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CORK Bibliography: Alcoholics Anonymous (AA)

97 citations. January 2003 to present

Prepared: January 2008

Arroyo JA; Miller WR; Tonigan JS. The influence of Hispanic ethnicity on long-term outcome in three alcohol-treatment modalities. Journal of Studies on Alcohol 64(1): 98-104, 2003. (32 refs.)

Objective: Prior research has suggested that treatment seeking Hispanic clients are not likely to affiliate with Alcoholics Anonymous (AA). It was hypothesized that AA 12-step facilitation therapy (TSF) would therefore be less effective than cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET) for Hispanics, particularly for those with low acculturation. Method: Outcomes for nonHispanic white (n = 105; 70% male) and Hispanic (n = 100; 80% male) clients at the New Mexico site within Project MATCH were analyzed for evidence of differential treatment response. A pretreatment measure of acculturation to non-Hispanic white culture was available for 80 of the Hispanic clients. Results: Self- identified ethnicity mediated treatment response at distal follow-up, as measured by frequency and intensity of alcohol consumption (p < .02). Hispanics drank with more intensity than did non-Hispanic whites when assigned to TSF; non-Hispanic whites in TSF drank with less frequency than those in the combined CBT and MET conditions. The modest outcome advantage for TSF observed in Project MATCH appears to have been limited to non-Hispanic clients. Contrary to prediction, level of acculturation did not mediate treatment response at proximal (Months 1-6 after treatment) or distal follow-up (Months 7-12). Conclusions: Ethnic self-identification may interact with treatment outcomes in complex ways that are not directly associated with the factors tapped by commonly used measures of acculturation.

Bogart CJ; Pearce CE. "13th-Stepping:" Why Alcoholics Anonymous is not always a safe place for women. Journal of Addictions Nursing 14(1): 43-47, 2003. (15 refs.)

"Thirteenth-stepping " is a euphemistic term used among members of Alcoholics Anonymous (AA) to refer to people who target new, more vulnerable members for dates or sex. Previous research suggests that women frequently experience sexual harassment in AA meetings and even in chemical dependency treatment settings. The objective of this survey study is to describe the frequency of various 13th-stepping experiences in a sample of women involved in AA. Fifty-five women, aged 17-72 years, completed an anonymous survey to describe their experiences with 13th-stepping by men AA. Results showed that at least 50% of the participants had least occasionally experienced seven of the thirteen 13th-stepping behaviors listed in the survey. Also, compared to women who had never attended a female-only AA group, women who had attended such groups reported more 13th-stepping experiences from their attendance at coed groups. Two of the study participants volunteered that men they met in AA had raped them. It is important that chemical dependency treatment providers be aware of 13th-stepping in AA, particularly when treating women. Especially vulnerable women, such as those with histories of sexual abuse, should be referred to female-only groups when possible.

Bogenschutz MP; Tonigan JS; Miller WR. Examining the effects of alcoholism typology and AA attendance on self-efficacy as a mechanism of change. Journal of Studies on Alcohol 67(4): 562-567, 2006. (36 refs.)

Objective: Existing research indicates that increased self-efficacy to sustain abstinence is a strong causal mechanism explaining later reduction of drinking. Little is known about how mechanisms of change may differ among distinct subgroups of alcoholics. The purpose of this study was to evaluate the mediational role of self-efficacy on changes in drinking associated with Alcoholics Anonymous (AA) attendance in Type-A and Type-B alcoholics. Method: Analysis of covariance and structural equation modeling were used to model 6-, 9-, 12-, and 15-month data from Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) participants who were classified as Type-A or Type-B alcoholics (N = 1,284; 72% male). Measures of AA attendance and percent days abstinent were taken from the Form 90. Self-efficacy was assessed with the Alcohol Abstinence Self-Efficacy Scale. Results: Alcoholism typology and AA attendance were independent predictors of later self-efficacy, but there was no interaction between typology and AA attendance. Abstinence self-efficacy mediated a modest proportion of the effect of posttreatment AA attendance on later abstinence in both Type-A and Type-B alcoholics. The strength of this mediation did not differ by typology. Conclusions: Self-efficacy for abstinence has a strong direct relationship to abstinence across treatment conditions and typologies. Increases in self-efficacy mediate some of the beneficial effects of AA for Type-A and Type-B alcoholics. Further work is necessary to determine whether self-efficacy plays a different role in the recovery of Type-A versus Type-B alcoholics.

Bond J; Kaskutas LA; Weisner C. The persistent influence of social networks and Alcoholics Anonymous on abstinence. Journal of Studies on Alcohol 64(4): 579-588, 2003. (32 refs.)

Objective: The role of changes in Alcoholics Anonymous (AA) involvement and social networks in relation to abstinence following substance abuse treatment is studied. Specifically, the role of AA and network support for abstinence are examined in relation to their effect on changes in abstinence states between follow-ups. Method: Study sites were 10 representative public and private alcohol treatment programs in a northern California county. A recruitment of 367 men and 288 women seeking treatment were interviewed at intake and re-interviewed I and 3 years later to collect information about alcohol consumption, dependence symptoms, social support for reducing drinking, number of heavy drinkers in the social network and AA involvement. Results: Significant predictors of 90-day abstinence at both the 1- and 3-year follow-up interviews included AA involvement in the last year, percentage of heavy or problem drinkers in the social network, percentage encouraging alcohol reduction and AA-based support for reducing drinking. Panel models estimated an increase in AA participation between 12 and 36 months posttreatment increased the odds of abstinence at 3 years by 35% above those at 12 months. The only significant mediator of AA's effect on abstinence was the number of AA-based contacts supporting reduced drinking, which reduced the magnitude of the relationship by 16%. Conclusions: AA involvement and the type of support received from AA members were consistent contributors to abstinence 3 years following a treatment episode. The enduring effects observed from supportive networks demonstrate the importance of ongoing mechanisms of action that contribute to an abstinent lifestyle.

Bridges FS. Correlations for alcohol use, abuse, and treatment with suicide and homicide across 21 nations. Psychological Reports 96(3, Part 1): 783-786, 2005. (12 refs.)

In this study which followed Lester's work of 1998 and 2001 for 27 nations of the world, membership in Alcoholics Anonymous, but not alcohol consumption or cirrhosis mortality as measures of alcohol use, abuse, and treatment, correlated with homicide but not suicide rates. Changes in Alcoholics Anonymous membership were not associated with changes in age-adjusted rates of homicide or suicide.

Brigham GS. 12-Step participation as a pathway to recovery: The Maryhaven experience and implications for treatment and research. Science & Practice Perspectives 2(1), 2003. (23 refs.)

Maryhaven, a comprehensive, community-based drug abuse treatment facility, combines a core commitment to 12-step principles and practices with the use of scientifically derived treatment interventions. Treatment goals at Maryhaven include abstinence from substance abuse, patient engagement and progress in 12-step activities, and strong patient affiliation with 12-step organizations within the community. The author discusses the reasons why Maryhaven takes this approach, describes the program's use of empirically derived treatment tools to further 12-step objectives, argues that there are natural affinities between 12- step and some empirical treatment tools such as the Stages of Change model, and suggests research projects that he believes can improve treatment and illuminate the mechanisms by which 12-step activities help patients overcome addiction.

Public Domain

Brown AE; Whitney SN; Schneider MA; Vega CP. Alcohol recovery and spirituality: Strangers, friends, or partners? Southern Medical Journal 99(6): 654-657, 2006. (29 refs.)

Alcoholics Anonymous, with its steady but nonspecific promotion of belief in a higher power and its emphasis on the group process, long held a near-monopoly in the outpatient alcohol recovery field, but its hegemony has now been challenged by two very different perspectives. The first is a nonspiritual approach that emphasizes the individual's capability to find a personal pathway to sobriety, exemplified by Rational Recovery. The second is a faith-based method, built on a religious understanding of alcoholism, of which Celebrate Recovery is a prominent example, based upon Christianity. Most communities offer a variety of approaches, so clinicians who are aware of these differences are in a good position to help patients make intelligent choices among the competing recovery philosophies.

Brown H. Hi, My name is Boris. Forbes 180(8): 82-85, 2007. (0 refs.)

Lou Bantle, a former tobacco executive and alcoholic, battled apathy corruption and the mob to bring Alcoholics Anonymous to Russia.

Butler S; Jordan T. Alcoholics Anonymous in Ireland: AA's first European experience. Addiction 102(6): 879-886, 2007. (37 refs.)

Aim: To trace the evolution of Alcoholics Anonymous in Ireland from its establishment there in 1946, focusing on the efforts of early members to publicize the fellowship and negotiate a role for themselves in relation to existing religious and healthcare institutions. Methods Archival research, drawing mainly on primary sources in AA archives in New York and Dublin. Results: Anticipated tensions between this fellowship, which had its roots in Evangelical Protestantism, and the politically powerful Roman Catholic Church in Ireland were skillfully avoided; initial hostility from the medical profession quickly dissipated; and AA distanced itself from policy debate on the wider topic of alcoholism as disease. Conclusions: The relatively smooth introduction of AA to Ireland, the first European country in which it was established, may be attributed to the essentially pragmatic nature of the fellowship and the strategic abilities of its early members.

Cheever S. My Name Is Bill: Bill Wilson -- His Life and the Creation of Alcoholics Anonymous. New York: Simon & Schuster, 2004

This is a biography of Bill Wilson one of the two founders of Alcohlics Anonymous. His story is well known to those within the fellowship of AA. Bill had stayed away from alcohol until the age of 22 because of his family history of drinking problems. Having already suffered from episodes of depression, he took his first drink at 22 and experienced a glow of self-confidence and escape from dysphoria. This was followed by his descent into alcoholism and many failed attempts at detoxifications to curb his compulsive drinking. On June 10, 1935, Bill was traveling on business in Akron, Ohio, and struggling to control the urge to drink. The thought occuured to him, that were he able to sit down and speak with another alcoholic that would be helpful. Indeed, through a series of calls he was put in touch with another alcoholic, a physician. This meeting is counted as the beginning of AA, which drew heavily upon the Oxford movement. This book captures Bill Wilson's charisma, his organizational skills and role in the evolution of Alcoholics Anonymous. In addition to recounting the story of Bill Wilson, this book also captures the importance and role of AA in the life of its members. This book provides information on his early years, including his father's drinking. It also touches upon topics that are not as well known, his womanizing and his use of LSD>

Cloud RN; Ziegler CH; Blondell RD. What is Alcoholics Anonymous affiliation? Substance Use & Misuse 39(7): 1117-1136, 2004. (39 refs.)

An increasing body of research evidence supports the use of 12-step program affiliation as an effective adjunct and aftercare for formal treatment. Recently, three brief (9- or 10-item) measures of affiliation have been developed. However, the brief scales are difficult to interpret, and the question of exactly what is affiliation (or disaffiliation) remains unclear. This analysis examines the question of what is the essence of affiliation vs. disaffiliation. Data from the Project MATCH 1-year posttreatment Alcoholics Anonymous Involvement (AAI) scale (N = 1506) are used to identify the most salient items of Alcoholics Anonymous (AA) affiliation predicting 1-year posttreatment drinking outcomes. Analysis using stepwise regression suggests that a three-item solution can explain a similar amount of variance in the proportion of days abstinent in months 9 through 12 posttreatment, as does using the nine items. These three "core items predicting recovery" include AA attendance, sum of steps completed, and identifying self as an AA member. As an affiliation composite scale, these three items are easier to interpret and administer than the full AAI scale, and when combined, possess adequate reliability (alpha = 0.72).

Coleman P. Privilege and confidentiality in 12-step self-help programs: Believing the promises could be hazardous to an addict's freedom. (review). Journal of Legal Medicine 26(4): 435-474, 2005. (199 refs.)

