aa effectiveness – faith meets science

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 ProjectJune 26, 2007

Oakland, California

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




• 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

Abstinence & AA exposure

Ouimette et al., J Stud Alcohol 1998Thurstin et al., Int J Addict 1987

male VA inpatients1 yr n = 3018; 18 mo n = 91

05

10152025

3035404550

% a

bst

inen

t

AA no AA

at 1 yr.

at 18 mos.

Abstinence & meeting amount

Moos et al., J Clin Psychol 2001

0

10

20

30

40

50

60

70

% a

bst

inen

t m

os.

9-1

2

0 1-19 20-49 50+

# of meetings mos. 9-12

Male VA residential patientsn = 2376

Fiorentine, Am J Drug Alcohol Ab 1999

Abstinence & meeting frequency

01020304050607080

% a

bst

inen

t at

2 y

rs

never less thanweekly

weekly

meeting frequency, mos. 19-24

LA Target Cities, outpatientsn = 262

Abstinence & sustained attendance

0

10

20

30

40

50

60

70

80

% a

bst

inen

t 16

yea

rs

year 1 years 2-3 years 4-8

duration of AA attendance

none

1-8 wks

9-26 wks

27+ wks

Moos & Moos, J Clin Psychol 2006Also see Moos & Moos, JSAT 2004

meetings

Previously untreated problem drinkersn = 461

☼

0

50

100

150

200

250

TxEntry 1 year 3 years 5 years

# o

f A

A m

eeti

ng

s, p

st y

r

declining AAhigh AAmedium AAlow AA

AA meeting trajectories

Kaskutas et al., ACER 2005Dependent treatment seekersn = 349

Abstinence and meeting trajectories

0102030405060708090

100

1 year 3 years 5 years

% a

bsti

nent

declining AA

high AA

medium AA

low AA

no AA

Kaskutas et al., ACER 2005Dependent treatment seekersn = 349

a Ouimette et al., J Stud Alcohol 1998b Timko et al., J Stud Alcohol 2000

Consistency across samples & time

0

10

20

30

40

50

60

70

% a

bst

inen

t

1 year 3 years 8 years

nothing

outpatient only

AA only

AA + outpatient

a b b

aMale VA inpatients bPreviously untx prob drnkrsn = 3018 n = 466

Consistency across samples

0

1

2

3

4

5

6

ha

zard

s o

f a

bs

tin

en

ce

(v

s.

no

thin

g)

formal tx only 12-step only 12-step + tx

(Dawson, Addiction 2006)NESARC; dependent Tx 12-step both nothingn = 4422 n=239 n=138 n=829 n=3217

Consistency across time

AA involvement over 10 years

Abstinence at 10 years

Cross et al., ACER 1990Inpatientsn=158

significant

Alcohol abstinence following AA

Percent daysabstinentmos. 7-12

AA involvementmos. 1-6

Outpatient β = .29

Connors et al., J Stud Alcohol 2001

Aftercare β = .34

Project MATCH n = 480 outpatients, n = 434 aftercare

Substance use following AA/NA

12-step activitiesmos. 1-3

Alcohol and drug usemos. 4-6

12-step meetingsmos. 1-3 N.S.

Signif.

Weiss et al., Drug Alcohol Depen 2005

Cocaine-dependent outpatients in 6-month treatment programn = 336

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

Randomizing to AAto remove selection effect

0

5

10

15

20

25

30

35

40

% a

bst

inen

t at

2 y

rs

Hospital inpatient AA meetings Choice

Walsh et al., New Engl J Med 1991Alcohol abusers + EAP referredn = 227: n=73 hospital; n=83 AA; n=71 choice

Randomize to TSFto remove selection effect:

Outpatient sample

05

10

15

2025

30

35

40

% a

bst

inen

t, p

ast

3 m

os.

