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

Abstinence & AA exposure

50 45 40 35 30 25 20 15 10 5 0 AA
male VA inpatients 1 yr n = 3018; 18 mo n = 91

% abstinent

at 1 yr. at 18 mos.

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

70

% abstinent mos. 9-12

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

Abstinence & meeting frequency

80 70 60 50 40 30 20 10 0 never less than weekly weekly

% abstinent at 2 yrs

meeting frequency, mos. 19-24

LA Target Cities, outpatients n = 262

Fiorentine, Am J Drug Alcohol Ab 1999

Abstinence & sustained attendance

% abstinent 16 years
80 70 60 50 40 30 20 10 0 year 1 years 2-3 years 4-8 duration of AA attendance

meetings

none 1-8 wks 9-26 wks 27+ wks

Previously untreated problem drinkers n = 461

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

AA meeting trajectories
250
# of AA meetings, pst yr

200 150 100 50 0 TxEntry 1 year 3 years 5 years

declining AA high AA medium AA low AA

Dependent treatment seekers n = 349

Kaskutas et al., ACER 2005

Abstinence and meeting trajectories

100 90 80 70 60 50 40 30 20 10 0 1 year
Dependent treatment seekers n = 349

declining AA high AA medium AA low AA no AA

% abstinent

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 60

% abstinent

50 40 30 20 10 0 1 year
a

nothing outpatient only AA only AA + outpatient

3 years

8 years

aMale

VA inpatients n = 3018

bPreviously

untx prob drnkrs n = 466

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

Consistency across samples

6

hazards of abstinence (vs. nothing)

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

significant

Abstinence at 10 years

Inpatients n=158

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
mos. 1-6

Outpatient = .29 Aftercare = .34

Percent days abstinent

mos. 7-12

Project MATCH n = 480 outpatients, n = 434 aftercare

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

40

% abstinent at 2 yrs

35 30 25 20 15 10 5 0 Hospital inpatient AA meetings Choice

Alcohol abusers + EAP referred n = 227: n=73 hospital; n=83 AA; n=71 choice

Walsh et al., New Engl J Med 1991

Randomize to TSF to remove selection effect: Outpatient sample

40 35 30 25 20 15 10 5 0 1-yr follow-up
p = .0024 Project MATCH n = 806 outpatients at yr 3

% abstinent, past 3 mos.

12-step Motiv Cog Beh

3-yr follow-up
p < .007 PMRG, J Stud Alcohol 1997 PMRG, ACER 1998

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

% abstinent mos 13-15

Motiv

Cog Beh

PMRG, J Stud Alcohol 1997

AA Meeting Attendance by Project MATCH Sample And Treatment Assignment

% Days AA Mtgs
.5 .5

.4

Green = 12-step Yellow = Motiv Grey = Cog Beh

.4

Green = 12-step Yellow = Motiv Grey = Cog Beh

.3

.3

.2

.2

.1

.1

0.0

0.0

Intake

15 Month

Intake

15 Month

Outpatient*
Project MATCH *n = 952 Outpatients, **n = 774 Aftercare

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
Drinking is a habit

Solution
Drink refusal skills Emergency planning Choose alternative behavior

Theory
Cognitive Behavioral Social Learning

Everyone around me drinks

environmental cues
See others succeed Self-efficacy Better role models Address needs

Drink due to unmet needs/ psych. states Drink due to spiritual condition

Psychodynamic

mood
Spiritual awakening

Consistency with Theory

Problem
Predisposed to develop alcoholism Brain becomes addicted

Solution
Drugs

Theory
Genetic Neurobiology

Drugs

Mechanism from meetings

Cog Beh Soc Lrn cue need Psy

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

alternative

Mechanism from meetings

Cog Beh Soc Lrn cue need succeed skills Psy

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

alternative

Mechanism from meetings

Cog Beh Soc Lrn cue need succeed skills mood alternative efficacy Psy

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

alternative

Mechanism from fellowship

Cog Beh Soc Lrn Psy

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

cue model cue need

Mechanism from fellowship

Cog Beh Soc Lrn Psy

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

cue model cue need

need

Mechanism from the steps

Cog Beh Soc Lrn Psy

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

need

Mechanism from the steps

Cog Beh Soc Lrn Psy

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

need

mood

Evidence of mechanism: cognitive behavioral

AA involvement Abstinence

Self-efficacy*

Coping skills**
*1Morgenstern et al., J Consult Clin Psych 1997 *2Kelly et al., J Stud Alcohol 2002 **1Timko et al., ACER 2005 **2 male VA inpatients 2Humphreys et al., Ann Behav Med 1999 ** n=2,337

*1 Resi or IOP n = 100

*2

asolescent inpatients n=74

**1 initially untx PDs n=466

Evidence of mechanism: social learning

AA involvement
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

Abstinence

*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

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 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, 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

Duration of AA matters more for women

% in remission year 8
90 80 70 60 50 40 30 20 10 0 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 (contd)
What matters most about AA?
Weekly attendance Increasing AA activities early on Having, being a sponsor Doing service Working the steps

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

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 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

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

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

1 Project

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

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

5 Kaskutas

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 (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

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 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

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

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

Manual Available Now

lkaskutas@arg.org

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)