Is it beneficial to have an alcoholics anonymous sponsor?

Alcoholics Anonymous (AA) attendance is predictive of increased abstinence for many problem drinkers and treatment referral to AA is common. Strong encouragement to acquire an AA sponsor is likewise typical, and findings about the benefits associated with social support for abstinence in AA support this practice, at least indirectly. Despite this widespread practice, however, prospective tests of the unique contribution of having an AA sponsor are lacking. This prospective study investigated the contribution of acquiring an AA sponsor using a methodologically rigorous design that isolated the specific effects of AA sponsorship. Participants were recruited from AA and outpatient treatment. Intake and follow-up assessments included questionnaires, semi-structured interviews, and urine toxicology screens. Eligibility criteria limited prior treatment and AA histories to clarify the relationship of interest while, for generalizability purposes, broad substance abuse criteria were used. Of the 253 participants, 182 (72%) provided complete data on measures central to the aims of this study. Overall reductions in alcohol, marijuana, and cocaine use were found over 12-months and lagged analyses indicated that AA attendance significantly predicted increased abstinence. During early AA affiliation but not later logistic regressions showed that having an AA sponsor predicted increased alcohol-abstinence and abstinence from marijuana and cocaine after first controlling for a host of AA-related, treatment, and motivational measures that are associated with AA exposure or are generally prognostic of outcome.

Adolescent substance abuse: the effects of alcohol and marijuana on neuropsychological performance

BACKGROUND

Adolescence is a period in which cognition and brain undergo dramatic parallel development. Whereas chronic use of alcohol and marijuana is known to cause cognitive impairments in adults, far less is known about the effect of these substances of abuse on adolescent cognition, including possible interactions with developmental processes.

METHODS

Neuropsychological performance, alcohol use, and marijuana use were assessed in 48 adolescents (ages 12 to 18), recruited in 3 groups: a healthy control group (HC, n = 15), a group diagnosed with substance abuse or dependence (SUD, n = 19), and a group with a family history positive for alcohol use disorder (AUD) but no personal substance use disorder (FHP, n = 14). Age, drinks per drinking day (DPDD), percentage days drinking, and percentage days using marijuana were considered as covariates in a MANCOVA in which 6 neuropsychological composites (Verbal Reasoning, Visuospatial Ability, Executive Function, Memory, Attention, and Processing Speed) served as dependent variables.

RESULTS

More DPDD predicted poorer performance on Attention and Executive Function composites, and more frequent use of marijuana was associated with poorer Memory performance. In separate analyses, adolescents in the SUD group had lower scores on Attention, Memory, and Processing Speed composites, and FHP adolescents had poorer Visuospatial Ability.

CONCLUSIONS

In combination, these analyses suggest that heavy alcohol use in adolescence leads to reduction in attention and executive functioning and that marijuana use exerts an independent deleterious effect on memory. At the same time, premorbid deficits associated with family history of AUD appeared to be specific to visuospatial ability.

Negative affect, relapse, and Alcoholics Anonymous (AA): does AA work by reducing anger?

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.

12-Step Therapy and Women with and without Social Phobia: A Study of the Effectiveness of 12-Step Therapy to Facilitate AA Engagement

Alcoholism treatment often encourages involvement in Alcoholics Anonymous (AA). Little provision is made for women with social phobia (SP), who have been reported to have worse outcomes in twelve-step-facilitation (TSF) relative to cognitive behavioral therapy. This study examined whether SP moderated the effects of gender for these women in TSF. 133 SP alcoholics assigned to TSF (35 females and 98 males) in Project MATCH were compared to a non-SP control group. SP women drank earlier and more intensely than non-SP women and all males, had equivalent AA attendance and completion of Step 5, and were less likely to acquire a sponsor during TSF.

Mechanisms of behavior change in alcoholics anonymous: does Alcoholics Anonymous lead to better alcohol use outcomes by reducing depression symptoms?

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.

Adolescent Self-reported Alcohol/other Drug Use Consequences: Moderators of Self and Parent Agreement

While the reliability of assessment instruments designed for use with adults is well established, much less is known about the adequacy of these instruments for adolescent substance abusers. As part of a comprehensive intake evaluation, the Inventory of Drug Use Consequences (InDUC) was administered both to forty adolescents assigned to a probationary substance abuse treatment program and to one of their parents. The correlation was statistically significant between Parent and Adolescent InDUC score(s), but the interrater reliability was relatively low. IQ scores and level of substance use were considered as moderator variables, but neither showed a significant effect. History of head injury, however, significantly moderated this relationship; those adolescents reporting no history of head injury showed little correspondence with Parent InDUC Score(s), whereas those adolescents with a history of head injury showed significant correlations with parent InDUC scores. This suggests that a history of head injury may affect the way in which adolescents perceive substance-related consequences.

From in-session behaviors to drinking outcomes: a causal chain for motivational interviewing

Client speech in favor of change within motivational interviewing sessions has been linked to treatment outcomes, but a causal chain has not yet been demonstrated. Using a sequential behavioral coding system for client speech, the authors found that, at both the session and utterance levels, specific therapist behaviors predict client change talk. Further, a direct link from change talk to drinking outcomes was observed, and support was found for a mediational role for change talk between therapist behavior and client drinking outcomes. These data provide preliminary support for the proposed causal chain indicating that client speech within treatment sessions can be influenced by therapists, who can employ this influence to improve outcomes. Selective eliciting and reinforcement of change talk is proposed as a specific active ingredient of motivational interviewing.

Effects of alcoholism typology on response to naltrexone in the COMBINE study

BACKGROUND

This study investigated whether subgroups of alcohol-dependent patients responded differently to naltrexone versus placebo in the NIAAA COMBINE study. In particular, the A versus B and the Early Onset versus Late Onset typologies were examined. Relative to Type A alcoholics, Type B alcoholics are characterized by greater severity, earlier onset, stronger family history, more childhood risk factors (e.g., conduct disorder), and greater frequency of comorbid psychiatric and substance use disorders.

