Alcoholics perceptions of AAs helpfulness: Qualitative responses and association with drinking outco

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Alcoholics perceptions of AAs helpfulness
Qualitative responses and association with
drinking outcomes

• Elizabeth A.R. Robinson, Ph.D.
• Addiction Research Center
• University of Michigan

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Research Questions

• What proportion of alcoholics in a mixed sample
  of treatment seekers and non-seekers perceive AA
  as helpful or unhelpful?
• Which respondents found AA helpful or not
  helpful?
• Do perceptions of AAs helpfulness or
  unhelpfulness relate to drinking outcomes?
• What elements of AA are perceived to be helpful
  or not helpful in managing drinking problems?

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Why does this matter?The answers can inform
research and clinical efforts by

• Identifying mediators of AAs effects, including
  demographic and clinical variables and their
  potential interaction with AA characteristics.
• Suggesting clinical assessments and interventions
  that might support AA involvement.

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Prior work on perceptions of AA and relationship
to outcomes

• Not much has been done on this topic. Two
  examples
• Tonigan, Miller Connors (2000, ATQ)
• Large MATCH subsample ratings of AAs
  helpfulness were one component of AA involvement
  engagement in AA measured more broadly predicted
  drinking outcomes.
• Laudet (in Galanter Kaskutas, 2008).
• 205 drug and alcohol clients reporting NA AA
  exposure and perceptions at treatment entry no
  perceived difference in ratings of helpfulness of
  NA vs AA
• Qualitative analysis indicated NA/AA most helpful
  in promoting recovery sobriety and in providing
  support, acceptance, fellowship
• Dislikes reported by 35 of NA attendees 52 of
  AA attendees. Specific dislikes members who use,
  deal, or are phony, repetitious or boring not
  liking meeting format.

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Our Methods

• Data from a 2 ½ to 3 year longitudinal survey of
  364 alcoholics recruited from 4 sites,
  interviewed every 3 months re drinking and every
  6 months re other variables.
• At 18 months, the 286 respondents still in the
  study were asked What do you think helps people
  deal with alcohol problems?
• Qualitative responses were first categorized into
  4 groups (1) AA was helpful to me, (2) mixed,
  (3) not helpful to me, or (4) no mention of AA.
• Demographic and clinical characteristics of the
  groups were compared across groups.
• Drinking data at each time point from baseline to
  18 months were compared across these 4 groups.
• Subsequent detailed content analysis was carried
  out on specific aspects of AA that were perceived
  to be helpful and/or not helpful.

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Sample Demographics
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Sample Clinical Characteristics
All respondents met DSM-IV criteria for alcohol
dependence.
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Quantitative Measures

• Time-Line Follow-back (Sobell Sobell, 1992)
  drinking data
• Percent days abstinent in last 90 days
• Percent heavy drinking in last 90 days
• Mean drinks per drinking day in last 90 days
• Days since last drink
• SCID (First et al, 1997) severity, age of onset.
• SIP (Short Inventory of Problems Miller,
  Tonigan, Longabaugh, 1995) consequences of
  dependence
• AA Involvement scale (Tonigan, Connors, Miller,
  1996), includes meetings

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Qualitative analysis

• Examined transcripts of responses at 18 months to
  the question What do you think helps people
  deal with alcohol problems?
• We only used responses that indicated how
  useful/not useful AA was to this respondent.
• Based on the first 40 responses, categories of
  AAs helpfulness and not helpfulness were
  developed. The first three helpful and first
  three not helpful comments were coded into one of
  these categories, with additional code categories
  developed as needed. These categories were
  transformed into 6 nominal SPSS variables.

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Results
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AA-related responses to the question What do
you think helps people with alcohol problems?

• Of the 286 respondents interviewed at 18 months
• 42.3 (121) had found AA helpful to them
• 18.2 (52) gave mixed comments about AAs
  helpfulness
• 19.2 (55) had found AA unhelpful to them
• 20.3 (58) made no mention of AA

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Demographics by AA Helpfulness
Differences between groups significant at p
lt.01
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Clinical Characteristics by AA Helpfulness
Differences between groups significant at p
lt.05 p lt.01 p lt.000
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Percent Days Abstinent in last 90 days by AA
Helpfulness
Significance across AA helpfulness groupings
plt.001
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Percent Heavy Drinking Days in last 90 days by AA
helpfulness
Significance plt.001 Significance plt.01
Significance plt.05
Note Heavy drinking days for men lt5 standard
drinks, for women lt4 standard drinks.
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Drinks per Drinking Day in last 90 days by AA
helpfulness
Significance plt.01 Significance plt.05
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Days since last drink in last 90 days by AA
helpfulness
Significance plt.01 Significance plt.001
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AA involvement scores




Significance plt.001
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Qualitative findings What did people say was
helpful and not helpful about AA?
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Whats helpful?

