Alcohol use disorders (AUDs) are highly prevalent in the United States and often are chronic conditions that require ongoing episodes of care over many years to achieve full sustained remission. Despite substantial scientific advances in specialized care, professional resources alone have not been able to cope with the immense burden of disease attributable to alcohol. Perhaps in tacit recognition of this, peer-run mutual-help groups (MHGs), such as Alcoholics Anonymous (AA), have emerged and proliferated in the past 75 years and continue to play an important role in recovery from AUDs. This article describes the nature and prevalence of MHGs, particularly AA, and reviews evidence for their effectiveness and cost effectiveness and the mechanisms through which they may exert their effects. The article also provides details about how health care professionals can facilitate their alcohol-dependent patients’ participation in such groups and reviews the evidence for the benefits of doing so.
Objective: Religious practices among adults are associated with more 12-step participation which, in turn, is linked to better treatment outcomes. Despite recommendations for adolescents to participate in mutual-help groups, little is known about how religious practices influence youth 12-step engagement and outcomes. This study examined the relationships among lifetime religiosity, during-treatment 12-step participation, and outcomes among adolescents, and tested whether any observed beneficial relation between higher religiosity and outcome could be explained by increased 12-step participation.
Method: Adolescents (n = 195; 52% female, ages 14–18) court-referred to a 2-month residential treatment were assessed at intake and discharge. Lifetime religiosity was assessed with the Religious Background and Behaviors Questionnaire; 12-step assessments measured meeting attendance, step work (General Alcoholics Anonymous Tools of Recovery), and Alcoholics Anonymous (AA)/Narcotics Anonymous (NA)-related helping. Substance-related outcomes and psychosocial outcomes were assessed with toxicology screens, the Adolescent–Obsessive Compulsive Drinking Scale, the Children's Global Assessment Scale, and the Narcissistic Personality Inventory.
Results: Greater lifetime formal religious practices at intake were associated with increased step work and AA/NA-related helping during treatment, which in turn were linked to improved substance outcomes, global functioning, and reduced narcissistic entitlement. Increased step work mediated the effect of religious practices on increased abstinence, whereas AA/NA-related helping mediated the effect of religiosity on reduced craving and entitlement.
Conclusions: Findings extend the evidence for the protective effects of lifetime religious behaviors to an improved treatment response among adolescents and provide preliminary support for the 12-step proposition that helping others in recovery may lead to better outcomes. Youth with low or no lifetime religious practices may assimilate less well into 12-step–oriented treatment and may need additional 12-step facilitation, or a different approach, to enhance treatment response.
Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have proven to be cost-effective recovery resources for adults and also appear helpful for youth. However, anecdotal concerns about adolescents’ safety at meetings have dampened enthusiasm regarding youth participation. Unfortunately, little information exists to evaluate such concerns. Outpatients (N = 127; 24% female) were assessed at intake, and 3, 6, and 12-months regarding perceived safety at AA/NA, experience of negative incidents, and reasons for non-attendance/discontinuation. By 12-month follow-up, 57.5% reported some AA/NA attendance with a combined lifetime exposure of 5,340 meetings. Of these, 21.9% reportedat least one negative experience, which was more common among NA than AA attendees. Overall, youthreported feeling very safe at meetings and ratings did not differ by age or gender. Reasons for discontinuation or non-attendance were unrelated to safety or negative incidents. Weighing risks against documented benefits, these preliminary findings suggest referral to AA/NA should not be discouraged, but, similar to adults, youth experiences at meetings should be monitored.
OBJECTIVE: Research on instruments designed to measure endorsement of 12 step beliefs and practices among individuals with substance use disorders is virtually nonexistent. The goal of this study was to examine the psychometric properties of a novel instrument called the 12 Step Affiliation and Practices Scale (TSAPS) using a sample of young adults receiving 12 step-based residential treatment for alcohol and drug dependence.
METHOD: As part of a naturalistic treatment outcome study, 300 young adults receiving residential treatment completed the TSAPS and several other assessments during and after treatment. Analyses of the TSAPS examined its factor structure, internal consistency, sensitivity to change over time, and convergent and predictive validity.
