Prior Alcoholics Anonymous (AA) affiliation and the acceptability of the Twelve Steps to patients entering UK statutory addiction treatment

Rates and predictors of Alcoholics Anonymous attendance across sexual orientations

Sexual minority (e.g., gay, lesbian, bisexual) individuals experience alcohol dependence at 2-6 times the rates of heterosexual individuals. Among the general population, Alcoholics Anonymous (AA) serves as the most common source of support for alcohol-related problems in the United States. Yet, relatively little is known about sexual minority involvement in AA, including rates and predictors of AA attendance among sexual minorities. This paper aims to: 1) Compare rates of AA attendance across sexual orientations; 2) Compare relationships between AA attendance and common predictors of AA attendance across sexual orientations. Using five waves of the National Alcohol Survey (N = 7862 respondents with at least one lifetime AUD symptom), this study found lesbian and bisexual women, but not gay and bisexual men, had greater odds of attending AA, even while controlling for lifetime AUD severity, gender, race/ethnicity, age, religiosity, and current income. Interaction models for women showed there was a stronger association between older age and AA attendance, a stronger association between greater religiosity and AA attendance, and a weaker association between lifetime AUD severity and AA attendance for sexual minority women relative to heterosexual women. This study did not find significant interactions between sexual orientation and these covariates for men. These results suggest AA may serve as a promising resource for sexual minority individuals experiencing alcohol-related problems, particularly for sexual minority women who are older, more religious, and have less severe AUD.

Racial/Ethnic Disparities in Mutual Help Group Participation for Substance Use Problems

Mutual help groups are a ubiquitous component of the substance abuse treatment system in the United States, showing demonstrated effectiveness as a treatment adjunct; so, it is paramount to understand whether they are as appealing to, and as effective for, racial or ethnic minority groups as they are for Whites. Nonetheless, no known comprehensive reviews have examined whether there are racial/ethnic disparities in mutual help group participation. Accordingly, this study comprehensively reviewed the U.S. literature on racial/ethnic disparities in mutual help participation among adults and adolescents with substance use disorder treatment need. The study identified 19 articles comparing mutual help participation across specific racial/ethnic minority groups and Whites, including eight national epidemiological studies and 11 treatment/community studies. Most compared Latinx and/or Black adults to White adults, and all but two analyzed 12-step participation, with others examining "self-help" attendance. Across studies, racial/ethnic comparisons yielded mostly null (N = 17) and mixed (N = 9) effects, though some findings were consistent with a racial/ethnic disparity (N = 6) or minority advantage (N = 3). Findings were weakly suggestive of disparities for Latinx populations (especially immigrants, women, and adolescents) as well as for Black women and adolescents. Overall, data were sparse, inconsistent, and dated, highlighting the need for additional studies in this area.

An Apologetic Interpretation of Alcoholics Anonymous (AA): Timeless Wisdom, Outdated Language

BACKGROUND

The Twelve Steps of Alcoholics Anonymous (AA) has proven to be an effective aid in recovery for many people with alcohol use disorder. While constructive criticisms of AA can be beneficial to the organization, other criticisms have merely served as rhetorical devices intent on discrediting the 12-step approach.

OBJECTIVES

This paper examines six prominent critiques of AA, paying special attention to the premises, tone, and factual basis of the statements. Interpretations grounded in AA literature are offered to address claims or critiques around prominent themes, which are organized into two main classes: purported causes of alcoholism and factors maintaining alcoholism.

RESULTS

Findings reveal tenuous statements in the AA literature that appear contradictory and thereby invite a misreading. These statements, some of which misrepresent the tenets of AA and its founders, underscore certain vocal criticisms that are not entirely unfounded. While many pages of the AA literature are imbued with timeless wisdom, even the most apologetic interpretations-distilled into benefit-of-the-doubt renderings-largely falter in defending the nature of the language that originated in the early 1900s at odds with 21st century understandings of alcohol use disorder. Conclusions/Importance: The AA literature essentially presents a valid target for critics, fueling resistance to this free community-based resource that may prevent people who could benefit from AA from seeking the help of the 12-steps.

