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, 2012
Fort Worth, TX
Perspectives on AA
Effectiveness
• AA members: I know AA works and there is
no need for research to prove that
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
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
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
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
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
% abstinent
Abstinence & AA exposure
50
45
40
35
30
25
20
15
10
5
0
at 1 yr.
at 18 mos.
AA
male VA inpatients
1 yr n = 3018; 18 mo n = 91
no AA
Ouimette et al., J Stud Alcohol 1998
Thurstin et al., Int J Addict 1987
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 & meeting amount
% abstinent mos. 9-12
70
60
50
40
30
20
10
0
0
1-19
20-49
50+
# of meetings mos. 9-12
Male VA residential patients
n = 2376
Moos et al., J Clin Psychol 2001
% abstinent at 2 yrs
Abstinence & meeting frequency
80
70
60
50
40
30
20
10
0
never
less than
weekly
weekly
meeting frequency, mos. 19-24
LA Target Cities, outpatients
n = 262
Fiorentine, Am J Drug Alcohol Ab 1999
% abstinent 16 years
Abstinence &
sustained attendance
80
70
60
meetings
50
40
30
20
10
0
none
1-8 wks
9-26 wks
27+ wks
year 1
years 2-3
years 4-8
duration☼ of AA attendance
Previously untreated problem drinkers
n = 461
Moos & Moos, J Clin Psychol 2006
Also see Moos & Moos, JSAT 2004
AA meeting trajectories
# of AA meetings, pst yr
250
200
declining AA
high AA
medium AA
low AA
150
100
50
0
TxEntry
Dependent treatment seekers
n = 349
1 year
3 years
5 years
Kaskutas et al., ACER 2005
% abstinent
Abstinence and meeting
trajectories
100
90
80
70
60
50
40
30
20
10
0
declining AA
high AA
medium AA
low AA
no AA
1 year
Dependent treatment seekers
n = 349
3 years
5 years
Kaskutas et al., ACER 2005
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
Consistency across samples & time
70
% abstinent
60
50
nothing
outpatient only
AA only
AA + outpatient
40
30
20
10
0
1 year
aMale
VA inpatients
n = 3018
a
3 years
bPreviously
b
untx prob drnkrs
n = 466
8 years
b
a
Ouimette et al., J Stud Alcohol 1998
b Timko et al., J Stud Alcohol 2000
Consistency across samples
hazards of abstinence
(vs. nothing)
6
5
4
3
2
1
0
formal tx only
NESARC; dependent
n = 4422
Tx
n=239
12-step only
12-step
n=138
both
n=829
12-step + tx
nothing
n=3217
(Dawson, Addiction 2006)
Consistency across time
AA involvement
over 10 years
Inpatients
n=158
significant
Abstinence
at 10 years
Cross et al., ACER 1990
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
Substance use following AA/NA
12-step meetings
mos. 1-3
No
Alcohol and drug use
Yes
mos. 4-6
12-step activities
mos. 1-3
Cocaine-dependent outpatients
n = 336
Weiss et al., Drug Alcohol Depen 2005
Alcohol abstinence following AA
AA involvement
Outpatient β = .29
mos. 1-6
Aftercare β = .34
Project MATCH
n = 480 outpatients, n = 434 aftercare
Percent days
abstinent
mos. 7-12
Connors et al., J Stud Alcohol 2001
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
Randomizing to AA
to remove selection effect
% abstinent at 2 yrs
40
35
30
25
20
15
10
5
0
Hospital inpatient
Alcohol abusers + EAP referred
n = 227: n=73 hospital; n=83 AA; n=71 choice
AA meetings
Choice
Walsh et al., New Engl J Med 1991
% abstinent, past 3 mos.
