Special populations in Alcoholics Anonymous

The vast majority of Alcoholics Anonymous (AA) members in the United States are white, and only a few studies have investigated the program's effectiveness for ethnic minorities. Project MATCH, a multisite research study aimed at developing guidelines for assigning alcoholics to appropriate treatment approaches, also assessed AA effectiveness for minority clients. Some differences in AA attendance existed among white, African-American, and Hispanic Project MATCH participants who had received some inpatient treatment before entering the study, but not among participants who had not received inpatient treatment. Further analyses of white and Hispanic Project MATCH participants demonstrated that although Hispanic clients attended AA less frequently than white clients, their involvement with and commitment to AA was higher than among white clients. For both Hispanics and whites, AA involvement predicted increased abstinence.

Intercessory prayer in the treatment of alcohol abuse and dependence: a pilot investigation

OBJECTIVE

To conduct a pilot study of the effect of intercessory prayer on patients entering treatment for alcohol abuse or dependence.

DESIGN

In addition to standard treatment, 40 patients admitted to a public substance abuse treatment facility for treatment of alcohol problems who consented to participate were randomized to receive or not receive intercessory prayer (double-blind) by outside volunteers. Assessments were conducted at baseline, 3 months, and 6 months.

RESULTS

No differences were found between prayer intervention and nonintervention groups on alcohol consumption. Compared with a normative group of patients treated at the same facility participants in the prayer study experienced a delay in drinking reduction. Those who reported at baseline that a family member or friend was already praying for them were found to be drinking significantly more at 6 months than were those who reported being unaware of anyone praying for them. Greater frequency of prayer by the participants themselves was associated with less drinking, but only at months 2 and 3.

CONCLUSION

Intercessory prayer did not demonstrate clinical benefit in the treatment of alcohol abuse and dependence under these study conditions. Prayer may be a complex phenomenon with many interacting variables.

The reliability of Form 90: an instrument for assessing alcohol treatment outcome

OBJECTIVE

Project MATCH is a randomized clinical trial consisting of five outpatient and five aftercare units at nine sites. Of importance in this multisite trial examining the efficacy of client-treatment matching was the cross- and within-site reliability of the structured interview used to assess alcohol treatment outcomes, the Form 90. Evaluation of the reliability of Form 90 is the subject of this article.

METHOD

The reliability of Form 90 was evaluated in two test-retest studies. The cross-site reliability study consisted of 70 paired test-retest interviews conducted by different interviewers. Clients for this study were recruited from inpatient, outpatient and college settings. The within-site reliability study had a total of 108 paired test-retest interviews, with 54 of the retests conducted by different interviewers and 54 by the same interviewer. Clients for this study were most often presenting for alcohol treatment at the nine sites and were selected to be representative of the larger Project MATCH sample.

RESULTS

Good-to-excellent reliability was found for all key summary measures of alcohol consumption and psychosocial functioning, and most frequently used illicit drugs had moderate reliability. No decay in consistency of self-reported drinking was found at more distal points from dates of test-retest interviews. Application of 68% confidence intervals for primary alcohol consumption measures suggests that trained researchers and clinicians can obtain consistent information regarding client drinking.

CONCLUSIONS

Form 90 appears to be a reliable instrument for alcohol treatment assessment research when interviewers have received careful training and supervision in its use.

Are reconstructed self-reports of drinking reliable?

When follow-up interviews are missed, researchers sometimes try to reconstruct the data that would have been obtained by asking clients to recall the missed interval when they are interviewed at a later point. Are such data reliable? The reliability of remote reconstruction was estimated by asking 57 participants in a clinical trial to recall their drinking for the 12-month follow-up interval when interviewed, on average, 33 weeks later. These reports were obtained after delays averaging 231 days. These reconstructed reports were compared with the same clients' self-reports obtained during the 12-month interview. Reconstructed data were found to be reasonably accurate estimates of clients' reports at the time of original interview on global alcohol use variables including percentage of drinking days and total volume of consumption. No systematic bias was found for over-reporting or under-reporting at the point of reconstruction. However, on some variables (e.g. total drinks consumed), clients on average reported more drinking at the reconstruction period than during the initial interview. Discrepancies between initial and reconstructed reports were found to be unrelated to the length of delay in the second interview or to client characteristics.

What predicts relapse? Prospective testing of antecedent models

Predictors of relapse to drinking were examined in a clinical sample of 122 individuals seeking outpatient treatment for alcohol problems. Drinking status and a variety of predictor variables were measured every two months for one year following presentation for treatment. In addition to pretreatment characteristics, potential antecedents of relapse were assessed at each point within five domains: (1) the occurrence of negative life events; (2) cognitive appraisal variables including self-efficacy, alcohol expectancies, and motivation for change; (3) client coping resources; (4) craving experiences; and (5) affective/mood status. Although the occurrence of adverse life events did not predict 6-month relapse, all other domains singly accounted for significant variance in drinking outcomes. Proximal antecedents (from the prior 2-month interval) significantly and substantially improved predictive power over that achieved from pretreatment characteristics alone. When analyzed jointly, these predictors accounted for a majority of variance in 6-month relapse status. A prospective test supported Marlatt's developmental model of relapse, pointing to two client factors as optimally predictive of resumed drinking: lack of coping skills and belief in the disease model of alcoholism.