A wide gap exists between perception and reality on the question of whether an individual can prevent others from revealing statements he or she made while dealing with addiction in a 12-step self-help group. The simple but troubling explanation for this disparity is that, although people are routinely assured whatever they say during meetings will not be repeated, neither state nor federal laws support these promises. As a variety of studies demonstrate the advantages associated with participating in peer-run programs, especially when attendance is combined with conventional treatment, researchers encourage physicians to persuade their patients to participate. These recommendations are appropriate as most people in recovery benefit from the support of others who also are struggling with sobriety and from the continual monitoring organizations like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) provide. Traditional lengthy therapy, even if it were as effective, is not a good alternative because it has become too expensive. Thus, physicians should refer their patients to established self-help groups, but only after fully explaining the limitations on confidentiality and privilege. Failure to do so could subject physicians to both disciplinary action and civil liability. This article provides information important for people in these programs as well as their attorneys and therapists. Part I defines addiction and discusses the human and financial costs attributed to this compulsive disorder. Part II explains the law surrounding confidentiality, privilege, and the duty to report certain information. Part III briefly describes the history and evolution of self-help groups in treating people with drug and alcohol problems. It also compares and contrasts such programs to group therapy and substance abuse counseling with an eye toward determining whether the differences justify disparate protections. Part IV analyzes relevant court decisions. Part V canvasses state statutes on group therapy and points out that they do not encompass associations lacking a professional therapist or clergyman to whom confidentiality and privilege might apply. This section also reviews federal and state legislative treatment of substance abuse counselors and suggests these laws could be expanded to include self-help members. Part VI cautions physicians who refer patients to these groups that, to avoid both civil liability and licensure problems, they should alert their patients that, under exceptional circumstances, their statements made in working through the 12 steps might be disclosed. This warning will satisfy the duty to alert patients to potential risks and protect physicians from claims that they failed to obtain informed consent for the recommended treatment--namely, joining a self-help group. Finally, Part VII proposes a uniform statute that grants confidentiality and a qualified privilege to communications between and among self-help participants. The article concludes that the only way to eliminate the problem is to pass legislation that shields these conversations absent either consent to release or clear and convincing evidence of a compelling need for the information.

Dermatis H; Guschwan MT; Galanter M; Bunt G. Orientation toward spirituality and self-help approaches in the therapeutic community. Journal of Addictive Diseases 23(1): 39-54, 2004. (26 refs.)

Although Alcoholics Anonymous and other Twelve-Step interventions are among the most widely utilized self-help options by persons with chemical dependency, little is known concerning whether this approach should be integrated with non-spirituality based self-help approaches. The purpose of this study was to assess the extent to which clients receiving inpatient treatment in a residential therapeutic community (TC) felt that spirituality based interventions should be featured in TC treatment. Three hundred twenty-two members of the Daytop TC completed a survey assessing personal orientation to spirituality and attitudes towards spirituality based treatments. The majority of clients believed that the TC program should feature spirituality more in treatment. Nearly half agreed that the Twelve-Step (AA) approach should be more a part of TC treatment. Preference for Twelve-Step meeting interventions was positively correlated with past attendance at Twelve-Step meetings. Personal spiritual orientation to life was positively correlated with endorsement of spirituality based interventions in TC treatment. These findings highlight the importance of integrating treatment approaches which address the spiritual needs of TC residents.

Donovan DM; Carroll KM; Kadden RM; Diclemente CC; Rounsaville BJ. Therapies for matching: Selection, development, implementation, and costs. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 42-61. (275 book refs.)

The selection, development, implementation, and costs of therapies used in the treatment research project, Project MATCH, are discussed. Three therapies were chosen: Cognitive-Behavioral Therapy (CBT), Motivational Enhancement Therapy (MET), and Twelve Step Facilitation (TSF). In this book chapter, the therapies are described, with a focus on selection, training, supervision, and monitoring of therapists; evaluation of interventions in terms of discriminability; procedures for dealing with clients; and costs involved. The therapies selected were capable of producing a strong working alliance between clients and therapists. More than 80 therapists were trained and supervised to deliver these therapies. The costs of the therapies in community settings, although more expensive than typical outpatient treatment, were considered to be reasonable given their quality and potential effectiveness. Section headings in this chapter include: (1) Selection of therapies, including criteria used; (2) Description of the therapies, including CBT, MET, and TSF; (3) Internal versus external validity; (4) Implementation of the therapies, including development of treatment manuals, selection of therapists, therapist training, ongoing supervision of therapists, treatment compliance, discriminability of the therapies, unique versus nonspecific treatment components; (5) Clinical deterioration guidelines; and (6) Costs of Project MATCH therapies. Contrasts among Project MATCH therapies are presented in table format.

Public Domain

Durant A. African-American alcoholics: An interpretive/constructivist model of affiliation with Alcoholics Anonymous (AA). Journal of Ethnicity in Substance Abuse 4(1): 5-21, 2005. (45 refs.)

It is estimated that two million African-Americans suffer directly and indirectly from alcoholism and its related problems. Yet, because of their cultural background, African-American alcoholics do not readily accept that alcoholism is a disease. This study explores how African-American alcoholics modify the steps and traditions of AA to affiliate with the organization. Data was collected from intensive and semi-structured interviews and participant observation. Procedures and analysis generic to grounded theory were used in the context of an interpretive/constructivist paradigm.

Falby A. The modern confessional: Anglo-American religious groups and the emergence of lay psychotherapy. Journal of the History of the Behavioral Sciences 39(3): 251-267, 2003. (80 refs.)

This article reconceives of secularization as a gradual process of increasing interaction between the (social) scientific and spiritual realms by examining the influence of Christian ideas of group confession on lay psychotherapeutic groups in Britain, Canada, and the U.S. in the early twentieth century. This article focuses on three religious group leaders of the interwar period: Frank Buchman (1878-1961), Gerald Heard (1889-1971), and Henry Burton Sharman (1865-1953). Influenced by Natural Theology and the holiness movement, they placed sin and its redemption within the world, reconceiving it as psychological individualism and its redemption as self-sacrifice to the group. This reconception endorsed the moral power of groups and influenced Alcoholics Anonymous and various groups within the Human Potential Movement.

Fazzio L; Galanter M; Dermatis H; Levounis P. Evaluation of medical student attitudes toward Alcoholics Anonymous. Substance Abuse 24(3): 175-185, 2003. (23 refs.)

This is a two-phase study on attitudes of medical students toward Alcoholics Anonymous. The first phase compares views of addiction faculty to third-year medical students on the importance of spirituality in addiction treatment. We administered a questionnaire to assess attitudes toward spiritual, biological, and psychosocial approaches to addiction treatment. The faculty viewed spirituality as relatively more important in addiction treatment than did the students. The second phase was designed to assess whether medical student attitudes toward spiritually based treatments changed over the course of a psychiatry clerkship. At the beginning of the clerkship, students rated a spiritually oriented approach as important in addiction treatment as a biological approach, whereas, at the end of the clerkship, they rated the biological approach as more important. It may be important to educate medical students about the spiritual dimensions of recovery so they can integrate this into their treatment of addiction.

Fenster J. Characteristics of clinicians likely to refer clients to 12-Step programs versus a diversity of post-treatment options. Drug and Alcohol Dependence 83(3): 238-246, 2006. (30 refs.)

Most clients in substance abuse treatment are referred for continuing care. However, post-treatment services vary widely in their approaches to helping individuals achieve better substance use outcomes. This study examined the attitudes of outpatient treatment staff who refer clients exclusively to 12-Step groups (12-Step subgroup) and staff who refer clients both to 12-Step groups and to other continuing care options (Diversity subgroup) toward seven mutual-aid and professional psychosocial post-treatment options: Twelve-Step Programs (12-Step), Cognitive-Behavioral Therapy (CBT), Moderation Management (MM), Smart Recovery� (SMART), Psychodynamic-oriented Therapy (PSY), Secular Organizations for Sobriety (SOS), and Women for Sobriety (WFS). A large percentage of clinicians lacked knowledge about the effectiveness of all alternatives to 12-Step programs with the exception of CBT. Clinicians in the 12-Step subgroup were more likely than those in the Diversity subgroup to be unfamiliar with alternatives to 12-Step programs and to believe less strongly in the effectiveness of CBT and PSY. A logistic regression found beliefs about CBT effectiveness and clinician preference for the 12-Step model to be related to the likelihood of referring exclusively to 12-Step groups. Findings suggest that clinicians could benefit from information and training on assessing and referring clients to various options for continuing care.

Ferri M; Amato L; Davoli M. Alcoholics Anonymous and other 12-step programmes for alcohol dependence. Cochrane Database of Systematic Reviews 3(article no. CD005032), 2006. (69 refs.)

BACKGROUND: Alcoholics Anonymous (AA) is an international organization of recovering alcoholics that offers emotional support through self-help groups and a model of abstinence for people recovering from alcohol dependence, using a 12-step approach. Although it is the most common, AA is not the only 12-step intervention available there are other 12-step approaches (labelled Twelve Step Facilitation (TSF)). OBJECTIVES: To assess the effectiveness of AA or TSF programmes compared to other psychosocial interventions in reducing alcohol intake, achieving abstinence, maintaining abstinence, improving the quality of life of affected people and their families, and reducing alcohol associated accidents and health problems. SEARCH STRATEGY: We searched the Specialized Register of Trials of the Cochrane Group on Drugs and Alcohol, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE from 1966, EMBASE from 1980, CINAHL from 1982, PsychINFO from 1967. Searches were updated in February 2005. We also inspected lists of references for relevant studies. SELECTION CRITERIA: Studies involving adults (<18) of both genders with alcohol dependence attending on a voluntary or coerced basis AA or TSF programmes comparing no treatment, other psychological interventions, 12-step variants. DATA COLLECTION AND ANALYSIS: One reviewer (MF) assessed studies for inclusion and extracted data using a pre-defined data extraction form. Studies were evaluated for methodological quality and discussed by all reviewers. MAIN RESULTS: Eight trials involving 3417 people were included. AA may help patients to accept treatment and keep patients in treatment more than alternative treatments, though the evidence for this is from one small study that combined AA with other interventions and should not be regarded as conclusive. Other studies reported similar retention rates regardless of treatment group. Three studies compared AA combined with other interventions against other treatments and found few differences in the amount of drinks and percentage of drinking days. Severity of addiction and drinking consequence did not seem to be differentially influenced by TSF versus comparison treatment interventions, and no conclusive differences in treatment drop out rates were reported. Included studies did not allow a conclusive assessment of the effect of TSF in promoting complete abstinence. AUTHORS' CONCLUSIONS: No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems. One large study focused on the prognostic factors associated with interventions that were assumed to be successful rather than on the effectiveness of interventions themselves, so more efficacy studies are needed.

Fiorentine R; Hillhouse MP. Why extensive participation in treatment and twelve-step programs is associated with the cessation of addictive behaviors: An application of the addicted-self model of recovery. Journal of Addictive Diseases 22(1): 35-55, 2003. (85 refs.)

Applying the Addicted-Self Model of recovery to explain why extensive participation in recovery activities predicts abstinence, it was hypothesized that high levels of participation in treatment and Twelve-step programs promote abstinence because these activities reinforce the notion that controlled use is not possible for dependent alcohol and drug users. Findings from a prospective treatment outcomes study (n = 356) indicate general support for this hypothesis. Yet the cognitive transformation described by the Addicted-Self Model involving acknowledgement of loss of control over alcohol and other drugs is only a partial explanation of why extensive participation in recovery activities promotes recovery. Reiterating the conclusion that "more is better", frequent counseling participation, treatment completion, and weekly or more frequent participation in Twelve-Step programs promote abstinence independently from their influence on controlled use self-efficacy. Theoretical and clinical implications, and directions for future research are discussed.

Gabhainn SN. Assessing sobriety and successful membership of Alcoholics Anonymous. Journal of Substance Use 8(1): 55-61, 2003. (39 refs.)

The goal of this study was to identify appropriate measures of successful membership of Alcoholics Anonymous (AA) and to investigate membership patterns and perceptions of sobriety across sociodemographic categories of AA membership. The study uses a cross-sectional survey design, and participants (n=77) were community-based members of nine individual AA groups. All data were collected using a self-completion questionnaire, which included open-ended and closed questions on understanding of successful AA membership, meeting attendance, 12-stepping activity, and length of membership. The following results of the study were seen: (1) association of successful AA membership with sobriety as well as longevity of membership, attendance at AA meetings, and commitment to 12-step work; and (2) few differences across sociodemographic groups in perceived successful membership. It is concluded that simple measures of success as volunteered in this study by AA members themselves have the advantage of not illustrating bias according to sociodemographic group and can be easily employed in further research.