METHODS

COMBINE study participants were categorized as Type A or Type B using k-means cluster analysis and variables from 5 domains that have been shown to replicate the original Babor typology efficiently. Early Onset was defined as alcohol dependence beginning before age 25. For the planned analyses, the sample was reduced to the 618 participants receiving naltrexone alone or placebo, either with medical management (MM) alone or with MM plus the Combined Behavioral Intervention (CBI). The a priori primary outcome was percent heavy drinking days during treatment in the groups receiving MM without CBI.

RESULTS

Among those receiving MM without CBI, Type A alcoholics had better drinking outcomes with naltrexone than placebo, whereas medication condition did not influence outcomes significantly in the Type Bs. Age of onset was not significantly related to outcome. For those receiving CBI, no significant effects were found for either typology.

CONCLUSIONS

In this sample, the beneficial effects of opioid antagonism were limited to Type A alcoholics receiving treatment in a MM model. Future studies should investigate the relationship between clinically relevant genotypes, phenotypes such as typologies, and treatment response. More work is also needed to develop practical algorithms for phenotypic assignment.

The test-retest reliability of the Form 90-DWI: an instrument for assessing intoxicated driving

Although driving while intoxicated (DWI) is a pervasive problem, reliable measures of this behavior have been elusive. In the present study, the Form 90, a widely utilized alcohol and substance use instrument, was adapted for measurement of DWI and related behaviors. Levels of reliability for the adapted instrument, the Form 90-DWI, were tested among a university sample of 60 undergraduate students who had consumed alcohol during the past 90 days. The authors administered the instrument once during an intake interview and again, 7-30 days later, to determine levels of test-retest reliability. Overall, the Form 90-DWI demonstrated high levels of reliability for many general drinking and DWI behaviors. Levels of reliability were lower for riding with an intoxicated driver and for variables involving several behavioral conjunctions, such as seat belt use and the presence of passengers when driving with a blood alcohol concentration above .08. Overall, the Form 90-DWI shows promise as a reliable measure of DWI behavior in research on treatment outcome and prevention.

The pretreatment social networks of women with alcohol dependence

OBJECTIVE

Research indicates that the social networks of women differ from those of men. Although studies indicate that social support greatly affects alcohol use, little attention has been paid to gender differences in this area. The objective of the current study is to examine the pretreatment social networks of women seeking conjoint treatment for an alcohol-use disorder.

METHOD

As part of a larger randomized clinical trial, 102 women in committed heterosexual relationships who were seeking treatment for an alcohol-use disorder at an outpatient clinic were interviewed before treatment entry. Participants completed the Important People and Activities Instrument to assess the size and composition of the women's social networks. Pretreatment drinking was assessed using the Timeline Followback interview.

RESULTS

Participants in this study reported fairly large supportive networks. Drinking quantity and frequency in the 3 months before treatment were examined in light of social network connection. Women with moderate/heavy drinking partners reported more drinking days but drank fewer drinks per drinking day than women with light drinking/abstaining partners. In addition, we found a positive association between the number of drinkers in the social network and the participant percentage of drinking days.

CONCLUSIONS

The main findings of this study were the significant interrelationships between moderate or heavy drinking among social network members and the drinking patterns of women with alcohol-use disorders.

Client language as a mediator of motivational interviewing efficacy: where is the evidence?

BACKGROUND

Identifying in-session indicators of client outcomes is important in determining the mechanisms of psychotherapeutic treatments, including Motivational Interviewing (MI). The current studies sought to determine if clinician behavior influences client speech, and the extent to which client speech predicted treatment outcome in clients receiving treatment for substance abuse.

METHODS

Study 1 examined 38 sessions from 5 sites in Project MATCH. Sessions were coded using the Sequential Code for Process Exchanges (SCOPE) behavioral coding system. Transition probabilities and inter-rater reliability were calculated. Study 2 examined 45 sessions from the New Mexico site in Project MATCH. Sessions were coded using the MISC 1.0 behavioral coding system. Distal outcome measures were calculated for proportion of days abstinent (PDA) and drinks per drinking day (DDD). Hierarchical multiple regression and hierarchical logistic regression were used to characterize the relationship between client speech and outcome.

RESULTS

In Study 1, inter-rater reliability estimates indicate that coders reliably distinguished between the categories within the SCOPE. Behaviors consistent with MI (MICO) were significantly likely to be followed by client Change Talk (CT) and behaviors inconsistent with MI (MIIN) were significantly likely to be followed by Counterchange Talk (CCT). There was also a significant negative transition probability between MICO and CCT. In Study 2, CT was found to account for significant portions of outcome variability beyond that attributable to baseline measures of problem severity.

CONCLUSIONS

Client speech during early therapy sessions appears to be a powerful predictor of substance abuse outcome. The pattern of therapist behaviors and subsequent client language found in this data supports the intervention test in the causal chain we have described for motivational interviewing. These studies provide preliminary support for a causal chain between therapist behaviors, subsequent client speech, and drinking outcomes within motivational interviewing sessions. The results of both studies provide further support to the proposition that client speech impacts the likelihood of behavioral change, and that the occurrence of such speech is influenced by the therapist.

Statistical considerations in identifying mechanisms of change

The statistical search for mechanisms of change involves multiple inferential tests, ones that generally follow a fixed sequence designed to demonstrate mediation. While there are several popular approaches to conducting such tests, e.g., SEM and MRA, the inflated Type I error rate problem associated with conducting these tests has received little, if any, attention. This paper offers 2 solutions to avoid committing Type I errors associated with mediational tests. Most straightforward, investigators may choose to use a Bonferroni adjustment. In contrast, a design-based approach can be used that tests rival explanations for the observed effects. Examples drawn from addiction research are provided.

