A randomized pilot trial of brief family-involved treatment for alcohol use disorder: Treatment engagement and outcomes

OBJECTIVE

Involving family members in a patient's treatment for alcohol use disorder (AUD) leads to more positive outcomes, but evidence-based family-involved treatments have not been adopted widely in AUD treatment programs. Study aims the following: (a) modify an empirically supported 12-session AUD treatment, alcohol behavioral couple therapy (ABCT) to make it shorter and appropriate for any concerned family member and (b) conduct a small clinical trial to obtain feasibility data and effect size estimates of treatment efficacy.

METHOD

ABCT content was adapted to three-sessions following input from clinicians, patients, and family members. Patient and family member dyads were recruited from an inpatient treatment program and randomized to the new treatment, brief family-involved treatment (B-FIT), or treatment-as-usual (TAU). Drinking was assessed using the Form-90; family support and family functioning were assessed using the Family Environment Scale Conflict and Cohesion subscales and the Family Adaptability and Cohesion Evaluation Scale-IV, Communication scale. Dyads (n = 35) were assessed at baseline and 4-month follow-up.

RESULTS

On average, dyads received one of three B-FIT sessions with 6 dyads receiving no sessions due to scheduling conflicts or patient discharge. At follow-up, there was a large-to-medium effect size estimate favoring B-FIT for proportion drinking days (patient report, n = 22; Hedges' g = 1.01; patient or family report, n = 28; Hedges' g = .48). Results for family support or family functioning measures favored TAU.

CONCLUSIONS

Implementation of brief family-involved treatment in inpatient AUD treatment was challenging, but preliminary data suggest the potential value of B-FIT in impacting drinking outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Relative and Interactive Associations of Psychosocial Intervention and Alcoholics Anonymous Attendance With Alcohol Use Disorder Outcomes

OBJECTIVE

Psychosocial intervention and Alcoholics Anonymous (AA)/mutual help organization attendance are both associated with alcohol use disorder (AUD) outcomes. However, no research has explored the relative or interactive associations of psychosocial intervention and AA attendance with AUD outcomes.

METHOD

This was a secondary analysis of data from the Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) outpatient arm participants (N = 952), who were randomly assigned to complete 12-session cognitive-behavioral therapy (CBT, n = 301), 12-session 12-step facilitation (TSF, n = 335), or 4-session motivational enhancement therapy (MET, n = 316). Regression analyses tested the association of psychosocial intervention attendance only, AA attendance only (measured as past-90-day attendance immediately after psychosocial intervention, as well as 1 and 3 years after intervention), and their interaction with the percentage of drinking days and percentage of heavy drinking days after intervention, 1 year after intervention, and 3 years after intervention.

RESULTS

When accounting for AA attendance and other variables, attending more psychosocial intervention sessions was consistently associated with fewer drinking days and heavy drinking days after intervention. AA attendance was consistently associated with a lower percentage of drinking days at 1 and 3 years after intervention, when accounting for psychosocial intervention attendance and other variables. Analyses failed to identify an interaction between psychosocial intervention attendance and AA attendance with AUD outcomes.

CONCLUSIONS

Psychosocial intervention and AA attendance are robustly associated with better AUD outcomes. Replication studies comprising samples of individuals who attend AA more than once per week are needed to further test the interactive association of psychosocial intervention attendance and AA attendance with AUD outcomes.

Percentage of Heavy Drinking Days Following Psilocybin-Assisted Psychotherapy vs Placebo in the Treatment of Adult Patients With Alcohol Use Disorder: A Randomized Clinical Trial

IMPORTANCE

Although classic psychedelic medications have shown promise in the treatment of alcohol use disorder (AUD), the efficacy of psilocybin remains unknown.

OBJECTIVE

To evaluate whether 2 administrations of high-dose psilocybin improve the percentage of heavy drinking days in patients with AUD undergoing psychotherapy relative to outcomes observed with active placebo medication and psychotherapy.

DESIGN, SETTING, AND PARTICIPANTS

In this double-blind randomized clinical trial, participants were offered 12 weeks of manualized psychotherapy and were randomly assigned to receive psilocybin vs diphenhydramine during 2 day-long medication sessions at weeks 4 and 8. Outcomes were assessed over the 32-week double-blind period following the first dose of study medication. The study was conducted at 2 academic centers in the US. Participants were recruited from the community between March 12, 2014, and March 19, 2020. Adults aged 25 to 65 years with a DSM-IV diagnosis of alcohol dependence and at least 4 heavy drinking days during the 30 days prior to screening were included. Exclusion criteria included major psychiatric and drug use disorders, hallucinogen use, medical conditions that contraindicated the study medications, use of exclusionary medications, and current treatment for AUD.

INTERVENTIONS

Study medications were psilocybin, 25 mg/70 kg, vs diphenhydramine, 50 mg (first session), and psilocybin, 25-40 mg/70 kg, vs diphenhydramine, 50-100 mg (second session). Psychotherapy included motivational enhancement therapy and cognitive behavioral therapy.

MAIN OUTCOMES AND MEASURES

The primary outcome was percentage of heavy drinking days, assessed using a timeline followback interview, contrasted between groups over the 32-week period following the first administration of study medication using multivariate repeated-measures analysis of variance.

RESULTS

A total of 95 participants (mean [SD] age, 46 [12] years; 42 [44.2%] female) were randomized (49 to psilocybin and 46 to diphenhydramine). One participant (1.1%) was American Indian/Alaska Native, 3 (3.2%) were Asian, 4 (4.2%) were Black, 14 (14.7%) were Hispanic, and 75 (78.9%) were non-Hispanic White. Of the 95 randomized participants, 93 received at least 1 dose of study medication and were included in the primary outcome analysis. Percentage of heavy drinking days during the 32-week double-blind period was 9.7% for the psilocybin group and 23.6% for the diphenhydramine group, a mean difference of 13.9%; (95% CI, 3.0-24.7; F1,86 = 6.43; P = .01). Mean daily alcohol consumption (number of standard drinks per day) was also lower in the psilocybin group. There were no serious adverse events among participants who received psilocybin.

