Rigorous reviews of the science on the effectiveness of Alcoholics Anonymous (AA) indicate that AA and related 12-step treatment are at least as helpful as other intervention approaches. Exactly how AA achieves these beneficial outcomes is less well understood, yet, greater elucidation of AA's mechanisms could inform our understanding of addiction recovery and the timing and content of alcohol-related interventions. Empirical studies examining AA's mechanisms were located from searches in Pubmed, Medline, PsycINFO, Social Service Abstracts and from published reference lists. Thirteen studies completed full mediational tests. A further six were included that had completed partial tests. Mechanisms examined fell into three domains: (1) Common processes; (2) AA-specific practices; and (3) Social and spiritual processes. Results suggest AA helps individuals recover through common process mechanisms associated with enhancing self-efficacy, coping skills, and motivation, and by facilitating adaptive social network changes. Little research or support was found for AA's specific practices or spiritual mechanisms. Conclusions are limited by between-study differences in sampling, measurement, and assessment time-points, and by insufficient theoretical elaboration of recovery-related change. Similar to the common finding that theoretically-distinct professional interventions do not result in differential patient outcomes, AA's effectiveness may not be due to its specific content or process. Rather, its chief strength may lie in its ability to provide free, long-term, easy access and exposure to recovery-related common therapeutic elements, the dose of which, can be adaptively self-regulated according to perceived need.
Kelly, J. F., & Yeterian, J. (2008). Mutual-help groups. In W. O'Donohue & J. R. Cunningham (Ed.), Evidence-Based Adjunctive Treatments (pp. 61-106) . Philadelphia: Elsevier.
Kelly, J. F., & Renner, J. (2008). Alcohol related disorders. In T. A. Stern, J. F. Rosenbaum, M. Fava, J. Biederman, & S. L. Rauch (Ed.), Massachusetts General Hospital Comprehensive Clinical Psychiatry (pp. 337-354) . Philadelphia: Elsevier.
Mutual-help groups (MHGs), such as Alcoholics Anonymous (AA), have been shown to be helpful to a broad range of individuals suffering from substance use disorders (SUD). However, for the substantial number of SUD individuals suffering from co-occurring psychiatric conditions, purely substance-focused groups, such as AA, may not be as good a fit. Consequently, MHGs have emerged that focus more explicitly on both substance use and other psychiatric concerns. In this review, we describe, compare, and discuss the four largest “dual-focused” mutual-help organizations and examine the evidence for any incremental benefit they may offer dually diagnosed individuals. We also provide evidence-based recommendations for ways in which clinicians can facilitate patients’ participation in these groups.
Abundant evidence indicates that the neuronal nicotinic acetylcholine receptor (nAChR) system is integral to regulation of attentional processes and is dysregulated in schizophrenia. Nicotinic agonists may have potential for the treatment of cognitive impairment in this disease. This study investigated the effects of transdermal nicotine on attention in individuals with schizophrenia (n=28) and healthy controls (n=32). All participants were nonsmokers in order to eliminate confounding effects of nicotine withdrawal and reinstatement that may occur in the study of smokers. Subjects received 14 mg transdermal nicotine and identical placebo in a randomized, placebo-controlled, crossover design. A cognitive battery was conducted before and 3 h after each patch application. The primary outcome measure was performance on the Continuous Performance Test Identical Pairs (CPT-IP) Version. Nicotine significantly improved the performance on the CPT-IP as measured by hit reaction time, hit reaction time standard deviation and random errors in both groups. In addition, nicotine reduced commission errors on the CPT-IP and improved the performance on a Card Stroop task to a greater extent in those with schizophrenia vs controls. In summary, nicotine improved attentional performance in both groups and was associated with greater improvements in inhibition of impulsive responses in subjects with schizophrenia. These results confirm previous findings that a single dose of nicotine improves attention and suggest that nicotine may specifically improve response inhibition in nonsmokers with schizophrenia.
OBJECTIVE: To test the effectiveness of a care coordination program for telephone counseling in raising referral and treatment rates for smoking cessation.
STUDY DESIGN: A demonstration project implementing a smoking cessation care coordination program offering telephone counseling and medication management to patients referred from primary care.
METHODS: The study was performed at 18 Veterans Health Administration (VA) sites in California. Participants were VA patients receiving primary care. We randomly allocated 10 of 18 sites to receive the Telephone Care Coordination Program, which included simple 2-click referral, proactive care coordination, medication management, and 5 follow-up telephone calls. Each patient received a 30- to 45-minute counseling session from the California Smokers' Helpline. Patients at control sites received usual care.