Affiliation to alcoholics anonymous or narcotics anonymous among patients attending an English specialist addiction service

Purpose

Attendance at alcoholics anonymous (AA) or narcotics anonymous (NA) meetings and affiliation with the fellowship has potential benefits for people with alcohol or drug use disorders. This effect is present whether or not the individual attends professional treatment services, but the two process can have a synergistic effect. Limited information exists about the extent to which people attending UK specialist treatment services also attend AA/NA and their views about such attendance. The paper aims to discuss these issues.

Design/methodology/approach

A cross-sectional survey of 200 consecutive attendees at the specialist treatment service in an English region was conducted between January and April 2018. A measure of past attendance and affiliation with AA/NA (AAAS) and a scale designed to quantify future readiness to attend (Survey of Readiness for Alcoholics Anonymous Participation) were administered and anonymously linked to data supplied to the National Drug Treatment Monitoring Service (NDTMS).

Findings

A minority of the sample had ever attended an AA meeting (31 per cent, n=59) or an NA meeting (41 per cent, n=79), and only 14 per cent (n=27) and 24 per cent (n=45) had attended an AA or NA meeting, respectively, in the past year. Only two variables significantly predicted level of readiness to attend AA or NA in a regression model: attended more AA/NA meetings in the past (ß=0.149, p=0.036) and previous level of participation (AAAS score) (ß=0.409, p < 0.001).

Practical implications

A significant proportion of attendees of a specialist drug and alcohol treatment service had never attended AA/NA, despite many positive views about their potential benefits. Given the established benefits of attending AA/NA meetings and participating in the AA or NA fellowship, these results suggest that professional treatment services should do more to explain the process and challenge preconceived ideas about how they operate.

Originality/value

The authors are not aware of any published research that captures the rates of attendance of and participation in both AA and NA groups in a UK-based community treatment sample. These results may therefore provide a baseline for evaluating the impact of interventions to increase attendance/participation, and also provide some insight into the potential barriers to attendance in this population.

Effects of Social Support and 12-Step Involvement on Recovery among People in Continuing Care for Cocaine Dependence

Background: Social networks that support recovery lead to enhanced treatment outcomes and sobriety regardless if this support stems from family, peer groups or 12-Step programs. Treatment process factors including readiness to change and commitment to abstinence also impact substance use. However, little is understood about the relationship between social support to treatment process factors during and after treatment for substance use disorders. Objectives: To identify the ways in which different social networks foster substance use change in a sample of individuals with cocaine dependence from intensive outpatient programs (IOPs). Methods: Data were drawn from two studies examining adults (N = 489) with cocaine dependence in IOPs for substance use disorders collected between 2004 and 2009. Assessment data were collected at 3- to 6-month intervals from baseline to 24-months and included the University of Rhode Island change assessment questionnaire, timeline followback, thoughts about abstinence, perceived social support - friend, and family versions and analyzed using GEE and mediational analyses. Results: Greater perceived friend social support was associated with greater readiness to change whereas greater perceived familial social support was associated with substance use goal; greater social support from both friends and family were associated with less substance use. Greater AA/NA participation was associated with substance use goal and readiness to change, and less substance use. Substance use goals partially mediated the impact of social support on later substance use. Conclusions/Importance: While peer and familial support are key to sustained recovery, their impact differentially affects treatment process variables. This information could be used to inform social support treatment interventions.

Correlates of alcoholics anonymous affiliation among justice-involved women

BACKGROUND

Alcohol use disorder (AUD) constitutes a major public health problem and is associated with a substantial amount of disability and premature death worldwide. Several treatment and self-help options including Alcoholics Anonymous (AA) meetings are available. Nevertheless, factors associated with AA affiliation in some disadvantaged groups such as justice-involved women are not well understood. The purpose of this study is to report on previously unexamined correlates of past year AA affiliation among women in pretrial jail detention.

METHODS

The current study used cross-sectional data from 168 women with DSM-5 diagnosis of  AUD in pretrial jail detention. The study examined factors related to women's concept of self and others (i.e., disbelief that others are trustworthy, lack of autonomy to choose who they interact with, experience of violent victimization, low investment in self-care, higher stress levels, and homelessness) as correlates of past-year AA affiliation, controlling for severity of AUD and demographic factors.

RESULTS

Women who believe that others are inherently trustworthy, women who met less AUD criteria, and women who are older reported more past-year AA affiliation in both univariate and multivariate analyses.

CONCLUSION

Introducing AA outreach and alternative interventions for younger, less severely addicted women might improve AUD outcomes. Moreover, designing more individualized treatment plan for women who believe others are not trust worthy might help AUD treatment engagement in this population.