CONCLUSIONS AND RELEVANCE

Psilocybin administered in combination with psychotherapy produced robust decreases in percentage of heavy drinking days over and above those produced by active placebo and psychotherapy. These results provide support for further study of psilocybin-assisted treatment for AUD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02061293.

Prenatal maternal posttraumatic stress disorder as a risk factor for adverse birth weight and gestational age outcomes: A systematic review and meta-analysis

BACKGROUND

Although not routinely assessed, prenatal posttraumatic stress disorder (PTSD) is associated with poor maternal mental health and mother-infant bonding. Prenatal PTSD may also be associated with birth weight and gestational age outcomes, but this remains unclear. This systematic review and meta-analysis investigated the association of prenatal PTSD with risk of low birth weight (LBW) or preterm birth (PTB) (dichotomous medically-defined cut-offs) or with birth weight (BW) or gestational age (GA) (continuous variables).

METHODS

A comprehensive literature search was conducted in Web of Science, MedLine, PubMed, and PsychInfo. Data were collected and processed according to Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Study quality was assessed with the Newcastle-Ottowa Quality Assessment Scale. Pooled effect sizes were estimated with random-effects models (correlation for continuous and odds ratios for dichotomous outcomes).

RESULTS

Sixteen studies with 51,470 participants (prenatal PTSD 8%) were included in 4 meta-analyses. Maternal prenatal PTSD was associated with higher risks of LBW (OR = 1.96; 95% CI, 1.26, 3.03; P = .003), PTB (OR = 1.42; 95% CI, 1.16, 1.73; P = .001), and reduced GA (r = -0.04; 95% CI, -0.06, -0.01; P = .002).

LIMITATIONS

Different designs across studies, variety of PTSD assessment practices, and a small pool of studies were noted.

CONCLUSIONS

Findings suggest prenatal PTSD presents increased risks of LBW, PTB, and reduced GA. Evidence of physical harm to neonates from prenatal PTSD provides a powerful rationale to increase prenatal PTSD screening and identify effective prenatal interventions to improve maternal and child outcomes.

Stroop-related cerebellar and temporal activation is correlated with negative affect and alcohol use disorder severity

Impairment in cognitive control in alcohol use disorder (AUD) contributes to difficulty controlling alcohol use and, in many populations, difficulties with emotion regulation. However, the most reliable and robust marker of clinically-relevant deficits in cognitive control in AUD is unclear. Our aims were to measure relationships between BOLD signal during a Stroop task and AUD severity and change in BOLD signal and change in drinking over three weeks. We also aimed to explore the relationships between BOLD signal and subjective negative affect. Thirty-three individuals with AUD underwent a multisensory Stroop task during functional magnetic resonance imaging (fMRI), as well as a battery of neuropsychological tests and self-report assessments of negative affect and AUD severity. Greater activation in temporal gyrus and cerebellum during incongruent trials compared to congruent trials was observed, and percent signal change (incongruent minus congruent) in both clusters was positively correlated with AUD severity and self-reported negative affect. Neuropsychological task performance and self-reported impulsivity were not highly correlated with AUD severity. Hierarchical regression analyses indicated that percent signal change (incongruent minus congruent) in cerebellum was independently associated with negative affect after controlling for recent and chronic drinking. In a subset of individuals (n = 23) reduction in cerebellar percent signal change (incongruent minus congruent) was correlated with increases in percent days abstinent over 3 weeks. BOLD activation during this Stroop task may therefore be an important objective marker of AUD severity and negative affect. The potential importance of the cerebellum in emotion regulation and AUD severity is highlighted.

The Validity of the Short Inventory of Problems and Drinking Intensity among Urban American Indian Adults

BACKGROUND

American Indian (AI) adults have both high prevalence rates of alcohol abstinence and alcohol use disorders compared to non-Hispanic White adults. We investigated the applicability and validity of the Short Inventory of Problems (SIP) among AI urban adults and the moderating effect of biological sex.

METHODS

AI adults from three Alcoholics Anonymous samples (n = 124) provided baseline, 3-, 6- and 9-month data. Measures included Form 90 and the SIP, which includes 5 domains of alcohol-related negative consequences including interpersonal, intrapersonal, physical, impulse control and social. Drinking frequency and intensity were assessed by percent days abstinent (PDA) and drinks per drinking day (DPDD).

RESULTS

Cronbach alphas of the SIP were similar between urban AI adults and the mainstream treatment-seeking population reported in the SIP manual. DPDD was a significant and positive predictor of all five SIP scales collected 9-months later. Higher PDA was significantly and negatively associated with later consequences, and all 5 SIP scales. Moderation tests indicated that the association between consequences and drinking intensity was stronger for AI females with fewer drinking days resulting in significantly fewer consequences for AI males relative to AI females.

CONCLUSIONS

Findings highlight the acceptability of SIP as a measure to assess drinking related consequences among AI urban adults, with clinical implications related to alcohol use and sex. Further research is warranted to examine differential drinking related outcomes among AI men and women in addition to adaptations of the SIP that more fully capture the range of negative drinking consequences.

Aligning three substance use disorder interventions among a tribe in the Southwest United States: Pilot feasibility for cultural re-centering, dissemination, and implementation

In this article we describe cultural re-centering, dissemination, and implementation activities in partnership between an American Indian reservation community and a university in the Southwest United States. We offer examples of cultural adaptation and implementation of evidence-based treatments (e.g., Motivational Interviewing, Community Reinforcement Approach and the Community Reinforcement and Family Training) using the Interactive Systems Framework. Facilitators and barriers are described within each study including recruitment strategies, training, and sustainability of counselors in the community. Through this Tribal-university partnership, we offer insight on the cultural adaptation and implementation process that will be translatable and clinically meaningful to other rural and reservation communities.