1-yr follow-up 3-yr follow-up

12-step

Motiv

Cog Beh

PMRG, J Stud Alcohol 1997PMRG, ACER 1998

p = .0024 p < .007

Project MATCHn = 806 outpatients at yr 3

Randomize to TSFto remove selection effect:

Aftercare sample

05

101520253035404550

% a

bst

inen

t m

os

13-1

5

12-step Motiv Cog Beh

PMRG, J Stud Alcohol 1997Project MATCH aftercaren = 714 at 1-year follow-up

.5

.4

.3

.2

.1

0.0

.5

.4

.3

.2

.1

0.0

AA Meeting Attendance by Project MATCH Sample And Treatment Assignment

Outpatient* Aftercare**

% DaysAA Mtgs Green = 12-

stepYellow = MotivGrey = Cog Beh

Green = 12-stepYellow = MotivGrey = Cog Beh

Intake 15 Month Intake 15 Month

Tonigan et al., Tx Match Alcohol 2003Project MATCH *n = 952 Outpatients, **n = 774 Aftercare

Statistical models to study selection effect

Motivation negative

Alcoholproblems

AAinvolvement

Psychopathology

negative

no difference

Baseline 2 years1 year

McKellar et al., J Consult Clin Psych 2003Male VA inpatientsN=2,319

Consistency with Theory

Problem Solution TheoryDrinking is a habit Drink refusal skills

Emergency planning

Choose alternative behavior

Cognitive Behavioral

Everyone around me drinks

Δ environmental cues

See others succeed

Self-efficacy

Better role models

Social Learning

Drink due to unmet needs/ psych. states

Address needs

Δ moodPsychodynamic

Drink due to spiritual condition

Spiritual awakening

Consistency with Theory

Problem Solution TheoryPredisposed 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 Psy

alternative cue

need



• What you hear– Others had similar experiences– Ways people coped instead of

drinking

Cog Beh Soc Lrn Psy

alternative cue

need

succeed

skills



• 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 Psy

alternative cue

need

succeed

skills

mood

alternative efficacy

Mechanism from fellowship

• Friendship– Adds sober people supportive

of your abstinence– Role models of new behavior– Helps learn how to have fun

sober

Cog Beh Soc Lrn Psy

cue

model

alternative cue need

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

Cog Beh Soc Lrn Psy

cue

model

alternative cue need

emerg plan

need

Mechanism from the steps

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

Cog Beh Soc Lrn Psy

need

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

Cog Beh Soc Lrn Psy

need

mood

Evidence of mechanism:cognitive behavioral

AbstinenceAA

involvement

Coping skills**

Self-efficacy*

*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 n=74 n=466 n=2,337

Evidence of mechanism:social learning

AbstinenceAA

involvement

Enhancedfriendshipnetworks**

Fewerpro-drinkinginfluences*

More friends†

# who supportabstinencefrom 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 n=2,337 n=466 n=655

Evidence of mechanism:psychodynamic

AbstinenceAA

involvement

Motivationfor abstinence**

Life meaning*

*White & Laudet, CPDD 2006**Kelly et al., J Stud Alcohol 2002

*In recovery **adolescent inpatients n = 354 n = 74

Evidence of mechanism:spirituality

AbstinenceAA

involvement

Spiritualawakening

Δ religious beliefs

& behaviors

Zemore, ACER in press Day Hosp & Residential, managed care n = 537


Strength of associationDose-response relationshipConsistency of associationTemporally-correct association

– Specificity of the associationCoherence with existing information


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, 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

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

Duration of AAmatters more for women

0

10

20

30

40

50

60

70

80

90

% i

n r

em

issio

n y

ear

8

0 wks 1-8 wks 9-26 wks 27+ wks

of AA

Men

Women

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

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

How to get patients to attend AA after treatment?

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

• 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

AA Referral: Standard vs. Intense

Making Alcoholics Anonymous Easier(MAAEZ):

a group TSF approach

Developed at the Alcohol Research Group, Berkeley

byLee Ann Kaskutas

andEdward 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 19972 Project MATCH Research Group, ACER 1998

3 CSAT, Substance abuse treatment: Group Therapy 20054 Weiss, et al., Harvard Review of Psychiatry 2004

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 20026 Bond et al, JSA 2003

7 Riessman, Social Policy 19768 Zemore, Southern Medical Journal, 2007

9 Alcoholics Anonymous, 1939

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 MUCHTHANK 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)

aa effectiveness – faith meets science

Documents

cue model

establish

remove selection

drink personal

correct association

response relationship

action cochrane

abstinence