TRIAL REGISTRATION

NCT01970293 , 10/28/2013.

Benefits of peer support groups in the treatment of addiction

Objective

Peer support can be defined as the process of giving and receiving nonprofessional, nonclinical assistance from individuals with similar conditions or circumstances to achieve long-term recovery from psychiatric, alcohol, and/or other drug-related problems. Recently, there has been a dramatic rise in the adoption of alternative forms of peer support services to assist recovery from substance use disorders; however, often peer support has not been separated out as a formalized intervention component and rigorously empirically tested, making it difficult to determine its effects. This article reports the results of a literature review that was undertaken to assess the effects of peer support groups, one aspect of peer support services, in the treatment of addiction.

Methods

The authors of this article searched electronic databases of relevant peer-reviewed research literature including PubMed and MedLINE.

Results

Ten studies met our minimum inclusion criteria, including randomized controlled trials or pre-/post-data studies, adult participants, inclusion of group format, substance use-related, and US-conducted studies published in 1999 or later. Studies demonstrated associated benefits in the following areas: 1) substance use, 2) treatment engagement, 3) human immunodeficiency virus/hepatitis C virus risk behaviors, and 4) secondary substance-related behaviors such as craving and self-efficacy. Limitations were noted on the relative lack of rigorously tested empirical studies within the literature and inability to disentangle the effects of the group treatment that is often included as a component of other services.

Conclusion

Peer support groups included in addiction treatment shows much promise; however, the limited data relevant to this topic diminish the ability to draw definitive conclusions. More rigorous research is needed in this area to further expand on this important line of research.

Perceptions of twelve-step mutual-help groups and their associations with motivation, treatment attendance and alcohol outcomes among chronically homeless individuals with alcohol problems

BACKGROUND

Twelve-step mutual-help groups (TMGs) are among the most available forms of support for homeless individuals with alcohol problems. Qualitative research, however, has suggested that this population often has negative perceptions of these groups, which has been shown to be associated with low TMG attendance. It is important to understand this population's perceptions of TMGs and their association with alcohol outcomes to provide more appropriate and better tailored programming for this multiply affected population. The aims of this cross-sectional study were to (a) qualitatively examine perception of TMGs in this population and (b) quantitatively evaluate its association with motivation, treatment attendance and alcohol outcomes.

METHODS

Participants (N=62) were chronically homeless individuals with alcohol problems who received single-site Housing First within a larger evaluation study. Perceptions of TMGs were captured using an open-ended item. Quantitative outcome variables were created from assessments of motivation, treatment attendance and alcohol outcomes.

RESULTS

Findings indicated that perceptions of TMGs were primarily negative followed by positive and neutral perceptions, respectively. There were significant, positive associations between perceptions of TMGs and motivation and treatment attendance, whereas no association was found for alcohol outcomes.

CONCLUSIONS

Although some individuals view TMGs positively, alternative forms of help are needed to engage the majority of chronically homeless individuals with alcohol problems.

Treatment Process and Participant Characteristic Predictors of Substance Use Outcome in Mentorship for Addiction Problems (MAP)

There are a variety of self-help treatments which have components of sponsorship or peer support. Although there has been a recent surge in the utilization of peer support interventions within clinical settings, there is limited data on substance use outcome predictors for interventions designed solely for peer support within community treatment settings that are empirically based. We examined both treatment process and participant characteristic variables as predictors of substance use outcomes within our Stage I pilot which developed a new intervention, Mentorship for Addiction Problems (MAP). We found treatment process variables to be significantly associated with substance use outcome and no participant characteristic variables.

Motivational intervention to enhance post-detoxification 12-Step group affiliation: a randomized controlled trial

AIMS

To compare a motivational intervention (MI) focused on increasing involvement in 12-Step groups (TSGs; e.g. Alcoholics Anonymous) versus brief advice (BA) to attend TSGs.

DESIGN

Patients were assigned randomly to either the MI or BA condition, and followed-up at 6 months after discharge.

SETTING AND PARTICIPANTS

One hundred and forty substance use disorder (SUD) patients undergoing in-patient detoxification (detox) in Norway.

MEASUREMENTS

The primary outcome was TSG affiliation measured with the Alcoholics Anonymous Affiliation Scale (AAAS), which combines meeting attendance and TSG involvement. Substance use and problem severity were also measured.