Galanter M. Spirituality and addiction: A research and clinical perspective. American Journal on Addictions 15(4): 286-292, 2006. (71 refs.)

Spirituality is a construct that has recently gained currency among clinicians because of its close association with twelve-step modalities and its perceived role in the promotion of meaningfulness in recovery from addiction. This article draws on studies from physiology, psychology, and cross-cultural sources to examine its nature and its relationship to substance use disorders. Illustrations of its potential and limitations as a component of treatment in spiritually oriented recovery movements like Alcoholics Anonymous, meditative practices, and treatment systems for the dually diagnosed are given.

Galanter M. Spirituality in Alcoholics Anonymous: A valuable adjunct to psychiatric services. (editorial). Psychiatric Services 57(3): 307-309, 2006. (15 refs.)

Alcoholics Anonymous ( AA) is described as a spiritual fellowship by many of its members, but its spiritual orientation needs to be better understood by clinicians and researchers. Spirituality is a latent construct, one that is inferred from multiple component dimensions, such as social psychology, neurophysiology, and treatment outcome research. Mechanisms related to its role in promotion of recovery in AA are discussed from the perspective of these findings, along with related options for professionally grounded treatment, such as Twelve-Step Facilitation. This discussion illustrates the importance of further research on AA and spirituality and of employing them in the provision of psychiatric services.

Gossop M; Harris J; Best D; Man LH; Manning V; Marshall J; Strang J. Is attendance at Alcoholics Anonymous meetings after inpatient treatment related to improved outcomes? A 6-month follow-up study. Alcohol and Alcoholism 38(5): 421-426, 2003. (43 refs.)

Aims: This study investigates the relationship between attendance at Alcoholics Anonymous (AA) meetings prior to, during, and after leaving treatment, and changes in clinical outcome following inpatient alcohol treatment. Methods: A longitudinal design was used in which participants were interviewed at admission (within 5 days of entry), and 6 months following departure. The sample comprised 150 patients in an inpatient alcohol treatment programme who met ICD-10 criteria for alcohol dependence. The full sample was interviewed at admission to treatment. Six months after departure from treatment, 120 (80%) were re-interviewed. Results: Significant improvements in drinking behaviours (frequency, quantity and reported problems), psychological problems and quality of life were reported. Frequent AA attenders had superior drinking outcomes to non-AA attenders and infrequent attenders. Those who attended AA on a weekly or more frequent basis after treatment reported greater reductions in alcohol consumption and more abstinent days. This relationship was sustained after controlling for potential confounding variables. Frequent AA attendance related only to improved drinking outcomes. Despite the improved outcomes, many of the sample had alcohol and psychiatric problems at follow-up. Conclusions: The importance of aftercare has long been acknowledged. Despite this, adequate aftercare services are often lacking. The findings support the role of Alcoholics Anonymous as a useful aftercare resource.

Harris J; Best D; Gossop M; Marshall J; Man L-H; Manning V et al. Prior Alcoholics Anonymous (AA) affiliation and the acceptability of the twelve steps to patients entering UK statutory addiction treatment. Journal of Studies on Alcohol 64(2): 257-261, 2003. (29 refs.)

Objective: The study investigates levels of affiliation with AA and beliefs about the organization and its philosophy among a cohort of alcoholics entering a UK (non-AA) alcohol treatment service. Method: A total of 150 consecutive admissions (75% men) were interviewed by an independent researcher within 5 days of their entry into a residential alcohol treatment unit. Results: Although about three quarters of these patients had previously attended AA meetings, levels of affiliation were low, with only 16% having worked any of the Twelve Steps. Previous AA attenders were more likely to be older, drinking greater daily quantities prior to treatment and to have first sought alcohol treatment at a younger age. Roughly equal groups expressed "positive," "neutral" and "negative" current attitudes towards AA (38%, 36% and 26%, respectively). Each of these three AA-attitude groups expressed greater endorsement of "Personal Responsibility" steps than of "Higher Power mediated" steps. Conclusions: Few participants were universally negative to AA or the Twelve Steps--most regarded some of the steps as positive, but many rejected those referring to a Higher Power. Most also regarded some aspects of the organization and its philosophy worth-while, with attitudes spread across the continuum.

Hoffmann HC. Criticism as deviance and social control in Alcoholics Anonymous. Journal of Contemporary Ethnography 35(6): 669-695, 2006. (52 refs.)

Emile Durkheim recognized many years ago that all groups -- even a "society of saints" -- produce deviants. Group members must then come to terms with how to respond to and control those who violate the group's moral order. The Alcoholics Anonymous (AA) meeting offers an interesting context to explore this process. AA members, by their own admission, are far from being "saints," some admitting to adultery, theft, and assault during their active alcoholism. In this article, the author describes the moral order of AA that functions to prevent and create deviant behavior, focusing on AA members' use of criticism as both a method of social control and a violation of AA's normative system. This seeming contradiction is explained by showing that criticism is a social control strategy available primarily to high-status members, used primarily against lower-status members.

Humphreys K. Alcoholics Anonymous and 12-step alcoholism treatment programs. IN: Galanter M, ed. Recent Developments in Alcoholism. Volume 16: Research on Alcoholism Treatment. Methodology/Psychosocial Treatment/Selected Treatment Topics/Research Priorities. New York: Kluwer Academic, 2003. pp. 149-164. (32 refs.)

Alcoholics Anonymous (AA) and 12-step alcoholism treatment programs are discussed. The author notes that AA self-help groups are the most commonly accessed component of treatment for alcoholism and alcohol-related problems. Additionally, the concepts and approaches of AA have significantly influenced other twelve-step programs in professional treatment. Research has indicated that participation in AA or other 12-step programs results in reductions in substance abuse and also in psychiatric problems, reducing health care costs over time. The author suggests that future research should address the following topics: evaluation of the unique features of self-help organizations; representation of African-Americans and women in research samples; increased statistical power through larger sample sizes and more reliable measurement; longitudinal evaluation of AA and 12-step treatment outcomes, particularly in outpatient samples; aspects of AA that influence outcome; and health care cost consequences of 12-step program participation. Section headings in this book chapter include: (1) nature and prevalence of AA; (2) nature and prevalence of 12-step treatment programs; (3) evaluations of community-based AA groups; (4) evaluation research on 12-step oriented professional treatment programs; and (5) potential future research directions.

Humphreys K. The trials of Alcoholics Anonymous. (editorial). Addiction 101(5): 617-618, 2006. (15 refs.)

Jhirwal OP. Involvement of Alcoholics Anonymous and other self-help groups in professional treatment of substance abusers: An Indian perspective. (letter). Journal of Substance Abuse Treatment 29(1): 65-65, 2005. (3 refs.)

Kahler CW; Kelly JF; Strong DR; Stuart GL; Brown RA. Development and initial validation of a 12-step participation expectancies questionnaire. Journal of Studies on Alcohol 67(4): 538-542, 2006. (15 refs.)

Objective: There are no available instruments that assess expectancies for participation in 12-step mutual-help groups despite the impact such expectancies may have on actual participation. The purpose of the present study was to develop a measure of attitudes and expectancies regarding 12-step participation, to conduct preliminary analyses on its psychometric properties, and to explore its concurrent and predictive validity. Method: Alcohol-dependent patients (N = 48) undergoing inpatient detoxification completed a questionnaire that included subscales assessing expected benefits of, concerns about, and barriers to 12-step participation. Participants also completed measures of 12-step group participation and drinking outcomes at 1, 3, and 6 months following discharge. Results: After examining the internal consistency of the items within each subscale and refining the questionnaire accordingly, an exploratory factor analysis showed that the scales could be combined into a higher-order total score. This total score correlated significantly with prior 12-step experience and goals for attending future 12-step meetings. In addition, the Expectancies Total Score at baseline significantly predicted 12-step group participation during follow-up. Conclusions: The measure of attitudes and expectancies regarding 12-step group participation demonstrated good internal consistency, concurrent validity, and predictive validity. The measure may have clinical utility in highlighting patients' expectancies regarding 12-step participation, allowing treatment providers to explore with patients the benefits, concerns, and barriers to involvement that they have endorsed.

Kaskutas L; Room R; Ammon L; Bond J; Delucchi K; Weisner C. AA careers in the 5 years after alcohol treatment. (meeting abstract). Alcoholism: Clinical and Experimental Research 28(5 Supplement): 195A-195A, 2004. (0 refs.)

Kaskutas LA; Ammon L; Delucchi K; Room R; Bond J; Weisner C. Alcoholics Anonymous careers: Patterns of AA involvement five years after treatment entry. Alcoholism: Clinical and Experimental Research 29(11): 1983-1990, 2005. (50 refs.)

Background: Most formal treatment programs recommend Alcoholics Anonymous (AA) attendance during treatment and as a form of aftercare, but we know very little about treatment seekers' patterns of AA involvement over time and how these relate to abstinence. Method: This paper applies latent class growth curve modeling to longitudinal data from 349 dependent drinkers recruited when they were entering treatment and were re-interviewed at one or more follow-up interviews one, three and five years later, and who reported having attended AA at least once. Results: Four classes of AA "careers" of meeting attendance emerged: The low AA group mainly just attended AA during the 12 months following treatment entry. The medium and high AA groups were characterized by stable attendance at the second and third follow-ups-at about 60 meetings a year for the medium group and over 200 meetings per year for the high group, followed by slight increases for the medium group and slight decreases for the high group by year five. The declining AA group doubled its meeting attendance postbaseline, to almost 200 meetings during the year following treatment entry, but by year five they were only attending about six meetings on average. Decreases in AA meetings did not necessarily signal disengagement from AA; at the five-year follow-up, a third of the low AA group and over half of the declining AA group said they felt like a member of AA. Activities other than meeting attendance, such as having a sponsor, otherwise paralleled the meeting careers, but social networks were similar by year five. Rates of abstinence by year five (for the past 30 days) were 43% for the low AA group, 73% for the medium group, 79% for the high group and 61% for the declining group. Rates of dependence symptoms and social consequences of drinking did not differ between the groups at year five. Conclusions: The prototypical AA careers derived empirically are consistent with anecdotal data about AA meetings: some never connect; some connect but briefly; and others maintain stable (and sometimes quite high) rates of AA attendance. However, contrary to AA lore, many who connect only for a while do well afterwards.

Kaskutas LA; Turk N; Bond J; Weisner C. The role of religion, spirituality and Alcoholics Anonymous in sustained sobriety. Alcoholism Treatment Quarterly 21(1): 1-16, 2003. (26 refs.)

Spirituality or belief in a higher being is an integral part of Alcoholics Anonymous (AA). This study examines the role of religiosity in AA involvement and long-term sobriety in a representative sample of 587 men and women (ages 30 to 44 yrs) interviewed upon entering treatment and re-interviewed 1 and 3 years later. Religiosity is defined as spiritual, religious, secular (atheist or agnostic) and unsure, using the Religious Beliefs and Practices Scale employed in Project MATCH. Similar proportions within each religiosity group reported prior 12-month AA exposure at baseline; and over 40% of the unsure, spiritual and religious respondents and 25% of the secular respondents reported having gone to at least one AA meeting in the 12 months before the year 3 interview. Those who reported a spiritual awakening at year 3 were at the highest odds of continuous sobriety for the last year; religious self-definition was not associated with a significantly higher odds of sobriety at year 3 after controlling for other influences. An increase in AA activities, other than AA meetings, between baseline and the year 1 follow-up was also associated with a higher odds of sobriety, highlighting the importance of increased AA involvement in the period immediately following treatment episodes.

Kelly JF; McKellar JD; Moos R. Major depression in patients with substance use disorders: Relationship to 12-Step self-help involvement and substance use outcomes. Addiction 98(4): 499-508, 2003. (40 refs.)