The Relationship Between Perceived Alcoholics Anonymous Social Group Dynamics and Getting an AA Sponsor

Research has shown that aspects of group dynamics of AA meetings are associated with AA attendance, alcohol use, and engagement in prescribed AA behaviors. This study investigated whether perceptions of AA meeting group dynamics changed over 12-months and whether these dynamics predicted the probability that a new member would get a sponsor. Results showed that perceptions of the group dynamics of AA meetings did not change over the 12-month assessment period. Member perception of group cohesion was the only AA meeting group dynamic that predicted a new member getting a sponsor. Findings suggest that group cohesion plays an important role in AA members recovery efforts.

The search for mechanisms of cognitive behavioral therapy for alcohol or other drug use disorders: A systematic review

The emphasis in addictions research has shifted toward a greater interest in identifying the mechanisms involved in patient behavior change. This systematic review investigated nearly 30 years of mediation research on cognitive behavioral therapy (CBT) for alcohol or other drug use disorders (AUD/SUD).

METHOD

Study inclusion criteria targeted analyses occurring in the context of a randomized clinical trial where both intervention/intervention ingredient to mediator (a path) and mediator to outcome (b path) paths were reported. Between- and within-condition analyses were eligible, as were studies that formally tested mediation and those that conducted path analysis only.

RESULTS

The review sample included K = 15 reports of primarily between-condition analyses. Almost half of these reports utilized Project MATCH (k = 2) or COMBINE (k = 4) samples. Among the mediator candidates, support for changes in coping skills was strongest, although the specificity of this process to CBT or CBT-based treatment remains unclear. Similarly, support for self-efficacy as a statistical mediator was found in within-, but not between-condition analyses.

CONCLUSIONS

A coherent body of literature on CBT mechanisms is significantly lacking. Adopting methodological guidelines from the Science of Behavior Change Framework, we provide recommendations for future research in this area of study.

Urban American Indian Adult Participation and Outcomes in Culturally Adapted and Mainstream Alcoholics Anonymous Meetings

Very little is known about American Indian (AI) adults' participation in Alcoholics Anonymous (AA) despite their elevated rates of negative sequelae due to heavy alcohol consumption and alcohol use disorders. This study sought to fill that gap and examined the engagement in AA by urban Southwest AI (S-AI) adult problem drinkers and whether enculturation and acculturation accounted for type of AA attended (mainstream versus culturally adapted AA; CA-AA). Additionally, we compared three and six-month drinking outcomes of urban S-AI adults by type of meeting attended. Sixty-one urban S-AI adults were consented and assessed at baseline, three and six-months. We examined the association between frequency of AA attendance and differences between types of meetings attended regressed on the outcomes of proportion abstinent days and drinks per drinking day. Results indicate that AA attendance is the model approach and assists urban S-AI adults in reducing their drinking. Despite higher engagement among those attending both AA and CA-AA, this did not translate into differential AA-related benefit which speaks to the need for additional research to assist AI adults in effectively reducing their alcohol use.

A meta-analysis of cognitive-behavioral therapy for alcohol or other drug use disorders: Treatment efficacy by contrast condition

OBJECTIVE

This meta-analysis examined 30 randomized controlled trials (32 study sites; 35 study arms) that tested the efficacy of cognitive-behavioral therapy (CBT) for alcohol or other drug use disorders. The study aim was to provide estimates of efficacy against three levels of experimental contrast (i.e., minimal [k = 5]; nonspecific therapy [k = 11]; specific therapy [k = 19]) for consumption frequency and quantity outcomes at early (1 to 6 months [kes = 41]) and late (8+ months [kes = 26]) follow-up time points. When pooled effect sizes were statistically heterogeneous, study-level moderators were examined.

METHOD

The inverse-variance weighted effect size was calculated for each study and pooled under random effects assumptions. Sensitivity analyses included tests of heterogeneity, study influence, and publication bias.

RESULTS

CBT in contrast to minimal treatment showed a moderate and significant effect size that was consistent across outcome type and follow-up. When CBT was contrasted with a nonspecific therapy or treatment as usual, treatment effect was statistically significant for consumption frequency and quantity at early, but not late, follow-up. CBT effects in contrast to a specific therapy were consistently nonsignificant across outcomes and follow-up time points. Of 10 pooled effect sizes examined, two showed moderate heterogeneity, but multivariate analyses revealed few systematic predictors of between-study variance.

CONCLUSIONS

The current meta-analysis shows that CBT is more effective than a no treatment, minimal treatment, or nonspecific control. Consistent with findings on other evidence-based therapies, CBT did not show superior efficacy in contrast to another specific modality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

More than Taking a Chair: The Perceived Group Social Dynamics of Alcoholics Anonymous Related to Changes in Spiritual Practices

Alcoholics Anonymous (AA) meeting attendance and spiritual practices are established predictors of abstinence. This study utilized longitudinal data from two studies of AA to investigate 1) how perceived within meeting social dynamics in AA meetings affect later AA attendance, and thus exposure to the emphasis of spiritual practices and 2) influence the extent that spiritual gains are mobilized, beyond AA attendance. Findings revealed that greater group cohesion was associated with lower AA attrition, and that expressiveness, or openness, of the group predicted reported practice of spiritual behaviors. Findings reveal distinct group dynamics may foster distinct mechanism of change of AA attendees.

AA attendance and abstinence for dually diagnosed patients: a meta-analytic review

BACKGROUND AND AIMS

There is consensus that best clinical practice for dual diagnosis (DD) is integrated mental health and substance use treatment augmented with Alcoholics Anonymous (AA) attendance. This is the first quantitative review of the direction and magnitude of the association between AA attendance and alcohol abstinence for DD patients.

METHOD

A systematic literature search (1993-2017) identified 22 studies yielding 24 effect sizes that met our inclusion criteria (8075 patients). Inverse-variance weighting of correlation coefficients (r) was used to aggregate sample-level findings and study aims were addressed using random- and mixed-effect models. Sensitivity and publication bias analyses were conducted to assess the likelihood of bias in the overall estimate of AA-related benefit.