Randomize to TSF
to remove selection effect:
Outpatient sample
40
35
30
25
20
15
10
5
0
12-step
Motiv
Cog Beh
1-yr follow-up
p = .0024
Project MATCH
n = 806 outpatients at yr 3
3-yr follow-up
p < .007
PMRG, J Stud Alcohol 1997
PMRG, ACER 1998
% abstinent mos 13-15
Randomize to TSF
to remove selection effect:
Aftercare sample
50
45
40
35
30
25
20
15
10
5
0
12-step
Project MATCH aftercare
n = 714 at 1-year follow-up
Motiv
Cog Beh
PMRG, J Stud Alcohol 1997
AA Meeting Attendance by Project MATCH Sample
And Treatment Assignment
% Days
AA Mtgs
.5
.4
.5
Green = 12-step
Yellow = Motiv
Grey = Cog Beh
.4
.3
.3
.2
.2
.1
.1
0.0
0.0
Intake
Outpatient*
Project MATCH
*n = 952 Outpatients, **n = 774 Aftercare
15 Month
Green = 12-step
Yellow = Motiv
Grey = Cog Beh
Intake
15 Month
Aftercare**
Tonigan et al., Tx Match Alcohol 2003
Specificity:
Randomizing to Intensive AA/NA Referral
% abstinent at 6, 12 mos
60
50
40
30
20
10
51.4%
40.7%
Intensive Referral
Standard Referral
0
VA outpatients
n = 207: n=161 intensive; n=146 standard referral
Timko & DeBendetti, Drug Alc Dep, 2007
Timko’s results for 12-step
involvement at 6 months
Standard Intensive
Referral Referral
# of meetings
P
Value
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 nonsignificant in the high prior AA group.
Specificity:
Randomizing to MAAEZ
(Making AA Easier)
12-month Outcomes
Usual
MAAEZ
care
% 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
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
Example Using Propensity Score Method to Remove
Selection Effect:
Odds of Abstinence before adjustment
N
Non-AA
228
AA
334
* p<0.05, ** p<0.01, *** p<0.01
Odds Ratios
associated with
AA attendance
3.60
Odds of Abstinence after propensity score stratification
N
Stratum 1
(lowest PS)
Stratum 2
Stratum 3
Stratum 4
Stratum 5
(highest PS)
Total
Adjusted
* p<0.05, *** p<0.01
Non-AA
AA
Non-AA
AA
Non-AA
AA
Non-AA
AA
Non-AA
AA
88
23
68
45
44
68
18
96
10
102
Non-AA
228
AA
334
Odds Ratios
associated with
AA attendance
2.72*
6.85***
4.10***
2.39
1.33
2.93*
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
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
alternative
cue
Psy
need
succeed
skills
mood
alternative efficacy
Consistency with theory:
FELLOWSHIP
Cog Beh
• Friendship
– Adds sober people supportive
of your abstinence
– Role models of new behavior
– Helps learn how to have fun
sober
alternative
• Sponsorship
– Someone to call
emerg
plan
– Someone to provide
emotional support
Soc Lrn
Psy
cue
model
cue
need
need
Consistency with theory:
STEPS
Cog Beh Soc Lrn
• 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
Psy
need
mood
Evidence of mechanism:
cognitive behavioral
AA
involvement
Abstinence
Self-efficacy*
Coping skills**
*1 Resi or IOP
n = 100
*2
asolescent inpatients
n=74
**1 initially untx PDs
n=466
*1Morgenstern et al., J Consult Clin Psych 1997
*2Kelly et al., J Stud Alcohol 2002
**1Timko et al., ACER 2005
**2 male VA inpatients
2
** Humphreys et al., Ann Behav Med 1999
n=2,337
Evidence of mechanism:
social learning
AA
involvement
Abstinence
Fewer
pro-drinking
influences*
Enhanced
friendship
networks**
More friends†
# who support
abstinence
from AA‡
* treated ** male VA inpat. † init. untx. PDs ‡ treated
n = 722
n=2,337
n=466
n=655
*Kaskutas et al., Addiction 2002
**Humphreys et al., Ann Behav Med 1999
† Timko et al., ACER 2005
‡ Bond et al., J Stud Alcohol 2003
Evidence of mechanism:
social learning?
MAAEZ
Abstinence
Service
6+12mos;
high psych
Sponsor
Comfort speak; be
@ meetings
# who support
abstinence
Kaskutas et al., JSAT 2009
Evidence of mechanism:
psychodynamic
AA
involvement
Abstinence
Life meaning*
Motivation
for abstinence**
*In recovery
n = 354
**adolescent inpatients
n = 74
*White & Laudet, CPDD 2006
**Kelly et al., J Stud Alcohol 2002
Evidence of mechanism:
spirituality
AA
involvement
Abstinence
Δ religious
beliefs
& behaviors
Spiritual
awakening
Day Hosp & Residential, managed care
n = 537
Zemore, ACER in press
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
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@arg.org)
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):891-900
et al, JSA 2003;64(4):579-588
7 Riessman, Social Policy 1976;7:41-45
8 Zemore, Southern Medical Journal, forthcoming
9 Alcoholics Amonymous, 1939
6 Bond
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