FINDINGS

At 6 months after treatment, compared with the BA group, the MI group had higher TSG affiliation [0.91 point higher AAAS score; 95% confidence interval (CI) = 0.04 to 1.78; P = 0.041]. The MI group reported 3.5 fewer days of alcohol use (2.1 versus 5.6 days; 95% CI = -6.5 to -0.6; P = 0.020) and 4.0 fewer days of drug use (3.8 versus 7.8 days; 95% CI = -7.5 to -0.4; P = 0.028); however, abstinence rates and severity scores did not differ between conditions. Analyses controlling for duration of in-patient treatment did not alter the results.

CONCLUSIONS

A motivational intervention in an in-patient detox ward was more successful than brief advice in terms of patient engagement in 12-Step groups and reduced substance use at 6 months after discharge. There is a potential benefit of adding a maintenance-focused element to standard detox.

Stimulant abuser groups to engage in 12-step: a multisite trial in the National Institute on Drug Abuse Clinical Trials Network

AIMS

The study evaluated the effectiveness of an 8-week combined group plus individual 12-step facilitative intervention on stimulant drug use and 12-step meeting attendance and service.

DESIGN

Multisite randomized controlled trial, with assessments at baseline, mid-treatment, end of treatment, and 3- and 6-month post-randomization follow-ups (FUs).

SETTING

Intensive outpatient substance treatment programs.

PARTICIPANTS

Individuals with stimulant use disorders (n = 471) randomly assigned to treatment as usual (TAU) or TAU into which the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention was integrated.

MEASUREMENTS

Urinalysis and self-reports of substance use and 12-step attendance and activities.

INTERVENTION

Group sessions focused on increasing acceptance of 12-step principles; individual sessions incorporated an intensive referral procedure connecting participants to 12-step volunteers.

FINDINGS

Compared with TAU, STAGE-12 participants had significantly greater odds of self-reported stimulant abstinence during the active 8-week treatment phase; however, among those who had not achieved abstinence during this period, STAGE-12 participants had more days of use. STAGE-12 participants had lower Addiction Severity Index Drug Composite scores at and a significant reduction from baseline to the 3-month FU, attended 12-step meetings on a greater number of days during the early phase of active treatment, engaged in more other types of 12-step activities throughout the active treatment phase and the entire FU period, and had more days of self-reported service at meetings from mid-treatment through the 6-month FU.

CONCLUSIONS

The present findings are mixed with respect to the impact of integrating the STAGE-12 intervention into intensive outpatient drug treatment compared with TAU on stimulant drug use. However, the results more clearly indicate that individuals in STAGE-12 had higher rates of 12-step meeting attendance and were engaged in more related activities throughout both the active treatment phase and the entire 6-month FU period than did those in TAU.

Does active referral by a doctor or 12-Step peer improve 12-Step meeting attendance? Results from a pilot randomised control trial

BACKGROUND

Active engagement in 12-Step self-help groups (SHG) is associated with improvements in substance use outcomes during and after treatment, yet levels of participation in SHG meetings in the U.K. remain low.

METHOD

An RCT investigating the impact of active referral to SHG, delivered by doctors or 12-Step peers during inpatient treatment on both inpatient and post-treatment meeting attendance was conducted. 151 inpatients with alcohol, opiate, crack-cocaine or benzodiazepine dependence undergoing detoxification, received one of two active referral interventions: 12-Step peer intervention (PI), doctor intervention (DI), or no intervention (NI). 83% of the sample was followed up, 2-3 months following discharge.

RESULTS

Active referral interventions significantly increased attendance at 12-Step meetings during inpatient treatment (88% versus 73%, p<.05). Rates of post-discharge meeting attendance were PI=64%, DI=48%, NI=33%, with those in the PI group significantly (OR=3.6; CI=1.3, 9.8) more likely to have attended. Inpatient meeting attenders were three times as likely to have attended meetings post-discharge (59% versus 20%, p<.01), and post-discharge meeting attenders reported significantly higher abstinence rates (60.8% versus 39.2%, p<.05) at follow-up. However, abstinence rates did not differ significantly across intervention groups (44% [PI], 41% [DI] and 36% [NI]).