RESULTS: During 10 months, we received 2965 referrals. We were unable to reach 1156 patients (39%), despite at least 3 attempts. We excluded 73 patients (3%), and 391 patients (13%) were not interested. We connected the remaining 1345 patients (45%) to the Helpline. At 6-month followup, 335 patients (11% of all referrals and 25% of participating patients) were abstinent. Providers at intervention sites reported referring many more patients to telephone counseling than providers at control sites (15.6 vs 0.7 in the prior month).
CONCLUSIONS: The program generated a large number of referrals; almost half of the patients referred were connected with the Helpline. Long-term abstinence was excellent. These results suggest that managed care organizations may be able to improve tobacco control by implementing a similar system of care coordination.
Adolescents treated for substance use disorders (SUD) appear to benefit from AA/NA participation. However, as compared to adults, fewer adolescents attend, and those who do attend do so less intensively and discontinue sooner. It is unknown whether this disparity is due to a lowered expectation for youth participation by the clinicians treating them, as they may adapt the adult-based model to fit a less dependent cohort, or whether recommendations are similar to those of clinicians who work with adults, and other factors are responsible. All clinical staff (N = 114) at five adolescent programs (3 residential, 2 outpatient) were surveyed anonymously about referral practices and other beliefs about 12-step groups. Staff rated AA/NA participation as very important and helpful to adolescent recovery and referral rates were uniformly high (M = 86%, SD = 28%). Desired participation frequency was over 3 times per week. The theoretical orientation and level of care of the programs influenced some results. Findings suggest lower adolescent participation in 12-step groups is not due to a lack of clinician enthusiasm or referrals, but appears to be due to other factors.
OBJECTIVES: Referral to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) is a common continuing care recommendation. Evidence suggests some youth benefit, yet, despite referrals, youth participation is low. Little is known about adolescents' experiences of AA/NA. Greater knowledge would inform and help tailor aftercare recommendations. METHOD: Two clinical samples of youth (N = 74 and N= 377) were asked about their perceptions of, and experiences with, AA/NA with responses categorized by content into domains assessed for face validity and reliability. RESULTS: The aspects of AA/NA youth liked best were general group dynamic processes related to universality, support, and instillation of hope. The most common reason for discontinuing was boredom/lack of fit. CONCLUSIONS: General group-therapeutic, and not 12-step-specific, factors are most valued by youth during early stages of recovery and/or degree of AA/NA exposure. Many youth discontinue due to a perceived lack of fit, suggesting a mismatch between some youth and aspects of AA/NA.
BACKGROUND: Despite widespread use of 12-step treatment approaches and referrals to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) by youth providers, little is known about the significance of these organizations in youth addiction recovery. Furthermore, existing evidence is based mostly on short-term follow-up and is limited methodologically.
METHODS: Adolescent inpatients (n = 160; mean age = 16, 40% female) were followed at 6-months, and at 1, 2, 4, 6, and 8 years posttreatment. Time-lagged, generalized estimating equations modeled treatment outcome in relation to AA/NA attendance controlling for static and time-varying covariates. Robust regression (locally weighted scatterplot smoothing) explored dose-response thresholds of AA/NA attendance on outcome.
RESULTS: The AA/NA attendance was common and intensive early posttreatment, but declined sharply and steadily over the 8-year period. Patients with greater addiction severity and those who believed that they could not use substances in moderation were more likely to attend. Despite declining attendance, the effects related to AA/NA remained significant and consistent. Greater early participation was associated with better long-term outcomes.
CONCLUSIONS: Even though many youth discontinue AA/NA over time, attendees appear to benefit, and more severely substance-involved youth attend most. Successful early posttreatment engagement of youth in abstinence-supportive social contexts, such as AA/NA, may have long-term implications for alcohol and drug involvement into young adulthood.
Youth treatment programs frequently employ 12-Step concepts and encourage participation in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Since AA/NA groups are easily accessible at no charge and provide flexible support at times of high relapse risk they hold promise as a treatment adjunct in an increasingly cost-constricting economic climate. Yet, due to concerns related to adolescents' developmental status, skepticism exists regarding the utility of AA/NA for youth. This review evaluates the empirical evidence in this regard, identifies and discusses knowledge gaps, and recommends areas for future research. Searches were conducted in PsychINFO, Medline, relevant literature and by personal correspondence. Findings suggest youth may benefit from AA/NA participation following treatment, but conclusions are limited by four important factors: (1) a small number of studies; (2) no studies with outpatients; (3) existing evidence is solely observational; and (4) only partial measurement of the 12-Step construct. While surveys of adolescent SUD treatment programs indicate widespread clinical interest and application of adult-derived 12-Step approaches this level of enthusiasm has not been reflected in the research community. Qualitative research is needed to improve our understanding of youth-specific AA/NA barriers, and efficacy, comparative effectiveness, and process studies are still needed to inform clinical practice guidelines for youth providers.
