinking and health outcomes. Treatment-naive men and women having an alcohol use disorder with (n = 73) or without (n = 491) recent violence victimization were assessed at baseline and 1 and 8 years later. Victimized individuals had more days intoxicated, drinking problems, symptoms of depression, and physical health problems at baseline, and were more likely to attend Alcoholics Anonymous (AA) during Year 1. Victimization at baseline predicted re-victimization at 1 year, and more depressive symptoms and physical health problems at 8 years. Participation in alcohol-related treatment or AA during Year 1 was associated with fewer drinking problems. In addition, treatment or AA participation was of greater benefit to victimized individuals in terms of reducing drinking-related or health problems. Alcohol use disorder interventions are effective for men and women with recent victimization, but additional services may be needed to remedy problems with depression and physical health and to prevent further victimization.

Schonbrun YC; Strong DR; Anderson BJ; Caviness CM; Brown RA; Stein MD. Alcoholics Anonymous and hazardously drinking women returning to the community after incarceration: Predictors of attendance and outcome. Alcoholism: Clinical and Experimental Research 35(3): 532-539, 2011. (50 refs.)

Background: The number of women incarcerated within the United States has risen dramatically in recent decades, and high rates of alcohol problems are evident among this population. Although little is known about the patterns of help utilization and efficacy for alcohol problems, preliminary evidence suggests that Alcoholics Anonymous (AA) is a widely available resource for this population. Methods: Data were collected as part of a study evaluating the effect of a brief intervention to reduce alcohol use among hazardously drinking (i.e., score of 8 or above on the Alcohol Use Disorders Identification Test or 4 or more drinks at a time on at least 3 days in prior 3 months) incarcerated women. The current study characterized demographic, clinical, and previous AA attendance variables associated with AA attendance in the 6 months following incarceration. Associations between frequency of AA attendance and drinking outcomes following incarceration were also evaluated. Results: Among the 224 participants who provided data about AA attendance, 54% reported some AA attendance during the follow-up assessment period. AA attendance in the year prior to study entry (OR = 4.02; 95% CI: 3.32 to 4.71) and greater baseline consequences of alcohol use (OR = 2.09; 95% CI: 1.73 to 2.44) were associated with increased odds of higher frequency of AA attendance following incarceration. Weekly or greater AA attendance was associated with reductions in negative drinking consequences (B = -0.45; p < 0.01) and frequency of drinking days (B = -0.28; p < 0.01) following incarceration. Conclusions: Findings from this study suggest that AA is frequently utilized by hazardously drinking women following incarceration. Alcohol outcomes may be enhanced by AA attendance at a weekly or greater frequency is associated with better alcohol outcomes relative to lower levels of AA attendance. Evaluation of clinical guidelines for prescribing AA attendance for incarcerated women remains a task for future research.

Stroud MW; Bombardier CH; Dyer JR; Rimmele CT; Esselman PC. Preinjury alcohol and drug use among persons with spinal cord injury: Implications for rehabilitation. Journal of Spinal Cord Medicine 34(5): 461-472, 2011. (45 refs.)

Context/objective: To describe preinjury alcohol and drug use and opportunities for secondary prevention among persons with recent spinal cord injury (SCI). Design: Survey. Setting: Acute inpatient rehabilitation program. Participants: Participants were 118 (84.8%) of 139 consecutive admissions who met inclusion criteria and were screened for preinjury alcohol and drug use. Interventions: None. Outcome measures: Alcohol and drug use, toxicology results, alcohol problems, readiness to change, and treatment preferences. Results: Participants were on average 37 years old, 84% were men, and 85% were white. Fifty-one percent of the sample was considered 'at-risk' drinkers. Significant lifetime alcohol-related problems were reported by 38% of the total sample. Thirty-three percent reported recent illicit drug use and 44% of the 82 cases with toxicology results were positive for illicit drugs. Seventy-one percent of at-risk drinkers reported either considering changes in alcohol use or already taking action. Forty-one percent reported interest in trying substance abuse treatment or Alcoholics Anonymous (AA). Motivation to change alcohol use was significantly and positively associated with self-reported indicators of alcohol problem severity. Conclusion: Preinjury alcohol and drug abuse are common among persons with recent SCI. Substance abuse screening is feasible and detects not only salient clinical problems but also significant motivation to change and interest in AA or treatment, all of which represent an important window of opportunity for appropriate brief interventions and referrals. In contrast with the idea that alcoholism is a 'disease of denial', the majority of at-risk drinkers with new onset SCI indicate they are considering making changes.