RESULTS: A maximum likelihood estimation factor analysis using oblique rotation produced 4 factors accounting for 61.16% of the variance. Internal consistency was very high and scores on the TSAPS significantly increased across the course of treatment. Convergent validity was demonstrated by relationships with scales of treatment attitudes, twelve step expectancies and commitment to sobriety. Predictive validity was also found, as evidenced by a relationship between total TSAPS score at 3 months post-treatment and percent of abstinent days at 6 months post-treatment.
CONCLUSIONS: The TSAPS shows promise as a psychometrically sound, internally reliable measure of 12 step affiliation and practices among individuals with substance dependence.
Existing measures of 12-step mutual-help activity typically capture only a narrow range of experiences and combine fellowships with explicitly different substance-specific emphases (e.g., Alcoholics versus Narcotics Anonymous). To help expand our knowledge in this important area, we report on the development and use of a comprehensive multidimensional measure of 12-step experiences in two clinical samples of young adults and adolescents (N=430). One-week test-retest reliability was verified on a subsample. Results indicated high content validity and reliability across seven dimensions of experience (meeting attendance, meeting participation, fellowship involvement, step work, mandated attendance, affiliation, and safety), and the measure successfully discriminated between samples on anticipated activity levels. This measure provides rich data on mutual-help activities and deepens our understanding of individuals' experiences across different 12-step organizations.
OBJECTIVE: Many individuals entering treatment are involved in social networks and activities that heighten relapse risk. Consequently, treatment programs facilitate engagement in social recovery resources, such as Alcoholics Anonymous (AA), to provide a low risk network. While it is assumed that AA works partially through this social mechanism, research has been limited in rigor and scope. This study used lagged mediational methods to examine changes in pro-abstinent and pro-drinking network ties and activities.
METHOD: Adults (N=1726) participating in a randomized controlled trial of alcohol use disorder treatment were assessed at intake, and 3, 9, and 15 months. Generalized linear modeling (Generalized linear modeling) tested whether changes in pro-abstinent and pro-drinking network ties and drinking and abstinent activities helped to explain AA's effects.
RESULTS: Greater AA attendance facilitated substantial decreases in pro-drinking social ties and significant, but less substantial increases in pro-abstinent ties. Also, AA attendance reduced engagement in drinking-related activities and increased engagement in abstinent activities. Lagged mediational analyses revealed that it was through reductions in pro-drinking network ties and, to a lesser degree, increases in pro-abstinent ties that AA exerted its salutary effect on abstinence, and to a lesser extent, on drinking intensity.
CONCLUSIONS: AA appears to facilitate recovery by mobilizing adaptive changes in the social networks of individuals exhibiting a broad range of impairment. Specifically by reducing involvement with pro-drinking ties and increasing involvement with pro-abstinent ties. These changes may aid recovery by decreasing exposure to alcohol-related cues thereby reducing craving, while simultaneously increasing rewarding social relationships.
BACKGROUND: Evidence indicates Alcoholics Anonymous (AA) can play a valuable role in recovery from alcohol use disorder. While AA itself purports it aids recovery through "spiritual" practices and beliefs, this claim remains contentious and has been only rarely formally investigated. Using a lagged, mediational analysis, with a large, clinical sample of adults with alcohol use disorder, this study examined the relationships among AA, spirituality/religiousness, and alcohol use, and tested whether the observed relation between AA and better alcohol outcomes can be explained by spiritual changes.
METHOD: Adults (N = 1,726) participating in a randomized controlled trial of psychosocial treatments for alcohol use disorder (Project MATCH) were assessed at treatment intake, and 3, 6, 9, 12, and 15 months on their AA attendance, spiritual/religious practices, and alcohol use outcomes using validated measures. General linear modeling (GLM) and controlled lagged mediational analyses were utilized to test for mediational effects.
RESULTS: Controlling for a variety of confounding variables, attending AA was associated with increases in spiritual practices, especially for those initially low on this measure at treatment intake. Results revealed AA was also consistently associated with better subsequent alcohol outcomes, which was partially mediated by increases in spirituality. This mediational effect was demonstrated across both outpatient and aftercare samples and both alcohol outcomes (proportion of abstinent days; drinks per drinking day).
