Transcript Assessing Alcoholics Anonymous Participation: What Matters

AA Effectiveness –
Faith Meets Science
Lee Ann Kaskutas, Dr.P.H.
Alcohol Research Group, Emeryville, CA
School of Public Health, UC Berkeley
East Bay Community Recovery Project
June 26, 2007
Oakland, California
Perspectives on AA Effectiveness
• AA members: I know AA works and there is
no need for research to prove that
Perspectives on AA Effectiveness
• AA members: I know AA works and there is
no need for research to prove that
• AA critics: AA is a cult that relies on God as
mechanism of action
Perspectives on AA Effectiveness
• AA members: I know AA works and there is
no need for research to prove that
• AA critics: AA is a cult that relies on God as
mechanism of action
• Cochrane Review: no experimental evidence
of effectiveness
Perspectives on AA Effectiveness
• AA members: I know AA works and there is
no need for research to prove that
• AA critics: AA is a cult that relies on God as
mechanism of action
• Cochrane Review: no experimental evidence
of effectiveness
• Moos: first send people to AA, not treatment
Criteria to establish causation
•
•
•
•
•
•
Strength of association
Dose-response relationship
Consistency of association
Temporally-correct association
Specificity of the association
Coherence with existing information
Mausner & Kramer, Epidemiology -- text 1985
Criteria to establish causation
•
•
•
•
•
•
Strength of association
Dose-response relationship
Consistency of association
Temporally-correct association
Specificity of the association
Coherence with existing information
Mausner & Kramer, Epidemiology -- text 1985
% abstinent
Abstinence & AA exposure
50
45
40
35
30
25
20
15
10
5
0
at 1 yr.
at 18 mos.
AA
male VA inpatients
1 yr n = 3018; 18 mo n = 91
no AA
Ouimette et al., J Stud Alcohol 1998
Thurstin et al., Int J Addict 1987
Criteria to establish causation
•
•
•
•
•
•
Strength of association
Dose-response relationship
Consistency of association
Temporally-correct association
Specificity of the association
Coherence with existing information
Mausner & Kramer, Epidemiology -- text 1985
Abstinence & meeting amount
% abstinent mos. 9-12
70
60
50
40
30
20
10
0
0
1-19
20-49
50+
# of meetings mos. 9-12
Male VA residential patients
n = 2376
Moos et al., J Clin Psychol 2001
% abstinent at 2 yrs
Abstinence & meeting frequency
80
70
60
50
40
30
20
10
0
never
less than
weekly
weekly
meeting frequency, mos. 19-24
LA Target Cities, outpatients
n = 262
Fiorentine, Am J Drug Alcohol Ab 1999
% abstinent 16 years
Abstinence &
sustained attendance
80
70
60
meetings
50
40
30
20
10
0
none
1-8 wks
9-26 wks
27+ wks
years 4-8
years 2-3
duration☼ of AA attendance
year 1
Previously untreated problem drinkers
n = 461
Moos & Moos, J Clin Psychol 2006
Also see Moos & Moos, JSAT 2004
AA meeting trajectories
# of AA meetings, pst yr
250
200
declining AA
high AA
medium AA
low AA
150
100
50
0
TxEntry
Dependent treatment seekers
n = 349
1 year
3 years
5 years
Kaskutas et al., ACER 2005
% abstinent
Abstinence and meeting
trajectories
100
90
80
70
60
50
40
30
20
10
0
declining AA
high AA
medium AA
low AA
no AA
1 year
Dependent treatment seekers
n = 349
3 years
5 years
Kaskutas et al., ACER 2005
Criteria to establish causation
•
•
•
•
•
•
Strength of association
Dose-response relationship
Consistency of association
Temporally-correct association
Specificity of the association
Coherence with existing information
Mausner & Kramer, Epidemiology -- text 1985
Consistency across samples & time
70
% abstinent
60
50
nothing
outpatient only
AA only
AA + outpatient
40
30
20
10
0
1 year
aMale
VA inpatients
n = 3018
a
3 years
bPreviously
b
untx prob drnkrs
n = 466
8 years
b
a
Ouimette et al., J Stud Alcohol 1998
b Timko et al., J Stud Alcohol 2000
Consistency across samples
hazards of abstinence
(vs. nothing)
6
5
4
3
2
1
0
formal tx only
NESARC; dependent
n = 4422
Tx
n=239
12-step only
12-step
n=138
both
n=829
12-step + tx
nothing
n=3217
(Dawson, Addiction 2006)
Consistency across time
AA involvement
over 10 years
Inpatients
n=158
significant
Abstinence
at 10 years
Cross et al., ACER 1990
Criteria to establish causation
•
•
•
•
•
•
Strength of association
Dose-response relationship
Consistency of association
Temporally-correct association
Specificity of the association
Coherence with existing information
Mausner & Kramer, Epidemiology -- text 1985
Alcohol abstinence following AA
AA involvement
Outpatient β = .29
mos. 1-6
Aftercare β = .34
Project MATCH
n = 480 outpatients, n = 434 aftercare
Percent days
abstinent
mos. 7-12
Connors et al., J Stud Alcohol 2001
Substance use following AA/NA
12-step meetings
mos. 1-3
N.S.
