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

9. 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 Moos et al., J Clin Psychol 2001 Male VA residential patients n = 2376

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

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

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

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

15. 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. a Ouimette et al., J Stud Alcohol 1998 b Timko et al., J Stud Alcohol 2000 Consistency across samples & time a b b a Male VA inpatients b Previously untx prob drnkrs n = 3018n = 466

17. Consistency across samples (Dawson, Addiction 2006) NESARC; dependent Tx12-stepbothnothing n = 4422 n=239n=138n=829n=3217

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

19. 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

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

21. Substance use following AA/NA 12-step activities mos. 1-3 Alcohol and drug use mos. 4-6 12-step meetings mos. 1-3 N.S. Signif. Weiss et al., Drug Alcohol Depen 2005 Cocaine-dependent outpatients in 6-month treatment program n = 336

22. 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

23. 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

24. Randomizing to AA to remove selection effect Walsh et al., New Engl J Med 1991 Alcohol abusers + EAP referred n = 227: n=73 hospital; n=83 AA; n=71 choice

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

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

27. AA Meeting Attendance by Project MATCH Sample And Treatment Assignment Outpatient* Aftercare** % Days AA Mtgs Green = 12-step Yellow = Motiv Grey = Cog Beh Green = 12-step Yellow = Motiv Grey = Cog Beh Intake 15 Month Tonigan et al., Tx Match Alcohol 2003 Project MATCH *n = 952 Outpatients, **n = 774 Aftercare

28. Statistical models to study selection effect Motivation negative Alcohol problems AA involvement Psychopathology negative no difference Baseline2 years1 year McKellar et al., J Consult Clin Psych 2003 Male VA inpatients N=2,319

29. 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

30. Consistency with Theory ProblemSolutionTheory Drinking 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 mood Psychodynamic Drink due to spiritual condition Spiritual awakening

31. Consistency with Theory ProblemSolutionTheory Predisposed to develop alcoholism Drugs Genetic Brain becomes addicted Drugs Neurobiology

32. Mechanism from meetings What you do –Place to go instead of bar –Talk about your problems Cog BehSoc LrnPsy alternativecue need

33. 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 Cog BehSoc LrnPsy alternativecue need succeed skills

34. 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 –Don’t drink a day at a time Cog BehSoc LrnPsy alternativecue need succeed skills mood alternativeefficacy

35. Mechanism from fellowship Friendship –Adds sober people supportive of your abstinence –Role models of new behavior –Helps learn how to have fun sober Cog BehSoc LrnPsy cue model alternativecueneed

36. 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 BehSoc LrnPsy cue model alternativecueneed emerg plan need

37. Mechanism from the steps Change how you treat others, or you will drink –Personal inventory; amends Cog BehSoc LrnPsy need

38. 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 BehSoc LrnPsy need mood

39. Evidence of mechanism: cognitive behavioral Abstinence AA involvement Coping skills** Self-efficacy* * 1 Morgenstern et al., J Consult Clin Psych 1997 * 2 Kelly et al., J Stud Alcohol 2002 ** 1 Timko et al., ACER 2005 ** 2 Humphreys 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

40. Evidence of mechanism: social learning Abstinence AA involvement Enhanced friendship networks** Fewer pro-drinking influences* 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

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

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

43. 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 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

45. 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=.48 AA-PDA for Type B –R=.15 AA-PDA for Type A Morgenstern et al., Addiction 1998

46. 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

47. Duration of AA matters more for women Moos et al., Clin Med Res 2006

48. 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

49. Summary (cont’d) What matters most about AA? Weekly attendance Increasing AA activities early on Having, being a sponsor Doing service Working the steps

50. 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

51. 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

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

53. 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

54. 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

55. 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

56. 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

57. 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 2002 6 Bond et al, JSA 2003 7 Riessman, Social Policy 1976 8 Zemore, Southern Medical Journal, 2007 9 Alcoholics Anonymous, 1939

58. 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

59. 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

60. 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

61. 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

62. 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

63. 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

64. Manual Available Now lkaskutas@arg.org

65. 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

66. 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 THANK YOU VERY MUCH

67. 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)