Psychometrics of the Drinker Inventory of Consequences (DrInC)

The Drinker Inventory of Consequences (DrInC) was developed for Project MATCH to assess the consequences of drinking in five domains. The present study, using baseline data from the 1382 participants involved in the COMBINE Study, analyzed the psychometrics of the 50-item DrInC and its shorter form, the 15-item SIP. Findings indicate the DrInC is reliable, valid, and clinically useful and that DrInC subscales are internally consistent and non-redundant. In an examination of the shorter version of the DrInC, findings suggest that the SIP is suitable when assessing the overall level of drinking-related consequences.

Spirituality and Alcoholics Anonymous

What can be confidently said about AA in general and about the role of spirituality in AA in particular? First, there is convincing evidence that alcoholism severity predicts later AA attendance. Second, atheists are less likely to attend AA, relative to individuals who already hold spiritual and/or religious beliefs. However, belief in God before AA attendance does not offer any advantage in AA-related benefits, and atheists, once involved, are at no apparent disadvantage in deriving AA-related benefits. Third, the spiritually-based principles of AA appear to be endorsed in AA meetings regardless of the perceived social dynamics or climate of a particular meeting, eg, highly cohesive or aggressive. Fourth, significant increases in spiritual and religious beliefs and practices seem to occur among AA-exposed individuals. Fifth, in spite of much discussion to the contrary there is little evidence that spirituality directly accounts for later abstinence. We are finding, however, that spirituality has an important indirect effect in predicting later drinking reductions. Specifically, in the past 20 years a number of effective methods have been developed to facilitate initial AA attendance (AA dropout is high, with some estimates ranging as high as 80%). Interventions that lead to initial increases in spirituality appear to lead to sustained AA affiliation, which, in turn, produces sustained recovery over time.

The predictive validity of the survey of readiness for alcoholics anonymous participation

OBJECTIVE

This study evaluated the predictive validity of the Survey of Readiness for Alcoholics Anonymous Participation (SYRAAP), which is a 15-item, self-administered instrument.

METHOD

Bivariate and multivariate analyses examined whether responses to the SYRAAP within 1 week of entering substance-use treatment (T1) were associated with posttreatment Alcoholics Anonymous (AA) participation at 3-month (T2) and 6-month (T3) follow-up assessments. The T1 assessment was completed by 268 respondents; the T2 and T3 assessments were completed by 232 (86%) and 217 (81%) respondents, respectively.

RESULTS

Results revealed that responses to the SYRAAP at T1 predicted AA participation at T2 and T3.

CONCLUSIONS

The findings indicate the SYRAAP is a valid measure for assessing readiness for participating in AA. Future research in relation to the SYRAAP and limitations of the current study are discussed.

The development and initial evaluation of the survey of readiness for alcoholics anonymous participation

This article presents 5 studies related to the development and initial evaluation of the Survey of Readiness for Alcoholics Anonymous Participation (SYRAAP). The SYRAAP is a brief, multidimensional, self-administered instrument that assesses beliefs associated with Alcoholics Anonymous (AA) participation. Study 1 generated 239 candidate items for potential inclusion in the instrument. Study 2 assessed the content validity of these items according to 3 criteria and identified a subset of 60 with the highest values on the criteria for further consideration. Study 3 produced a shorter version of the SYRAAP and evaluated its structure, internal reliability, and validity. Study 4 reevaluated the structure and internal reliability of the SYRAAP and yielded findings that were generally consistent with those from Study 3. Study 5 established stability reliability for the instrument. The collective findings indicated the SYRAAP can reliably and validly assess individual-level beliefs associated with AA participation. The potential use of the SYRAAP for researchers and clinicians, along with limitations of the work presented here, are discussed.

Cognitive impairment influences drinking outcome by altering therapeutic mechanisms of change

Serious neuropsychological impairments are seen in a minority of addiction treatment clients, and, theoretically, these impairments should undermine behavioral changes targeted by treatment; however, little evidence supports a direct influence of impairment on treatment response. To address this paradox, the authors used structural equation modeling and Project MATCH data (N=1,726) to examine direct, mediated, and moderated paths between cognitive impairment, therapeutic processes, and treatment outcome. Mediated relations were found, wherein impairment led to less treatment compliance, lower self-efficacy, and greater Alcoholics Anonymous Involvement, which, in turn, more proximally predicted drinking. Impairment further moderated the effect of self-efficacy, making it a poor predictor of drinking outcomes in impaired clients, thereby suggesting that impaired and unimpaired clients traverse different pathways to addiction recovery.

Cognitive impairment influences drinking outcome by altering therapeutic mechanisms of change

Serious neuropsychological impairments are seen in a minority of addiction treatment clients, and, theoretically, these impairments should undermine behavioral changes targeted by treatment; however, little evidence supports a direct influence of impairment on treatment response. To address this paradox, the authors used structural equation modeling and Project MATCH data (N=1,726) to examine direct, mediated, and moderated paths between cognitive impairment, therapeutic processes, and treatment outcome. Mediated relations were found, wherein impairment led to less treatment compliance, lower self-efficacy, and greater Alcoholics Anonymous Involvement, which, in turn, more proximally predicted drinking. Impairment further moderated the effect of self-efficacy, making it a poor predictor of drinking outcomes in impaired clients, thereby suggesting that impaired and unimpaired clients traverse different pathways to addiction recovery.

