Does Age Moderate the Effect of Spirituality/Religiousness in Accounting for Alcoholics Anonymous Benefit?

OBJECTIVE: Gains in spiritual/religious (S/R) practices among Alcoholics Anonymous (AA) members are associated with reductions in drinking. This study had the following aims: (a) examine spirituality/religiousness as a mediator of the relationship between AA attendance and reductions in drinking behavior to replicate past research findings and to (b) examine age-cohort as a moderator of the mediational analyses given that empirical evidence (e.g., generational differences in spirituality) suggests that age may influence the acquisition of gains in spirituality/religiousness during AA as well as the expression of these gains on drinking behavior. METHOD: Measures were administered to 253 participants recruited from community-based AA and outpatient treatment programs at baseline, 3, 6, 9, and 12-months, and 210 (83%) participants provided complete data to test study aims. RESULTS: Gains in S/R practices mediated the relationship between AA attendance and increased abstinence, but not drinking intensity. Simple slopes analyses indicated a positive association between AA attendance and gains in S/R practices among younger AA affiliates but not older AA affiliates in the moderated-mediational analyses. However, age was not found to moderate the global mediational effect. CONCLUSIONS: The results from the current study inform efforts to increase positive change in AA affiliates' drinking behavior by highlighting specific aspects of S/R practices that should be targeted based on the age of an AA affiliate.

A longitudinal model of intake symptomatology, AA participation and outcome: retrospective study of the project MATCH outpatient and aftercare samples.

OBJECTIVE: The present study used data gathered in Project MATCH to longitudinally assess intake symptomatology, Alcoholics Anonymous (AA) participation, and outcome. Three primary constructs were considered: intake symptomatology, engagement in prescribed AA-related activities and functioning after engagement in AA-related behaviors. METHOD: The participants were 480 outpatient and 434 aftercare clients who participated in Project MATCH. RESULTS: Similar findings were found for each sample. Intake symptomatology positively predicted AA participation during the first 6 months following treatment. Although network support for drinking was negatively related to AA participation, such support did not mediate the relationship between intake symptomatology and subsequent AA participation. AA participation, in turn. positively predicted frequency of abstinent days in Months 7-12 posttreatment. This latter relationship was mediated by perceived self-efficacy to avoid drinking (Month 6). AA participation was positively related to self-efficacy to avoid drinking, which, in turn, predicted more days abstinent. One difference between the outpatient and aftercare samples emerged, involving the latent construct intake symptomatology. Intake symptomatology among outpatients was not predictive of percentage of abstinent days (Months 7-12), whereas intake symptomatology was negatively predictive of percentage of abstinent days in the aftercare sample. CONCLUSIONS: Intake symptomatology positively predicted participation in AA, which predicted subsequent abstinent days. The positive relationship between AA participation and self-efficacy to avoid drinking may explain in part why AA engagement predicts subsequent increases in abstinence.

Comparison of outcomes for clients in randomized versus open trials of treatment for alcohol use disorders.

OBJECTIVE: There has been continuing concern that clients who accept randomization into a controlled trial may not be representative of those in noncontrolled trials or ordinary treatment situations. However, it is not possible to test the impact of randomization through a randomized trial. Two parallel studies conducted at the same treatment facility provided an opportunity for a quasi-experimental study to evaluate whether participation in a controlled trial itself affects treatment outcome. METHOD: Two concomitant samples of clients were enrolled during overlapping recruitment periods: one (n = 226) into a randomized clinical trial (RCT) and the other (n = 122) offered treatment as usual (non-RCT). Both samples were given extensive baseline and follow-up assessment. RESULTS: Baseline assessment indicated demographic similarity of the two samples, with somewhat higher problem severity in the non-RCT sample, consistent with the RCT selection criteria. Client retention in treatment was somewhat comparable, and follow-up rates exceeded 90% in both studies. Overall outcomes did not differ for the RCT and non-RCT samples. CONCLUSIONS: It appeared that clients enrolled into an RCT did not differ from those receiving ordinary treatment. Retention was similarly high in both studies, clients completed a comparable number of outpatient sessions, and the number of informal treatment sessions attended during the 6 months of follow-up was comparable. There are some aspects of this study that limit the ability to draw firmer conclusions but despite some pretreatment differences, participation in the RCT did not itself exert an apparent effect on aggregate treatment outcomes.

Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members.

In a randomized clinical trial, 130 concerned significant others (CSOs) were offered 1 of 3 different counseling approaches: (a) an Al-Anon facilitation therapy designed to encourage involvement in the 12-step program, (b) a Johnson Institute intervention to prepare for a confrontational family meeting, or (c) a community reinforcement and family training (CRAFT) approach teaching behavior change skills to use at home. All were manual-guided, with 12 hr of contact. Follow-up interviews continued for 12 months, with 94% completed. The CRAFT approach was more effective in engaging initially unmotivated problem drinkers in treatment (64%) as compared with the more commonly practiced Al-Anon (13%) and Johnson interventions (30%). Two previously reported aspects of the Johnson intervention were replicated: that most CSOs decide not to go through with the family confrontation (70% in this study) and that among those who do, most (75%) succeed in getting the drinker into treatment. All 3 approaches were associated with similar improvement in CSO functioning and relationship quality. Overall treatment engagement rates were higher for CSOs who were parents than for spouses. On average, treatment engagement occurred after 4 to 6 sessions.

The topography of relapse in clinical samples.

In two clinical samples, alcohol consumption, other drug use, and tobacco use were measured at approximately 6 months following admission of individuals into treatment. Using only the alcohol consumption variables, cluster analyses with several different solutions consistently identified abstinent, moderate, and unremitted groups. With the addition of tobacco and other drug use, analyses identified a largely abstinent group, a drug use group that did not drink, a heavy drinking group that did not use other drugs, and a group using both alcohol and other drugs, indicating the need for broad definitions of relapse. All solutions distinguished clusters of tobacco users and nonusers in remission from alcohol and other drug use, and tobacco users and nonusers tended to be differentiated among those continuing to drink or use other drugs, suggesting that the presence or absence of tobacco use marks different outcome groups. Generally speaking, clustering methods using complete and average linkage as agglomeration measures with cosine similarity as a proximity measure produced the most consistent clusters and the most clinically interpretable results.

Comparison of treatment utilization and outcome for Hispanics and non-Hispanic whites.

OBJECTIVE: To examine the use of formal alcohol treatment and Alcoholics Anonymous (AA) by Hispanics and non-Hispanic whites, and to compare ethnic groups on posttreatment functioning. METHOD: Data from a publicly funded substance abuse treatment center in New Mexico were used to investigate possible differences between Hispanic (n = 46) and non-Hispanic white (n = 62) men (n = 76) and women (n = 32) on percent days alcohol therapy and AA attendance for 6 months after study recruitment. RESULTS: Hispanic clients were more often male (80% vs 63%), had fewer years of education (mean = 11.6 vs 12.6) and were less likely to live alone (7% vs 29%) than were non-Hispanic white clients. The heavy drinking (drinks per drinking day mean = 16.7; standard drink units in prior 90 days mean = 941.00) and few abstinent days (mean = 0.44) that characterized both groups at intake improved over time with Hispanics engaging in more formal alcohol therapy sessions but attending fewer AA meetings than non-Hispanic whites over the course of 6 months of follow-up. Attendance at treatment and AA were separately associated with decreased intensity and quantity of alcohol use, but not abstinent days, for both ethnic groups. CONCLUSIONS: Hispanic and non-Hispanic white clients used somewhat different treatment strategies to deal with alcohol-related problems, these paths, however, ultimately resulted in similar posttreatment drinking outcomes (frequency, intensity and quantity of alcohol consumption).

Special populations in Alcoholics Anonymous.

The vast majority of Alcoholics Anonymous (AA) members in the United States are white, and only a few studies have investigated the program's effectiveness for ethnic minorities. Project MATCH, a multisite research study aimed at developing guidelines for assigning alcoholics to appropriate treatment approaches, also assessed AA effectiveness for minority clients. Some differences in AA attendance existed among white, African-American, and Hispanic Project MATCH participants who had received some inpatient treatment before entering the study, but not among participants who had not received inpatient treatment. Further analyses of white and Hispanic Project MATCH participants demonstrated that although Hispanic clients attended AA less frequently than white clients, their involvement with and commitment to AA was higher than among white clients. For both Hispanics and whites, AA involvement predicted increased abstinence.

