AA Effectiveness – Faith Meets Science Lee Ann Kaskutas, Dr.P.H. Alcohol Research Group, Emeryville, CA School of Public Health, UC Berkeley Presented

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, 2012Fort Worth, TX

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









Substance use following AA/NA

12-step activitiesmos. 1-3

Alcohol and drug usemos. 4-6

12-step meetingsmos. 1-3 No

Yes

Weiss et al., Drug Alcohol Depen 2005Cocaine-dependent outpatientsn = 336

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









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

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

Specificity: Randomizing to Intensive AA/NA Referral

51.4% 40.7%0

10

20

30

40

50

60

% a

bst

inen

t at

6,

12 m

os

Intensive Referral Standard Referral

Timko & DeBendetti, Drug Alc Dep, 2007VA outpatientsn = 207: n=161 intensive; n=146 standard referral

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

Standard

Referral

Intensive

Referral

P

Value

# of meetings 57 64 ns

Did service 45% 56% < .05

Had awakening 39% 52% < .01

Had a sponsor 38% 48% <.05

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)

12-month Outcomes

Usual care

MAAEZ

% Clean 71 79

% Sober 83 92

% Clean & Sober

72 82

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

Motivation negative

Alcoholproblems

AAinvolvement

Psychopathology

negative

no difference

Baseline 2 years1 year

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

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

Cog Beh Soc Lrn Psy

alternative cue

need

succeed

skills

mood

alternative efficacy

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

Cog Beh Soc Lrn Psy

cue

model

alternative cue need

emerg plan

need

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

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:social learning?

AbstinenceMAAEZ

Sponsor

Service 6+12mos;

high psych

Comfort speak; be

@ meetings

# who supportabstinence

Kaskutas et al., JSAT 2009

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


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 ([email protected])

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):891-9006 Bond et al, JSA 2003;64(4):579-5887 Riessman, Social Policy 1976;7:41-458 Zemore, Southern Medical Journal, forthcoming9 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

Principles, not Personalities

• Common objections to AA– It is a cult

• No single person speaks for AA• Homework

– Ask someone you don’t know at meeting, for their phone #• Telephone them (and talk to them)

before next session

Sponsorship

• 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

Living Sober

• Sober fun: or, Is there life after sobriety?– What are some things you are worried

about being able to do without the help of alcohol or drugs?

• Homework: do something with one or more people from AA who have more sobriety than you

Acknowledgements:Funding

• 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)

Acknowledgements:People

• Eddie Oberste– co-developed MAAEZ

• Thomasina Borkman, Constance Weisner, David Pating– expert panel on MAAEZ development

• Ann Munoz, Sarah Zemore, Jane Witbrodt, Mina Subbaraman– fieldwork and analysis for MAAEZ study

Documents

AA Effectiveness – Faith Meets Science Lee Ann Kaskutas, Dr.P.H. Alcohol Research Group, Emeryville, CA School of Public Health, UC Berkeley Presented