AA Effectiveness Faith Meets Science

Transcription

1 AA Effectiveness Faith Meets Science Lee Ann Kaskutas, Dr.P.H. Alcohol Research Group, Emeryville, CA School of Public Health, UC Berkeley East Bay Community Recovery Project June 26, 2007 Oakland, California

2 Perspectives on AA Effectiveness AA members: I know AA works and there is no need for research to prove that

3 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

4 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

5 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

6 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

7 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

8 Abstinence & AA exposure % abstinent AA no AA at 1 yr. at 18 mos. male VA inpatients 1 yr n = 3018; 18 mo n = 91 Ouimette et al., J Stud Alcohol 1998 Thurstin et al., Int J Addict 1987

9 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

10 Abstinence & meeting amount % abstinent mos # of meetings mos Male VA residential patients n = 2376 Moos et al., J Clin Psychol 2001

11 Abstinence & meeting frequency % abstinent at 2 yrs never less than weekly weekly meeting frequency, mos LA Target Cities, outpatients n = 262 Fiorentine, Am J Drug Alcohol Ab 1999

12 Abstinence & sustained attendance % abstinent 16 years year 1 years 2-3 years 4-8 meetings none 1-8 wks 9-26 wks 27+ wks duration of AA attendance Previously untreated problem drinkers n = 461 Moos & Moos, J Clin Psychol 2006 Also see Moos & Moos, JSAT 2004

13 AA meeting trajectories # of AA meetings, pst yr TxEntry 1 year 3 years 5 years declining AA high AA medium AA low AA Dependent treatment seekers n = 349 Kaskutas et al., ACER 2005

14 Abstinence and meeting trajectories % abstinent year 3 years 5 years declining AA high AA medium AA low AA no AA Dependent treatment seekers n = 349 Kaskutas et al., ACER 2005

15 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

16 Consistency across samples & time % abstinent nothing outpatient only AA only AA + outpatient 0 1 year 3 years 8 years a b b a Male VA inpatients b Previously untx prob drnkrs n = 3018 n = 466 a Ouimette et al., J Stud Alcohol 1998 b Timko et al., J Stud Alcohol 2000

17 Consistency across samples 6 hazards of abstinence (vs. nothing) formal tx only 12-step only 12-step + tx NESARC; dependent Tx 12-step both nothing n = 4422 n=239 n=138 n=829 n=3217 (Dawson, Addiction 2006)

18 Consistency across time AA involvement over 10 years significant Abstinence at 10 years Inpatients n=158 Cross et al., ACER 1990

19 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

20 Alcohol abstinence following AA AA involvement mos. 1-6 Outpatient β =.29 Aftercare β =.34 Percent days abstinent mos Project MATCH n = 480 outpatients, n = 434 aftercare Connors et al., J Stud Alcohol 2001

21 Substance use following AA/NA 12-step meetings mos. 1-3 N.S. Signif. Alcohol and drug use mos step activities mos. 1-3 Cocaine-dependent outpatients in 6-month treatment program n = 336 Weiss et al., Drug Alcohol Depen 2005

22 Which Activities During Treatment Mattered the Most in that Study? Speaking at a meeting Making coffee Talking with sponsor outside the meeting Reading literature Working on a step What about increasing what you do? Increasing attendance from one month to the next: no effect Increasing participation from one month to the next: affected drug use the next month Weiss et al., Drug Alcohol Depen 2005

23 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

24 Randomizing to AA to remove selection effect % abstinent at 2 yrs Hospital inpatient AA meetings Choice Alcohol abusers + EAP referred n = 227: n=73 hospital; n=83 AA; n=71 choice Walsh et al., New Engl J Med 1991

25 Randomize to TSF to remove selection effect: Outpatient sample % abstinent, past 3 mos yr follow-up 3-yr follow-up 12-step Motiv Cog Beh p =.0024 p <.007 Project MATCH n = 806 outpatients at yr 3 PMRG, J Stud Alcohol 1997 PMRG, ACER 1998

26 Randomize to TSF to remove selection effect: Aftercare sample % abstinent mos step Motiv Cog Beh Project MATCH aftercare n = 714 at 1-year follow-up PMRG, J Stud Alcohol 1997

27 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

28 Statistical models to study selection effect Baseline 1 year 2 years Motivation AA involvement negative Alcohol problems Psychopathology Male VA inpatients N=2,319 McKellar et al., J Consult Clin Psych 2003

