AA Effectiveness Faith Meets Science

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AA Effectiveness Faith Meets Science

• Presented by Sarah Zemore, Ph.D.
• Written by Lee Ann Kaskutas, Dr.P.H.
• Alcohol Research Group, Emeryville, CA
• University of California, Berkeley, CA
• Presented at the University of Michigans
  conference on How Alcoholics Anonymous (AA) and
  Narcotics Anonymous (NA) Work Cross-disciplinary
  Perspectives
• September 25, 2009
• Ann Arbor, Michigan

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Perspectives on AA Effectiveness

• AA members I know AA works and there is no need
  for research to prove that

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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

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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

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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

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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
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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
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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
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MOOS MOOS A 16-year study
Outcomes by Treatment AA status measured at
Year 1
Timko et al., JSA 2000 Moos Moos, ACER, 2005
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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
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Abstinence meeting amount
Male VA residential patients n 2376
Moos et al., J Clin Psychol 2001
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Abstinence meeting frequency
LA Target Cities, outpatients n 262
Fiorentine, Am J Drug Alcohol Ab 1999
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AA meeting trajectories
Dependent treatment seekers n 349
Kaskutas et al., ACER 2005
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Abstinence and meeting trajectories
Dependent treatment seekers n 349
Kaskutas et al., ACER 2005
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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
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Consistency across samples
NESARC dependent Tx 12-step both nothing n
4422 n239 n138 n829 n3217
(Dawson, Addiction 2006)
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Consistency across time
AA involvement assessed immediately post-tx
Abstinence at 10 years
significant
Inpatients n158
Cross et al., ACER 1990
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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
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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
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Alcohol abstinence following AA
Percent days abstinent mos. 7-12
AA involvement mos. 1-6
Outpatient ß .29
Aftercare ß .34
Project MATCH n 480 outpatients, n 434
aftercare
Connors et al., J Stud Alcohol 2001
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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
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Randomizing to AAto remove selection
effectWalsh, 1991
Alcohol abusers EAP referred n 227 n73
hospital n83 AA n71 choice
Walsh et al., New Engl J Med 1991
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Ditman, 1967

• Sample Court-referred chronic drunk offenders
  Men who had received either 2 drunk arrests in
  the previous month or 3 in the previous year.
• Three conditions
• AA alone (N86)
• alcoholism clinic (N82)
• no treatment (N73)
• AA was equivalent to other conditions Rates of
  re-arrest were equivalent across conditions, with
  AA alone at 69, the clinic at 68, and no
  treatment at 56. Similar results obtained for
  time to re-arrest. Drinking outcomes were not
  assessed.

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Brandsma, 1980

• Sample Male drunk-driving offenders between 24
  and 58 years of age. Screened to establish that
  they were alcoholic.
• Three conditions
• AA alone (initial N38, final N12)
• Rational-behavioral therapy (RBT) (initial N42,
  final N42)
• No treatment (N31)
• AA alone was similar to RBT on most outcomes
  (including abstinence, drinks per drinking day,
  and re-arrest), and both were better than no
  treatment. AA alone showed higher binge rates
  than RBT at 3 months (with no differences at 12).
  However, participants were excluded from the
  study for exceeding the maximum treatment
  criterion.

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Randomize to TSFto remove selection effect
Outpatient sample
p .0024
p lt .007
Project MATCH n 806 outpatients at yr 3
PMRG, J Stud Alcohol 1997 PMRG, ACER 1998
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Randomize to TSFto remove selection effect
Aftercare sample
Project MATCH aftercare n 714 at 1-year
follow-up
PMRG, J Stud Alcohol 1997
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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
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Statistical models to study selection effect
Baseline
2 years
1 year
Motivation
negative
Alcohol problems
AA involvement
negative
no difference
Psychopathology
Male VA inpatients N2,319
McKellar et al., J Consult Clin Psych 2003
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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
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Consistency with Theory
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Mechanism from meetings

• What you do
• Avoid going to a bar
• Talk about your problems

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Mechanism from meetings

• What you do
• Avoid going to a bar
• Talk about your problems
• What you hear
• That others had similar
• experiences, succeeded
• Coping strategies

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Mechanism from meetings

• What you do
• Avoid going to a bar
• Talk about your problems
• What you hear
• That others had similar
• experiences, succeeded
• Coping strategies
• What happens
• Your mood changes
• You avoid drinking for that day

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Mechanism from fellowship

• Friendship
• Adds sober people supportive of abstinence
• Generates new role models
• Helps you learn how to have fun sober

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Mechanism from fellowship

• Friendship
• Adds sober people supportive of abstinence
• Generates new role models
• Helps you learn how to have fun sober
• Sponsorship
• Provides someone to call in need
• Provides emotional support

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Evidence of mechanismcognitive behavioral
Abstinence
AA involvement
Self-efficacy
Coping skills
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 n74
n466 n2,337
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Evidence of mechanismsocial learning
Abstinence
AA involvement
Fewer pro-drinking influences
Enhanced friendship networks
More friends
Support for 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 n2,337 n466
n655
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Evidence of mechanismpsychodynamic
Abstinence
AA involvement
Life meaning
Motivation for abstinence
White Laudet, CPDD 2006 Kelly et al., J Stud
Alcohol 2002
In recovery adolescent inpatients n 354
n 74
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Evidence of mechanismspirituality
Abstinence
AA involvement
Religious beliefs behaviors
Spiritual awakening
Day Hosp Residential, managed care n 537
Zemore, ACER 2007
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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
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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_at_arg.org)

Kaskutas Oberste, MAAEZ 2002
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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)

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