RESULTS

AA exposure and abstinence for DD patients were associated significantly and positively [r_w  = 0.249; 95% confidence interval (CI) = 0.203-0.293; tau = 0.097). There was also significant heterogeneity in the distribution of effect sizes and high between-sample variance (I²  = 74.6, P < 0.001). Subgroup analyses indicated that the magnitude of AA-related benefit did not differ between 6- (k = 7) and 12- (k = 12) month follow-up (Q = 0.068, P = 0.794), type of treatment received (in-patient k = 9; intensive out-patient, out-patient, community k = 15; Q = 2.057, P = 0.152), and whether a majority of patients in a sample had (k = 11) or did not have (k = 13) major depression (Q = 0.563, P = 0.453). Sensitivity analyses indicated that the overall meta-analytical estimate of AA benefit was not impacted adversely or substantively by pooling randomized controlled trial (RCT) and observational samples (Q = 0.763, P = 0.382), pooling count, binary and ordinal-based AA (Q = 0.023, P = 0.879) and outcome data (Q = 1.906, P = 0.167) and reversing direction of correlations extracted from studies (Q = 0.006, P = 0.937). No support was found for publication bias.

CONCLUSIONS

Clinical referral of dual diagnosis patients to Alcoholics Anonymous is common and, in many cases, dual diagnosis patients who attend Alcoholics Anonymous will report higher rates of alcohol abstinence relative to dual diagnosis patients who do not attend Alcoholics Anonymous.

Low rates of alcohol and tobacco use, strong cultural ties for Native American college students in the Southwest

INTRODUCTION

College attendance is associated with an increased risk for substance use yet we know little about substance use among Native American college students and its regional variation. This study examined alcohol, tobacco, and drug use and their relation to gender, institution, age, and cultural involvement among Native American college students in the Southwest.

METHODS

Native American community college and university students in a large Southwest city (N = 347) completed an online survey about past-month and lifetime substance use and involvement in cultural activities.

RESULTS

Cultural involvement was related to less past-month substance use. In the past month, 43% drank alcohol, 27% binge drank, 20% used drugs, and 13% were current smokers. Males, community college students, and older individuals were more likely to have a positive CAGE-AID and have used drugs more than 100 times. Younger individuals were more likely to use marijuana in the past month.

CONCLUSIONS

These findings highlight cultural strengths and comparatively low rates of tobacco and alcohol use among Native American college students in the Southwest.

Do what you say and say what you are going to do: A preliminary meta-analysis of client change and sustain talk subtypes in motivational interviewing

Objective: This meta-analysis examines the predictive validity of client change language subtypes in motivational interviewing (MI) sessions addressing addictive behavior change. Method: A systematic review identified k = 13 primary studies, contributing 16 MI conditions (N = 1556). The pooled correlation coefficient was used to assess the significance, direction, and strength of seven language subtypes (i.e., reason, desire, need, ability, commitment, taking steps, and other) by three valences (i.e., frequency positive or change talk, frequency negative or sustain talk, and proportion change talk) and their relationship to subsequent engagement in addictive behavior. Results: For frequency measures, more sustain talk related to reason, desire, ability, and other were associated with more addictive behavior at follow up. Other change talk was associated with MI outcomes but in an unexpected direction (i.e., more addictive behavior). Proportion measures showed more proportion change talk-reason and -other statements were associated with less addictive behavior at follow up. Sensitivity analyses indicated some heterogeneity and instability of effect sizes, but no evidence of publication bias. Conclusions: This preliminary meta-analysis suggests that aggregate measures of change and sustain talk are comprised of statement subtypes that are not equally meaningful in predicting outcome following MI for addictive behavior change.

A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change

OBJECTIVE

In the present meta-analysis, we test the technical and relational hypotheses of Motivational Interviewing (MI) efficacy. We also propose an a priori conditional process model where heterogeneity of technical path effect sizes should be explained by interpersonal/relational (i.e., empathy, MI Spirit) and intrapersonal (i.e., client treatment seeking status) moderators.

METHOD

A systematic review identified k = 58 reports, describing 36 primary studies and 40 effect sizes (N = 3,025 participants). Statistical methods calculated the inverse variance-weighted pooled correlation coefficient for the therapist to client and the client to outcome paths across multiple target behaviors (i.e., alcohol use, other drug use, other behavior change).

RESULTS

Therapist MI-consistent skills were correlated with more client change talk (r = .55, p < .001) as well as more sustain talk (r = .40, p < .001). MI-inconsistent skills were correlated with more sustain talk (r = .16, p < .001), but not change talk. When these indicators were combined into proportions, as recommended in the Motivational Interviewing Skill Code, the overall technical hypothesis was supported. Specifically, proportion MI consistency was related to higher proportion change talk (r = .11, p = .004) and higher proportion change talk was related to reductions in risk behavior at follow up (r = -.16, p < .001). When tested as two independent effects, client change talk was not significant, but sustain talk was positively associated with worse outcome (r = .19, p < .001). Finally, the relational hypothesis was not supported, but heterogeneity in technical hypothesis path effect sizes was partially explained by inter- and intrapersonal moderators.

CONCLUSIONS

This meta-analysis provides additional support for the technical hypothesis of MI efficacy; future research on the relational hypothesis should occur in the field rather than in the context of clinical trials. (PsycINFO Database Record

Alcoholics Anonymous-Related Benefit for Urban Native Americans: Does Urban Native American Gender Moderate AA Engagement and Outcomes?

Alcoholics Anonymous (AA) is one of the most commonly accessed resources for individuals seeking to reduce their drinking. How urban Native Americans fare in AA is only beginning to be investigated in spite of circumstantial evidence suggesting that a majority of treatment-seeking urban Native Americans will receive 12-step treatment. Even less is known about Native American gender differences with regard to AA-related benefit. The current study addressed this gap by investigating urban Native American gender differences in AA attendance rates and outcomes. To this end, as part of two larger NIH-funded studies we recruited 63 Native American men and women and followed them for 9 months in this naturalistic study (n= 35 males, n = 28 females). Urban Native Americans significantly reduced their drinking over the study period, and AA attendance explained, in part, increased abstinence of study participants. No significant differences in AA attendance and drinking outcomes were observed between Native American men and women; however, descriptively men reported greater reductions in hazardous drinking relative to women. Clinical implications and future directions are discussed.