Subbaraman MS; Kaskutas LA; Zemore S. Sponsorship and service as mediators of the effects of Making Alcoholics Anonymous Easier (MAAEZ), a 12-step facilitation intervention. Drug and Alcohol Dependence 116(1-3): 117-124, 2011. (46 refs.)

A recent trial (n = 508) of "Making Alcoholics Anonymous Easier" (MAAEZ), a group-format 12-step facilitation program, showed that MAAEZ participants had increased odds of abstinence (OR = 1.58; p = 0.063). Effects were especially marked in several subgroups, including those with more prior AA/NA/CA exposure, and those with severe psychiatric problems. This paper examines whether the effects of MAAEZ were explained by higher engagement in particular Alcoholics Anonymous (AA) and other 12-step organization activities. Mediation analyses were performed, estimating MAAEZ effects attributable to AA/NA/CA meeting attendance, overall AA/NA/CA involvement, having a sponsor, and engaging in 12-step service. The only variable that appeared to mediate MAAEZ effects in the sample overall was doing service at either 6 months or at both 6 and 12 months. Among those with high prior AA/NA/CA attendance, both having a sponsor and doing service emerged as mediators, with having a sponsor explaining approximately 25% of the MAAEZ effect. Doing service also partially explained the MAAEZ effect among those with high psychiatric severity. Results highlight the value of studying specific AA/NA/CA activities as mediators of treatment effects, and demonstrate the importance of exploring subgroups when trying to understand treatment mechanisms. Findings also suggest that treatment programs should emphasize specific activities for particular clients. For example, individuals may have attended many AA/NA/CA meetings, but never known how to ask for a sponsor or get involved in service; doing service may represent a non-threatening way of connecting with 12-step members for clients with psychiatric problems such as social anxiety.

Sussman S. A review of Alcoholics Anonymous/Narcotics Anonymous programs for teens. Evaluation & the Health Professions 33(1): 26-55, 2010. (84 refs.)

The investigation of the applicability of Alcoholics Anonymous/Narcotics Anonymous (AA/NA) for teens has only been a subject of empirical research investigation since the early 1990s. In the present review, the author describes teen involvement in AA/NA programming, provides an exhaustive review of the outcomes of 19 studies that used an AA/NA model as part of their formal teen substance abuse treatment programs, and provides data on the effects of AA/NA attendance on abstinence at follow-up, on which youth tend to become involved in AA/NA, and on mediation of the benefits of AA/NA participation. In addition, the author suggests the reasons for somewhat limited participation by teens in more informal, community-based 12-step meetings, and makes suggestions for maximizing participation at meetings in the community. The author concludes that AA/NA participation is a valuable modality of substance abuse treatment for teens and that much can be done to increase teen participation, though more research is needed.

Timko C; Desai A; Blonigen DM; Moos BS; Moos RH. Driving while intoxicated among individuals initially untreated for alcohol use disorders: One- and sixteen-year follow-ups. Journal of Studies on Alcohol and Drugs 72(2): 173-184, 2011. (80 refs.)