Community reinforcement and family training (CRAFT): engaging unmotivated drug users in treatment.

Although motivation for drug abuse treatment is a substantial problem, unilateral intervention through concerned significant others (CSOs) represents a promising method for engaging unmotivated individuals. The Community Reinforcement and Family Training (CRAFT) program, based on principles of reinforcement was developed for this specific purpose. In Phase I, CSOs received the CRAFT intervention, whereby they were taught skills for modifying a loved one's drug-using behavior and for enhancing treatment engagement. CSOs were evaluated at 3 and 6 months. In Phase II, engaged drug users received treatment using the Community Reinforcement Approach (CRA). A total of 62 CSOs participated in this evaluation of the effectiveness of CRAFT. CSOs completed, on average, 87% of offered treatment sessions. During the 6-month study period, 74% succeeded in engaging their resistant loved one in treatment. Reported abstinence both from illicit drugs and alcohol increased significantly for drug users engaged in treatment, but not for unengaged cases. All CSOs showed significant reduction in depression, anxiety, anger, and physical symptoms, with average scores dropping into the normal range on all measures. CRAFT provides a promising alternative to confrontational and detachment approaches in counseling CSOs to help their loved ones.

The reliability of Form 90: an instrument for assessing alcohol treatment outcome.

OBJECTIVE: Project MATCH is a randomized clinical trial consisting of five outpatient and five aftercare units at nine sites. Of importance in this multisite trial examining the efficacy of client-treatment matching was the cross- and within-site reliability of the structured interview used to assess alcohol treatment outcomes, the Form 90. Evaluation of the reliability of Form 90 is the subject of this article. METHOD: The reliability of Form 90 was evaluated in two test-retest studies. The cross-site reliability study consisted of 70 paired test-retest interviews conducted by different interviewers. Clients for this study were recruited from inpatient, outpatient and college settings. The within-site reliability study had a total of 108 paired test-retest interviews, with 54 of the retests conducted by different interviewers and 54 by the same interviewer. Clients for this study were most often presenting for alcohol treatment at the nine sites and were selected to be representative of the larger Project MATCH sample. RESULTS: Good-to-excellent reliability was found for all key summary measures of alcohol consumption and psychosocial functioning, and most frequently used illicit drugs had moderate reliability. No decay in consistency of self-reported drinking was found at more distal points from dates of test-retest interviews. Application of 68% confidence intervals for primary alcohol consumption measures suggests that trained researchers and clinicians can obtain consistent information regarding client drinking. CONCLUSIONS: Form 90 appears to be a reliable instrument for alcohol treatment assessment research when interviewers have received careful training and supervision in its use.

Are reconstructed self-reports of drinking reliable?

When follow-up interviews are missed, researchers sometimes try to reconstruct the data that would have been obtained by asking clients to recall the missed interval when they are interviewed at a later point. Are such data reliable? The reliability of remote reconstruction was estimated by asking 57 participants in a clinical trial to recall their drinking for the 12-month follow-up interval when interviewed, on average, 33 weeks later. These reports were obtained after delays averaging 231 days. These reconstructed reports were compared with the same clients' self-reports obtained during the 12-month interview. Reconstructed data were found to be reasonably accurate estimates of clients' reports at the time of original interview on global alcohol use variables including percentage of drinking days and total volume of consumption. No systematic bias was found for over-reporting or under-reporting at the point of reconstruction. However, on some variables (e.g. total drinks consumed), clients on average reported more drinking at the reconstruction period than during the initial interview. Discrepancies between initial and reconstructed reports were found to be unrelated to the length of delay in the second interview or to client characteristics.

Intercessory prayer in the treatment of alcohol abuse and dependence: a pilot investigation.