CONCLUSION

Attendance at 12-Step SHGs is associated with greater rates of abstinence and active referral, especially by 12-Step peers, increases 12-Step SHG attendance rates. However, improved clinical outcomes among attendees might not occur until stronger recovery peer support networks are established. These results show promise for the benefit of incorporating Twelve Step Facilitation into U.K. treatment settings.

The courage to change: patient perceptions of 12-Step fellowships

BACKGROUND

From a health services perspective, peer-based resources merit special attention. Participation in self-help fellowships, like the Twelve Step Groups (TSGs), have been shown to improve outcomes of patients with substance use disorder (SUD) and they represent a valuable adjunct to the SUD treatment system. This study investigated the relationship between patient perceptions of TSGs and the intent to participate in TSGs after receiving detoxification treatment.

METHODS

We included 139 patients that entered a detoxification unit (detox) in Kristiansand, Norway. We analyzed factors associated with the intention to participate in TSGs post-discharge with contingency tables and ordinal regression analysis.

RESULTS

Forty-eight percent of patients had participated in TSGs before entering detox. Respondents saw more advantages than disadvantages in TSG participation, but only 40% of patients showed high intentions of participating in TSGs post-discharge. A high intention to participate in TSGs was most strongly correlated with the notion that participation in TSGs could instill the courage to change. In a multivariate analysis, the perception that TSGs were beneficial was the strongest factor related to a high intention of TSG participation after treatment.

CONCLUSIONS

Our findings increased the understanding of factors most likely to influence decisions to attend TSGs in SUD treatment contexts with uncommon TSG participation. Our results suggested that the majority of patients may be sufficiently influenced by highlighting the potential gains of TSG participation. Treatment programs that do not focus on self-help group attendance during and after treatment should consider implementing facilitative measures to enhance utilization of these fellowships.

Mentorship for Alcohol Problems (MAP): a peer to peer modular intervention for outpatients

AIMS

This is a Stage I open pilot to develop a new intervention, Mentorship for Alcohol Problems (MAP), for individuals with alcohol-use disorders in community treatment programs.

METHODS

Ten mentors participated for 6 months until 30 mentees received MAP for 12 weeks. Behavioral and biological measures were conducted in addition to fidelity measures. Four focus groups were held with participants and clinician feedback surveys were completed.

RESULTS

Feasibility and acceptance data in the domains of patient interest, safety and satisfaction were promising. Mentees reduced their alcohol and substance use and the majority of mentors sustained abstinence. Fidelity measures indicated that mentors adhered to the delivery of treatment.

CONCLUSION

MAP shows promise to be incorporated into professionally run outpatient alcohol treatment programs to assist in the reduction of alcohol and substance use.

The role of AA sponsors: a pilot study

AIMS

The aim of this study was to explore the roles of Alcoholics Anonymous (AA) sponsors and to describe the characteristics of a sample of sponsors.

METHODS

Twenty-eight AA sponsors, recruited using a purposive sampling method, were administered an unstructured qualitative interview and standardized questionnaires. The measurements included: a content analysis of sponsors' responses; Severity of Alcohol Dependence Questionnaire-Community version (SADQ-C) and Alcoholics Anonymous Affiliation Scale (AAAS).

RESULTS

Sample characteristics were as follows: the median length of AA attendance was 9.5 years (range 5-28); the median length of sobriety was 11 years (range 4.5-28); the median number of sponsees per sponsor was 1 but there was a wide range (0-17, interquartile range 3.75); and the sponsors were highly affiliated to AA (median AAAS score 8.75, range 5.5-8.75, maximum possible score 9). Past alcohol dependence scores were surprisingly low: 5 (18%) sponsors had mild, 14 (50%) moderate and 9 (32%) severe dependence according to the SADQ-C (median 26.5, range 11-56). Sponsorship roles were as follows: 16 roles were identified through the initial content analysis. These were distilled into three super-ordinate roles through a thematic analysis: (1) encouraging sponsees to work the programme of AA (doing the 12 steps and engaging in AA activity); (2) support (regular contact, emotional support and practical support); and (3) carrying the message of AA (sharing sponsor's personal experience of recovery with sponsees).

CONCLUSIONS

The roles identified broadly corresponded with the AA literature delineating the duties of a sponsor. This non-random sample of sponsors was highly engaged in AA activity but only had a past history of moderate alcohol dependence.