• The Fellowship
• Identifying with other alcoholics, people whove
  been there, who know (45 mentions)
• Sharing, talking, listening to stories (41)
• Support group, reinforcement (24)
• Fellowship, group of sober people, NOS (21)
• Sober options, activities (14)
• Not feeling alone, different, unique (13)
• Making connections (10)
• Other fellowship related comments (6) being able
  to call when want to drink, no peer pressure to
  drink

Denominator 173 found AA helpful to some degree
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Whats helpful?

• The program
• Sponsor, having a sponsor, NOS (25)
• Working the steps (21)
• Sponsors support, connection (10)
• Meetings, going to meetings, taking what you need
  from them (10)
• Applying steps, structure to life (9)
• Big Book, other AA literature (6)
• Admitting the problem (5)
• Other program related comments (12) accessible,
  sponsoring others, honesty, self-awareness,
  surrendering control

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Whats helpful?

• Other aspects
• Helps you not drink, NOS (29)
• Getting advice, help with problems, guidance (11)
• Spirituality, NOS (11)
• Higher Power, God (8)
• Learning coping strategies, how to deal with
  everyday life, NOS (9)
• Learning from seeing consequences in others (8)
• Other comments (8) prayer/meditation, having a
  safety net, reminders to remember the past,
  learning to live a richer life

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Whats not helpful?

• Cant relate to others in AA groups/meetings (19)
• Looks too much at negative, too much complaining
  (16)
• Thought I could handle it on my own (16)
• Vague waste of time (15)
• Dislike model, structure, language of AA (12)
• Too religious (11)
• Court-ordered people (9)
• Im not that bad, not like those people (9)
• People talk too much about drinking (8)
• Too depressing (8)
• Dont like groups in general (8)
• Dont believe in God/Higher Power (7)
• People are hypocritical/phony (7)
• Needed more than AA (7)
• Other comments (34) makes people want to drink,
  dont want to admit being out of control, people
  with non-alcohol issues, stories are repetitive,
  too male, too cult-like, dogmatic, never wanted
  to stop drinking, court ordered, looks too much
  at the past

Denominator 107 people who found AA unhelpful
to some degree
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Summary

• The only demographic variable associated with
  perceptions of AAs helpfulness or
  non-helpfulness was age. Greater age was
  associated with greater perceived helpfulness of
  AA. Perceived helpfulness is not associated with
  gender, ethnicity, marital status, employment
  status, education, or income.
• All but one clinical variable was associated with
  perceptions of AAs helpfulness (or
  non-helpfulness) specifically, AA was more
  helpful among those with prior alcohol treatment,
  more severe dependence, higher levels of
  consequences of dependence, wanting to be
  abstinent, a family history of alcohol problems,
  and a prior history of attending AA. It was not
  associated with age of onset.

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Summary, continued

• Perceptions of AAs helpfulness at 18 months was
  strongly associated with all measures of drinking
  at almost all time points.
• The largest group of comments about AAs
  helpfulness were about the fellowship and the
  program.
• Comments about AAs unhelpfulness ranged more
  widely and included a dislike of groups, not
  being able or willing to identify with AA
  members, irritation with stories and members
  problems/concerns, desire for individual
  solutions, perceptions of AA as dogmatic, and
  lack of belief in God/Higher Power.

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Conclusions

• It appears that the greater ones need for
  sobriety e.g., the more severe ones
  dependence, consequences, family history the
  more likely one may be open to the benefits of
  AA.
• Qualitative comments indicate the importance of
  being able to be in a group, to obtain benefit
  from others experiences, and continue to search
  for AA meetings and members with whom one finds
  compatibility.
• Alcoholism is not contagious, but recovery is.
  (Kurtz, unknown date) mutuality of AA
  involvement and commitment.

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Clinical and Research Recommendations

• In clinical settings, greater emphasis on
• Variety of groups trying different groups,
  shopping around, finding a group where one feels
  at home, discussion of that process
• Range of levels type of participation e.g.,
  service options getting a sponsor the process
  of finding a sponsor
• Variety of definitions of ones Higher Power
• Research (and policy) issues
• Does court-mandated AA attendance work?
• Can judges/courts broaden their definition of
  acceptable mutual-help groups beyond AA
• Are on-line mutual help groups as useful for
  those who are not comfortable in groups?

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Acknowledgements

• NIAAA (R01AA014442)
• Our respondents
• Research assistants
• Amanda Price
• Georgia Stamatopoulos
• Mike Finn
• Ernest Kurtz, Ph.D.
• Kirk J. Brower, M.D.
• Univ. Michigan Addiction Research Center, Robert
  Zucker, Ph.D., Director