Examining the Effects of Alcoholism Typology and AA Attendance on Self-Efficacy as a Mechanism of Change

OBJECTIVE

Existing research indicates that increased self-efficacy to sustain abstinence is a strong causal mechanism explaining later reduction of drinking. Little is known about how mechanisms of change may differ among distinct subgroups of alcoholics. The purpose of this study was to evaluate the mediational role of self-efficacy on changes in drinking associated with Alcoholics Anonymous (AA) attendance in Type-A and Type-B alcoholics.

METHOD

Analysis of covariance and structural equation modeling were used to model 6-, 9-, 12-, and 15-month data from Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) participants who were classified as Type-A or Type-B alcoholics (N=1,284; 72% male). Measures of AA attendance and percent days abstinent were taken from the Form 90. Self- efficacy was assessed with the Alcohol Abstinence Self-Efficacy Scale.

RESULTS

Alcoholism typology and AA attendance were independent predictors of later self-efficacy, but there was no interaction between typology and AA attendance. Abstinence self-efficacy mediated a modest proportion of the effect of posttreatment AA attendance on later abstinence in both Type-A and Type-B alcoholics. The strength of this mediation did not differ by typology.

CONCLUSIONS

Self-efficacy for abstinence has a strong direct relationship to abstinence across treatment conditions and typologies. Increases in self-efficacy mediate some of the beneficial effects of AA for Type-A and Type-B alcoholics. Further work is necessary to determine whether self-efficacy plays a different role in the recovery of Type-A versus Type-B alcoholics.

Is alcoholism typology a predictor of both Alcoholics Anonymous affiliation and disaffiliation after treatment?

Twelve Steps (TS) has demonstrated effectiveness; induction into Alcoholics Anonymous (AA) is a primary objective of TS and is a pivotal mechanism explaining its effectiveness. However, evidence suggests that, after treatment, dropout from AA is high. This study investigated whether alcohol problem severity predicted both AA affiliation and disaffiliation among clients receiving TS. This study of a Project MATCH sample included 453 alcohol-dependent clients randomly assigned to TS who reported AA attendance during treatment. Greater alcohol problem severity predicted AA attendance; opposite to prediction, less alcohol-impaired clients were more than twice as likely to discontinue AA attendance after treatment. When sustained AA attendance is desired, the evaluation of client pretreatment alcohol involvement may be useful for identifying potential AA dropout after TS treatment. Findings also indicate that, among treatment-seeking problem drinkers, AA dropout and disaffiliation are distinct, albeit correlated, constructs that require future investigation.

Long-Term Posttreatment Functioning Among Those Treated for Alcohol Use Disorders

This article summarizes the proceedings of a symposium that was organized and chaired by Patrick R. Clifford and presented at the 2005 Research Society on Alcoholism meeting in Santa Barbara, California. The aims of the presentation were to focus on the prediction and explanation of longer-term functioning following alcohol use disorders (AUD) treatment. Along these lines, Stephen A. Maisto, PhD, presented data (i.e., Project MATCH outpatient sample) on the relationship between drinking behavior in the first year following AUD outpatient treatment initiation and functioning at 3-year follow-up. Robert L. Stout, PhD, using data from the Extended Case Monitoring Study, analyzed long-term drinking patterns using shorter-term information. James R. McKay, PhD, examined the relationship between treatment services received and problem severities across a 2-year follow-up period. J. Scott Tonigan, PhD, served as the panel discussant.

READINESS FOR CHANGE AND READINESS FOR HELP-SEEKING: A COMPOSITE ASSESSMENT OF CLIENT MOTIVATION

AIMS

To investigate the correspondence between readiness for behaviour change in general and readiness for alcohol related help-seeking in particular. A related aim was to examine how, if at all, measures of dependence severity, use, and consequences were related to a composite measure depicting agreements and disagreements between general change readiness and help-seeking readiness.

METHODS

Non-treatment seeking alcohol-dependent patients, numbering 549, from general hospitals in Germany were interviewed.

RESULTS

When taking into account both dimensions of motivation, findings indicate 42% of the subjects were characterized by different motivation levels regarding readiness for change and readiness for help-seeking. Higher help-seeking readiness was associated with higher alcohol problem severity. Readiness to change was not affected by alcohol problem severity.

CONCLUSIONS

Findings underscore the need to evaluate both motivational constructs in determining clients' need and receptivity to formal help.

Active ingredients: how and why evidence-based alcohol behavioral treatment interventions work

This article summarizes the proceedings of a symposium that was organized and chaired by Richard Longabaugh and presented at the 2004 Research Society on Alcoholism meeting in Vancouver, British Columbia, Canada. The aim of the presentation was to focus on evidence for the active ingredients of behavioral therapies for patients with alcohol use disorders. Dennis M. Donovan, PhD, reviewed evidence for the active ingredients of cognitive behavioral therapy. Barbara S. McCrady, PhD, presented a conceptual model for mechanisms of change in alcohol behavior couples therapy and reviewed evidence for this model. J. Scott Tonigan, PhD, presented data testing three hypothesized mechanisms of change in twelve-step facilitation treatment. Mitchell P. Karno, PhD, presented therapy process data that tested whether matching therapist behaviors to client attribute across three therapies affected drinking outcomes. Jon Morgenstern served as discussant.

Readiness to change versus readiness to seek help for alcohol problems: the development of the Treatment Readiness Tool (TReaT)

OBJECTIVE

This study developed and psychometrically evaluated a short self-report measure for treatment readiness, a construct correlated with but distinct from general change readiness. This measure, the Treatment Readiness Tool (TReaT), was based on the transtheoretical model of behavior change.

METHOD

A nontreatment-seeking sample of 748 patients from general hospitals who met criteria for at-risk or harmful drinking was recruited as part of an intervention study in Western Pomerania, Germany.