29 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

30 Consistency with Theory Problem Solution Theory Drinking is a habit Everyone around me drinks Drink due to unmet needs/ psych. states Drink due to spiritual condition Drink refusal skills Emergency planning Choose alternative behavior Δ environmental cues See others succeed Self-efficacy Better role models Address needs Δ mood Spiritual awakening Cognitive Behavioral Social Learning Psychodynamic

31 Consistency with Theory Problem Solution Theory Predisposed to develop alcoholism Drugs Brain becomes addicted Drugs Genetic Neurobiology

32 Mechanism from meetings What you do Place to go instead of bar Talk about your problems Cog Beh Soc Lrn Psy alternative cue need

33 Mechanism from 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 Cog Beh Soc Lrn Psy alternative cue need succeed skills

34 Mechanism from 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

35 Mechanism from fellowship Friendship Adds sober people supportive of your abstinence Role models of new behavior Helps learn how to have fun sober Cog Beh Soc Lrn Psy cue model alternative cue need

36 Mechanism from 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

37 Mechanism from the steps Change how you treat others, or you will drink Personal inventory; amends Cog Beh Soc Lrn Psy need

38 Mechanism from the 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

39 Evidence of mechanism: cognitive behavioral AA involvement Abstinence Self-efficacy* Coping skills** * 1 Resi or IOP *2 asolescent inpatients ** 1 initially untx PDs ** 2 male VA inpatients n = 100 n=74 n=466 n=2,337 * 1 Morgenstern et al., J Consult Clin Psych 1997 * 2 Kelly et al., J Stud Alcohol 2002 ** 1 Timko et al., ACER 2005 ** 2 Humphreys et al., Ann Behav Med 1999

40 Evidence of mechanism: social learning AA involvement Abstinence Fewer pro-drinking influences* Enhanced friendship networks** More friends * treated ** male VA inpat. init. untx. PDs treated n = 722 n=2,337 n=466 n=655 # who support 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

41 Evidence of mechanism: psychodynamic AA involvement Abstinence Life meaning* Motivation for abstinence** *In recovery **adolescent inpatients n = 354 n = 74 *White & Laudet, CPDD 2006 **Kelly et al., J Stud Alcohol 2002

42 Evidence of mechanism: spirituality AA involvement Abstinence Δ religious beliefs & behaviors Spiritual awakening Day Hosp & Residential, managed care n = 537 Zemore, ACER in press

43 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

44 When is AA s Effect Stronger? More substance use * More psychosocial problems * White, less educated, younger, unstably employed ** Less religious, fewer interpersonal skills ** Type B (more impulsive, tense, sensationseeking, more drug use, more psych probs, less motivated) *Morgenstern et al., Drug Alcohol Depen 2003 **Timko et al., Drug Alcohol Depen 2006 Morgenstern et al., Addiction 1998

45 What about Type A, Type B? Typology distinguishes severity based on vulnerability & severity Type B is more severe than Type A: More impulsive, sociopathic, sensation-seeking, tense and hostile, more drug use, more psych probs Less motivation to seek treatment, probs with treatment engagement Type B benefits more from high 12-step involvement R=.48 AA-PDA for Type B R=.15 AA-PDA for Type A Morgenstern et al., Addiction 1998

46 What About Gender? Women benefit more from AA attendance Men benefit more from aftercare Women had better outcomes Maybe because of having more AA Timko, Addiction 2002

47 Duration of AA matters more for women % in remission year wks 1-8 wks 9-26 wks 27+ wks of AA Men Women Moos et al., Clin Med Res 2006

48 Summary Effectiveness AA involvement is associated with abstinence at 1 month, 6 months, 1 yr, 3 yrs, 5 yrs, and 10 yrs after treatment At 1 yr, 8 yrs, and 16 yrs after seek help This only applies to those who will go to (and stick with) AA

49 Summary (cont d) What matters most about AA? Weekly attendance Increasing AA activities early on Having, being a sponsor Doing service Working the steps

50 Summary (cont d) What are some key mechanisms of action for AA? Changing social networks Improving coping skills Having confidence you can resist a drink Having meaning in one s life

51 How to get patients to attend AA after treatment? Meeting thresholds during treatment are key: 24% of TSF outpatients quit attending after tx If attended 3+ meetings per week during tx: continued to attend after tx If continued to attend after tx: attendance decreased, activities increased after tx Tonigan et al., Tx Match Alcohol 2003

