AA Effectiveness Faith Meets Science

1
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

2
Perspectives on AA Effectiveness

• AA members I know AA works and there is no need
  for research to prove that

3
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

4
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

5
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

6
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
7
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
8
Abstinence AA exposure
Ouimette et al., J Stud Alcohol 1998 Thurstin et
al., Int J Addict 1987
male VA inpatients 1 yr n 3018 18 mo n 91
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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
10
Abstinence meeting amount
Male VA residential patients n 2376
Moos et al., J Clin Psychol 2001
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Abstinence meeting frequency
LA Target Cities, outpatients n 262
Fiorentine, Am J Drug Alcohol Ab 1999
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Abstinence sustained attendance
meetings

Previously untreated problem drinkers n 461
Moos Moos, J Clin Psychol 2006 Also see Moos
Moos, JSAT 2004
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AA meeting trajectories
Dependent treatment seekers n 349
Kaskutas et al., ACER 2005
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Abstinence and meeting trajectories
Dependent treatment seekers n 349
Kaskutas et al., ACER 2005
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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
16
Consistency across samples time
a b b
a Ouimette et al., J Stud Alcohol 1998b Timko
et al., J Stud Alcohol 2000
aMale VA inpatients bPreviously untx prob
drnkrs n 3018 n 466
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Consistency across samples
NESARC dependent Tx 12-step both nothing n
4422 n239 n138 n829 n3217
(Dawson, Addiction 2006)
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Consistency across time
AA involvement over 10 years
Abstinence at 10 years
significant
Inpatients n158
Cross et al., ACER 1990
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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
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Alcohol abstinence following AA
Percent days abstinent mos. 7-12
AA involvement mos. 1-6
Outpatient ß .29
Aftercare ß .34
Project MATCH n 480 outpatients, n 434
aftercare
Connors et al., J Stud Alcohol 2001
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Substance use following AA/NA
12-step meetings mos. 1-3
Alcohol and drug use mos. 4-6
N.S.
Signif.
12-step activities mos. 1-3
Cocaine-dependent outpatients in 6-month
treatment program n 336
Weiss et al., Drug Alcohol Depen 2005
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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
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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
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Randomizing to AAto remove selection effect
Alcohol abusers EAP referred n 227 n73
hospital n83 AA n71 choice
Walsh et al., New Engl J Med 1991
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Randomize to TSFto remove selection effect
Outpatient sample
p .0024
p Project MATCH n 806 outpatients at yr 3
PMRG, J Stud Alcohol 1997 PMRG, ACER 1998
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Randomize to TSFto remove selection effect
Aftercare sample
Project MATCH aftercare n 714 at 1-year
follow-up
PMRG, J Stud Alcohol 1997
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AA Meeting Attendance by Project MATCH Sample And
Treatment Assignment
Days AA Mtgs
Green 12-step Yellow Motiv Grey Cog Beh
Green 12-step Yellow Motiv Grey Cog Beh
Intake
15 Month Intake
15 Month
Outpatient
Aftercare
Project MATCH n 952 Outpatients, n 774
Aftercare
Tonigan et al., Tx Match Alcohol 2003
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Statistical models to study selection effect
Baseline
2 years
1 year
Motivation
negative
Alcohol problems
AA involvement
negative
no difference
Psychopathology
Male VA inpatients N2,319
McKellar et al., J Consult Clin Psych 2003
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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
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Consistency with Theory
31
Consistency with Theory
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Mechanism from meetings

• What you do
• Place to go instead of bar
• Talk about your problems

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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

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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
• Dont drink a day at a time

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Mechanism from fellowship

• Friendship
• Adds sober people supportive of your abstinence
• Role models of new behavior
• Helps learn how to have fun sober

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Mechanism from fellowship

• Friendship
• Adds sober people supportive of your abstinence
• Role models of new behavior
• Helps learn how to have fun sober
• Sponsorship
• Someone to call
• Someone to provide emotional support

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Mechanism from the steps

• Change how you treat others, or you
  will drink
• Personal inventory amends

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Mechanism from the steps

• 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

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Evidence of mechanismcognitive behavioral
Abstinence
AA involvement
Self-efficacy
Coping skills
1Morgenstern et al., J Consult Clin Psych
1997 2Kelly et al., J Stud Alcohol 2002 1Timko
et al., ACER 2005 2Humphreys et al., Ann Behav
Med 1999
1 Resi or IOP 2 asolescent inpatients
1 initially untx PDs 2 male VA
inpatients n 100 n74
n466 n2,337
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Evidence of mechanismsocial learning
Abstinence
AA involvement
Fewer pro-drinking influences
Enhanced friendship networks
More friends
who support abstinence from AA
Kaskutas et al., Addiction 2002 Humphreys et
al., Ann Behav Med 1999 Timko et al., ACER
2005 Bond et al., J Stud Alcohol 2003
treated male VA inpat. init. untx. PDs
treated n 722 n2,337 n466
n655
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Evidence of mechanismpsychodynamic
Abstinence
AA involvement
Life meaning
Motivation for abstinence
White Laudet, CPDD 2006 Kelly et al., J Stud
Alcohol 2002
In recovery adolescent inpatients n 354
n 74
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Evidence of mechanismspirituality
Abstinence
AA involvement
? religious beliefs behaviors
Spiritual awakening
Day Hosp Residential, managed care n 537
Zemore, ACER in press
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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
44
When is AAs Effect Stronger?

• More substance use
• More psychosocial problems
• White, less educated, younger, unstably employed
  
• Less religious, fewer interpersonal skills
• Type B (more impulsive, tense, sensation-seeking,
  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
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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
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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
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Duration of AAmatters more for women
Moos et al., Clin Med Res 2006
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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

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Summary (contd)

• What matters most about AA?
• Weekly attendance
• Increasing AA activities early on
• Having, being a sponsor
• Doing service
• Working the steps

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Summary (contd)

• 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 ones life

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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
52
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
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Getting People to AA (continued)

• Project MATCH Twelve-Step Facilitation (TSF)
• 12 manual-guided INDIVIDUAL sessions led by
  trained therapist
• Goals relate to AAs 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
54
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
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Making Alcoholics Anonymous Easier(MAAEZ) a
group TSF approach

• Developed at the
• Alcohol Research Group, Berkeley
• by
• Lee Ann Kaskutas
• and
• Edward Oberste

MAAEZ NA too
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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 2
Project MATCH Research Group, ACER 1998 3 CSAT,
Substance abuse treatment Group Therapy 2005 4
Weiss, et al., Harvard Review of Psychiatry 2004
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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 AAs
  effect on abstinence 5,6
• Helping clients fill a purposeful role early on
• Helping helps the helper (Reissmans Helper
  Therapy Principle) 7,8 and is consistent with
  AAs stated goal 9

5 Kaskutas et al, Addiction 2002 6 Bond et al,
JSA 2003 7 Riessman, Social Policy 1976 8 Zemore,
Southern Medical Journal, 2007 9 Alcoholics
Anonymous, 1939
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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

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Structure of MAAEZ (contd)

• 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

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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

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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 dont think you
  are God
• Spirituality in AA
• Its 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 dont know,
  who has more sobriety than you

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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 dont know at meeting, for their
  phone
• Telephone them (and talk to them) before next
  session

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Sponsorship

• What is a sponsor? Why get one?
• Who should you ask?
• Youre 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, theyre too busy
• Homework ask somebody to be your temporary
  sponsor

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Manual Available Now

• lkaskutas_at_arg.org

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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

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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

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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)

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