Alcohol and drug use
Signif.
mos. 4-6
12-step activities
mos. 1-3
Cocaine-dependent outpatients in 6-month treatment program
n = 336
Weiss et al., Drug Alcohol Depen 2005
Which Activities
During Treatment Mattered
the Most in that Study?
•
•
•
•
•
Speaking at a meeting
Making coffee
Talking with sponsor outside the meeting
Reading literature
Working on a step
• What about increasing what you do?
– Increasing attendance from one month to the next: no effect
– Increasing participation from one month to the next: affected
drug use the next month
Weiss et al., Drug Alcohol Depen 2005
Criteria to establish causation
•
•
•
•
•
•
Strength of association
Dose-response relationship
Consistency of association
Temporally-correct association
Specificity of the association
Coherence with existing information
Mausner & Kramer, Epidemiology -- text 1985
Randomizing to AA
to remove selection effect
% abstinent at 2 yrs
40
35
30
25
20
15
10
5
0
Hospital inpatient
Alcohol abusers + EAP referred
n = 227: n=73 hospital; n=83 AA; n=71 choice
AA meetings
Choice
Walsh et al., New Engl J Med 1991
% abstinent, past 3 mos.
Randomize to TSF
to remove selection effect:
Outpatient sample
40
35
30
25
20
15
10
5
0
12-step
Motiv
Cog Beh
1-yr follow-up
p = .0024
Project MATCH
n = 806 outpatients at yr 3
3-yr follow-up
p < .007
PMRG, J Stud Alcohol 1997
PMRG, ACER 1998
% abstinent mos 13-15
Randomize to TSF
to remove selection effect:
Aftercare sample
50
45
40
35
30
25
20
15
10
5
0
12-step
Project MATCH aftercare
n = 714 at 1-year follow-up
Motiv
Cog Beh
PMRG, J Stud Alcohol 1997
AA Meeting Attendance by Project MATCH Sample
And Treatment Assignment
% Days
AA Mtgs
.5
.5
Green = 12-step
Yellow = Motiv
Grey = Cog Beh
.4
.4
.3
.3
.2
.2
.1
.1
0.0
0.0
Intake
Outpatient*
Project MATCH
*n = 952 Outpatients, **n = 774 Aftercare
15 Month
Green = 12-step
Yellow = Motiv
Grey = Cog Beh
Intake
15 Month
Aftercare**
Tonigan et al., Tx Match Alcohol 2003
Statistical models
to study selection effect
Baseline
1 year
2 years
Motivation
AA
involvement
negative
Alcohol
problems
Psychopathology
Male VA inpatients
N=2,319
McKellar et al., J Consult Clin Psych 2003
Criteria to establish causation
•
•
•
•
•
•
Strength of association
Dose-response relationship
Consistency of association
Temporally-correct association
Specificity of the association
Coherence with existing information
Mausner & Kramer, Epidemiology -- text 1985
Consistency with Theory
Problem
Solution
Theory
Drinking is a habit
Drink refusal skills
Emergency planning
Choose alternative
behavior
Cognitive
Behavioral
Everyone around me
drinks
Δ environmental cues
Social Learning
Drink due to unmet
needs/ psych. states
Address needs
Drink due to spiritual
condition
Spiritual awakening
See others succeed
Self-efficacy
Better role models
Δ mood
Psychodynamic
Consistency with Theory
Problem
Solution
Theory
Predisposed to develop
alcoholism
Drugs
Genetic
Brain becomes addicted
Drugs
Neurobiology
Mechanism from meetings
• What you do
– Place to go instead of bar
– Talk about your problems
Cog Beh
Soc Lrn
alternative
cue
Psy
need
Mechanism from meetings
• What you do
– Place to go instead of bar
– Talk about your problems