Aims: Many patients treated for substance use disorders (SUDs) who become involved in 12-Step self-help groups have improved treatment outcomes. However, due to high rates of psychiatric comorbidity and major depressive disorder (MDD), among SUD patients in particular, concerns have been raised over whether these benefits extend to dual diagnosis patients. This study examined the influence of comorbid MDD among patients with SUDs on 12-Step self-help group involvement and its relation to treatment outcome. Design A quasi-experimental, prospective, intact group design was used with assessments completed during treatment and 1 and 2 years postdischarge. Participants: A total of 2161 male patients recruited during in-patient SUD treatment, of whom 110 had a comorbid MDD diagnosis (SUD-MDD) and 2051 were without psychiatric comorbidity (SUD-only). Findings: SUD-MDD patients were initially less socially involved in and derived progressively less benefit from 12-Step groups over time compared to the SUD-only group. However, substance use outcomes did not differ by diagnostic cohort. In contrast, despite using substantially more professional outpatient services, the SUD-MDD cohort continued to suffer significant levels of depression. Conclusions: Treatment providers should allocate more resources to targeting depressive symptoms in SUD-MDD patients. Furthermore, SUD-MDD patients may not assimilate as readily into, nor benefit as much from, traditional 12-Step self-help groups such as Alcoholics Anonymous, as psychiatrically noncomorbid patients. Newer, dual-diagnosis-specific, self-help groups may be a better fit for these patients, but await further study.

Kingree JB; Simpson A; Thompson M; McCrady B; Tonigan JS. The predictive validity of the Survey of Readiness for Alcoholics Anonymous Participation. Journal of Studies on Alcohol 68(1): 141-148, 2007. (33 refs.)

Objective: This study evaluated the predictive validity of the Survey of Readiness for Alcoholics Anonymous Participation (SYRAAP), which is a 15-item, self-administered instrument. Method: Bivariate and multivariate analyses examined whether responses to the SYRAAP within I week of entering substance-use treatment (T1) were associated with posttreatment Alcoholics Anonymous (AA) participation at 3-month (T2) and 6-month (T3) follow-up assessments. The T I assessment was completed by 268 respondents; the T2 and T3 assessments were completed by 232 (86%) and 217 (81%) respondents, respectively. Results: Results revealed that responses to the SYRAAP at T1 predicted AA participation at T2 and T3. Conclusions: The findings indicate the SYRAAP is a valid measure for assessing readiness for participating in AA. Future research in relation to the SYRAAP and limitations of the current study are discussed.

Kingree JB; Simpson A; Thompson M; McCrady B; Tonigan JS; Lautenschlager G. The development and initial evaluation of the Survey of Readiness for Alcoholics Anonymous Participation. Psychology of Addictive Behaviors 20(4): 453-462, 2006. (43 refs.)

This article presents 5 studies related to the development and initial evaluation of the Survey of Readiness for Alcoholics Anonymous Participation (SYRAAP). The SYRAAP is a brief, multidimensional, self-administered instrument that assesses beliefs associated with Alcoholics Anonymous (AA) participation. Study 1 generated 239 candidate items for potential inclusion in the instrument. Study 2 assessed the content validity of these items according to 3 criteria and identified a subset of 60 with the highest values on the criteria for further consideration. Study 3 produced a shorter version of the SYRAAP and evaluated its structure, internal reliability, and validity. Study 4 reevaluated the structure and internal reliability of the SYRAAP and yielded findings that were generally consistent with those from Study 3. Study 5 established stability reliability for the instrument. The collective findings indicated the SYRAAP can reliably and validly assess individual-level beliefs associated with AA participation. The potential use of the SYRAAP for researchers and clinicians, along with limitations of the work presented here, are discussed.

Kissin W; McLeod C; McKay J. The longitudinal relationship between self-help group attendance and course of recovery. Evaluation and Program Planning 26(3): 311-323, 2003. (25 refs.)

Most alcohol and other drug (AOD) abuse patients participate in self-help (SH) programs such as Alcoholics Anonymous or Narcotics Anonymous at some time, but few studies investigate longitudinal SH attendance patterns. The present study examines the relationship between longitudinal SH attendance patterns and level of AOD use over 30 months in a large sample of adults seeking public AOD treatment. Continuous SH participation was associated with lowest AOD use at followup, while non-attendance was linked to highest use, even after controlling for length of formal treatment and participants' perceived severity of their AOD problem. Results suggest that both SH and formal substance abuse treatment are independently associated with reduced AOD use, and SH participation is associated with treatment. This study supports the importance of SH attendance and of formal treatment by individuals with AOD abuse disorders.

Kuruvilla PK; Vijayakumar N; Jacob KS. A cohort study of male subjects attending an Alcoholics Anonymous program in India: One-year follow-up for sobriety. Journal of Studies on Alcohol 65(4): 546-549, 2004. (10 refs.)

Objective: The objective of this study was to follow up a cohort of subjects who completed detoxification treatment and a deaddiction program based on the Alcoholics Anonymous (AA) model. The factors associated with complete abstinence were investigated. Method: Patients (187 men) admitted consecutively to an addiction facility, who fulfilled the DSM-IV criteria for alcohol dependence, were recruited for the study. Patients with major psychopathology were excluded from the cohort. The program was based on the principles of AA. The final outcome at 1 year was determined by visiting the patient and talking to the family and members of the local AA group. Results: Of the 187 initially recruited, five were excluded due to the presence of major psychopathology, one committed suicide and seven could not be traced. Of the 174 patients followed up, 58 (33.3%) remained sober (complete abstinence for the past year) at 1 year. Patients coming from distant places and those with follow-up workers in their localities fared better than those from the local area and those from towns where there was no one to motivate them to continue with AA meetings. These variables were significantly associated with sobriety even after adjusted for other confounders using multivariate techniques. Conclusions: A third of the cohort remained sober at 1-year follow-up. The patients' initial motivation and continued support once they returned to their communities were associated with being sober at follow-up.

Laudet AB; Magura S; Cleland CM; Vogel HS; Knight EL; Rosenblum A. The effect of 12-step based fellowship participation on abstinence among dually diagnosed persons: A two-year longitudinal study. Journal of Psychoactive Drugs 36(2): 207-216, 2004. (35 refs.)

A large percentage of individuals are dually-diagnosed with a psychiatric disorder and a substance use disorder. Such persons typically face more difficulties and have poorer outcomes than do single disorder substance users. Among noncomorbid substance users, treatment and participation in 12-Step groups have been shown to enhance the likelihood of abstinence from substance misuse. Specialized 12-Step based fellowships have recently emerged to address the recovery needs of dually-diagnosed persons. The present study is a longitudinal investigation of the effect of such 12-Step based groups on abstinence among dually-diagnosed persons. Participants were members of Double Trouble in Recovery (DTR) who were recruited at community-based meetings in New York City and reinterviewed twice at yearly intervals. Generalized estimating equation analysis indicated that, over the two-year study period, ongoing DTR attendance was significantly associated with a greater likelihood of abstinence after controlling for other pertinent variables, such as mental health symptoms. For clinicians, these findings underline the importance of fostering stable affiliation with specialized 12-Step based groups among their clients.

Ledgerwood DM; McCaul ME; Petry NM. Psychotherapy and pharmacotherapy in treatment of substance use disorders. IN: Kranzler HR; Ciraulo DA, eds. Clinical Manual of Addiction Psychopharmacology. Washington DC: American Psychiatric Press, 2005. pp. 339-356. (112 refs.)

This concluding chapter, following 8 chapters dealing with specific drug classes, addresses the general role of psychotherapy and pharmacotherapy in treating substance use disorders. Specific treatment approaches discussed are brief interventions, motivational enhancement therapy, cognitive-behavioral therapy, behavioral couples therapy, and 12-step treatments. The interaction between these psychotherapies and drug therapies is reviewed.

Litt MD; Kadden RM; Kabela-Cormier E; Petry N. Changing network support for drinking: Initial findings from the network support project. Journal of Consulting and Clinical Psychology 75(4): 542-555, 2007. (49 refs.)

The aim of this study was to determine whether a socially focused treatment can effect change in the patient's social network from one that reinforces drinking to one that reinforces sobriety. Alcohol dependent men and women (N = 210) recruited from the community 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 for 186 participants at 15 months indicated a significant interaction effect of Treatment X Time, with both NS conditions yielding better outcomes than the CaseM condition. Analyses of social network variables at posttreatment indicated that the NS conditions did not reduce social support for drinking relative to the CaseM condition but did increase behavioral and attitudinal support for abstinence as well as Alcoholics Anonymous (AA) involvement. Both the NS variables and AA involvement variables were significantly correlated with drinking outcomes. These findings indicate that drinkers' social networks can be changed by a treatment that is specifically designed to do so, and that these changes contribute to improved drinking outcomes.

Lobdell JC. This Strange Illness: Alcoholism and Bill W.. New York: Walter de Gruyter, Inc.,, 2004

This work considers the impact of Bill Wilson in the formation of Alcoholics Anonymous and its conceptualiztion of the disesase as an illness of the mind, body, and spirit. It considers the evolving definitions of alcoholism, including theoretical formulations, statistically derived typologies and the changing definitions used by the medical community. The first chapters set forth the historical context and a historical perspective of AA, tracing its origins through Bill Wilson. and Dr Bob Smith. Several chapters are devoted to providing a biological and genetic perspective of alcoholism, presenting studies related to behavioral genetic, biochemical and genetic aspects of alcoholism. The final chapters endeavor to integrate the psychology and biology of alcoholism with the philosophy, theology and traditions of AA to provide a unified paradigm to support future research.

MacKillop J; Lisman SA; Weinstein A; Rosenbaum D. Controversial treatments for alcoholism. IN: Lilienfeld SO; Lynn SJ; Lohr JM, eds. Science and Pseudoscience in Clinical Psychology. New York: Guilford Press, 2003. pp. 273-305. (154 refs.)

Two frameworks for the treatment of alcoholism have evolved over the course of understanding the disorder. The large gaps between the lay and scientific treatment communities and even within the clinical community itself have resulted in substantial controversy regarding treatment approaches to alcoholism. This chapter examines "controversial" treatments for alcoholism, namely those that have been widely adopted or generated popular appeal, but have been demonstrated by controlled research to be of questionable or even nonexistent efficacy. Specifically, the chapter discusses the efficacy of Alcoholics Anonymous, the Johnson Intervention, disulfiram pharmacotherapy, the debates about moderation as a treatment goal, and Project DARE. The second portion of the chapter describes the theory, evidence, and procedures of a selection of evidence-based treatments. The chapter concludes with a comment on the increasing visibility and influence of the scientific perspective in alcoholism treatment.

Magura S; Fong C; Staines GL; Cleland C; Foote J; Rosenblum A et al. The combined effects of treatment intensity, self-help groups and patient attributes on drinking outcomes. Journal of Psychoactive Drugs 37(1): 85-92, 2005. (36 refs.)

Better understanding of the diverse factors that predict alcoholism treatment outcomes is essential to improving treatment strategies. Patients accepted for treatment at a multimodality program were inter-viewed and followed-up at three months and one year after admission. The study tested a set of hypotheses relating to the effects on drinking outcomes of treatment modality, modality matching, treatment retention, aftercare, self-help group participation and patient attributes at admission. Drinking frequency diminished substantially between baseline and the two follow-ups. Outcomes for inpatient were better than for outpatient treatment in bivariate analysis, but outcomes for these modalities were equal after adjusting for the effect of patient-treatment mismatching. Aftercare treatment, time in treatment for outpatients, community 12-Step group participation, and several patient attributes such as motivation for change and psychiatric severity significantly predicted drinking outcomes at one or both follow-ups. Clinical implications of the results are discussed.

Mann RE; Smart RG; Rush BR; Zalcman RF; Suurvali H. Cirrhosis mortality in Ontario: Effects of alcohol consumption and Alcoholics Anonymous participation. Addiction 100(11): 1669-1679, 2005. (62 refs.)