CONCLUSIONS: Findings suggest that AA leads to better alcohol use outcomes, in part, by enhancing individuals' spiritual practices and provides support for AA's own emphasis on increasing spiritual practices to facilitate recovery from alcohol use disorder.
Objective: Failure to maintain abstinence despite incurring severe harm is perhaps the key defining feature of addiction. Relapse prevention strategies have been developed to attenuate this propensity to relapse, but predicting who will, and who will not, relapse has stymied attempts to more efficiently tailor treatments according to relapse risk profile. Here we examine the psychometric properties of a promising relapse risk measure - the Advance WArning of RElapse scale (AWARE) scale (Miller and Harris, 2000) in an understudied but clinically important sample of young adults.
Method: Inpatient youth (N=303; Age 18-24; 26% female) completed the AWARE scale and the Brief Symptom Inventory-18 (BSI) at the end of residential treatment, and at 1-, 3-, and 6-months following discharge. Internal and convergent validity was tested for each of these four timepoints using confirmatory factor analysis and correlations (with BSI scores). Predictive validity was tested for relapse 1, 3, and 6 months following discharge, as was incremental utility, where AWARE scores were used as predictors of any substance use while controlling for treatment entry substance use severity and having spent time in a controlled environment following treatment.
Results: Confirmatory factor analysis revealed a single, internally consistent, 25-item factor that demonstrated convergent validity and predicted subsequent relapse alone and when controlling for other important relapse risk predictors.
Conclusions: The AWARE scale may be a useful and efficient clinical tool for assessing short-term relapse risk among young people and, thus, could serve to enhance the effectiveness of relapse prevention efforts.
Single-item measures of psychological experiences are often viewed as psychometrically suspect. The purpose of this study was to evaluate the validity and utility of a single-item measure of self-efficacy in a clinical sample of treatment-seeking young adults. Inpatient young adults (N = 303, age = 18-24, 26% female) were assessed at intake to residential treatment, end of treatment, and at 1, 3, and 6 months following discharge. The single-item measure of self-efficacy consistently correlated positively with a well-established 20-item measure of self-efficacy and negatively with temptation scores from the same scale, demonstrating convergent and discriminant validity. It also consistently predicted relapse to substance use at 1-, 3-, and 6-month assessments postdischarge, even after controlling for other predictors of relapse (e.g., controlled environment), whereas global or subscale scores of the 20-item scale did not. Based on these findings, we encourage the use of this single-item measure of self-efficacy in research and clinical practice.
Substance-related terminology is often a contentious topic because certain terms may convey meanings that have stigmatizing consequences and present a barrier to treatment. Chief among these are the labels, “abuse” and “abuser.” While intense rhetoric has persisted on this topic, little empirical information exists to inform this debate. We tested whether referring to an individual as “a substance abuser (SA)” versus “having a substance use disorder” (SUD) evokes different judgments about treatment need, punishment, social threat, problem etiology, and self-regulation. Participants (N = 314, 76% female, 81% White, M age 38) from an urban setting completed an online 35-item assessment comparing two individuals labeled with these terms. Dependent t-tests were used to examine subscale differences. Compared to the SUD individual, the SA was perceived as engaging in willful misconduct, a greater social threat, and more deserving of punishment. The “abuser” label may perpetuate stigmatizing attitudes and serve as a barrier to help-seeking.
Substance use disorder (SUD) patients who become involved in 12-step mutual-help groups (MHGs), such as Alcoholics Anonymous, experience better outcomes and have reduced healthcare costs. In spite of this, many do not attend at all and other initial attendees drop out. Reasons for non-attendance and dropout have not been systematically studied, yet such knowledge could enhance the efficiency of twelve-step facilitation (TSF) efforts or help clinicians decide which patients might prefer non-12-step MHGs (e.g., SMART Recovery). This study developed and tested a measure of reasons for non-participation and dropout from 12-step MHGs. Items were generated and clustered into eight domains using a rational keying approach. Male veterans (N = 60; M age = 49; 41% African American) undergoing SUD treatment were asked to complete a brief assessment about prior MHG experiences. Psychometric analyses produced a 24-item measure containing seven internally consistent, face-valid, subscales. Co-morbid psychiatric issues and, to a lesser degree, spiritual concerns, were found to be particularly important dimensions relating to this phenomenon. The measure could serve as a useful screening tool for barriers to 12-step participation and subsequently focus TSF efforts or inform referral to non-12 step MHGs.