OBJECTIVE: To conduct a pilot study of the effect of intercessory prayer on patients entering treatment for alcohol abuse or dependence. DESIGN: In addition to standard treatment, 40 patients admitted to a public substance abuse treatment facility for treatment of alcohol problems who consented to participate were randomized to receive or not receive intercessory prayer (double-blind) by outside volunteers. Assessments were conducted at baseline, 3 months, and 6 months. RESULTS: No differences were found between prayer intervention and nonintervention groups on alcohol consumption. Compared with a normative group of patients treated at the same facility participants in the prayer study experienced a delay in drinking reduction. Those who reported at baseline that a family member or friend was already praying for them were found to be drinking significantly more at 6 months than were those who reported being unaware of anyone praying for them. Greater frequency of prayer by the participants themselves was associated with less drinking, but only at months 2 and 3. CONCLUSION: Intercessory prayer did not demonstrate clinical benefit in the treatment of alcohol abuse and dependence under these study conditions. Prayer may be a complex phenomenon with many interacting variables.

What predicts relapse? Prospective testing of antecedent models.

Predictors of relapse to drinking were examined in a clinical sample of 122 individuals seeking outpatient treatment for alcohol problems. Drinking status and a variety of predictor variables were measured every two months for one year following presentation for treatment. In addition to pretreatment characteristics, potential antecedents of relapse were assessed at each point within five domains: (1) the occurrence of negative life events; (2) cognitive appraisal variables including self-efficacy, alcohol expectancies, and motivation for change; (3) client coping resources; (4) craving experiences; and (5) affective/mood status. Although the occurrence of adverse life events did not predict 6-month relapse, all other domains singly accounted for significant variance in drinking outcomes. Proximal antecedents (from the prior 2-month interval) significantly and substantially improved predictive power over that achieved from pretreatment characteristics alone. When analyzed jointly, these predictors accounted for a majority of variance in 6-month relapse status. A prospective test supported Marlatt's developmental model of relapse, pointing to two client factors as optimally predictive of resumed drinking: lack of coping skills and belief in the disease model of alcoholism.

Alcohol, drug use and consequences among Hispanics seeking treatment for alcohol-related problems.

OBJECTIVE: Ethnic differences in alcohol consumption patterns are often reported in general population surveys, but less is known about variation among ethnic groups presenting for treatment. METHOD: Within a larger clinical trial, patterns of drinking, drug use and related problems were compared for Hispanic (n = 102) and non-Hispanic white (n = 104) male (n = 154) and female (n = 52) clients presenting at a public clinic for outpatient treatment of alcohol problems. RESULTS: Relatively few reliable ethnic differences were observed in alcohol /drug use patterns. Non-Hispanic white men reported significantly more pretreatment tobacco use than did Hispanic men (84.7% vs 61.3% of past 90 days). Hispanic women reported significantly fewer legal problems (28.6% vs 83.9%), symptoms of dependence and negative consequences of drinking relative to non-Hispanic white women. Measures of acculturation and acculturative stress failed to differentiate drinking patterns among Hispanic clients. CONCLUSIONS: Within a treatment-seeking sample, Hispanics and non-Hispanics may be more similar with regard to drinking practices than is the case in the general population. High consumption, adverse consequences and dependence symptoms were characteristic of men presenting for alcohol treatment regardless of ethnic identification. In contrast, Hispanic treatment-seeking women had the lowest consumption, adverse consequences and dependence symptoms of all the groups described, and they reported significantly fewer alcohol-related problems and symptoms than did non-Hispanic women.

Meta-analysis of the literature on Alcoholics Anonymous: sample and study characteristics moderate findings.

OBJECTIVE: Reviews of research on Alcoholics Anonymous (AA) have speculated how findings may differ when grouped by client and study characteristics. A meta-analytic review by Emrick et al. in 1993 provided empirical support for this concern but did not explore its implications. This review divided results of AA affiliation and outcome research by sample origin and global rating of study quality. The review also examined the statistical power of studies on AA. METHOD: Meta-analytic procedures were used to summarize the findings of 74 studies that examined AA affiliation and outcome. Results were divided by whether samples were drawn from outpatient or inpatient settings and a global rating of study quality that jointly considered use of subject selection and assignment, reliability of measurement and corroboration of self-report. Efficacy of dividing study results was examined by changes in magnitude of correlations and unexplained variance. RESULTS: AA participation and drinking outcomes were more strongly related in outpatient samples, and better designed studies were more likely to report positive psychosocial outcomes related to AA attendance. In general, AA studies lacked sufficient statistical power to detect relationships of interest. CONCLUSIONS: AA experiences and outcomes are heterogeneous, and it makes little sense to seek omnibus profiles of AA affiliates or outcomes. Well-designed studies with large outpatient samples may afford the best opportunity to detect predictors and effects of AA involvement.