Objective: This study examined associations between frequency of driving while intoxicated (DWI) at baseline and obtaining alcohol-related help at follow-up, and between obtaining help and subsequent reductions in DWI. It also examined improvements on personal functioning and life context indices as mediators between obtaining help and reduced occurrences of DWI. Method: A total of 628 individuals who were initially untreated for alcohol use problems completed a baseline inventory; follow-ups were 1, 3, and 16 years later. Results: More extended participation in outpatient treatment and Alcoholics Anonymous (AA) during Year I was associated with a lower likelihood of DWI at the 1-year follow-up. More extended participation in AA through Year 3 was associated with a lower likelihood of DWI at the 16-year follow-up. Improvement on personal functioning and life context indices was associated with reduced risk of subsequent occurrences of DWI. Decreases in drinking-related problems, impulsivity, and drinking to reduce tension mediated associations between more AA participation and reductions in DWI at I year. Conclusions: Among initially untreated individuals, sustained mutual help may be associated with a reduced number of occurrences of DWI via fewer drinking consequences and improved psychological functioning and coping. Treatment providers should attend to these concomitants of DWI and consider actively referring individuals to AA to ensure ongoing AA affiliation.

Timko C; Moos BS; Moos RH. Gender differences in 16-year trends in assault- and police-related problems due to drinking. Addictive Behaviors 34(9): 744-750, 2009. (52 refs.)

This study examined the frequency and predictors of physical assault and having trouble with the police due to drinking over 16 years among women and men who, at baseline, were untreated for their alcohol use disorder. Predictors examined were the personal characteristics of impulsivity, self-efficacy, and problem-solving and emotional-discharge coping, as well as outpatient treatment and Alcoholics Anonymous (AA) participation. Women and men were similar on rates of perpetrating assault due to drinking, but men were more likely to have had trouble with the police due to drinking. Respondents who, at baseline. were more impulsive and relied more on emotional discharge coping, and less on problem-solving coping, assaulted others more frequently during the first year of follow-up. Similarly, less problem-solving coping at baseline was related to having had trouble with the police more often at one and 16 years due to drinking. The association between impulsivity and more frequent assault was stronger for women, whereas associations of self-efficacy and problem-solving coping with less frequent assault and police trouble were stronger for men. Participation in AA was also associated with a lower likelihood of having trouble with the police at one year, especially for men. Interventions aimed at decreasing impulsivity and emotional discharge coping, and bolstering self-efficacy and problem-solving coping, during substance abuse treatment, and encouragement to become involved in AA, may be helpful in reducing assaultive and other illegal behaviors.

Tonigan JS; Rice SL. Is it beneficial to have an Alcoholics Anonymous sponsor? Psychology of Addictive Behaviors 24(3): 397-403, 2010. (38 refs.)

Alcoholics Anonymous (AA) attendance is predictive of increased abstinence for many problem drinkers and treatment referral to AA is common. Strong encouragement to acquire an AA sponsor is likewise typical, and findings about the benefits associated with social support for abstinence in AA support this practice, at least indirectly. Despite this widespread practice, however, prospective tests of the unique contribution of having an AA sponsor are lacking. This prospective study investigated the contribution of acquiring an AA sponsor using a methodologically rigorous design that isolated the specific effects of AA sponsorship. Participants were recruited from AA and outpatient treatment. Intake and follow-up assessments included questionnaires, semi-structured interviews, and urine toxicology screens. Eligibility criteria limited prior treatment and AA histories to clarify the relationship of interest while, for generalizability purposes, broad substance abuse criteria were used. Of the 253 participants, 182 (72%) provided complete data on measures central to the aims of this study. Overall reductions in alcohol, marijuana, and cocaine use were found over 12-months and lagged analyses indicated that AA attendance significantly predicted increased abstinence. During early AA affiliation but not later logistic regressions showed that having an AA sponsor predicted increased alcohol-abstinence and abstinence from marijuana and cocaine after first controlling for a host of AA-related, treatment, and motivational measures that are associated with AA exposure or are generally prognostic of outcome.