RESULTS

Exploratory (n = 498) and confirmatory (n = 250) factor analyses supported the presence of a three-factor structure (Precontemplation, Contemplation and Preparation) among high-risk drinkers who were not seeking treatment. High internal item consistency was found for the three TReaT scales, and strong convergent validity was obtained with measures of alcohol use and consequences. Pearson correlations between the three TReaT scales and parallel scales collected by a measure of general change readiness indicated that the two constructs were relatively distinct (19% shared variance).

CONCLUSIONS

The findings suggest that measurement of treatment readiness might have advantages in predicting treatment compliance, processes and outcome relative to measures of general behavior change readiness. The predictive validity of the measure needs to be investigated in future studies, however.

Assessment of Alcohol and Other Drug Use by Runaway Youths: A Test-Retest Study of the Form 90

While excellent adolescent alcohol and drug screening tools are available, there are relatively few, if any, psychometrically validated measures to use in the assessment of adolescent treatment outcome. This study conducted a test-retest exercise of the Form 90 Drug and Alcohol (Form 90 DnA) to determine the stability of adolescent responses when administering the day-by-day calendar/grid approach. Homeless youth (N = 37) with alcohol, drug, or alcohol and drug abuse/dependence combined were recruited to participate in the test-retest study. High pre-post stability in means was obtained on measures of frequency of substance use in general, and on specific measures of alcohol, cocaine, marijuana use. The findings from this paper provide support for the reliability and validity of the Form 90 for use with adolescent runaways with a substance abuse or dependence diagnosis.

Effectiveness of customized Victim Impact Panels on first-time DWI offender inmates

This study investigates the effectiveness of a customized Victim Impact Panel (VIP) on reducing 'driving while impaired' recidivism, alcohol consumption and drinking and driving behavior. The study was conducted at a 28-day Detention/Treatment Program in a largely rural county in northwestern New Mexico. Study participants were randomly assigned to attend or not attend a VIP while participating in the program for court-defined first-time driving while intoxicated (DWI) offenders. There were no significant differences between the two groups on alcohol consumption, drinking and driving behavior, or recidivism within 2 years. These findings support the findings of other studies that VIPs do not produce a differential benefit with regards to recidivism of those convicted as a first-time DWI offenders.

Project Match treatment participation and outcome by self-reported ethnicity

BACKGROUND

There is a lively ongoing debate concerning the need for culturally congruent alcohol treatment, with the assumption that such treatment would meaningfully address treatment outcome disparities among ethnic minorities. Although valid on the face of it, no randomized clinical trials have yet prospectively investigated and documented whether, in fact, different ethnic groups actually fare better or worse from one another when offered mainstream, culturally "incongruent" treatment. The purpose of this study was to contrast Hispanic, black, and white client treatment engagement and outcome in an effort to identify potential health disparities related to client ethnicity.

METHODS

The Project Match outpatient (N = 952) and aftercare (N = 774) samples were divided according to self-reported ethnicity: Hispanic (n = 141; 8%), black (n = 168; 10%), and white (n = 1380; 80%). Controlling for socioeconomic status using the Hollingshead Occupational scale, the three ethnic groups were contrasted on pretreatment characteristics, rates of treatment attendance, three scales of therapeutic alliance, satisfaction with treatment, and drinking outcomes for the 12 months after treatment.

RESULTS

Ethnic differences in rates of therapy attendance were not robust and dissipated after controlling for socioeconomic status. No mean ethnic differences in ratings of therapeutic bonding and agreement with therapy goals were obtained, but blacks and Hispanics reported higher agreement on the value of therapeutic tasks relative to whites. Nevertheless, whites reported significantly higher global satisfaction with treatment relative to Hispanics and blacks. No ethnic main effect was found in drinking intensity during the 12-month follow-up. In contrast and only in the outpatient sample, blacks (n = 51) reported significantly higher rates of monthly abstinence relative to whites (n = 679).

CONCLUSIONS

Pretreatment characteristics predictive of positive treatment outcome favored white clients relative to Hispanic and black clients, but Hispanic and black clients fared at least as well as white clients during the 12-month follow-up, at least on two measures of drinking behavior. The absence, then, of poorer drinking outcomes for the ethnic minorities suggests that they may mobilize (1). different behavior change strategies and/or (2). additional social resources to achieve comparable drinking outcomes with white clients. Specific recommendations for future research are made.

Motivational interviewing in drug abuse services: a randomized trial

Motivational interviewing (MI) is a directive, client-centered brief intervention to elicit behavior change by helping clients explore and resolve ambivalence. In this clinical trial, 152 outpatients and 56 inpatients entering public agencies for treatment of drug problems were randomly assigned to receive or not receive a single session of manual-guided MI. Drug use was assessed by self-report, urine toxicology, and collateral reports from significant others at baseline, 3, 6, 9, and 12 months. Contrary to prior reports, MI showed no effect on drug use outcomes when added to inpatient or outpatient treatment, although both groups showed substantial increases in abstinence from illicit drugs and alcohol.

Participation in alcoholics anonymous: intended and unintended change mechanisms

This article is a compilation of the information presented at a symposium at the 2001 RSA Meeting in Montreal, Canada. The presentations were: (1) Maintaining change after conjoint behavioral alcohol treatment for men: the role of involvement with Alcoholics Anonymous, by Barbara S. McCrady and Elizabeth E. Epstein; (2) Changing AA practices and outcomes: Project MATCH 3-year follow-up, by J. Scott Tonigan; (3) Life events and patterns of recovery of AA-exposed adults and adolescents, by Patricia L. Owen and Valerie Slaymaker; (4) Social networks and AA involvement as mediators of change, by Lee Ann Kaskutas and Keith Humphreys; and (5) What do we know about Alcoholics Anonymous? by William R. Miller, discussant.