Alcohol, drug use and consequences among Hispanics seeking treatment for alcohol-related problems

OBJECTIVE

Ethnic differences in alcohol consumption patterns are often reported in general population surveys, but less is known about variation among ethnic groups presenting for treatment.

METHOD

Within a larger clinical trial, patterns of drinking, drug use and related problems were compared for Hispanic (n = 102) and non-Hispanic white (n = 104) male (n = 154) and female (n = 52) clients presenting at a public clinic for outpatient treatment of alcohol problems.

RESULTS

Relatively few reliable ethnic differences were observed in alcohol /drug use patterns. Non-Hispanic white men reported significantly more pretreatment tobacco use than did Hispanic men (84.7% vs 61.3% of past 90 days). Hispanic women reported significantly fewer legal problems (28.6% vs 83.9%), symptoms of dependence and negative consequences of drinking relative to non-Hispanic white women. Measures of acculturation and acculturative stress failed to differentiate drinking patterns among Hispanic clients.

CONCLUSIONS

Within a treatment-seeking sample, Hispanics and non-Hispanics may be more similar with regard to drinking practices than is the case in the general population. High consumption, adverse consequences and dependence symptoms were characteristic of men presenting for alcohol treatment regardless of ethnic identification. In contrast, Hispanic treatment-seeking women had the lowest consumption, adverse consequences and dependence symptoms of all the groups described, and they reported significantly fewer alcohol-related problems and symptoms than did non-Hispanic women.

Meta-analysis of the literature on Alcoholics Anonymous: sample and study characteristics moderate findings

OBJECTIVE

Reviews of research on Alcoholics Anonymous (AA) have speculated how findings may differ when grouped by client and study characteristics. A meta-analytic review by Emrick et al. in 1993 provided empirical support for this concern but did not explore its implications. This review divided results of AA affiliation and outcome research by sample origin and global rating of study quality. The review also examined the statistical power of studies on AA.

METHOD

Meta-analytic procedures were used to summarize the findings of 74 studies that examined AA affiliation and outcome. Results were divided by whether samples were drawn from outpatient or inpatient settings and a global rating of study quality that jointly considered use of subject selection and assignment, reliability of measurement and corroboration of self-report. Efficacy of dividing study results was examined by changes in magnitude of correlations and unexplained variance.

RESULTS

AA participation and drinking outcomes were more strongly related in outpatient samples, and better designed studies were more likely to report positive psychosocial outcomes related to AA attendance. In general, AA studies lacked sufficient statistical power to detect relationships of interest.

CONCLUSIONS

AA experiences and outcomes are heterogeneous, and it makes little sense to seek omnibus profiles of AA affiliates or outcomes. Well-designed studies with large outpatient samples may afford the best opportunity to detect predictors and effects of AA involvement.

AA group dynamics and 12-step activity

OBJECTIVE

AA groups may differ in perceived social dynamics but little is known about diversity in other potentially curative processes within AA. This study examined how three AA groups differed in perceived social dynamics, group emphasis on the 12 steps of AA, and completion of the 12 steps.

METHOD

Questionnaires were completed by AA members affiliated with three mainstream AA groups. Surveys were done after investigators paid several visits to meetings as an aid to identifying group members. A majority of the AA members were male (64%) and had, on average, 45 months of continuous sobriety.

RESULTS

Profile analyses showed that the three AA groups differed in perceived group cohesiveness, independence, aggressiveness and expressiveness. The AA groups also differed in how frequently members reported that the 12 steps were discussed in meetings. Step discussion was lowest in the group with highest aggressiveness. Differences were also found in the reported frequency of completing AA steps, such that members in the group with highest cohesiveness and step discussion reported having completed the fewest surrender (1-3) steps.

CONCLUSIONS

AA groups appear to differ not only in perceived social environment (fellowship) characteristics, but in AA program implementation as reflected in discussion and completion of the 12 steps. Such differences may be stable within groups across time. These findings further caution against regarding AA as a homogeneous entity. Clearer understanding of the heterogeneity among AA groups may provide bases for initial matching of individuals to AA experiences.

Does Alcoholics Anonymous involvement predict treatment outcome?

Patients receiving inpatient treatment for alcohol dependence were followed for 31 weeks after discharge. Alcoholics Anonymous (AA) attenders, when compared with nonattenders, were not distinguishable on pretreatment patient characteristics. Posttreatment attendance of AA was not predictive of drinking outcomes. However, a measure of the degree to which patients had become involved in AA did predict more favorable outcomes.