Vederhus JK; Kristensen O; Laudet A; Clausen T. Attitudes towards 12-step groups and referral practices in a 12-step naive treatment culture: A survey of addiction professionals in Norway. BMC Health Services Research 9: e-147, 2009. (31 refs.)

Background: Addressing substance use disorders effectively requires a long-term approach. Substance abuse treatment is typically of short duration; referring patients to Twelve Step based self-help groups (TSGs) - e. g. Narcotics Anonymous, represents a promising complementary recovery resource. Clinicians' attitudes and referral practices towards the TSGs have mainly been studied in countries with high integration of the 12-step philosophy in their substance abuse services and where the TSGs are widely available, such as the US. In Norway, there are currently 294 weekly TSG meetings (6 per 100,000 inhabitants). This study describes clinicians' attitudes and referral practices to TSGs in Norway where health authorities seek to promote self-help participation, but where the treatment culture is unfamiliar with 12-step fellowships. Methods: Data collected by a self-administered questionnaire, adapted from established US and UK instruments. Information covered the attitudes, knowledge and referral practices towards TSGs among addiction treatment professionals in Norway in mid 2008. Results: The return rate was 79.7% (n = 291). Participants had moderately positive attitude scores towards TSGs, but referral to these groups among Norwegian addiction professionals was low, as was the level of knowledge about TSGs. More than six out of ten did not refer any patients to TSGs in the previous week. Local variation with more referrals to TSGs in the county with the one established 12-step treatment facility was observed. Respondents' integration of the 12-steps in their own treatment work, higher self-efficacy for making a successful referral, and greater TSG knowledge were associated with referring patients. Conclusion: Low referral rates to TSGs point to the need for education and training to raise the awareness and knowledge about it among addiction professionals unfamiliar with these 12-step fellowships. Training should focus on the usefulness of these groups for all types of treatment models regardless of therapeutic orientation. Increased knowledge is expected to lead to higher referral rates, which in turn would maximize the likelihood of positive long-term patient outcomes.

Walitzer KS; Dermen KH; Barrick C. Facilitating involvement in Alcoholics Anonymous during out-patient treatment: A randomized clinical trial. Addiction 104(3): 391-401, 2009. (37 refs.)

This study evaluated two strategies to facilitate involvement in Alcoholics Anonymous (AA)-a 12-Step-based directive approach and a motivational enhancement approach-during skills-focused individual treatment. Randomized controlled trial with assessments at baseline, end of treatment and 3, 6, 9 and 12 months after treatment. A total of 169 alcoholic out-patients (57 women) assigned randomly to one of three conditions: a directive approach to facilitating AA, a motivational enhancement approach to facilitating AA or treatment as usual, with no special emphasis on AA. Self-report of AA meeting attendance and involvement, alcohol consumption (percentage of days abstinent, percentage of days heavy drinking) and negative alcohol consequences. Participants exposed to the 12-Step directive condition for facilitating AA involvement reported more AA meeting attendance, more evidence of active involvement in AA and a higher percentage of days abstinent relative to participants in the treatment-as-usual comparison group. Evidence also suggested that the effect of the directive strategy on abstinent days was mediated partially through AA involvement. The motivational enhancement approach to facilitating AA had no effect on outcome measures. These results suggest that treatment providers can use a 12-Step-based directive approach to effectively facilitate involvement in AA and thereby improve client outcome.

Weegmann M; Piwowoz-Hjort E. 'Naught but a story': Narratives of successful AA recovery. Health Sociology Review 18(3): 273-283, 2009. (34 refs.)