52 Getting People to AA Systematic encouragement & community access vs. standard referral to AA * 100% of the encouragement group attended within the week and continued to attend over next 4 weeks None of the standard referral group attended Peer helping during treatment ** More peer helping during treatment was associated with more AA involvement following treatment AA involvement following treatment predicted abstinence at 6-month follow-up *Sisson & Mallams, Am J Drg Alc Abuse 1981 **Zemore et al., Addiction 2004

53 Getting People to AA (continued) Project MATCH Twelve-Step Facilitation (TSF) 12 manual-guided INDIVIDUAL sessions led by trained therapist Goals relate to AA s first 3 steps: Acceptance Surrender AA attendance between recruitment and year after treatment was higher for TSF patients 81% of TSF outpatients, half of CBT & MET outpatients 95% of TSF aftercare patients, over 80% of the CBT & MET aftercare patients Tonigan et al., Tx Match Alcohol 2003

54 AA Referral: Standard vs. Intense Intense Referral: Contacted AA/NA member from list during session Arranged for AA/NA member to meet patient at meeting AA involvement in Intense Referral at 6 mos.: Low prior AA Attended more meetings than standard referral Overall More involved in AA/NA, had sponsor, did service Timko, Addiction 2006

55 Making Alcoholics Anonymous Easier (MAAEZ): a group TSF approach Developed at the Alcohol Research Group, Berkeley by Lee Ann Kaskutas and Edward Oberste MAA*EZ *NA too

56 Rationale for MAAEZ Success of Project MATCH TSF Manualized, individual format, 12 sessions Higher 30-day abstinence rates at 1 and 3 yrs 1,2 36% of TSF outpatients 25-28% of CBT & MET outpatients Usefulness of manualized group format Group is modal form of treatment delivery 3,4 Increases ease and likelihood of implementation Prepares clients for group context of 12-step programs Manual guides coverage and consistency of topics 1 Project MATCH Research Group, JSA Project MATCH Research Group, ACER CSAT, Substance abuse treatment: Group Therapy Weiss, et al., Harvard Review of Psychiatry 2004

57 Goal of MAAEZ 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 Bond et al, JSA Riessman, Social Policy Zemore, Southern Medical Journal, Alcoholics Anonymous, 1939

58 Structure of MAAEZ 6 sessions Run by counselors experienced in running groups, who are in recovery and active in a 12-step program 90 minutes each Manualized session outline Indicates when to open it up for discussion Provides time guidelines for each point in the session minute check-in Includes reporting on how doing the action homework FELT 10-minute break 5 minute summary: what are the take-home messages? 5 minutes to assign homework Action Reading from Big Book or Living Sober or Sponsorship Pamphlet

59 Structure of MAAEZ (cont d) 6-week intervention Six sessions, attended 1-week apart Need time for doing weekly homework Intro session First and Last session attended Programs must run an intro session every week For newcomers and graduates 4 core sessions Spirituality, sponsorship, principles not personalities, living sober Attended in any order Programs cycle-through the 4 sessions over 4-week period

60 Introduction Counselor and client introduction Layout of MAAEZ intervention Graduate vignettes of their AA and MAAEZ experience Why go to AA? Were you going to AA when you relapsed? 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

61 Spirituality Why is spirituality necessary for recovery? AA is spiritual, not religious program Things to think about when you hear God as we understood Him What does spirituality mean to you? Can be anything, so long as you don t think you are God 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

62 Principles, not Personalities What are some things that turned you away from AA? Common objections to AA It is a cult Alcoholism is a disease No single person speaks for AA Leadership rotates; diversity of meetings; diversity of how program is interpreted Why do they suggest 90/90? Homework Ask someone you don t know at meeting, for their phone # Telephone them (and talk to them) before next session

63 Sponsorship What is a sponsor? Why get one? 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

64 Manual Available Now

65 Conclusions How can treatment increase AA engagement? Encouraging attendance at 3 meetings per week Providing opportunities for patients to help one another Introducing the AA concepts of acceptance and surrender Demonstrating the benefits of the AA fellowship

66 Implications Move beyond requiring meeting attendance Prepare clients for dealing with the philosophy of AA and the people in AA Learn from AA (not all clients will attend) Help clients change their social networks THANK YOU VERY MUCH

67 AA Acknowledgements NIAAA grants R01 AA (Kaskutas, PI) R21 AA (Kaskutas, PI) R01 AA (Kaskutas, PI) R01 AA 9750 (Weisner, PI) P50 AA 5595 (Greenfield, PI) NIDA grant R01 DA (Kaskutas, PI) CSAT contract # (Kaskutas, PI)

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