Cigarette and alcohol use often develop concurrently, and smoking is especially common among youth treated for alcohol and other drug (AOD) use disorders. Special considerations for adolescent smoking cessation treatment include peer influences, motivation, and nicotine dependence. Little research has addressed smoking cessation treatment for youth with AOD use disorders, but the few available studies suggest that tobacco cessation efforts are feasible and potentially effective for this population. Findings to date suggest that adolescents with AOD use disorders may benefit more from relatively intensive multicomponent programs rather than brief treatment for smoking cessation. Additional research is needed to further address the inclusion of tobacco-specific interventions for adolescents in AOD use disorder treatment programs.
Objective: The aim of this study was to use pretreatment and treatment factors to predict dropout from residential substance use disorder program and to examine how the treatment environment modifies the risk for dropout.
Method: This study assessed 3649 male patients at entry to residential substance use disorder treatment and obtained information about their perceptions of the treatment environment.
Results: Baseline factors that predicted dropout included younger age, greater cognitive dysfunction, more drug use, and lower severity of alcohol dependence. Patients in treatment environments appraised as low in support or high in control also were more likely to drop out. Further, patients at high risk of dropout were especially likely to dropout when treated in a highly controlling treatment environment.
Conclusion: Better screening of risk factors for dropout and efforts to create a less controlling treatment environment may result in increased retention in substance use disorder treatment.
BACKGROUND: Addiction-focused mutual-help group participation is associated with better substance use disorder (SUD) treatment outcomes. However, little has been documented regarding which types of mutual-help organizations patients attend, what levels of participation may be beneficial, and which patients, in particular, are more or less likely to participate. Furthermore, much of the evidence supporting the use of these organizations comes from studies examining participation and outcomes concurrently, raising doubts about cause-effect connections, and little is known about influences that may moderate the degree of any general benefit.
METHOD: Alcohol-dependent outpatients (N=227; 27% female; M age=42) enrolled in a randomized-controlled telephone case monitoring trial were assessed at treatment intake and at 1, 2, and 3 years postdischarge. Lagged-panel, hierarchical linear models tested whether mutual-help group participation in the first and second year following treatment predicted subsequent outcomes and whether these effects were moderated by gender, concurrent axis I diagnosis, religious preference, and prior mutual-help experience. Robust regression curve analysis was used to examine dose-response relationships between mutual-help and outcomes.
RESULTS: Mutual-help participation was associated with both greater abstinence and fewer drinks per drinking day and this relationship was not found to be influenced by gender, Axis I diagnosis, religious preference, or prior mutual-help participation. Mutual-help participants attended predominantly Alcoholics Anonymous and tended to be Caucasian, be more educated, have prior mutual-help experience, and have more severe alcohol involvement. Dose-response curve analyses suggested that even small amounts of participation may be helpful in increasing abstinence, whereas higher doses may be needed to reduce relapse intensity.
CONCLUSIONS: Use of mutual-help groups following intensive outpatient SUD treatment appears to be beneficial for many different types of patients and even modest levels of participation may be helpful. Future emphasis should be placed on ways to engage individuals with these cost-effective resources over time and to gather and disseminate evidence regarding additional mutual-help organizations.
OBJECTIVE: There are no available instruments that assess expectancies for participation in 12-step mutual-help groups despite the impact such expectancies may have on actual participation. The purpose of the present study was to develop a measure of attitudes and expectancies regarding 12-step participation, to conduct preliminary analyses on its psychometric properties, and to explore its concurrent and predictive validity.
METHOD: Alcohol-dependent patients (N=48) undergoing inpatient detoxification completed a questionnaire that included subscales assessing expected benefits of, concerns about, and barriers to 12-step participation. Participants also completed measures of 12-step group participation and drinking outcomes at 1, 3, and 6 months following discharge.
RESULTS: After examining the internal consistency of the items within each subscale and refining the questionnaire accordingly, an exploratory factor analysis showed that the scales could be combined into a higher-order total score. This total score correlated significantly with prior 12-step experience and goals for attending future 12-step meetings. In addition, the Expectancies Total Score at baseline significantly predicted 12-step group participation during follow-up.
CONCLUSIONS: The measure of attitudes and expectancies regarding 12-step group participation demonstrated good internal consistency, concurrent validity, and predictive validity. The measure may have clinical utility in highlighting patients' expectancies regarding 12-step participation, allowing treatment providers to explore with patients the benefits, concerns, and barriers to involvement that they have endorsed.