AA group dynamics and 12-step activity.

OBJECTIVE: AA groups may differ in perceived social dynamics but little is known about diversity in other potentially curative processes within AA. This study examined how three AA groups differed in perceived social dynamics, group emphasis on the 12 steps of AA, and completion of the 12 steps. METHOD: Questionnaires were completed by AA members affiliated with three mainstream AA groups. Surveys were done after investigators paid several visits to meetings as an aid to identifying group members. A majority of the AA members were male (64%) and had, on average, 45 months of continuous sobriety. RESULTS: Profile analyses showed that the three AA groups differed in perceived group cohesiveness, independence, aggressiveness and expressiveness. The AA groups also differed in how frequently members reported that the 12 steps were discussed in meetings. Step discussion was lowest in the group with highest aggressiveness. Differences were also found in the reported frequency of completing AA steps, such that members in the group with highest cohesiveness and step discussion reported having completed the fewest surrender (1-3) steps. CONCLUSIONS: AA groups appear to differ not only in perceived social environment (fellowship) characteristics, but in AA program implementation as reflected in discussion and completion of the 12 steps. Such differences may be stable within groups across time. These findings further caution against regarding AA as a homogeneous entity. Clearer understanding of the heterogeneity among AA groups may provide bases for initial matching of individuals to AA experiences.

Does Alcoholics Anonymous involvement predict treatment outcome?

Patients receiving inpatient treatment for alcohol dependence were followed for 31 weeks after discharge. Alcoholics Anonymous (AA) attenders, when compared with nonattenders, were not distinguishable on pretreatment patient characteristics. Posttreatment attendance of AA was not predictive of drinking outcomes. However, a measure of the degree to which patients had become involved in AA did predict more favorable outcomes.

Comparison of three alcohol consumption measures: a concurrent validity study.

OBJECTIVE: The major objective of the current research was to compare three different alcohol consumption measures. METHOD: A 90-day timeline follow-back measure was compared with two averaging measures (a quantity-frequency scale and a grid measure) in a counterbalanced design with 42 male and 30 female subjects. RESULTS: Reasonable agreement was found among the three measures; the grid approach yielded significantly higher estimates of drinking days and total consumption, but lower estimates of peak intoxication levels. Subjects reported significantly less confidence in the accuracy of their own reports on the timeline, relative to the averaging methods. CONCLUSIONS: The merits of the various measures and implications for their use in treatment outcome research are discussed.

Classical analytical methods for detecting matching effects on treatment outcome.

This article presents a classical approach for analyzing repeated measures designs with specific application to treatment matching studies. The generic treatment matching hypothesis is formulated under the multivariate general linear model, transforming the dependent variables to account for the repeated measures structure of the data. Issues of primary importance in the use of this approach (such as correcting for inflated Type I error and robustness of statistical tests to parametric assumptions) are discussed. The article concludes with an assessment of the strengths and weaknesses of this approach compared with alternative approaches.

Assessment issues and strategies in alcoholism treatment matching research.

Sensitive and comprehensive client assessment entails complex conceptual and methodological considerations. Such activity is at the heart of matching clients to appropriate treatments. This article begins by specifying the goals and functions of assessment to support matching. This is followed by a discussion of the strategies employed in Project MATCH to identify matching and outcome variables. The assessment battery used in Project MATCH is next described. Finally, an overview of issues surrounding administration of assessment measures is provided. Particular attention is given to the topics of sequencing and timing of measures.

Differences among AA groups: implications for research.

Clinical writings and research often imply the homogeneity of Alcoholics Anonymous. Survey data from four groups reflected some consistencies as well as substantial variation in group environment that could have an important impact on outcomes and research.