Facilitating involvement in twelve-step programs

Twelve-step programs represent a readily available resource for individuals with substance use disorders. These programs have demonstrated considerable effectiveness in helping substance abusers achieve and maintain abstinence and improve their overall psychosocial functioning and recovery. Despite these positive benefits associated with increased involvement in twelve-step self-help programs, many substance abusers do not affiliate or do so for only a short period of time before dropping out. Because of this, clinicians and researchers have sought ways to increase involvement in such self-help groups by facilitating meeting attendance and engagement in other twelve-step activities. The present chapter reviews the impact of treatment program orientation and specific interventions designed to facilitate twelve-step program involvement, subsequent meeting attendance, engagement in twelve-step activities, and alcohol and drug use. The findings of studies evaluating these approaches indicate that it is possible to increase twelve-step involvement and that doing so results in reduced substance use. The results suggest that incorporating these evidence-based interventions into standard treatment programs may lead to improved outcomes.

The Effect of Johrei Healing on Substance Abuse Recovery: A Pilot Study

OBJECTIVE

The purpose of the present study was to determine the effectiveness of Johrei healing, a form of energy healing, on substance use and psychologic symptoms in a sample of clients receiving substance abuse treatment.

METHODS

Twenty-one (21) persons in residential substance-abuse treatment participated in a randomized, wait-list control pilot study of Johrei healing. Twelve (12) of the participants received three 20-minute Johrei sessions for 5 weeks in addition to their regular treatment.

RESULTS

The results are from the first treatment wave. Individual healing sessions were evaluated pre-post with the Johrei Experience Scale. Participants showed significant decreases in stress/depression and physical pain and increases in positive emotional/spiritual state, energy, and overall well-being after an individual Johrei healing session. The Global Assessment of Individual Need (GAIN), Profile of Mood States (POMS), General Alcoholics Anonymous Tools of Recovery, and 12-Step Participation scales were administered before and after the 5-week intervention to assess change in substance use, psychologic distress, mood, and 12-Step participation. Improvements in depression and trauma symptoms, externalizing behaviors (GAIN), and vigor (POMS) were found for the treatment group. Despite comparable 12-Step attendance the treatment group showed greater improvement than the wait-list control group in the use of 12-Step recovery tools. No difference in substance use was found between the two groups.

CONCLUSIONS

Variables related to substance use and relapse showed improvement in the treatment group suggesting that Johrei healing shows promise and should be studied with a larger sample, over a longer treatment period, with sham controls.

Demand for prior treatment in alcoholic patients

The aim of this study is to analyze the use of health care resources by alcoholic patients. A prospective study of 176 patients (147 males, 29 females; mean age 42.9 years) diagnosed as alcohol dependent, according to criteria DSM-IV, has been carried out over one year (June 2002 to June 2003) in three centers of treatment for alcoholics in Castilla y León (Spain). Of the 176 patients, 67% had previously requested treatment for their alcoholism in other centers, mainly in mental-health (37.5%), emergency (34.1%), and primary care (31.8%). On average, they had requested treatment 2.27 times, the women more frequently than the men. The current study shows that alcohol-dependent patients frequently use health care services during the history of their dependence to treat their illness.

Paths of Entry Into Alcoholics Anonymous: Consequences for Participation and Remission

BACKGROUND

This study compared individuals with alcohol use disorders who, in the first year after initiating help-seeking, entered Alcoholics Anonymous (AA) only, entered professional treatment and AA together, or entered professional treatment only

METHODS

A sample of initially untreated individuals (N = 362) was surveyed at baseline and 1 year, 3 years, 8 years, and 16 years later. At each contact point, participants described their participation in AA and treatment and their current alcohol-related functioning. They also described their reasons for entering AA and/or treatment and the perceived benefits of these sources of help

RESULTS

Compared with individuals who initially participated only in treatment but later entered AA, those who entered treatment and AA together participated in AA longer and more frequently and were more likely to achieve remission. Among individuals who initially participated only in AA, those who later entered treatment had poorer remission outcomes than those who did not enter treatment. Longer duration of participation in AA was associated with a higher likelihood of remission at all four follow-ups; individuals who dropped out of AA were more likely to relapse or remain nonremitted.

CONCLUSIONS

Compared with individuals who participated only in professional treatment in the first year after they initiated help-seeking, individuals who participated in both treatment and AA were more likely to achieve remission. Individuals who entered treatment but delayed participation in AA did not appear to obtain any additional benefit from AA.