Simulating drinking in social networks to inform alcohol prevention and treatment efforts

Adolescent drinking influences, and is influenced by, peer alcohol use. Several efficacious adolescent alcohol interventions include elements aimed at reducing susceptibility to peer influence. Modeling these interventions within dynamically changing social networks may improve our understanding of how such interventions work and for whom they work best. We used stochastic actor-based models to simulate longitudinal drinking and friendship formation within social networks using parameters obtained from a meta-analysis of real-world 10th grade adolescent social networks. Levels of social influence (i.e., friends affecting changes in one's drinking) and social selection (i.e., drinking affecting changes in one's friendships) were manipulated at several levels, which directly impacted the degree of clustering in friendships based on similarity in drinking behavior. Midway through each simulation, one randomly selected heavy-drinking actor from each network received an "intervention" that either (a) reduced their susceptibility to social influence, (b) reduced their susceptibility to social selection, (c) eliminated a friendship with a heavy drinker, or (d) initiated a friendship with a nondrinker. Only the intervention that eliminated targeted actors' susceptibility to social influence consistently reduced that actor's drinking. Moreover, this was only effective in networks with social influence and social selection that were at higher levels than what was found in the real-world reference study. Social influence and social selection are dynamic processes that can lead to complex systems that may moderate the effectiveness of network-based interventions. Interventions that reduce susceptibility to social influence may be most effective among adolescents with high susceptibility to social influence and heavier-drinking friends. (PsycINFO Database Record

How Much Is Too Much? Patterns of Drinking During Alcohol Treatment and Associations With Post-Treatment Outcomes Across Three Alcohol Clinical Trials

OBJECTIVE

This secondary data analysis examined patterns of drinking during alcohol treatment and associated drinking outcomes during the first year following treatment. The goal was to provide clinicians with guidance on which patients may be most at risk for negative long-term outcomes based on drinking patterns during treatment.

METHOD

This study was an analysis of existing data (N = 3,851) from three randomized clinical trials for alcohol use disorder: the COMBINE Study (n = 1,383), Project MATCH (n = 1,726), and the United Kingdom Alcohol Treatment Trial (n = 742). Indicators of abstinence, non-heavy drinking, and heavy drinking (defined as 4/5 or more drinks per day for women/men) were examined during each week of treatment using repeated-measures latent class analysis. Associations between drinking patterns during treatment and drinking intensity, drinking consequences, and physical and mental health 12 months following intake were examined.

RESULTS

Seven drinking patterns were identified. Patients who engaged in persistent heavy drinking throughout treatment and those who returned to persistent heavy drinking during treatment had the worst long-term outcomes. Patients who engaged in some heavy drinking during treatment had better long-term outcomes than persistent heavy drinkers. Patients who reported low-risk drinking or abstinence had the best long-term outcomes. There were no differences in outcomes between low-risk drinkers and abstainers.

CONCLUSIONS

Abstinence, low-risk drinking, or even some heavy drinking during treatment are associated with the best long-term outcomes. Patients who are engaging in persistent heavy drinking are likely to have the worst outcomes and may require a higher level of care.

Does Age Moderate the Effect of Spirituality/Religiousness in Accounting for Alcoholics Anonymous Benefit?

OBJECTIVE

Gains in spiritual/religious (S/R) practices among Alcoholics Anonymous (AA) members are associated with reductions in drinking. This study had the following aims: (a) examine spirituality/religiousness as a mediator of the relationship between AA attendance and reductions in drinking behavior to replicate past research findings and to (b) examine age-cohort as a moderator of the mediational analyses given that empirical evidence (e.g., generational differences in spirituality) suggests that age may influence the acquisition of gains in spirituality/religiousness during AA as well as the expression of these gains on drinking behavior.

METHOD

Measures were administered to 253 participants recruited from community-based AA and outpatient treatment programs at baseline, 3, 6, 9, and 12-months, and 210 (83%) participants provided complete data to test study aims.

RESULTS

Gains in S/R practices mediated the relationship between AA attendance and increased abstinence, but not drinking intensity. Simple slopes analyses indicated a positive association between AA attendance and gains in S/R practices among younger AA affiliates but not older AA affiliates in the moderated-mediational analyses. However, age was not found to moderate the global mediational effect.

CONCLUSIONS

The results from the current study inform efforts to increase positive change in AA affiliates' drinking behavior by highlighting specific aspects of S/R practices that should be targeted based on the age of an AA affiliate.

Lifetime Alcoholics Anonymous attendance as a predictor of spiritual gains in the Relapse Replication and Extension Project (RREP)

This study investigated the association between extent of lifetime attendance in Alcoholics Anonymous (AA) and spiritual gains among treatment seeking adults for alcohol use disorder. Participants included 246 individuals from 2 of the 3 sites in the Relapse Replication and Extension Project (Lowman, Allen, Stout, & The Relapse Research Group, 1996). Baseline characteristics included 63% male, 39.9% single, and the average age was 34 years (SD = 8.2). The Alcoholics Anonymous Involvement questionnaire (Tonigan, Connors, & Miller, 1996) was used to assess lifetime AA attendance. The Religious Beliefs & Behaviors Questionnaire (Connors, Tonigan, & Miller, 1996) was used to assess spirituality. Percent days abstinent (PDA) and drinks per drinking day (DPDD) were measured using the Form 90. At baseline, adults with more extensive AA histories were more severely alcohol impaired although they were no older relative to adults with less past AA exposure. Clear patterns of AA engagement were found between the high-low AA history groups over follow-up, with adults with less AA experience reporting less AA participation across a swath of AA-specific measures. Gains in spiritual practices significantly mediated AA-related benefit as measured by PDA and DPDD. Tests for moderated-mediation indicated that the magnitude of the mediational effect of spiritual gains did not differ between high-low AA history groups. Having an extensive AA history did not advantage (or disadvantage) adults in mobilizing future spiritual practices that are prescribed in AA. Clinical assessment of client AA history is important, however, because it predicts both the nature and extent that clients may participate in AA. (PsycINFO Database Record

Changes in depression mediate the effects of AA attendance on alcohol use outcomes

BACKGROUND

Depression may contribute to increased drinking in individuals with alcohol use disorder. Although Alcoholics Anonymous (AA) attendance predicts drinking reductions, there is conflicting information regarding the intermediary role played by reductions in depression.