The influence of Hispanic ethnicity on long-term outcome in three alcohol-treatment modalities

OBJECTIVE

Prior research has suggested that treatment-seeking Hispanic clients are not likely to affiliate with Alcoholics Anonymous (AA). It was hypothesized that AA 12-step facilitation therapy (TSF) would therefore be less effective than cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET) for Hispanics, particularly for those with low acculturation.

METHOD

Outcomes for non-Hispanic white (n = 105; 70% male) and Hispanic (n = 100; 80% male) clients at the New Mexico site within Project MATCH were analyzed for evidence of differential treatment response. A pretreatment measure of acculturation to non-Hispanic white culture was available for 80 of the Hispanic clients.

RESULTS

Self-identified ethnicity mediated treatment response at distal follow-up, as measured by frequency and intensity of alcohol consumption (p < .02). Hispanics drank with more intensity than did non-Hispanic whites when assigned to TSF; non-Hispanic whites in TSF drank with less frequency than those in the combined CBT and MET conditions. The modest outcome advantage for TSF observed in Project MATCH appears to have been limited to non-Hispanic clients. Contrary to prediction, level of acculturation did not mediate treatment response at proximal (Months 1-6 after treatment) or distal follow-up (Months 7-12).

CONCLUSIONS

Ethnic self-identification may interact with treatment outcomes in complex ways that are not directly associated with the factors tapped by commonly used measures of acculturation.

A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others

In a randomized clinical trial, 90 concerned significant others (CSOs) of treatment-refusing illicit drug users were assigned to either (a) community reinforcement and family training (CRAFT), which teaches behavior change skills, (b) CRAFT with additional group aftercare sessions after the completion of the individual sessions; or (c) Al-Anon and Nar-Anon facilitation therapy (Al-Nar FT). All protocols received 12 hr of manual-guided individual treatment. Follow-up rates for the CSOs were consistently at least 96%. The CRAFT conditions were significantly more effective than Al-Nar FT in engaging initially unmotivated drug users into treatment. CRAFT alone engaged 58.6%, CRAFT + aftercare engaged 76.7%, and Al-Nar FT engaged 29.0%. No CSO engaged a treatment-refusing loved one once individual sessions had been completed.

Atheists, agnostics and Alcoholics Anonymous

OBJECTIVE

In spite of the strong emphasis in AA on spiritual beliefs and practices, findings are mixed about the importance of such beliefs in predicting AA affiliation. This study of the Project MATCH outpatient (N = 952) and aftercare (N = 774) samples tested three hypotheses about the role of client God belief and subsequent AA attendance and benefit, taking into account that some individuals may, in fact, deny the existence of a God.

METHOD

Longitudinal analyses were conducted (N = 1,526) investigating client God beliefs, AA attendance, patterns of AA attendance and alcohol use. Assessments were conducted at intake and in 3-month intervals using the Form 90, Religious Behaviors and Background, and the Alcoholics Anonymous Inventory.

RESULTS

12-Step treatment was significantly more likely to promote pre-post shifts in client God beliefs, and atheist and agnostic clients attended AA significantly less often throughout follow-up relative to clients self-labeled as spiritual and religious. AA attendance, however, was significantly associated with increased abstinence and reductions in drinking intensity regardless of God belief. Finally, no differences in percent days abstinence and drinking intensity were found between atheist and agnostic versus spiritual and religious clients, but clients unsure about their God belief reported significantly higher drinking frequency relative to the other groups.

CONCLUSIONS

God belief appears to be relatively unimportant in deriving AA-related benefit, but atheist and agnostic clients are less likely to initiate and sustain AA attendance relative to spiritual and religious clients. This apparent reticence to affiliate with AA ought to be clinically recognized when encouraging AA participation.

Magdalena Pilot Project: motivational outreach to substance abusing women street sex workers

The Magdalena Pilot Project provided outreach to Albuquerque women sex workers who were also using illicit drugs, primarily cocaine and heroin. This initial uncontrolled trial evaluated the feasibility and potential impact of motivational interviewing (MI) on change in drug use and HIV risk behaviors. Twenty-seven women were enrolled and interviewed about their substance use, health risk behaviors, and plans for change, using the client-centered, directive method of MI. Four months later, 25 women (93%) were interviewed again to assess their drug use and health risk behaviors. Large reductions were reported in frequency (days) of drug use and sex work, with a corresponding increase in days of lawful employment. In identifying problems that most needed to be addressed in order to help them live healthier lives, the women prioritized (1) basic needs including decent housing, (2) mental health care, and (3) treatment for substance use disorders.

The inventory of drug use consequences (InDUC): test-retest stability and sensitivity to detect change

The Inventory of Drug Use Consequences (InDUC) is a self-administered measure of consequences of drug use. Psychometric characteristics have been published for its alcohol-focused parent instrument (Drinker Inventory of Consequences; W. Miller, J. Tonigan, & R. Longabough, 1995). Two studies provided information about the test-retest reliability (lifetime) of InDUC scales (Study 1, N = 34) and the replicability of findings to the 5 InDUC scales (recent; Study 2, N = 208). Four scales had good to excellent test-retest reliability. Findings also indicate that reductions in drug use and problems after treatment are large and that the magnitude of change differs between drug use and consequences. Consequences of drug use should be measured directly rather than be inferred from measures of use.

Utilization of AA by Hispanic and non-Hispanic white clients receiving outpatient alcohol treatment

OBJECTIVE

Research indicates that Hispanic clients are less likely than non-Hispanic white (NHW) clients to attend Alcoholics Anonymous (AA) after treatment. This study examined how, if at all, the nature of commitment to prescribed AA-related behaviors after treatment differed between Hispanic and non-Hispanic whites, and how such behaviors were associated with drinking reductions.