Objective: Measures of substance dependence severity that are both clinically efficient and sensitive to change can facilitate assessment of clinical innovation necessary for improving current evidence-based practices. The Leeds Dependence Questionnaire (LDQ) is a 10-item, continuous, self-report measure of dependence that is not specific to any particular substance and has shown promise in preliminary psychometric research. The present study investigates its psychometric properties in a large clinical sample of young adults.
Method: Emerging adults (N = 300) were enrolled in a naturalistic treatment process and outcome study of residential substance dependence treatment (mean age 20.4 [1.6], range 18–25; 27% female; 95% White). Dependence severity by demographic and diagnostic groupings, factor structure and internal consistency, and criterion- and construct-related validity were examined.
Results: Dependence severity in this cohort of youth overall was high (M = 18.65 [8.65]). LDQ scores were highest among opiate and stimulant users, and there was a trend for higher scores among women compared to men (t = 1.869, p = .063). Factor analysis using a robust alpha factoring extraction revealed a single factor accounting for 63% of the variance in reported dependence severity. The internal consistency was also very high (alpha = .93). Concurrent and convergent validity with dependence criteria, substance use frequency, and general symptom severity, respectively, were also acceptable.
Conclusions: The LDQ shows considerable promise as a brief, psychometrically sound, measure of substance dependence useful across a variety of substances, that has clinical and research utility. This study supports its use among emerging adults.
Rationale: Indices of negative affect, such as depression, have been implicated in stress-induced pathways to alcohol relapse. Empirically supported continuing care resources, such as Alcoholics Anonymous (AA), emphasize reducing negative affect to reduce relapse risk, but little research has been conducted to examine putative affective mechanisms of AA's effects.
Methods: Using lagged, controlled, hierarchical linear modeling and mediational analyses this study investigated whether AA participation mobilized changes in depression symptoms and whether such changes explained subsequent reductions in alcohol use. Alcohol-dependent adults (n = 1706), receiving treatment as part of a clinical trial, were assessed at intake, 3, 6, 9, 12 and 15 months.
Results: Findings revealed elevated levels of depression compared to the general population, which decreased during treatment and then remained stable over follow-up. Greater AA attendance was associated with better subsequent alcohol use outcomes and decreased depression. Greater depression was associated with heavier and more frequent drinking. Lagged mediation analyses revealed that the effects of AA on alcohol use was mediated partially by reductions in depression symptoms. However, this salutary effect on depression itself appeared to be explained by AA's proximal effect on reducing concurrent drinking.
Conclusions: AA attendance was associated both concurrently and predictively with improved alcohol outcomes. Although AA attendance was associated additionally with subsequent improvements in depression, it did not predict such improvements over and above concurrent alcohol use. AA appears to lead both to improvements in alcohol use and psychological and emotional wellbeing which, in turn, may reinforce further abstinence and recovery-related change.
Objective: Anger and other indices of negative affect have been implicated in a stress-induced pathway to relapse. The Alcoholics Anonymous (AA) literature states that reduction of anger is critical to recovery, yet this proposed mechanism has rarely been investigated. Using lagged, controlled hierarchical linear modeling analyses, this study investigated whether AA attendance mobilized changes in anger and whether such changes explained AA-related benefit.
Method: Alcohol-dependent adults (N = 1,706) receiving treatment as part of a clinical trial were assessed at intake and at 3, 6, 9, 12, and 15 months.
Results: Findings revealed substantially elevated levels of anger compared with the general population (98th percentile) that decreased over 15-month follow-up but remained high (89th percentile). AA attendance was associated with better drinking outcomes, and higher levels of anger were associated with heavier drinking. However, AA attendance was unrelated to changes in anger.
Conclusions: Although support was not found for anger as a mediator, there was strong convergence between AA's explicit emphasis on anger and the present findings: Anger appears to be a serious, enduring problem related to relapse and heavy alcohol consumption. Methodological factors may have contributed to the lack of association between AA and anger, but results suggest that AA attendance alone may be insufficient to alleviate the suffering and alcohol-related risks specifically associated with anger.