We test the hypotheses that cirrhosis mortality rates are positively associated with per capita alcohol consumption and negatively associated with Alcoholics Anonymous (AA) membership rates. The impact of alcohol consumption levels and AA membership rates on cirrhosis mortality rates in Ontario from 1968 to 1989 were examined. Time-series analyses with ARIMA modelling were applied to male and female cirrhosis mortality rates in three age groups: 15-44, 45-64 and 65 + years. Missing AA membership data were interpolated using two methods: linear splines and cubic splines. In general, cirrhosis mortality rates were positively associated with alcohol consumption and negatively associated with AA membership. For some age and gender combinations, these effects were not statistically significant. The limits of this study include restrictions in the length of series available and in the ability to infer causality. Despite these limitations, these findings are consistent with previous research demonstrating that per capita consumption is a strong determinant of cirrhosis mortality rates, and also that higher levels of AA membership can reduce cirrhosis mortality rates.

Mann RE; Zalcman RF; Smart RG; Rush BR; Suurvali H. Alcohol consumption, Alcoholics Anonymous membership, and homicide mortality rates in Ontario 1968 to 1991. Alcoholism: Clinical and Experimental Research 30(10): 1743-1751, 2006. (51 refs.)

Background: Research has shown a strong link between alcohol use and a variety of problems, including violence. Parker and colleagues have presented a selective disinhibition theory for the link between alcohol use and homicide (and other violence) that posits a causal relationship that is also influenced by other situational and contextual factors. This model is particularly well suited for aggregate-level investigations. In this study, we examine the impact of alcohol factors, including consumption measures and Alcoholics Anonymous (AA) membership rates, on homicide mortality rates in Ontario, and test predictions derived from the selective disinhibition model. Methods: Time series analyses with ARIMA modeling were applied to total, male, and female homicide rates in Ontario between 1968 and 1991. The analyses performed included total alcohol consumption, spirits consumption, beer consumption, and wine consumption. Missing AA membership data were interpolated with cubic splines. Results: For the total population and males, homicide rates were significantly and positively related to total alcohol consumption and to the consumption of beer and spirits. They were also negatively related to AA membership rates in the analyses involving spirits and wine and positively related to unemployment rates in the analyses involving beer, wine, and total alcohol. Among females, none of the measures were significant predictors of homicide mortality rates. Conclusions: These data provide important support for the selective disinhibition model and confirm important relationships between per capita consumption measures and homicide mortality rates, especially among males, seen in other studies. Additionally, the results for AA membership rates are consistent with the hypothesis that AA membership and treatment for misuse of alcohol can exert beneficial effects observable at the population level.

Mann RE; Zalcman RF; Smart RG; Rush BR; Suurvali H. Alcohol consumption, Alcoholics Anonymous membership, and suicide mortality rates, Ontario, 1968-1991. Journal of Studies on Alcohol 67(3): 445-453, 2006. (46 refs.)

Objective: The goal of this study is to identify alcohol-related factors that influence mortality rates from suicide. Specifically, we examine the impact of per capita consumption of total alcohol, distilled spirits, and beer and wine; unemployment rate; and Alcoholics Anonymous (AA) membership rate on total and male and female suicide mortality rates in Ontario between 1968 and 1991. Method: We studied the impact of alcohol consumption levels, AA membership rates, and unemployment rates on suicide mortality rates in Ontario from 1968 to 1991. Time series analyses with Auto Regressive Integrated Moving Average (ARIMA) modeling were applied to total and male and female suicide rates. The analyses performed included total alcohol consumption, distilled spirits consumption, beer consumption, and wine consumption. Missing AA membership data were interpolated with cubic splines. Results: Total alcohol consumption and consumption of each of beer, distilled spirits, and wine were significantly and positively related to total and female suicide mortality rates. AA membership rates were negatively related to total and female suicide rates. Although data for males did not reach significance (except for the relationship between wine consumption and suicide rate), the direction of effects was consistent with that observed for female and total suicide rates. Unemployment rates were positively related to male and total suicide rates in some models. Conclusions: These data confirm the important relationships between per capita consumption measures and suicide mortality rates seen by previous investigators. Additionally, the results for AA membership rates are consistent with the hypothesis that AA membership and treatment for misuse of alcohol can exert beneficial effects observable at the population level.

Masudomi I; Isse K; Uchiyama M; Watanabe H. Self-help groups reduce mortality risk: A 5-year follow-up study of alcoholics in the Tokyo metropolitan area. Psychiatry and Clinical Neurosciences 58(5): 551 -557, 2004. (32 refs.)

The present study aimed to determine whether alcoholics who attend self-help groups experience fewer deaths than those who do not. Subjects were patients from the Alcoholism Treatment Program (ATP) of Matsuzawa hospital. A cohort of alcoholic patients recruited into a prospective study was followed from April 1994 to March 1999. A total of 469 alcoholic patients met the International Classification of Diseases (10th edition) criteria for alcohol dependency. Of these, 94 patients refused to participate in the study, leaving a total of 375 participants. After discharge from the ATP and a complete explanation of the present study, subjects decided whether to attend a self-help group (SHG) or not. The SHG comprised 208 subjects, and the non-self-help group (NSHG) comprised 167 subjects. Outcomes were evaluated with regard to death during follow-up for a mean of 2.4 years. Death was ascertained through the records of the Setagaya Department of Health and Welfare center, Matsuzawa hospital and other hospitals, and through personal contact with informants, relatives, and significant others of subjects. Deaths were confirmed for 47 NSHG subjects and only five SHG subjects. NSHG displayed a significantly decreased cumulative survival compared with SHG (P < 0.0001). Cox proportion hazard analysis was used to examine variables that may help to predict mortality among alcoholics. Alcoholics who attended self-help groups differed from those who did not, with regard to mortality experience. Attending a self-help group represented the most important predictor of prognosis for alcoholics.

Matzger H; Delucchi K; Weisner C. Alcoholics Anonymous social networks and formal services' impact on alcohol consumption in a 5-year study of problem and dependent drinkers. (meeting abstract). Alcoholism: Clinical and Experimental Research 28(5 Supplement): 195A-195A, 2004. (0 refs.)

McCrady BS; Epstein EE; Kahler CW. Alcoholics Anonymous and relapse prevention as maintenance strategies after conjoint behavioral alcohol treatment for men: 18-month outcomes. Journal of Consulting and Clinical Psychology 72(5): 870 -878, 2004. (40 refs.)

Ninety men with alcohol problems and their female partners were randomly assigned to I of 3 outpatient conjoint treatments: alcohol behavioral couples therapy (ABCT), ABCT with relapse prevention techniques (RP/ABCT), or ABCT with interventions encouraging Alcoholics Anonymous (AA) involvement (AA/ABCT). Couples were followed for 18 months after treatment. Across the 3 treatments, drinkers who provided follow-up data maintained abstinence on almost 80% of days during follow-up, with no differences in drinking or marital happiness outcomes between groups. AA/ABCT participants attended AA meetings more often than ABCT or RP/ABCT participants, and their drinking outcomes were more strongly related to concurrent AA attendance. For the entire sample, AA attendance was positively related to abstinence during follow-up in both concurrent and time-lagged analyses. In the RP/ABCT treatment, attendance at posttreatment booster sessions was related to posttreatment abstinence. Across treatment conditions, marital happiness was related positively to abstinence in concurrent but not time-lagged analyses.

McKellar J; Stewart E; Humphreys K. Alcoholics Anonymous involvement and positive alcohol-related outcomes: Cause, consequence, or just a correlate? A prospective 2-year study of 2,319 alcohol-dependent men. Journal of Consulting and Clinical Psychology 71(2): 302-308, 2003. (44 refs.)

A positive correlation between Alcoholics Anonymous (AA) involvement and better alcohol-related outcomes has been identified in research studies, but whether this correlation reflects a causal relationship remains a subject of meaningful debate. The present study evaluated the question of whether AA affiliation appears causally related to positive alcohol-related outcomes in a sample of 2,319 male alcohol-dependent patients. An initial structural equation model indicated that 1-year posttreatment levels of AA affiliation predicted lower alcohol-related problems at 2-year follow-up, whereas level of alcohol-related problems at 1-year did not predict AA affiliation at 2-year follow-up. Additional models found that these effects were not attributable to motivation or psychopathology. The findings are consistent with the hypothesis that AA participation has a positive effect on alcohol-related outcomes.

Miller MM. Twelve step programs: An update. Addictive Disorders and Their Treatment 2(4): 157-160, 2003

This article is a primer on the twelve-step model, with a history of AA, a brief examination of how a twelve-step program works, a review of research on this treatment modality, and a discussion of handling common issues reported by clients regarding this psychosocial approach. The author points out that twelve-step programs are nonprofessional programs of self-help and peer support, and thus are distinguished from professional treatment. However, Alcoholics Anonymous (AA) and programs modeled after it have played an ever-increasing role in addiction treatment since AA's inception in the mid-1930s.

Miller WR. Spirituality, treatment, and recovery. IN: Galanter M, ed. Recent Developments in Alcoholism. Volume 16: Research on Alcoholism Treatment. Methodology/Psychosocial Treatment/Selected Treatment Topics/Research Priorities. New York: Kluwer Academic, 2003. pp. 391-404. (56 refs.)

Spirituality in treatment and recovery of alcoholic patients is discussed. The author notes that spirituality, which is best understood as characteristic of individuals, is not interchangeable with religion, which is a social phenomenon. There are many opportunities for enhancing spirituality as a complement to treatment and recovery, although there is a need for well-designed scientific studies of spirituality and alcohol. Many pieces of the alcoholism puzzle are missing with studies of treatment approaches, client characteristics, therapist and treatment processes, and posttreatment environment to date not explaining the variance in drinking outcomes. It is suggested that some of the missing pieces may be found in the exploration of spirituality. Section headings in this book chapter include: (1) defining spirituality; (2) spirituality and alcoholism; (3) spirituality and recovery; (4) spirituality and treatment, including Alcoholics Anonymous (AA) and treatment, AA and treatment outcome, 12-step facilitation (TSF) therapy; (5) beyond 12-step spirituality, including spiritual assessment, reengagement, spiritual disciplines; and (6) spirituality and science.

Miller WR; Longabaugh R. Summary and conclusions. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 207-221. (275 book refs.)

The findings of the patient-treatment matching study, Project MATCH, are presented and summarized. The three very different treatment methods of Cognitive-Behavioral Therapy or CBT, Motivation Enhancement Therapy or MET, and Twelve Step Facilitation or TSF produced similarly positive outcomes. The following results of the study were seen: (1) association of involvement with Alcoholics Anonymous with better outcomes; (2) modest support for matching clients to optimal treatments on the basis of pretreatment characteristics; (3) a finding that TSF was more effective than one or both of the other treatments with Outpatient clients without additional psychopathology, Outpatients with high social support for continued drinking, and Aftercare clients high in alcohol dependence; (4) a finding that MET was more effective than the other treatments for Outpatients high in anger; and (5) a finding that CBT was more effective than TSF for Aftercare clients low in alcohol dependence.

Public Domain

Moos RH; Moos BS. Help-seeking careers: Connections between participation in professional treatment and Alcoholics Anonymous. Journal of Substance Abuse Treatment 26(3): 167-173, 2004. (25 refs.)

This study examined the relationships between participation in professional treatment and Alcoholics Anonymous (AA) among 473 initially untreated individuals with alcohol use disorders. These individuals were assessed at baseline and at 1-year, 3-year, and 8-year followups. There were moderate positive concurrent associations between the duration of participation in professional treatment and in AA. More important, a longer duration of treatment in year 1 was associated with more sustained participation in AA in years 2 and 3, which was associated with less time in treatment in years 4 through 8. The strength of these findings varied somewhat in relation to whether individuals chose to enter treatment or AA first. The findings suggest that referral and alliance processes contribute to a positive association between the duration of an initial episode of treatment and subsequent AA, and then extended participation in AA contributes to better alcohol-related outcomes and reduced need for subsequent treatment.

Moos RH; Moos BS. Long-term Influence of duration and frequency of participation in Alcoholics Anonymous on individuals with alcohol use disorders. Journal of Consulting and Clinical Psychology 72(1): 81-90, 2004. (46 refs.)