METHOD

This retrospective study was conducted using Project MATCH data collected at the Albuquerque clinical research unit. Study aims were investigated using the Form 90, the Alcoholics Anonymous Inventory and the Religious Background and Behavior measures. A total of 100 Hispanic and 105 non-Hispanic clients were randomized to receive either Cognitive Behavioral Therapy (CBT), Motivational Enhancement Therapy (MET) or Twelve-Step Facilitation (TSF) therapy, and findings were divided according to whether clients were encouraged to attend AA (TSF) or not (CBT and MET).

RESULTS

Six months after treatment, Hispanic clients assigned to TSF reported significantly less AA attendance relative to NHW clients in TS, and no differences in AA attendance rates were found between Hispanics encouraged and not encouraged to attend AA (TSF vs CBT and MET). Among TSF clients, however, no ethnic differences were found in rates of specific AA-related behaviors. Controlling for intake beliefs, "God Consciousness" after treatment was significantly higher for Hispanic relative to NHW clients, and a main effect of treatment was also obtained (TSF vs CBT and MET). Specific AA-related practices were not associated with increased abstinence, in general.

CONCLUSIONS

Despite less frequent AA attendance, Hispanic clients showed increase in AA commitment comparable to that of NHW clients. It thus appears that differential commitment to AA does not explain why Hispanic clients report less frequent AA attendance but equal benefit, relative to NHW clients.

A longitudinal model of intake symptomatology, AA participation and outcome: retrospective study of the project MATCH outpatient and aftercare samples

OBJECTIVE

The present study used data gathered in Project MATCH to longitudinally assess intake symptomatology, Alcoholics Anonymous (AA) participation, and outcome. Three primary constructs were considered: intake symptomatology, engagement in prescribed AA-related activities and functioning after engagement in AA-related behaviors.

METHOD

The participants were 480 outpatient and 434 aftercare clients who participated in Project MATCH.

RESULTS

Similar findings were found for each sample. Intake symptomatology positively predicted AA participation during the first 6 months following treatment. Although network support for drinking was negatively related to AA participation, such support did not mediate the relationship between intake symptomatology and subsequent AA participation. AA participation, in turn. positively predicted frequency of abstinent days in Months 7-12 posttreatment. This latter relationship was mediated by perceived self-efficacy to avoid drinking (Month 6). AA participation was positively related to self-efficacy to avoid drinking, which, in turn, predicted more days abstinent. One difference between the outpatient and aftercare samples emerged, involving the latent construct intake symptomatology. Intake symptomatology among outpatients was not predictive of percentage of abstinent days (Months 7-12), whereas intake symptomatology was negatively predictive of percentage of abstinent days in the aftercare sample.

CONCLUSIONS

Intake symptomatology positively predicted participation in AA, which predicted subsequent abstinent days. The positive relationship between AA participation and self-efficacy to avoid drinking may explain in part why AA engagement predicts subsequent increases in abstinence.

Relationship Between Service Utilization and Runaway Youths' Alcohol and Other Drug Use

Runaway youths represent a vulnerable, high-risk population that has received little societal attention. Studies show that youths at greatest need are the least likely to access mental health, medical, and other social services. This study evaluated service utilization, including medical visits, psychological, alcohol and drug counseling and 12-step attendance, and substance use. Runaway youths (n = 51) between the ages of 12 and 17 with a diagnosis of alcohol abuse or dependence were recruited from two southwestern runaway shelters. Results showed that psychological counseling and medical visits were associated with less alcohol use while 12-step attendance was associated with more alcohol use at pretreatment. Service utilization was not associated with illicit drug use. The findings suggest that alcohol and other drug use are affected differently by service utilization in this sample of youths. More research is required to evaluate and develop treatments which can effectively intervene with this high-risk group.

Comparison of outcomes for clients in randomized versus open trials of treatment for alcohol use disorders

OBJECTIVE

There has been continuing concern that clients who accept randomization into a controlled trial may not be representative of those in noncontrolled trials or ordinary treatment situations. However, it is not possible to test the impact of randomization through a randomized trial. Two parallel studies conducted at the same treatment facility provided an opportunity for a quasi-experimental study to evaluate whether participation in a controlled trial itself affects treatment outcome.

METHOD

Two concomitant samples of clients were enrolled during overlapping recruitment periods: one (n = 226) into a randomized clinical trial (RCT) and the other (n = 122) offered treatment as usual (non-RCT). Both samples were given extensive baseline and follow-up assessment.

RESULTS

Baseline assessment indicated demographic similarity of the two samples, with somewhat higher problem severity in the non-RCT sample, consistent with the RCT selection criteria. Client retention in treatment was somewhat comparable, and follow-up rates exceeded 90% in both studies. Overall outcomes did not differ for the RCT and non-RCT samples.

CONCLUSIONS

It appeared that clients enrolled into an RCT did not differ from those receiving ordinary treatment. Retention was similarly high in both studies, clients completed a comparable number of outpatient sessions, and the number of informal treatment sessions attended during the 6 months of follow-up was comparable. There are some aspects of this study that limit the ability to draw firmer conclusions but despite some pretreatment differences, participation in the RCT did not itself exert an apparent effect on aggregate treatment outcomes.

Community reinforcement and family training (CRAFT): engaging unmotivated drug users in treatment

Although motivation for drug abuse treatment is a substantial problem, unilateral intervention through concerned significant others (CSOs) represents a promising method for engaging unmotivated individuals. The Community Reinforcement and Family Training (CRAFT) program, based on principles of reinforcement was developed for this specific purpose. In Phase I, CSOs received the CRAFT intervention, whereby they were taught skills for modifying a loved one's drug-using behavior and for enhancing treatment engagement. CSOs were evaluated at 3 and 6 months. In Phase II, engaged drug users received treatment using the Community Reinforcement Approach (CRA). A total of 62 CSOs participated in this evaluation of the effectiveness of CRAFT. CSOs completed, on average, 87% of offered treatment sessions. During the 6-month study period, 74% succeeded in engaging their resistant loved one in treatment. Reported abstinence both from illicit drugs and alcohol increased significantly for drug users engaged in treatment, but not for unengaged cases. All CSOs showed significant reduction in depression, anxiety, anger, and physical symptoms, with average scores dropping into the normal range on all measures. CRAFT provides a promising alternative to confrontational and detachment approaches in counseling CSOs to help their loved ones.

Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members

In a randomized clinical trial, 130 concerned significant others (CSOs) were offered 1 of 3 different counseling approaches: (a) an Al-Anon facilitation therapy designed to encourage involvement in the 12-step program, (b) a Johnson Institute intervention to prepare for a confrontational family meeting, or (c) a community reinforcement and family training (CRAFT) approach teaching behavior change skills to use at home. All were manual-guided, with 12 hr of contact. Follow-up interviews continued for 12 months, with 94% completed. The CRAFT approach was more effective in engaging initially unmotivated problem drinkers in treatment (64%) as compared with the more commonly practiced Al-Anon (13%) and Johnson interventions (30%). Two previously reported aspects of the Johnson intervention were replicated: that most CSOs decide not to go through with the family confrontation (70% in this study) and that among those who do, most (75%) succeed in getting the drinker into treatment. All 3 approaches were associated with similar improvement in CSO functioning and relationship quality. Overall treatment engagement rates were higher for CSOs who were parents than for spouses. On average, treatment engagement occurred after 4 to 6 sessions.

Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members

In a randomized clinical trial, 130 concerned significant others (CSOs) were offered 1 of 3 different counseling approaches: (a) an Al-Anon facilitation therapy designed to encourage involvement in the 12-step program, (b) a Johnson Institute intervention to prepare for a confrontational family meeting, or (c) a community reinforcement and family training (CRAFT) approach teaching behavior change skills to use at home. All were manual-guided, with 12 hr of contact. Follow-up interviews continued for 12 months, with 94% completed. The CRAFT approach was more effective in engaging initially unmotivated problem drinkers in treatment (64%) as compared with the more commonly practiced Al-Anon (13%) and Johnson interventions (30%). Two previously reported aspects of the Johnson intervention were replicated: that most CSOs decide not to go through with the family confrontation (70% in this study) and that among those who do, most (75%) succeed in getting the drinker into treatment. All 3 approaches were associated with similar improvement in CSO functioning and relationship quality. Overall treatment engagement rates were higher for CSOs who were parents than for spouses. On average, treatment engagement occurred after 4 to 6 sessions.

Reliability of Form 90D: An Instrument for Quantifying Drug Use

Clients just entering treatment for nonalcohol primary drug use were asked to report on their frequency of drug use at two times 2 days apart. Test-retest correlations for the lifetime use of drugs were fair to excellent, and those for drug use in the last 90 days, although variable, were generally very good. For lifetime use, correlations were highest for opiates and stimulants and lowest for inhalants, whereas for the recent period correlations were highest for opiates and lowest for stimulants. Correlations were uniformly high for measures of general life functioning. Initial validity assessments with urine drug screen results as criterion were good, with no false negative errors in four of six drug use categories. Overall Form 90D appears to be a reasonably reliable and valid interview instrument for measuring drug use occurrence and frequency for both lifetime and recent use. Care is warranted in assessing classes of drugs that are used less frequently.

Comparison of treatment utilization and outcome for Hispanics and non-Hispanic whites

OBJECTIVE

To examine the use of formal alcohol treatment and Alcoholics Anonymous (AA) by Hispanics and non-Hispanic whites, and to compare ethnic groups on posttreatment functioning.

METHOD

Data from a publicly funded substance abuse treatment center in New Mexico were used to investigate possible differences between Hispanic (n = 46) and non-Hispanic white (n = 62) men (n = 76) and women (n = 32) on percent days alcohol therapy and AA attendance for 6 months after study recruitment.

RESULTS

Hispanic clients were more often male (80% vs 63%), had fewer years of education (mean = 11.6 vs 12.6) and were less likely to live alone (7% vs 29%) than were non-Hispanic white clients. The heavy drinking (drinks per drinking day mean = 16.7; standard drink units in prior 90 days mean = 941.00) and few abstinent days (mean = 0.44) that characterized both groups at intake improved over time with Hispanics engaging in more formal alcohol therapy sessions but attending fewer AA meetings than non-Hispanic whites over the course of 6 months of follow-up. Attendance at treatment and AA were separately associated with decreased intensity and quantity of alcohol use, but not abstinent days, for both ethnic groups.

CONCLUSIONS

Hispanic and non-Hispanic white clients used somewhat different treatment strategies to deal with alcohol-related problems, these paths, however, ultimately resulted in similar posttreatment drinking outcomes (frequency, intensity and quantity of alcohol consumption).

The topography of relapse in clinical samples

In two clinical samples, alcohol consumption, other drug use, and tobacco use were measured at approximately 6 months following admission of individuals into treatment. Using only the alcohol consumption variables, cluster analyses with several different solutions consistently identified abstinent, moderate, and unremitted groups. With the addition of tobacco and other drug use, analyses identified a largely abstinent group, a drug use group that did not drink, a heavy drinking group that did not use other drugs, and a group using both alcohol and other drugs, indicating the need for broad definitions of relapse. All solutions distinguished clusters of tobacco users and nonusers in remission from alcohol and other drug use, and tobacco users and nonusers tended to be differentiated among those continuing to drink or use other drugs, suggesting that the presence or absence of tobacco use marks different outcome groups. Generally speaking, clustering methods using complete and average linkage as agglomeration measures with cosine similarity as a proximity measure produced the most consistent clusters and the most clinically interpretable results.