OBJECTIVES

We explored whether AA attendance reduces depressive symptoms, the degree to which improvement in depression results in reductions in drinking, and in which subgroups these effects occur.

METHODS

253 early AA affiliates (63% male) were recruited and assessed at baseline 3, 6, 9, 12, 18, and 24 months. Depression was measured using the Beck Depression Inventory (BDI) and was administered at baseline 3, 6, 12, 18, and 24 months. AA attendance and alcohol use outcomes were obtained with the Form 90. Mediation analyses were performed at early (3, 6, and 9 months) and late (12, 18, and 24 months) follow-up to investigate the degree to which reductions in depression mediated the effect of AA attendance on drinking, controlling for concurrent drinking. In addition, a series of moderated mediation analyses were performed using baseline depression severity as a moderator.

RESULTS

At early follow-up, reductions in depression (6 months) mediated the effects of AA attendance (3 months) on later drinking (drinks per drinking day) (9 months) (b = -0.02, boot CI [-0.055, -0.0004]), controlling for drinking at 6 months. Baseline depression severity did not moderate the degree to which BDI mediated the effects of AA attendance on alcohol use (ps > .05).

CONCLUSION

These findings provide further evidence that depression reduction is a mechanism by which AA attendance leads to reductions in alcohol use. Improving depression may help reduce alcohol use in individuals with AUD, and AA attendance may be an effective way to achieve that goal.

Coadministration of disulfiram and lorazepam in the treatment of alcohol dependence and co-occurring anxiety disorder: an open-label pilot study

BACKGROUND

Anxiety is common among persons with alcohol use disorder during early abstinence from alcohol. Although benzodiazepines are effective for short-term treatment of anxiety, they are rarely used beyond acute detoxification due to concerns about misuse or interactions with alcohol.

OBJECTIVES

We conducted an open-label trial to explore the effects of coadministering lorazepam and disulfiram to alcohol-dependent patients with anxiety disorder symptoms. The rationale for this model is to minimize the risks of the benzodiazepine, while also potentially enhancing adherence to disulfiram.

METHODS

Forty-one participants with DSM-IV alcohol dependence who also met syndromal criteria for anxiety disorder with or without co-occurring major depressive syndrome initiated treatment with lorazepam (starting dose 0.5 mg three times daily) and disulfiram (starting dose 500 mg three times weekly). Participants received 16 weeks of monitored pharmacotherapy with manualized medical management.

RESULTS

Adherence to treatment decreased steadily with time (85.4% at 4 weeks, 36.6% at 16 weeks). Participants showed significant increases in percent abstinent days during treatment and at 24 weeks follow-up. Large reductions in anxiety, depression, and craving were observed during treatment, and improvement remained significant at 24 weeks. Duration of adherence with disulfiram strongly predicted abstinence at 16 weeks. There was no evidence of misuse of lorazepam or dose escalation during the study.

CONCLUSION

Lorazepam can be safely used for short-term treatment of anxiety in combination with disulfiram treatment of alcohol use disorder. However, it is not clear that making lorazepam dispensing contingent on adherence to disulfiram enhances retention in disulfiram treatment.

Effects of long-term AA attendance and spirituality on the course of depressive symptoms in individuals with alcohol use disorder

Alcohol use disorder (AUD) is associated with depression. Although attendance at Alcoholics Anonymous (AA) meetings predicts reductions in drinking, results have been mixed about the salutary effects of AA on reducing depressive symptoms. In this single-group study, early AA affiliates (n = 253) were recruited, consented, and assessed at baseline, 3, 6, 9, 12, 18, and 24 months. Lagged growth models were used to investigate the predictive effect of AA attendance on depression, controlling for concurrent drinking and treatment attendance. Depression was measured using the Beck Depression Inventory (BDI) and was administered at baseline 3, 6, 12, 18, and 24 months. Additional predictors of depression tested included spiritual gains (Religious Background and Behavior questionnaire [RBB]) and completion of 12-step work (Alcoholics Anonymous Inventory [AAI]). Eighty-five percent of the original sample provided follow-up data at 24 months. Overall, depression decreased over the 24 month follow-up period. AA attendance predicted later reductions in depression (slope = -3.40, p = .01) even after controlling for concurrent drinking and formal treatment attendance. Finally, increased spiritual gains (RBB) also predicted later reductions in depression (slope = -0.10, p = .02) after controlling for concurrent drinking, treatment, and AA attendance. In summary, reductions in alcohol consumption partially explained decreases in depression in this sample of early AA affiliates, and other factors such as AA attendance and increased spiritual practices also accounted for reductions in depression beyond that explained by drinking. (PsycINFO Database Record

Associations of White Matter Microstructure with Clinical and Demographic Characteristics in Heavy Drinkers

Damage to the brain’s white matter is a signature injury of alcohol use disorders (AUDs), yet understanding of risks associated with clinical and demographic characteristics is incomplete. This study investigated alcohol problem severity, recent drinking behavior, and demographic factors in relation to white matter microstructure in heavy drinkers. Magnetic resonance imaging (MRI) scans, including diffusion tensor imaging (DTI), were collected from 324 participants (mean age = 30.9 ± 9.1 years; 30% female) who reported five or more heavy drinking episodes in the past 30 days. Drinking history and alcohol problem severity were assessed. A common white matter factor was created from fractional anisotropy (FA) values of five white matter tracts: body of corpus callosum, fornix, external capsule, superior longitudinal fasciculus, and cingulate gyrus. Previous research has implicated these tracts in heavy drinking. Structural equation modeling (SEM) analyses tested the hypothesis that, after controlling for duration of alcohol exposure, clinical and behavioral measures of alcohol use severity would be associated with lower white matter factor scores. Potential interactions with smoking status, gender, age, treatment-seeking status, and depression or anxiety symptoms also were tested. Controlling for number of years drinking, greater alcohol problem severity and recent drinking frequency were significantly associated with lower white matter factor scores. The effect of drinking frequency differed significantly for men and women, such that higher drinking frequency was linked to lower white matter factor scores in women but not in men. In conclusion, alcohol problem severity was a significant predictor of lower white matter FA in heavy drinkers, after controlling for duration of alcohol exposure. In addition, more frequent drinking contributed to lower FA in women but not men, suggesting gender-specific vulnerability to alcohol neurotoxicity.

