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 Presented at the Annual Meeting and Conference of the Federation of State Physician Health Programs (FSPHP) April 25, 2012 Fort Worth, TX

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

Abstinence & AA exposure male VA inpatients 1 yr n = 3018; 18 mo n = 91 Ouimette et al., J Stud Alcohol 1998 Thurstin et al., Int J Addict 1987

Abstinence & meeting amount Male VA residential patients n = 2376 Moos et al., J Clin Psychol 2001

Abstinence & meeting frequency LA Target Cities, outpatients n = 262 Fiorentine, Am J Drug Alcohol Ab 1999

Abstinence & sustained attendance meetings ☼ Previously untreated problem drinkers n = 461 Moos & Moos, J Clin Psychol 2006 Also see Moos & Moos, JSAT 2004

AA meeting trajectories Dependent treatment seekers n = 349 Kaskutas et al., ACER 2005

Abstinence and meeting trajectories Dependent treatment seekers n = 349 Kaskutas et al., ACER 2005

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

Consistency across samples NESARC; dependent Tx 12-step both nothing n = 4422 n=239 n=138 n=829 n=3217 (Dawson, Addiction 2006)

Consistency across time AA involvement over 10 years Abstinence at 10 years significant Inpatients n=158 Cross et al., ACER 1990

Substance use following AA/NA 12-step meetings mos. 1-3 Alcohol and drug use mos. 4-6 No Yes 12-step activities mos. 1-3 Cocaine-dependent outpatients n = 336 Weiss et al., Drug Alcohol Depen 2005

Alcohol abstinence following AA AA involvement mos. 1-6 Percent days abstinent mos. 7-12 Outpatient β = .29 Aftercare β = .34 Project MATCH n = 480 outpatients, n = 434 aftercare Connors et al., J Stud Alcohol 2001

Randomizing to AAto remove selection effect 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 TSFto remove selection effect: Outpatient sample p = .0024 p < .007 Project MATCH n = 806 outpatients at yr 3 PMRG, J Stud Alcohol 1997 PMRG, ACER 1998

Randomize to TSFto remove selection effect: Aftercare sample Project MATCH aftercare n = 714 at 1-year follow-up PMRG, J Stud Alcohol 1997

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

Timko’s results for 12-step involvement at 6 months Timko, Addiction, 2006

Groups where Intensive referral mattered in that study • The low prior AA group attended significantly more meetings in IR (vs. SR) at 6 months. Differences in meeting attendance were non-significant in the high prior AA group.

Specificity: Randomizing to MAAEZ (Making AA Easier)

Groups where MAAEZ dose seems to really matter • Unmarried • Had prior treatment • Attended 91+ prior AA meetings in lifetime • Has high ASI psychiatric problem severity • Drug dependent • Atheist, agnostic, unsure • No heavy drinkers or drug users in social network

Statistical models to study selection effect Baseline 1 year 2 years Motivation negative AA involvement Alcohol problems negative no difference Psychopathology Male VA inpatients N=2,319 McKellar et al., J Consult Clin Psych 2003

Example Using Propensity Score Method to Remove Selection Effect: Odds of Abstinence before adjustment * p<0.05, ** p<0.01, *** p<0.01

Odds of Abstinence after propensity score stratification * p<0.05, *** p<0.01

Consistency with theory: 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

Consistency with theory: 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

Consistency with theory: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

Evidence of mechanism:cognitive behavioral AA involvement Abstinence Self-efficacy* Coping skills** *1Morgenstern et al., J Consult Clin Psych 1997 *2Kellyet 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 AA involvement Abstinence 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 n=2,337 n=466 n=655

Evidence of mechanism:social learning? MAAEZ Abstinence Service 6+12mos; high psych Sponsor Comfort speak; be @ meetings # who support abstinence Kaskutas et al., JSAT 2009

Evidence of mechanism:psychodynamic AA involvement Abstinence Life meaning* Motivation for abstinence** *White & Laudet, CPDD 2006 **Kelly et al., J Stud Alcohol 2002 *In recovery **adolescent inpatients n = 354 n = 74

Evidence of mechanism:spirituality AA involvement Abstinence Δ religious beliefs & behaviors Spiritual awakening Day Hosp & Residential, managed care n = 537 Zemore, ACER in press

Getting People to AA Making AA Easier (MAAEZ) • Six 90-minute manual-guided GROUP sessions led by recovering counselor • Goals: To reduce patients’ immediate rejection of AA, and to help them connect with the AA fellowship • Manual available now (lkaskutas@arg.org) Kaskutas & Oberste, MAAEZ 2002

Why care about AA facilitation? • AA is the most widely-used source of help for alcoholism • Over time, those who attend AA have higher rates of abstinence than those who drop-out • Drop-out from AA is very high • Over half drop-out within their first year

Goal of MAA*EZ 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;97(7):891-900 6 Bond et al, JSA 2003;64(4):579-588 7 Riessman, Social Policy 1976;7:41-45 8 Zemore, Southern Medical Journal, forthcoming 9 Alcoholics Amonymous, 1939

Structure of MAA*EZ • 6-week intervention • Six sessions, attended 1-week apart • Need time for doing weekly homework • Intro session • First and Last session attended • For newcomers and graduates • 4 core sessions • Spirituality, sponsorship, principles not personalities, living sober • Attended in any order

Introduction • Graduate vignettes of their AA and MAA*EZ experience • 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 • AA is spiritual, not religious program • Things to think about when you hear ‘God as we understood Him” • 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

AA Effectiveness – Faith Meets Science