This study examined the influence of the duration and frequency of a baseline episode of participation in Alcoholics Anonymous (AA) among 473 individuals with alcohol use disorders on 1-year and 8-year outcomes and the effect of additional participation and delayed participation on outcomes. Compared with individuals who did not participate, individuals who affiliated with AA relatively quickly, and who participated longer, had better 1-year and 8-year alcohol-related outcomes. Individuals who continued to participate, and those who continued longer, had better alcohol-related outcomes than did individuals who discontinued participation, but individuals who delayed participation in AA had no better outcomes than those who never participated. In general, the frequency of participation was independently associated only with a higher likelihood of abstinence

Moos RH; Moos BS. Participation in treatment and Alcoholics Anonymous: A 16-year follow-up of initially untreated individuals. Journal of Clinical Psychology 62(6): 735-750, 2006. (51 refs.)

This study focused on the duration of participation in professional treatment and Alcoholics Anonymous (AA) for previously untreated individuals with alcohol use disorders. These individuals were surveyed at baseline and 1 year, 3 years, 8 years, and 16 years later. Compared with individuals who remained untreated, individuals who obtained 27 weeks or more of treatment in the first year after seeking help had better 16-year alcohol-related outcomes. Similarly, individuals who participated in AA for 27 weeks or more had better 1 6-year outcomes. Subsequent AA involvement was also associated with better 1 6-year outcomes, but this was not true of subsequent treatment. Some of the association between treatment and long-term alcohol-related outcomes appears to be due to participation in AA.

Moos RH; Moos BS. Paths of entry into Alcoholics Anonymous: Consequences for participation and remission. Alcoholism: Clinical and Experimental Research 29(10): 1858-1868, 2005. (42 refs.)

Background: This study compared individuals with alcohol use disorders who, in the first year after initiating help-seeking, entered Alcoholics Anonymous (AA) only, entered professional treatment and AA together, or entered professional treatment only Methods: A sample of initially untreated individuals (N = 362) was surveyed at baseline and 1 year, 3 years, 8 years, and 16 years later. At each contact point, participants described their participation in AA and treatment and their current alcohol-related functioning. They also described their reasons for entering AA and/or treatment and the perceived benefits of these sources of help Results: Compared with individuals who initially participated only in treatment but later entered AA, those who entered treatment and AA together participated in AA longer and more frequently and were more likely to achieve remission. Among individuals who initially participated only in AA, those who later entered treatment had poorer remission outcomes than those who did not enter treatment. Longer duration of participation in AA was associated with a higher likelihood of remission at all four follow-ups; individuals who dropped out of AA were more likely to relapse or remain nonremitted. Conclusions: Compared with individuals who participated only in professional treatment in the first year after they initiated help-seeking, individuals who participated in both treatment and AA were more likely to achieve remission. Individuals who entered treatment but delayed participation in AA did not appear to obtain any additional benefit from AA.

Moos RH; Moos BS. Risk factors for nonremission among initially untreated individuals with alcohol use disorders. Journal of Studies on Alcohol 64(4): 555-563, 2003. (61 refs.)

Objective: This study identified risk factors for I-year and 8-year nonremission among initially untreated individuals with alcohol use disorders and examined whether a longer duration of professional treatment or Alcoholics Anonymous (AA) increased the likelihood of remission, moderated the influence of risk factors on remission status and reduced modifiable risk factors. Method: A sample of individuals with alcohol use disorders (N = 473) was recruited at alcoholism information and referral centers and detoxification units and was surveyed at baseline and 1 year, 3 years and 8 years later. At each contact, participants completed an inventory that assessed their alcohol-related problems and personal characteristics and their participation in treatment and AA since the last assessment. Results: An 11-item baseline risk index was associated with 1-year nonremission. Longer duration of treatment and AA in the first year predicted remission and a decline in modifiable risk factors. In addition, longer duration of AA increased the likelihood of remission more among high-risk than among low-risk individuals. The risk factors at 1 year were associated with 8-year nonremission; longer duration of additional treatment or AA was associated with a higher likelihood of 8-year remission and further reductions in modifiable risk factors. Conclusions: Referral counselors and treatment providers can identify high-risk individuals early in their help-seeking career and intervene to reduce the likelihood of a chronic course of their alcohol use disorder.

Moos RH; Moos BS. The interplay between help-seeking and alcohol-related outcomes: Divergent processes for professional treatment and self-help groups. Drug and Alcohol Dependence 75(2): 155-164, 2004. (45 refs.)

This study examined the influence of self-selection, as reflected in alcohol-related functioning, on the duration of professional treatment and Alcoholics Anonymous (AA), and the influence of social causation, as reflected in the duration of treatment and AA, on alcohol-related outcomes. A sample of alcoholic individuals was surveyed at baseline and 1, 3, and 8 years later. At each point, participants completed an inventory that assessed participation in treatment and AA since the last assessment and alcohol-related functioning. There were divergent processes of self-selection and social causation with respect to the duration of participation in professional treatment and AA. Individuals with more severe alcohol-related problems obtained longer episodes of professional treatment, but this self-selection process was much less evident for AA. Longer participation in professional treatment in the first year predicted better alcohol-related outcomes; however, the duration of subsequent treatment was not associated with better subsequent outcomes. In contrast, longer participation in AA consistently predicted better subsequent alcohol-related outcomes. These findings are consistent with a need-based model of professional treatment, in which more treatment is selected by and allocated to individuals with more severe problems, and an egalitarian model of self-help, in which need factors play little or no role in continued participation.

Moos RH; Moos BS. Treated and untreated individuals with alcohol use disorders: Rates and predictors of remission and relapse. International Journal of Clinical and Health Psychology 6(3): 513-526, 2006. (35 refs.)

This observational descriptive study focused on whether individuals with alcohol use disorders who participate in professional treatment and/or Alcoholics Anonymous (AA) experience better long-term outcomes than individuals who do not obtain help. Participants were surveyed at baseline when they initiated help-seeking and 1 year, 3 years, 8 years, and 16 years later. Compared with individuals who obtained no help, individuals who participated in treatment and/or AA for 9 weeks or more in the first year after help-seeking had better 16-year outcomes. Participation in treatment and/or AA accelerated an overall pattern of change, so that individuals who obtained help improved somewhat more and more quickly than those who did not. Overall, individuals who did not obtain help were less likely to achieve remission and, even if they achieved remission, were more likely to relapse. The findings support the value of strengthening the referral process for individuals who seek help and indicate that providers should structure treatment programs to ensure continuing care and affiliation with AA.

Mueller SE; Petitjean S; Boening J; Wiesbeck GA. The impact of self-help group attendance on relapse rates after alcohol detoxification in a controlled study. Alcohol and Alcoholism 42(2): 108-112, 2007. (33 refs.)

Aims: Self-help groups such as Alcoholics Anonymous (AA) are widely recommended for aftercare of alcohol-dependent persons, even though scientific knowledge of its effectiveness is inconsistent. The aim of the present analysis was to elucidate whether persons attending AA groups regularly after detoxification have lower relapse rates within 1 year, compared to persons without self-help group attendance. Methods: Data for the present analysis were derived from the placebo-group of a multi-centre study in Germany (Wiesbeck et al., 2001). Patients were free to choose either self-help group attendance (N = 50) or no support (N = 28). Results: After 1-month of follow-up, there was a lower relapse rate in patients attending a self-help group as compared to the control group, a difference, however, that leveled off during the following months. Moreover, relapse rates did not differ significantly at any point of time between both groups. Levels of social functioning improved in both groups over 1 year. Conclusions: The present study was unable to show an advantage of self-help group attendance in reducing relapses compared to the control group.

O'Halloran S. Symmetry in interaction in meetings of Alcoholics Anonymous: The management of conflict. Discourse & Society 16(4): 535-560, 2005. (50 refs.)

This is a study of the interactive order of participants in meetings of Alcoholics Anonymous (AA). It explores, through a detailed examination of one instance of conflict, the turn-taking system of AA meetings and the discursive alignment of members to each other. It aims to demonstrate that the non-hierarchical, egalitarian nature of AA is reflected in and constituted through the way symmetrical interaction is managed. It is proposed that this symmetry is institutional and is constitutive of the aims of AA; demonstrating that discursive symmetry is constituted by members' access to and employment of a similar range of discursive practices which reflects and constitutes non-differentiated roles among members, mitigating against conflict. It is further proposed that the symmetry in AA discursive practices is exceptional in that, unlike the symmetry of mundane conversation between equals, it is institutional and that symmetry is displayed to a higher degree, i.e. that AA discourse is both institutional and highly symmetrical and that this has a particular bearing on conflict management within AA meetings.

Owen PL; Slaymaker V; Tonigan JS; McCrady BS; Epstein EE; Kaskutas LA et al. Participation in Alcoholics Anonymous: Intended and unintended change mechanisms. Alcoholism: Clinical and Experimental Research 27(3): 524-532, 2003. (37 refs.)

This article is a compilation of the information presented at a symposium at the 2001 RSA Meeting in Montreal, that focused upon Alcoholics Anonymous. There were five presentations. These considered (1) Maintaining change after conjoint behavioral alcohol treatment for men and the role of involvement with Alcoholics Anonymous; (2) Changing AA practices and outcomes: Project Match 3-year follow-up; (3) Life events and patterns of recovery of AA-exposed adults and adolescents; (4) Social networks and AA involvement as mediators of change: and (5) a summary discussion of what do we know about Alcoholics Anonymous? Among the conclusions presented in the discussion, there are seven conclusions: (a) that AA cannot be ignored in treatment outcomes; (b) it is possible to facilitate AA attendance; (c) treatment is the time to promote AA attendance; (d) attendance is not equivalent to involvement; (e) AA participation predicts better outcomes; (f) continuous abstinence is the outcome most likely to be affected by AA; (g) The abstinence message of AAA does not seem to be deleterious.

Pagano ME; Friend KB; Tonigan JS; Stout RL. Helping other alcoholics in Alcoholics Anonymous and drinking outcomes: Findings from Project MATCH. Journal of Studies on Alcohol 65(6): 766-773, 2004. (63 refs.)

Objective: Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholics in the world, its specific mechanisms that mobilize and sustain behavior change are poorly understood. The purpose of this study is to examine prospectively the relationship between helping other alcoholics and relapse in the year following treatment for alcohol use disorders. Method: Data were derived from Project MATCH, a longitudinal prospective investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence. Kaplan-Meier survival estimates were used to calculate probabilities of time to alcohol relapse. To identify the unique value of helping other alcoholics when controlling for the number of AA meetings attended, proportional hazards regressions were conducted to determine whether the likelihood of relapse was lower for those who were helping other alcoholics. Results: There were no demographic differences that distinguished participants in regard to involvement in helping other alcoholics, with the exception of age; those who were helping other alcoholics were, on average, 3 years older than those who were not helping alcoholics. Those who were helping were significantly less likely to relapse in the year following treatment, independent of the number of AA meetings attended. Conclusions: These findings provide compelling evidence that recovering alcoholics who help other alcoholics maintain long-term sobriety following formal treatment are themselves better able to maintain their own sobriety. Clinicians who treat persons with substance abuse disorders should encourage their clients to help other recovering alcoholics to stay sober.

Perkinson RR. Treating Alcoholism: Helping your Clients Find the Road to Recovery. Hoboken NJ: John Wiley & Sons, 2004. (182 book refs.)

This volume is directed to general clinicians. It is organized into ten chapters that deal with identification and assessment; core concepts; treatment planning; recovery tools; Alcoholics Anonymous steps; psychiatric co-morbidity; adolescent treatment; aftercare and relapse prevention; and the recovery community. Emphasis is placed upon explaining basic components of Alcoholics Anonymous, and efforts which can promote clients affiliation with AA. As part of this, there is discussion of the spiritual aspects of AA and how to utilize a "Higher Power" in treatment, use by the client and the therapist. Case vignettes are provided.

Poage ED; Ketzenberger KE; Olson J. Spirituality, contentment, and stress in recovering alcoholics. [rapid communication]. Addictive Behaviors 29(9): 1857-1862, 2004. (22 refs.)

The relationships among length of sobriety, spirituality, contentment, and stress were examined in a sample of recovering alcoholics attending Alcoholics Anonymous meetings. Length of sobriety was significantly associated with spirituality but not with contentment or stress. Spirituality and contentment were also positively related. There were significant gender differences in the relationships among spirituality, contentment, and stress level. Spirituality was significantly correlated with lower stress for women but not for men. Men's contentment was significantly related to lower stress levels, but contentment and stress was nonsignificant for women.