Active Ingredients of Treatment and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later

BACKGROUND

The current review revisits the article entitled: "Active Ingredients: How and Why Evidence-Based Alcohol Behavioral Treatment Interventions Work" published in Alcoholism: Clinical and Experimental Research. This work summarized proceedings from a 2004 Symposium of the same name that was held at the Annual Meeting of the Research Society on Alcoholism (RSA). A decade has passed, which provides occasion for an evaluation of progress. In 2014, an RSA symposium titled Active Treatment Ingredients and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later did just that.

METHODS

The current review revisits state-of-the-art research on the 3 treatments examined 10 years ago: cognitive behavioral therapy, alcohol behavior couples therapy, and 12-step facilitation. Because of its empirically validated effectiveness and robust research agenda on the study of process outcome, motivational interviewing has been selected as the fourth treatment modality to be discussed. For each of these 4 treatments, the reviewers provide a critical assessment of current theory and research with a special emphasis on key recommendations for the future.

RESULTS

Noteworthy progress has been made in identifying active ingredients of treatments and mechanisms of behavior change in these 4 behavioral interventions for alcohol and other drug use disorders. Not only have we established some of the mechanisms through which these evidence-based treatments work, but we have also uncovered some of the limitations in our existing frameworks and methods.

CONCLUSIONS

Further progress in this area will require a broader view with respect to conceptual frameworks, analytic methods, and measurement instrumentation.

The indirect effect of the therapeutic alliance and alcohol abstinence self-efficacy on alcohol use and alcohol-related problems in Project MATCH

BACKGROUND

Empirical literature indicates that the therapeutic alliance explains a modest but reliable proportion of variance in predicting alcohol-related outcomes among individuals in treatment for alcohol use disorders (AUDs). Hartzler and colleagues (2011) showed in the COMBINE data set that alcohol abstinence self-efficacy is a potentially important statistical mediator of the relationship between the alliance and client outcomes.

METHODS

The purpose of this study was to replicate this finding in the Project MATCH data set. We used total alliance ratings on the Working Alliance Inventory and tested both client and therapist ratings in mediation analyses.

RESULTS

We found that posttreatment self-efficacy accounted for the effect of therapist and client ratings of alliance (measured at session 2) on posttreatment drinking outcomes (drinks per drinking day and alcohol-related problems). In addition, we found a moderation effect of treatment, such that the association between the client's rating of the alliance and self-efficacy changes was positive for individuals in the cognitive behavioral treatment group but negative for those receiving motivation enhancement or Twelve-Step Facilitation.

CONCLUSIONS

This study reaffirms the importance of the therapeutic alliance and self-efficacy in predicting AUD outcomes. Future research should examine changes in the therapeutic alliance throughout treatment and how these changes are related to self-efficacy and AUD treatment outcomes over time.

Longitudinal trajectories of readiness to change: alcohol use and help-seeking behavior

OBJECTIVE

Pre-post changes in readiness for change (RC) are commonly assessed in treatment outcome studies, often with contradictory results. Little is known about 12-month RC trajectories among those initiating change or about the association between RC and either within- or between-person alcohol use or time-lagged help-seeking behavior.

METHOD

This observational longitudinal study measured RC as ambivalence, problem recognition, and taking steps. Participants (N = 253; 66.4% male) diagnosed with alcohol use disorders were recruited from treatment sites, Alcoholics Anonymous (AA) groups, and other community sources when first initiating change and assessed at baseline and 3, 6, 9, and 12 months.

RESULTS

Support for significant participant heterogeneity as well as linear and quadratic change in RC trajectories was found, although results differed across the three aspects of RC. Independent associations of both within- and between-person percentage of days abstinent were found for ambivalence and taking steps. Lagged, time-specific fluctuations in prior help-seeking behaviors within an individual predicting subsequent RC showed that both AA (B = -1.650, p < .05) and treatment attendance (B = 2.914, p < .01) were associated with subsequent ambivalence. Prior increases in taking steps within individuals were predictive of subsequent AA but not treatment attendance.

CONCLUSIONS

Results inform treatment providers about how RC trajectories vary depending on alcohol use, both within and between individuals, and how individuals may mobilize change attitudes and behaviors, especially in relation to AA attendance. Future research should investigate additional predictors of RC trajectories and the causal direction between RC and help seeking.

Do changes in selfishness explain 12-step benefit? A prospective lagged analysis

12-Step attendance is associated with increased abstinence. A strong claim made in 12-step literature is that alcoholics are pathologically selfish and that working the 12 steps reduces this selfishness, which, in turn, leads to sustained alcohol abstinence. This study tested this assumption by investigating the linkages between 12-step attendance, pathological narcissism, and drinking. One hundred thirty early Alcohol Anonymous (AA) affiliates with limited AA and treatment histories were recruited from treatment and community-based AA. A majority of the sample was alcohol dependent and reported illicit drug use before recruitment. Participants were interviewed at intake and at 3, 6, and 9 months. A majority of participants attended AA meetings throughout follow-up and such attendance predicted increased abstinence and reduced drinking intensity. 12-Step affiliates were significantly higher on pathological narcissism (PN) relative to general population samples and their PN remained elevated. Contrary to predictions, PN was unrelated to 12-step meeting attendance and did not predict later abstinence or drinking intensity. The findings did not support the hypothesis that reductions in PN explain 12-step benefit. An alternative function for the emphasis placed on pathological selfishness in 12-step programs is discussed and a recommendation is made to use unobtrusive measures of selfishness in future research.