The study invited individuals who used AA groups and philosophy as the mainstay of their recovery to talk about their ongoing relationship to AA, with the arm of understanding the factors that have helped them to achieve and sustain change Interpretive phenomenological analysis (IPA) was performed on nine transcribed interviews of participants who were continually sober from alcohol/drugs for a minimum of nine years (abstinence mean = 14 years) The method was used to discern themes and identify the concepts of recovery participants had found helpful. A number of themes are examined in the paper, including how subjects made sense of their addiction. initial appraisals of AA/NA meetings. concepts of acceptance and surrender, character change, spiritual change and evaluations of continuing progress. We argue that there are many roads to recovery from addiction and the 'AA/Fellowship route' offers a set of principles and narrative forms that have the attraction of consistency and coherency. The paper shows that as personal identity is continually construed, participants find that what can be called 'Fellowship narratives' and structures assist them greatly in appraising the post re-building their lives and finding direction. In addition, spiritual and other values help them to effectively address and resolve key issues and self-governance. We propose that addiction services can benefit from incorporating more emphasis on the role of narratives, identity and values in the recovery process

Whelan PJP; Marshall EJ; Ball DM; Humphreys K. The role of AA sponsors: A pilot study. Alcohol and Alcoholism 44(4): 416-422, 2009. (20 refs.)

Aims: The aim of this study was to explore the roles of Alcoholics Anonymous (AA) sponsors and to describe the characteristics of a sample of sponsors. Methods: Twenty-eight AA sponsors, recruited using a purposive sampling method, were administered an unstructured qualitative interview and standardized questionnaires. The measurements included: a content analysis of sponsors' responses; Severity of Alcohol Dependence Questionnaire-Community version (SADQ-C) and Alcoholics Anonymous Affiliation Scale (AAAS). Results: Sample characteristics were as follows: the median length of AA attendance was 9.5 years (range 5-28); the median length of sobriety was 11 years (range 4.5-28); the median number of sponsees per sponsor was 1 but there was a wide range (0-17, interquartile range 3.75); and the sponsors were highly affiliated to AA (median AAAS score 8.75, range 5.5-8.75, maximum possible score 9). Past alcohol dependence scores were surprisingly low: 5 (18%) sponsors had mild, 14 (50%) moderate and 9 (32%) severe dependence according to the SADQ-C (median 26.5, range 11-56). Sponsorship roles were as follows: 16 roles were identified through the initial content analysis. These were distilled into three super-ordinate roles through a thematic analysis: (1) encouraging sponsees to work the programme of AA (doing the 12 steps and engaging in AA activity); (2) support (regular contact, emotional support and practical support); and (3) carrying the message of AA (sharing sponsor's personal experience of recovery with sponsees). Conclusions: The roles identified broadly corresponded with the AA literature delineating the duties of a sponsor. This non-random sample of sponsors was highly engaged in AA activity but only had a past history of moderate alcohol dependence.

Witbrodt J; Romelsjo A. Gender differences in mutual-help attendance one year after treatment: Swedish and US samples. Journal of Studies on Alcohol and Drugs 71(1): 125-135, 2010. (71 refs.)

Objective: In the United States, many people turn to Alcoholics Anonymous (AA) and other mutual-help groups as a first source of help for an alcohol or drug problem, whereas others are introduced to AA while in treatment. Because AA and similar groups in the United States add to the treatment system and function without governmental funds, they represent an important element in ongoing care for individuals with substance-use disorders in the health care system. In countries with free (or more affordable) and more comprehensive systems of care, their role is less clearly defined. Method: In this study, we compared men and women from representative treatment samples from studies with parallel designs, one Swedish (n = 1,525) and the other American (n = 926), to explore whether rates and correlates of attendance at 1-year follow-up (63% and 78% followed) differ by gender. We explore individual characteristics (demographic, severity, motivational) and formal and informal influences (treatment, mutual help, coercive, social) as possible help-seeking correlates of attendance. Results: In both countries, similar proportions of men and women attended mutual-help groups. However, twice as many U.S. clients reported attendance. Moreover, twice as many U.S. clients set abstinence as a treatment goal. In multivariate models, having an abstinence goal, a perceived need for treatment, suggestions from one's employment environment, and prior mutual-help attendance predicted posttreatment attendance for men and women in both countries. Gender differences were also found. Conclusions: Given the stages in which individuals seek care and the cyclical nature of relapse and recovery, mutual-help groups are an efficient resource in the continuum of services.