Objective: Stigma is a frequently cited barrier to help-seeking for many with substance-related conditions. Common ways of describing individuals with such problems may perpetuate or diminish stigmatizing attitudes yet little research exists to inform this debate. We sought to determine whether referring to an individual as “a substance abuser” vs. “having a substance use disorder” evokes different judgments about behavioral self-regulation, social threat, and treatment vs. punishment.
Method: A randomized, between-subjects, cross-sectional design was utilized. Participants were asked to read a vignette containing one of the two terms and to rate their agreement with a number of related statements. Clinicians (N = 516) attending two mental health conferences (63% female, 81% white, M age 51; 65% doctoral-level) completed the study (71% response rate). A Likert-scaled questionnaire with three subscales [“perpetrator-punishment” (α = .80); “social threat” (α = .86); “victim-treatment” (α = .64)] assessed the perceived causes of the problem, whether the character was a social threat, able to regulate substance use, and should receive therapeutic vs. punitive action.
Results: No differences were detected between groups on the social threat or victim-treatment subscales. However, a difference was detected on the perpetrator-punishment scale. Compared to those in the “substance use disorder” condition, those in the “substance abuser” condition agreed more with the notion that the character was personally culpable and that punitive measures should be taken.
Conclusions: Even among highly trained mental health professionals, exposure to these two commonly used terms evokes systematically different judgments. The commonly used “substance abuser” term may perpetuate stigmatizing attitudes.
Evidence from multiple lines of research supports the effectiveness and practical importance of Alcoholics Anonymous and Narcotics Anonymous. Conference presenters discussed the relationship between 12-Step participation and abstinence among various populations, including adolescents, women, and urban drug users. Insight from the arts and humanities placed empirical findings in a holistic context.
Methamphetamine (meth) is a highly addictive psychostimulant which activates the brain's reward pathway like no other substance. It is associated with risky sexual practices, HIV/AIDS, antisocial behavior, and violence. For the first time, women are presenting for treatment with a primary methamphetamine use disorder at higher rates than men. Yet, current treatment and prevention initiatives may not be sufficiently sensitive to the unique risks associated with women's use of meth. This article describes the history and rise of methamphetamine and outlines the qualities of meth that contribute to its unique social and environmental impact. Specific attention is devoted to women's experiences with meth focusing on sexual practices, HIV/AIDS, antisocial and violent behavior. Implications for treatment, prevention and research are discussed.
Background: Despite advances in the development of treatments for adolescents with substance use disorders (SUD), relapse remains common following an index treatment episode. Community continuing care resources, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), have been shown to be helpful and cost-effective recovery resources among adults. However, little is known about the clinical utility and effectiveness of AA/NA for adolescents, despite widespread treatment referrals.
Method: Adolescents (N = 127; 24% female, 87% White, M age = 16.7 years) enrolled in a naturalistic, prospective study of community outpatient treatment were assessed at intake, and 3- and 6-months later using a battery of standardized and validated measures.
Results: Just over one-quarter of youth attended AA/NA meetings during the first 3-months, which was predicted by a goal of abstinence, prior AA/NA attendance, and prior SUD treatment experiences. Controlled multiple regression analyses revealed an independent effect of AA/NA on abstinence, in both contemporaneous and lagged models, which persisted over and above the effects of pre-treatment AA/NA attendance, prior treatment, self-efficacy, abstinence goal, and concomitant outpatient treatment.
Conclusions: Results suggest that, similar to findings comparing adult outpatients to inpatients, AA/NA participation is less common among less severe adolescent outpatients. Nonetheless, attendance appears to strengthen and extend the benefits of typical community outpatient treatment. Given the dramatic increase in rates of substance use among same-aged peers in the population at this life-stage, and the relative dearth of abstainers and recovery-specific supports, these resources may provide a concentrated cost-effective social recovery resource for young people.
Yeterian, J., Pachas, G., Evins, A. E., & Kelly, J. F. (2009). Assessment of alcohol and nicotine. In L. Baer & M. Blais (Ed.), Handbook of clinical rating scales and assessment in psychiatry and mental health (pp. 87-123) . Totowa: Humana Press.