• What you hear
– Others had similar experiences
– Ways people coped instead of
drinking
Cog Beh
Soc Lrn
alternative
cue
Psy
need
succeed
skills
Mechanism from meetings
• What you do
– Place to go instead of bar
– Talk about your problems
• What you hear
– Others had similar experiences
– Ways people coped instead of
drinking
• What happens
– Your mood changes
– Don’t drink a day at a time
Cog Beh
Soc Lrn
alternative
cue
Psy
need
succeed
skills
mood
alternative efficacy
Mechanism from fellowship
Cog Beh
• Friendship
– Adds sober people supportive
of your abstinence
– Role models of new behavior
– Helps learn how to have fun
sober
alternative
Soc Lrn
Psy
cue
model
cue
need
Mechanism from fellowship
Cog Beh
• Friendship
– Adds sober people supportive
of your abstinence
– Role models of new behavior
– Helps learn how to have fun
sober
alternative
• Sponsorship
– Someone to call
emerg
plan
– Someone to provide
emotional support
Soc Lrn
Psy
cue
model
cue
need
need
Mechanism from the steps
Cog Beh
• Change how you treat others,
or you will drink
– Personal inventory; amends
Soc Lrn
Psy
need
Mechanism from the steps
Cog Beh Soc Lrn
• Change how you treat others,
or you will drink
– Personal inventory; amends
• Key to sobriety is helping others
– Helping gets you to relinquish
negative self focus
Psy
need
mood
Evidence of mechanism:
cognitive behavioral
AA
involvement
Abstinence
Self-efficacy*
Coping skills**
*1 Resi or IOP
n = 100
*2
asolescent inpatients
n=74
**1 initially untx PDs
n=466
*1Morgenstern et al., J Consult Clin Psych 1997
*2Kelly et al., J Stud Alcohol 2002
**1Timko et al., ACER 2005
**2 male VA inpatients
2
** Humphreys et al., Ann Behav Med 1999
n=2,337
Evidence of mechanism:
social learning
AA
involvement
Abstinence
Fewer
pro-drinking
influences*
Enhanced
friendship
networks**
More friends†
# who support
abstinence
from AA‡
* treated ** male VA inpat. † init. untx. PDs ‡ treated
n = 722
n=2,337
n=466
n=655
*Kaskutas et al., Addiction 2002
**Humphreys et al., Ann Behav Med 1999
† Timko et al., ACER 2005
‡ Bond et al., J Stud Alcohol 2003
Evidence of mechanism:
psychodynamic
AA
involvement
Abstinence
Life meaning*
Motivation
for abstinence**
*In recovery
n = 354
**adolescent inpatients
n = 74
*White & Laudet, CPDD 2006
**Kelly et al., J Stud Alcohol 2002
Evidence of mechanism:
spirituality
AA
involvement
Abstinence
Δ religious
beliefs
& behaviors
Spiritual
awakening
Day Hosp & Residential, managed care
n = 537
Zemore, ACER in press
Criteria to establish causation
Strength of association
Dose-response relationship
Consistency of association
Temporally-correct association
– Specificity of the association
Coherence with existing information
Mausner & Kramer, Epidemiology -- text 1985
When is AA’s Effect Stronger?
• More substance use *
• More psychosocial problems *
• White, less educated, younger, unstably
employed **
• Less religious, fewer interpersonal skills **
• Type B (more impulsive, tense, sensationseeking, more drug use, more psych probs,
less motivated) ‡
*Morgenstern et al., Drug Alcohol Depen 2003
**Timko et al., Drug Alcohol Depen 2006
‡ Morgenstern et al., Addiction 1998
What about “Type A, Type B”?