Polcin DL; Zemore S. Psychiatric severity and spirituality, helping, and participation in Alcoholics Anonymous during recovery. American Journal of Drug and Alcohol Abuse 30(3): 577-592, 2004. (39 refs.)

Although helping others is a critical part of Alcoholics Anonymous (AA) and many treatment programs, measures for assessing helping and describing its relationship with sobriety are lacking. A sample of 200 subjects completed a Helper Therapy Scale including three subscales: Recovery Helping (alpha = 0.78), Life Helping (alpha = 0.62), and Community Helping (alpha = 0.60). A previous analysis using structural equation modeling found that length of sobriety predicted measures of spirituality, helping, and AA participation. The analysis reported here examined whether psychiatric severity was associated with these variables. Results indicated significant relationships between psychiatric severity and measures of spirituality (Self Transcendence, Forgiveness, Positive Coping, and Negative Coping) and AA Achievement (defined as completing the 12 steps and serving as a sponsor). However, no relationships were found between psychiatric severity and length of sobriety, the three Helper Therapy subscales, or AA involvement. The findings suggest that individuals with higher psychiatric severity may need assistance from their peers or professional service providers to develop a spiritual life, serve as a sponsor for others, or complete the steps of AA.

Randall CL; Del Boca FK; Mattson ME; Rychtarik R; Cooney NL; Donovan DM et al. Primary treatment outcomes and matching effects: Aftercare arm. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 135-149. (275 book refs.)

Primary treatment outcomes and matching effects for the aftercare arm of Project MATCH are discussed. The authors note that residential and day-hospital rehabilitation programs play an important role in the treatment of people with alcohol dependence, particularly those with more severe and persistent problems. Project MATCH investigated treatment matching for clients who had just completed a program of conventional inpatient or day-hospital treatment. The results of the study revealed no evidence for the superiority of any one treatment over another on the primary outcomes measures. Clients improved from baseline through a 15-month follow-up period, both in frequency and intensity of drinking. Only 1 of the 21 a priori matching hypotheses was confirmed. Clients with more severe dependence had better treatment outcomes with Twelve Step Facilitation (TSF) therapy and the lower scoring clients had better outcomes with Cognitive-Behavioral Therapy (CBT). Section headings in this book chapter include: (1) methods: recruitment sites and research participants; (2) statistical approach; (3) trends over time; (4) treatment effects; (5) prognostic effects; (6) tests of matching hypotheses; (7) exploratory analyses; (8) causal chain analyses and clinical significance of matching.

Public Domain

Robin B. The use of the 12 steps of the anonymous program to heal trauma. Journal of Social Work Practice in the Addictions 5(3): 103-105, 2005

This article discusses the use of the 12-Step program in regards to Alcoholics Anonymous (AA) in order to heal trauma. The author posits that this program is an effective approach to healing trauma, as many individuals who joined AA were highly traumatized with severe psychosocial consequences due to drinking and were in need of an intense healing process. Working through the steps that have slogans like "First things first," and "Keep it simple" allows patients to strengthen their shattered psyches which have resulted from attempts at restituting the shattered self and endeavors to heal the existing disorganization, anxiety and feeling of lack of safety. The author also posits that the spiritual healing that follows in steps 4-12 allows individuals to take personal responsibility for their actions and addictions, while accepting humility which softens the superego, strengthens the ego, as well as organizes the psyche. The author strongly believes that the principles and theoretical basis of 12-Step Programs can be highly beneficial to survivors of severe trauma, and that through the program's simplicity, it provides unrivaled profundity.

Robinson EAR; Cranford JA; Webb JR; Brower KJ. Six-month changes in spirituality, religiousness, and heavy drinking in a treatment-seeking sample. Journal of Studies on Alcohol and Drugs 68(2): 282-290, 2007. (51 refs.)

Objective: This descriptive and exploratory study investigated change in alcoholics' spirituality and/or religiousness (S/R) from treatment entry to 6 months later and whether those changes were associated with drinking outcomes. Method: Longitudinal survey data were collected from 123 outpatients with alcohol use disorders (66% male; mean age = 39; 83% white) on 10 measures of S/R, covering behaviors, beliefs, and experiences, including the Daily Spiritual Experiences and Purpose in Life scales. Drinking behaviors were assessed with the Timeline Followback interview. Alcoholics Anonymous (AA) participation and attendance were also measured. Results: Over 6 months, there were statistically significant increases in half of the S/R measures, specifically the Daily Spiritual Experiences scale, the Purpose in Life scale, S/R practices scale, Forgiveness scale, and the Positive Religious Coping scale. There were also clinically and statistically significant decreases in alcohol use. Multiple logistic regression analyses showed that increases in Daily Spiritual Experiences and in Purpose in Life scores were associated with increased odds of no heavy drinking at 6 months, even after controlling for AA involvement and gender. Conclusions: In the first 6 months of recovery, many dimensions of S/R increased, particularly those associated with behaviors and experiences. Values, beliefs, self-assessed religiousness, perceptions of God, and the use of negative religious coping did not change. Increases in day-to-day experiences of spirituality and sense of purpose/meaning in life were associated with absence of heavy drinking at 6 months, regardless of gender and AA involvement. The results of this descriptive study support the perspective of many clinicians and recovering individuals that changes in alcoholics' S/R occur in recovery and that such changes are important to sobriety.

Saarnio P; Knuuttila V. Study of risk factors in dropping out from inpatient treatment of substance abuse. Journal of Substance Use 8(1): 33-38, 2003. (27 refs.)

Risk factors for dropping out from inpatient treatment programs for substance abuse were studied. The goal of the study was to focus interventions aimed at improving the continuity of treatment. The research sample included 114 clients of a Finnish treatment institution, who responded to a questionnaire on background and substance abuse as well as a scale to assess readiness to change. Information on continuity of treatment was obtained from the main record of the institution. The following results of the study were seen: (1) a finding that significant risk factors for dropping out of treatment were age of the subject, contemplation of change, attitude toward Alcoholics Anonymous (AA)/Narcotics Anonymous (NA); (2) improvement in continuity of treatment with age and improved contemplation; (3) improvement in continuity of treatment with positive attitude toward AA/NA; and (4) more positive attitude toward AA/NA for younger clients. It is suggested that interventions to prevent dropping out should be aimed at younger clients who are not positively disposed to AA/NA and at older clients with an inadequate contemplation of change.

Sachs KS. Treating alcoholism as a disorder of the self: Insights from Alcoholics Anonymous and Masterson. Alcoholism Treatment Quarterly 21(2): 75-85, 2003. (20 refs.)

Psychological susceptibility to alcoholism can be viewed as being related to failures in establishing healthy attachments of the child to their parents. These difficulties interfere with the child's separation and eventual individuation from the parent and also leave the child susceptible to developing a co-existing disorder of the self. The treatment of alcoholism, combining both Alcoholics Anonymous and Masterson's approach to the treatment of disorders of the self are described. Following Masterson's approach, there is a differential treatment orientation that follows an accurate diagnosis of the disorder of the self. Awareness of these theoretical approaches may help the therapist treat both the patient's alcoholism as well as their co-existing disorder of the self. The combining of both AA along with his object-relations treatment approach is felt to be more clinically effective than attendance in AA or psychotherapy alone.

Schonbrun B. In the light of reason and experience: The scope of evidentiary privilege in the self-help setting. Alcoholics Anonymous examined. Cardozo Law Review 25: 1203-1242, 2004. (195 refs.)

... Cox cleaned the crime scene before departing, disposed of his bloodied clothes in an incinerator, and threw the murder weapon into a nearby body of water. ... This specifically addresses the issue that the Second Circuit left unanswered in Cox - "whether to protect the confidentiality of communications among members of AA," either by invoking the cleric-congregant privilege or by creating a distinct evidentiary privilege to protect communications in the self-help setting. ... Generally, the creation of an evidentiary privilege requires that it serve the public interest and also protect relationships where confidentiality is considered essential to the nature of the association. ... With this exposition the court attempted to elucidate the legislative intent behind the statute by extending the cleric-congregant privilege to "ministers of all religions," as "New York's test for the privilege's applicability distills to a single inquiry: whether the communication in question was made in confidence and for the purpose of obtaining spiritual guidance. ... If the privacy interest of AA members warranted the extension of a self-help privilege to AA, the brutal murder of the Chervus would have likely remained unsolved. ... Simply stated, AA is a support group of laymen that does not merit the protection of the cleric-congregant privilege or the creation of a distinct evidentiary privilege to shield its communications. ...

Slaski S; Zylicz PO. The effect of psychotherapy on self-awareness in incarcerated and nonincarcerated alcoholics: A pilot study. International Journal of Offender Therapy and Comparative Criminology 50(5): 559-569, 2006. (30 refs.)

Changes in self-awareness in incarcerated and nonincarcerated male alcoholics are measured before and after disaccustoming therapy based on Alcoholics Anonymous principles. The four-mode conception of self-awareness of Zaborowski is employed. The results show significant and expected changes in incarcerated participants (in defensive, individual, and reflective modes of self-awareness) and almost no changes in nonincarcerated individuals. An effect of motivation on therapy is also identified. Incarceration appears to be more conducive to recovery than to conditions outside the prison.

Staines G; Magura S; Rosenblum A; Fong C; Kosanke N; Foote J et al. Predictors of drinking outcomes among alcoholics. American Journal of Drug and Alcohol Abuse 29(1): 203-218, 2003. (23 refs.)

Collected intake data from the Addiction Severity Index and other standardized scales on 248 alcohol dependent/abusing patients (aged 19-72 yrs) entering an urban hospital treatment program. The outcome measure was frequency of drinking days in the past 30 days. Baseline data were used to identify predictors of posttreatment drinking frequency at 2 follow-up interviews (3 and 12 mo postbaseline). When psychosocial predictors were combined with an index of alcohol use severity, the proportions of variance explained were 31% and 28% at 3 and 12 mo, respectively. Two psychosocial predictors were significant at both time periods, and thus most likely to be replicated in future research: a treatment motivation index and an index of 12-step (self-help) participation. While the predictability of short-term (3 mo) outcomes could help clinicians tailor treatment strategies to maximize patient motivation and reduce drinking behavior, the predictability of longer term (12 mo) outcomes could help counselors plan aftercare programs, encourage self-help participation, and promote recovery-oriented activities to sustain initial treatment-induced gains.

Suire JG; Bothwell RK. The psychosocial benefits of Alcoholics Anonymous. American Journal on Addictions 15(3): 252-255, 2006. (15 refs.)

A quasi-experimental design was implemented to evaluate the attitudes of alcoholics toward themselves and others after they had worked all twelve steps of an AA program compared to those who had not yet completed all twelve steps. One hundred individuals who were attending AA meetings were selected so that one half had completed all of the steps and the other half had not. Participants were tested in individual sessions during which they completed a series of questionnaires. Measures were taken of global self-esteem, social self-esteem, social confidence, network trust, fear of negative evaluation, need for approval, preoccupation with relationships, discomfort with closeness, relationships as secondary, and optimism. A principal components analysis of participants' responses to these measures revealed that the factors being assessed could be divided into one regarding interpersonal insecurity and another regarding social potency. The data showed that alcoholics who had been able to stay in the program and work through all twelve steps had lower levels of interpersonal insecurity than those who were just beginning to work the steps. No significant differences were found in social potency between those who had completed the steps and those who had not completed the steps. Further research is needed to clarify the specific nature of changes that occur in personality as alcoholics work through the twelve steps within community-based AA programs.

Suissa AJ. Alcoholism as a disease in North America: A critical social analysis. Journal of Addictions Nursing 14(4): 201-208, 2003. (111 refs.)