Ye Y; Kaskutas LA. Using propensity scores to adjust for selection bias when assessing the effectiveness of Alcoholics Anonymous in observational studies. Drug and Alcohol Dependence 104(1-2): 56-64, 2009. (60 refs.)

Background: The effectiveness of Alcoholics Anonymous (AA) is difficult to establish. Observational studies consistently find strong dose-response relationships between AA meeting attendance and abstinence, and the only experimental studies favoring AA have been of 12-step facilitation treatment rather than of AA per se. Pending future randomized trials, this paper uses propensity score (PS) method to address the selection bias that potentially confounds the effect of AA in observational studies. Method: The study followed a treatment sample for 1 year to assess post-treatment AA attendance and abstinence (n = 569). Propensity scores were constructed based on known confounders including motivation, problem severity, and prior help-seeking. AA attendance during the 12-month follow-up period was studied as a predictor of alcohol abstinence for 30 days prior to the follow-up interview. PS stratification and PS matching techniques were used to adjust for the self-select bias associated with respondents' propensity to attend AA. Results: The overall advantage in abstinence initially observed narrowed when adjusted. The odds ratio associated with AA attendance reduced from 3.6 to 3.0 after PS stratification and 2.6 after PS matching to AA-attenders. Support for AA effectiveness was strengthened in the quintile with lower propensity scores and when AA-nonattenders were matched as the target group, but was weakened among those in the higher PS quintiles and when matching to AA-attenders. Discussion: These results confirm the robustness of AA effectiveness overall, because the results for higher abstinence associated with AA attendance following propensity score adjustment remained significant, and the reduction in the magnitude of AA's effect was moderate. However, the effect modification by propensity scores in both PS stratification and PS matching approaches seems to suggest that AA may be most helpful, or matter more, for those with a lower propensity to attend AA. Conversely, for those with a high propensity to go to AA (operationalized as higher motivation, greater problem severity, more prior AA and treatment exposure, etc.), attending AA may not make as much of a difference. It will be important that future studies replicate our results, as this is the first paper to use propensity score adjustment in this context.

Zemore SE; Kaskutas LA. Development and validation of the Alcoholics Anonymous Intention Measure (AAIM). Drug and Alcohol Dependence 104(3): 204-211, 2009. (56 refs.)

Background: Drop-out from 12-step groups is notoriously high, yet the field lacks strong models and scales for addressing this problem. We aim to determine whether the theory of planned behavior (TPB) can be applied to 12-step involvement, and to develop and validate a scale of 12-step readiness based on that theory: the Alcoholics Anonymous Intention Measure (AAIM). Method: Data were from a longitudinal trial of a manual-guided 12-step facilitation intervention called Making AA Easier (MAAEZ) involving two treatment programs in California (N = 508). Participants completed surveys at baseline, 7 weeks, 6 months, and 12 months. Surveys included the preliminary AAIM, a 12-step involvement measure, other readiness measures, and substance use outcomes. Results: The final, 17-item AAIM measured Attitude (5-item alpha's=.75-.83), Subjective Norm (4-item alpha's=.56-81), Perceived Control (5-item alpha's=.78-.85), and Intention (3-item alpha's=.80-95) regarding attendance at 12-step groups. Components were correlated with each other and other readiness measures as expected, supporting the AAIM's validity. Scale components predicted 31% of the variance in Intention to attend 12-step groups at 6 months and 41% of the variance in 12-step involvement at 12 months. Social factors were among the strongest predictors of 12-step involvement. Results did not support the expectancy-value formulation of the TPB, as unweighted (vs. weighted) belief items performed optimally. Conclusions: Results generally support the TPB as a model of 12-step involvement and suggest specific targets for 12-step facilitation interventions within attitude, norm, and control components. Findings also support the AAIM as a tool for identifying drop-out risks and tailoring individual interventions.