• Typology distinguishes severity based on vulnerability
& severity
– Type B is more severe than Type A:
• More impulsive, sociopathic, sensation-seeking,
tense and hostile, more drug use, more psych
probs…
• Less motivation to seek treatment, probs with
treatment engagement…
• Type B benefits more from high 12-step involvement
– R=.48AA-PDA for Type B
– R=.15AA-PDA for Type A
Morgenstern et al., Addiction 1998
What About Gender?
• Women benefit more from AA
attendance
• Men benefit more from aftercare
• Women had better outcomes
– Maybe because of having more AA
Timko, Addiction 2002
% in remission year 8
Duration of AA
matters more for women
90
80
70
60
50
40
Men
Women
30
20
10
0
0 wks
1-8 wks
9-26 wks
27+ wks
of AA
Moos et al., Clin Med Res 2006
Summary
Effectiveness
• AA involvement is associated with
abstinence
– at 1 month, 6 months, 1 yr, 3 yrs, 5 yrs, and
10 yrs after treatment
– At 1 yr, 8 yrs, and 16 yrs after seek help
• This only applies to those who will go to
(and stick with) AA
Summary (cont’d)
What matters most about AA?
•
•
•
•
•
Weekly attendance
Increasing AA activities early on
Having, being a sponsor
Doing service
Working the steps
Summary (cont’d)
What are some key mechanisms of
action for AA?
•
•
•
•
Changing social networks
Improving coping skills
Having confidence you can resist a drink
Having meaning in one’s life
How to get patients to attend
AA after treatment?
Meeting thresholds during treatment are key:
• 24% of TSF outpatients quit attending after tx
• If attended 3+ meetings per week during tx:
• continued to attend after tx
• If continued to attend after tx:
• attendance decreased, activities increased after tx
Tonigan et al., Tx Match Alcohol 2003
Getting People to AA
Systematic encouragement & community
access vs. standard referral to AA*
• 100% of the encouragement group attended within
the week and continued to attend over next 4 weeks
• None of the standard referral group attended
Peer helping during treatment **
• More peer helping during treatment was associated
with more AA involvement following treatment
• AA involvement following treatment predicted
abstinence at 6-month follow-up
*Sisson & Mallams, Am J Drg Alc Abuse 1981
**Zemore et al., Addiction 2004
Getting People to AA
(continued)
Project MATCH Twelve-Step Facilitation (TSF)
• 12 manual-guided INDIVIDUAL sessions led by
trained therapist
• Goals relate to AA’s first 3 steps:
– Acceptance
– Surrender
• AA attendance between recruitment and year after
treatment was higher for TSF patients
– 81% of TSF outpatients, half of CBT & MET outpatients
– 95% of TSF aftercare patients, over 80% of the CBT & MET
aftercare patients
Tonigan et al., Tx Match Alcohol 2003
AA Referral: Standard vs. Intense
• Intense Referral:
– Contacted AA/NA member from list during
session
– Arranged for AA/NA member to meet
patient at meeting
– AA involvement in Intense Referral at 6
mos.:
• Low prior AA
– Attended more meetings than standard referral
• Overall
– More involved in AA/NA, had sponsor, did service
Timko, Addiction 2006
Making Alcoholics Anonymous Easier
(MAAEZ):
a group TSF approach
Developed at the
Alcohol Research Group, Berkeley
by
Lee Ann Kaskutas
and
Edward Oberste
MAA*EZ
*NA too
Rationale for MAAEZ
• Success of Project MATCH TSF
– Manualized, individual format, 12 sessions
– Higher 30-day abstinence rates at 1 and 3 yrs 1,2
• 36% of TSF outpatients
• 25-28% of CBT & MET outpatients
• Usefulness of manualized group format
– Group is modal form of treatment delivery 3,4
• Increases ease and likelihood of implementation
– Prepares clients for group context of 12-step programs
– Manual guides coverage and consistency of topics
1 Project
MATCH Research Group, JSA 1997
MATCH Research Group, ACER 1998
CSAT, Substance abuse treatment: Group Therapy 2005
4 Weiss, et al., Harvard Review of Psychiatry 2004
2 Project
3
Goal of MAAEZ
To prepare clients to engage in the culture of
AA/NA/CA
– Making it easier to connect with AA members
• Changing social networks is a mechanism of AA’s effect
on abstinence 5,6
– Helping clients fill a purposeful role early on
• Helping helps the helper (Reissman’s Helper Therapy
Principle) 7,8 and is consistent with AA’s stated goal 9
5 Kaskutas
et al, Addiction 2002
et al, JSA 2003
7 Riessman, Social Policy 1976
8 Zemore, Southern Medical Journal, 2007
9 Alcoholics Anonymous, 1939
6 Bond
Structure of MAAEZ
• 6 sessions
– Run by counselors experienced in running groups, who are
in recovery and active in a 12-step program
– 90 minutes each
• Manualized session outline
– Indicates when to open it up for discussion
– Provides time guidelines for each point in the session
• 15-20 minute check-in
– Includes reporting on how doing the action homework FELT
• 10-minute break
• 5 minute summary: what are the “take-home” messages?