Comparison of three alcohol consumption measures: a concurrent validity study

OBJECTIVE

The major objective of the current research was to compare three different alcohol consumption measures.

METHOD

A 90-day timeline follow-back measure was compared with two averaging measures (a quantity-frequency scale and a grid measure) in a counterbalanced design with 42 male and 30 female subjects.

RESULTS

Reasonable agreement was found among the three measures; the grid approach yielded significantly higher estimates of drinking days and total consumption, but lower estimates of peak intoxication levels. Subjects reported significantly less confidence in the accuracy of their own reports on the timeline, relative to the averaging methods.

CONCLUSIONS

The merits of the various measures and implications for their use in treatment outcome research are discussed.

Classical analytical methods for detecting matching effects on treatment outcome

This article presents a classical approach for analyzing repeated measures designs with specific application to treatment matching studies. The generic treatment matching hypothesis is formulated under the multivariate general linear model, transforming the dependent variables to account for the repeated measures structure of the data. Issues of primary importance in the use of this approach (such as correcting for inflated Type I error and robustness of statistical tests to parametric assumptions) are discussed. The article concludes with an assessment of the strengths and weaknesses of this approach compared with alternative approaches.

Assessment issues and strategies in alcoholism treatment matching research

Sensitive and comprehensive client assessment entails complex conceptual and methodological considerations. Such activity is at the heart of matching clients to appropriate treatments. This article begins by specifying the goals and functions of assessment to support matching. This is followed by a discussion of the strategies employed in Project MATCH to identify matching and outcome variables. The assessment battery used in Project MATCH is next described. Finally, an overview of issues surrounding administration of assessment measures is provided. Particular attention is given to the topics of sequencing and timing of measures.

Comparison of Timeline Follow-Back and Averaging Methods for Quantifying Alcohol Consumption in Treatment Research

There is as yet no consensus regarding how best to quantify alcohol consumption as an outcome measure in treatment research. Two commonly used methods were compared: the timeline follow-back procedure which reconstructs daily drinking via a calendar, and the grid averaging method employed in the Drinker Profile system. A sample of outpatients being treated for alcoholism was interviewed using both approaches. Similar, though not identical, consumption patterns were obtained with each measure accounting for approximately half of the variance in the other. The relative advantages of these two assessment approaches are considered.

Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles

To investigate the impact of counselor style, a 2-session motivational checkup was offered to 42 problem drinkers (18 women and 24 men) who were randomly assigned to 3 groups: (a) immediate checkup with directive-confrontational counseling, (b) immediate checkup with client-centered counseling, or (c) delayed checkup (waiting-list control). Overall, the intervention resulted in a 57% reduction in drinking within 6 weeks, which was maintained at 1 year. Clients receiving immediate checkup showed significant reduction in drinking relative to controls. The 2 counseling styles were discriminable on therapist behaviors coded from audiotapes. The directive-confrontational style yielded significantly more resistance from clients, which in turn predicted poorer outcomes at 1 year. Therapist styles did not differ in overall impact on drinking, but a single therapist behavior was predictive (r = .65) of 1-year outcome such that the more the therapist confronted, the more the client drank.

Differences among AA groups: implications for research

Clinical writings and research often imply the homogeneity of Alcoholics Anonymous. Survey data from four groups reflected some consistencies as well as substantial variation in group environment that could have an important impact on outcomes and research.

Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles

To investigate the impact of counselor style, a 2-session motivational checkup was offered to 42 problem drinkers (18 women and 24 men) who were randomly assigned to 3 groups: (a) immediate checkup with directive-confrontational counseling, (b) immediate checkup with client-centered counseling, or (c) delayed checkup (waiting-list control). Overall, the intervention resulted in a 57% reduction in drinking within 6 weeks, which was maintained at 1 year. Clients receiving immediate checkup showed significant reduction in drinking relative to controls. The 2 counseling styles were discriminable on therapist behaviors coded from audiotapes. The directive-confrontational style yielded significantly more resistance from clients, which in turn predicted poorer outcomes at 1 year. Therapist styles did not differ in overall impact on drinking, but a single therapist behavior was predictive (r = .65) of 1-year outcome such that the more the therapist confronted, the more the client drank.

Brief interventions for alcohol problems: a review

Relatively brief interventions have consistently been found to be effective in reducing alcohol consumption or achieving treatment referral of problem drinkers. To date, the literature includes at least a dozen randomized trials of brief referral or retention procedures, and 32 controlled studies of brief interventions targeting drinking behavior, enrolling over 6000 problem drinkers in both health care and treatment settings across 14 nations. These studies indicate that brief interventions are more effective than no counseling, and often as effective as more extensive treatment. The outcome literature is reviewed, and common motivational elements of effective brief interventions are described. There is encouraging evidence that the course of harmful alcohol use can be effectively altered by well-designed intervention strategies which are feasible within relatively brief-contact contexts such as primary health care settings and employee assistance programs. Implications for future research and practice are considered.