This article describes the phenomenon of the social construction of alcoholism as a disease in North America. The goal of this study is to explicate the persistence of the view of alcoholism as a permanent disease, despite that for the past three decades opposite scientific evidence has been accumulating. Initially, scientific studies are reviewed that support the dominant paradigm of alcoholism as a disease. To do so, studies are explored that reveal the genetic theories and various significant studies concerning twins, genetic markers, and adoption. Further, this review includes the neuro-biological and neuro-behavioral theories. It concludes with the major ideological role of AA (Alcoholic Anonymous). This review illustrates how the dissemination and socialization of the disease discourse passes through the 12-Step philosophy of AA; specifically the first step that underlies the acceptance of lack of power and control over alcohol. Then, we raise an opposing view of the dominant disease discourse with a discussion on how the addiction process is understood as a multifactorial phenomenon.

Sykes T. What did I do last night?. Emmaus PA: Rodale, 2006. (0 refs.)

This is a well-written memoir of the author's emerging alcohol problem, the events that led him to recognize the need to cease drinking, and what he did to accomplish this, and his experience of this. The book covers a 15 year period. The chapters are titled in a count-down fashion, i.e the number of days prior to or after the day on which he had his last drink, Day 0. It begins on "-5214 days", when as a student at Eton in England he was allowed to drink at the the College's school bar, the Tap, which circumvented licensing laws by presenting itself as a private social club. It proceeds through a number of landmark occasions, if unrecognized at the time, such as on "-350 Days" finding the perfect job. In New York as a journalist, he became the bar columnist for the New York Post. It concludes on "+396 Days", when, still living in New York, he is headed to the airport to journey to Ireland where he and his wife will await the birth of their first son.

Terra MB; Barros HMT; Stein AT; Athayde IFLD; Palermo LH; Tergolina LP. Predictors of engagement in the Alcoholics Anonymous group or to psychotherapy among Brazilian alcoholics - A six-month follow-up study. European Archives of Psychiatry and Clinical Neuroscience 257(4): 237-244, 2007. (41 refs.)

Objective To ascertain factors associated with engagement of patients with alcohol dependence in Alcoholics Anonymous (AA) groups and psychotherapy. Methods About 300 hospitalized alcoholics were interviewed at hospitalization and again 3 and 6 months thereafter. Assessment included the administration of standardized instruments. Determinants of engagement in both interventions were assessed through logistic regression analysis. Results Higher educational level was predictive of engagement in AA after 6 months (OR = 2.19; CI 1.08-4.41). Engagement in psychotherapy after 6 months was related to having a university degree (OR = 3.60; CI 1.6-7.9), to a comorbid depressive disorder (OR = 3.47; CI 1.8-6.5), to the use of other drugs together with alcohol (OR = 3.08; CI 1.5-6.19), to previous treatment (OR = 2.87; CI 1.29-6.40), and to having a high school degree (OR = 2.44; Cl 1.24-4.80). The presence of substance-induced anxiety disorder was associated with non-engagement in psychotherapy (OR = 0.27; CI 0.63-0.003). Conclusion The identification of predictors of engagement is important to guide clinicians in the choice of the treatment strategies that are more likely to be successful.

Terra MB; Barros MHT; Stein AT; Figueira I; Athayde LD; Spanemberg L et al. Does co-occurring social phobia interfere with alcoholism treatment adherence and relapse? Journal of Substance Abuse Treatment 31(4): 403-409, 2006. (21 refs.)

This study investigates the impact of social phobia on adherence to and outcomes 6 months following standard alcohol treatment and Alcoholics Anonymous (AA) group meetings among alcohol-dependent patients with and without social phobia.In a cohort study, 300 detoxified alcohol-dependent individuals in Porto Alegre, Brazil, were interviewed during, as well as 3 and 6 months after hospital detoxification. At both follow-up points, treatment adherence was low and relapse rates were high among patients with and without social phobia, and no significant differences were seen between the two groups of patients in relapse, adherence to AA, or adherence to psychotherapy. Findings from this sample suggest that although alcohol-dependent patients with social phobia showed a tendency for less adherence at AA and felt less integrated with their AA group, social phobia comorbidity was not a significant risk factor for alcohol use relapse or for nonadherence to AA or psychotherapy.

Thatcher, MS. Bakhtin applied: Employing dialogism to analyze the interplay of the ideologies of individualism and community within the discourse of Alcoholics Anonymous. Journal of Applied Communication Research 34(4): 349-367, 2006. (63 refs.)

An ongoing debate regarding the nature of therapeutic communities concerns the extent to which these communities reinforce the ideologies of individualism and community. This article engages this discussion through a process of social text analysis informed by the dialogism theory of Russian philosopher and literary scholar Mikhail Bakhtin. Dialogism seeks to understand the multiple voices interpenetrating particular utterances, revealing an emergent social construction of meaning. Applying this approach to examples of discourse from a prominent therapeutic community, Alcoholics Anonymous, illustrates how meaning in the discourse of this movement can be understood to emerge among the interplay between the ideologies of individualism and community as expressed within the movement's narrative practice.

Timko C; Billow R; DeBenedetti A. Determinants of 12-step group affiliation and moderators of the affiliation-abstinence relationship. Drug and Alcohol Dependence 83(2): 111-121, 2006. (80 refs.)

This study examined characteristics of substance use disorder (SUD) outpatients at intake to treatment (N=345) that were associated with more 12-step group attendance and involvement, Steps worked, and acceptance of 12-step philosophy at a 6-month follow-up (N=281, 81.4%). Patient characteristics covered the domains of sociodemographics, SUD severity, personal functioning, and previous help received. Distinguishing baseline characteristics of patients who attended more 12-step group meetings during follow-up were being less-educated, more engaged in religious practices, and more extroverted and interpersonally competent, and having had more previous 12-step group exposure. These patient characteristics were generally similar to those associated with more 12-step meeting involvement and philosophy acceptance. More 12-step meeting attendance and involvement were related to abstinence at 6 months. Associations of attendance with abstinence were stronger among patients who were younger, white, less-educated, unstably employed, less religious, and less interpersonally skilled. These patients may have had fewer available social resources and so benefitted more from the fellowship and support for abstinence that 12-step group members often provide. We suggest methods by which treatment providers may encourage 12-step group affiliation among patients likely to benefit from it on substance use outcomes.

Timko C; DeBenedetti A; Moos BS; Moos RH. Predictors of 16-year mortality among individuals initiating help-seeking for an alcoholic use disorder. Alcoholism: Clinical and Experimental Research 30(10): 1711-1720, 2006. (86 refs.)

Background and Methods: We examined rates and predictors of mortality in individuals (47% women) who had just initiated help-seeking for their alcohol use disorders (AUDs) at the start of the study (n=628) and were followed for 16 years. Results: For both women and men, the observed-to-expected mortality ratio (1.4) was lower than rates found in samples of treated individuals with AUDs, suggesting that those initiating help-seeking careers have better chances of long-term survival. Of the individuals for whom cause of death was known, 68% died of alcohol-related causes. Men were more likely to die than were women. When gender was controlled, individuals who were older and unmarried and had more alcohol dependence symptoms at baseline were more likely to die over the 16-year period. When these baseline characteristics were controlled, better drinking outcomes at 1 year were associated with a lower likelihood of subsequent death. The combination of a shorter duration of inpatient/residential care and better drinking outcomes at 1 year was related to a lower probability of death, as was the combination of a longer duration of outpatient care or Alcoholics Anonymous attendance and better drinking outcomes at 1 year. Conclusions: Efforts should be made to help providers identify individuals who are not responding positively to inpatient or residential treatment and intervene to motivate participation in continuing outpatient care and community 12-step self-help groups to reduce the likelihood of a chronic and fatal AUD course.

Timko C; Finney JW; Moos RH. The 8-year course of alcohol abuse: Gender differences in social context and coping. Alcoholism: Clinical and Experimental Research 29(4): 612-621, 2005. (74 refs.)

Background: The aim of this study was to compare women (n = 230) and men (n = 236) who had alcohol use disorders in terms of social context and coping methods and in terms of changes in these indices associated with participation in professional treatment and Alcoholics Anonymous (AA). Methods: Initially untreated problem drinkers were followed up for 8 years. Results: Women and men did not differ in regard to the type of help received, but women had longer professional treatment. At baseline, women had more stressors and fewer resources from family and relied more on avoidance coping and drinking to cope. During the next 8 years, women, more so than men, increased on approach coping and reduced their use of avoidance coping and drinking to cope. When baseline status was controlled, women had better social resource, coping, and drinking outcomes than men did at 1 year and 8 years. A longer duration of professional treatment during year 1 was associated with improved approach coping among men but not women. A longer duration of AA attendance during year 1 and the full 8 years was associated with more resources from friends, more use of approach coping, and less drinking to cope. In turn, more friends resources and approach coping and less drinking to cope were associated with better drinking outcomes. Decreases in avoidance coping and drinking to cope were more strongly associated with better drinking outcomes among men than among women. Conclusions: It may be important to target men for formal services or self-help to increase their use of approach coping in efforts to maintain abstinence. Women's strategies for improving their social context need further explication to be adapted for transfer to male problem drinkers.

Tonigan JS; Bogenschutz MP; Miller WR. Is alcoholism typology a predictor of both Alcoholics Anonymous affiliation and disaffillation after treatment? Journal of Substance Abuse Treatment 30(4): 323-330, 2006. (32 refs.)

Twelve Steps (TS) has demonstrated effectiveness; induction into Alcoholics Anonymous (AA) is a primary objective of TS and is a pivotal mechanism explaining its effectiveness. However, evidence suggests that, after treatment, dropout from AA is high. This study investigated whether alcohol problem severity predicted both AA affiliation and disaffiliation among clients receiving TS. This study of a Project MATCH sample included 453 alcohol-dependent clients randomly assigned to TS who reported AA attendance during treatment. Greater alcohol problem severity predicted AA attendance; opposite to prediction, less alcohol-impaired clients were more than twice as likely to discontinue AA attendance after treatment. When sustained AA attendance is desired, the evaluation of client pretreatment alcohol involvement may be useful for identifying potential AA dropout after TS treatment. Findings also indicate that, among treatment-seeking problem drinkers, AA dropout and disaffiliation are distinct, albeit correlated, constructs that require future investigation.

Tonigan JS; Connors GJ; Miller WR. Participation and involvement in Alcoholics Anonymous. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 184-204. (275 book refs.)

Participation and involvement in Alcoholics Anonymous (AA) is discussed. It is noted that AA has rarely been studied with the kind of rigorous methodology used in Project MATCH, which is a study of patient-treatment matching. In this book chapter, the patterns of AA utilization, the relationship between AA participation and abstinence, and the benefits associated with AA participation are described. It is concluded that Twelve Step Facilitation (TSF) therapy was associated with increased AA attendance. Increased AA attendance was associated with increased abstinence from alcoholic beverages. The authors concluded that the findings highlight the importance of starting AA attendance during formal treatment, that there is compelling evidence for the value of AA as an adjunct to professional treatment. They suggest practical ways to maximize the potential benefits of AA through TSF. Section headings in this book chapter include: (1) prior research on Alcoholics Anonymous; (2) measurement issues of reliability and validity including Form-90, Alcoholics Anonymous Involvement Inventory (AAI), and subjective ratings of AA; (3) Outpatient and Aftercare differences; (4) treatment group differences; (5) evaluation of treatment; (6) patterns of AA utilization; and (7) AA attendance and alcohol use.

Public Domain

Tucker J; Vuchinich R; Rippens P. A factor analytic study of influences on patterns of help-seeking among treated and untreated alcohol dependent persons. Journal of Substance Abuse Treatment 26(3): 237-242, 2004. (21 refs.)

Influences on seeking help from professional alcohol treatment and from Alcoholics Anonymous (AA) were investigated using problem drinkers (N = 167) with different help-seeking experiences (no assistance, AA only, or treatment plus AA) and current drinking statuses (sustained abstinence for > 2 years or active problem drinking). Depending on their help-seeking experiences, participants rated barriers to or reasons for seeking help from treatment and AA, which were factor analyzed. Common impediments to help-seeking included privacy concerns and participants' beliefs that they could solve their problem on their own and that it was not serious enough to seek help. Common reasons for help-seeking included social and other functional problems related to drinking. There were also influences unique to treatment (e.g., cost) and to AA (e.g., group format). Help-seeking factors did not vary by drinking status. The implications for increasing help-seeking among problem drinkers are discussed.