• 5 minutes to assign homework
– Action
– Reading from Big Book or Living Sober or Sponsorship Pamphlet
Structure of MAAEZ (cont’d)
• 6-week intervention
– Six sessions, attended 1-week apart
• Need time for doing weekly homework
• Intro session
– First and Last session attended
– Programs must run an intro session every week
• For newcomers and graduates
• 4 core sessions
– Spirituality, sponsorship, principles not personalities, living
sober
• Attended in any order
– Programs cycle-through the 4 sessions over 4-week period
Introduction
• Counselor and client introduction
• Layout of MAAEZ intervention
• Graduate vignettes of their AA and MAAEZ
experience
• Why go to AA? Were you going to AA when
you relapsed?
• How do you pick a meeting?
– Meeting directories are passed-out
• Rules of the road at meetings
• Homework: go to a meeting
– Pick meeting now using directory
Spirituality
• Why is spirituality necessary for recovery?
• AA is spiritual, not religious program
– Things to think about when you hear ‘God as we understood
Him”
• What does spirituality mean to you?
– Can be anything, so long as you don’t think you are God
• Spirituality in AA
– It’s about your behavior and taking responsibility for it
• “Act your way into good thinking”
• Get outside yourself; do service
• Homework
– Talk to someone at a meeting who you don’t know, who has
more sobriety than you
Principles, not Personalities
• What are some things that turned you away from AA?
• Common objections to AA
– It is a cult
– Alcoholism is a disease
• No single person speaks for AA
– Leadership rotates; diversity of meetings; diversity of how
program is interpreted
– Why do they suggest 90/90?
• Homework
– Ask someone you don’t know at meeting, for their phone #
• Telephone them (and talk to them) before next session
Sponsorship
• What is a sponsor? Why get one?
• Who should you ask?
– You’re not imposing
• Role playing to ask someone to be temporary
sponsor; 4 vignettes:
–
–
–
–
Asking someone you went to coffee with
Ask someone whose phone # you got
Ask speaker at meeting whose talk you liked
Ask someone who said something you connected with, but
they said ‘no, they’re too busy’
• Homework: ask somebody to be your temporary
sponsor
Manual Available Now
[email protected]
Conclusions
How can treatment increase AA
engagement?
• Encouraging attendance at 3 meetings per
week
• Providing opportunities for patients to help one
another
• Introducing the AA concepts of acceptance
and surrender
• Demonstrating the benefits of the AA
fellowship
Implications
Move beyond requiring meeting
attendance
• Prepare clients for dealing with the philosophy of
AA and the people in AA
Learn from AA (not all clients will
attend)
• Help clients change their social networks
THANK YOU VERY MUCH
AA Acknowledgements
• NIAAA grants
–
–
–
–
–
R01 AA 11279 (Kaskutas, PI)
R21 AA 13066 (Kaskutas, PI)
R01 AA 14688 (Kaskutas, PI)
R01 AA 9750 (Weisner, PI)
P50 AA 5595 (Greenfield, PI)
• NIDA grant
– R01 DA 12297 (Kaskutas, PI)
• CSAT contract
– #270-94-0001 (Kaskutas, PI)