Involvement in 12-step activities and treatment outcomes

This study addresses the relative importance of specific 12-step activities to recovery, and how treatment affects participation in those activities. Data were from a clinical trial testing a 12-step facilitation intervention called MAAEZ (Making AA [Alcohol Anonymous] Easier). Participants (N = 508) were recruited at treatment entry. Analyses examined 8 activities measured at baseline, 7 weeks, 6 months, and 12 months. In simultaneous equations, meeting attendance and having a sponsor were the only strong and consistent predictors of abstinence across time points, though other activities (i.e., use of a home group, befriending members, service work, and reading the literature) were significant in some analyses. Treatment involvement had mixed effects on activity participation over time. Contradicting research suggesting that meeting attendance contributes little beyond other 12-step activities, the current results highlight the importance of consistent meeting attendance and sponsorship in recovery. The results suggest a need for enhanced facilitation of key activities even in typical 12-step-oriented treatment.

The 10-year course of Alcoholics Anonymous participation and long-term outcomes: a follow-up study of outpatient subjects in Project MATCH

This study investigates the 10-year course and impact of Alcoholics Anonymous (AA)-related helping (AAH), step-work, and meeting attendance on long-term outcomes. Data were derived from 226 treatment-seeking alcoholics recruited from an outpatient site in Project MATCH and followed for 10 years post treatment. Alcohol consumption, AA participation, and other-oriented behavior were assessed at baseline, end of the 3-month treatment period, and 1, 3, and 10 years post treatment. Controlling for explanatory baseline and time-varying variables, results showed significant direct effects of AAH and meeting attendance on reduced alcohol outcomes and a direct effect of AAH on improved other-oriented interest.

Longitudinal study of urban American Indian 12-step attendance, attrition, and outcome

OBJECTIVE

Strong opinions have been voiced about the "fit" between 12-step treatment, community-based 12-step practices, and American Indian beliefs and values. Little is known, however, about the relative benefit of 12-step programs for urban American Indians, although they are the most widely accessed type of treatment by American Indians. This study investigated rates of 12-step attendance, attrition, and substance use outcomes for American Indians for 9 months relative to non-Hispanic White participants.

METHOD

This study compared urban American Indian (n = 63) and non-Hispanic White (n = 133) 12-step attendance, attrition, and substance use over 9 months. The sample was formed by merging data from two prospective single-group longitudinal studies investigating behavior change in community-based 12-step programs. Participants were interviewed at baseline and at 3-, 6-, and 9-month follow-ups. No intervention was provided. Participants were recruited from Alcoholics Anonymous meetings in the community and as they presented for outpatient substance use disorder treatment. Substance use and patterns of 12-step attendance were measured using the Form 90 calendar-based interview, and the General Alcoholics Anonymous Tools of Recovery was administered to assess the adoption of prescribed 12-step practices and beliefs.

RESULTS

Trajectories in 12-step meeting attendance over 9 months did not differ between American Indian and non-Hispanic White participants. However, American Indian participants discontinued 12-step attendance significantly less often than non-Hispanic White participants. Higher rates of 12-step attendance predicted increased alcohol abstinence and decreased drinking intensity for both American Indian and non-Hispanic White participants. Twelve-step attendance was unrelated to later illicit drug use for both American Indian and non-Hispanic White participants.

CONCLUSIONS

Community-based 12-step program attendance is associated with drinking reductions among urban American Indians.

12-step facilitation for the dually diagnosed: a randomized clinical trial

There are few clinical trials of 12-step treatments for individuals with serious mental illness and alcohol or drug dependence. This randomized trial assessed the effects of adding a 12-session 12-step facilitation therapy (TSF), adapted from that used in Project MATCH, to treatment as usual in an outpatient dual diagnosis program. Participants were 121 individuals dually diagnosed with alcohol dependence and a serious mental disorder, followed during 12 weeks of treatment and 36 weeks post-treatment. Participants receiving TSF had greater participation in 12-step programs, but did not demonstrate greater improvement in alcohol and drug use. However, considered dimensionally, greater participation in TSF was associated with greater improvement in substance use, and greater 12-step participation predicted decreases in frequency and intensity of drinking. Findings suggest that future work with TSF in this population should focus on maximizing exposure to TSF, and maximizing the effect of TSF on 12-step participation.

Evaluating Alcoholics Anonymous's effect on drinking in Project MATCH using cross-lagged regression panel analysis

OBJECTIVE

The objective of the study is to determine whether Alcoholics Anonymous (AA) participation leads to reduced drinking and problems related to drinking within Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), an existing national alcoholism treatment data set.

METHOD

The method used is structural equation modeling of panel data with cross-lagged partial regression coefficients. The main advantage of this technique for the analysis of AA outcomes is that potential reciprocal causation between AA participation and drinking behavior can be explicitly modeled through the specification of finite causal lags.

RESULTS

For the outpatient subsample (n = 952), the results strongly support the hypothesis that AA attendance leads to increases in alcohol abstinence and reduces drinking/ problems, whereas a causal effect in the reverse direction is unsupported. For the aftercare subsample (n = 774), the results are not as clear but also suggest that AA attendance leads to better outcomes.

CONCLUSIONS

Although randomized controlled trials are the surest means of establishing causal relations between interventions and outcomes, such trials are rare in AA research for practical reasons. The current study successfully exploited the multiple data waves in Project MATCH to examine evidence of causality between AA participation and drinking outcomes. The study obtained unique statistical results supporting the effectiveness of AA primarily in the context of primary outpatient treatment for alcoholism.

Spirituality as a change mechanism in 12-step programs: a replication, extension, and refinement

This National Institutes of Health funded study investigated spiritual growth as a change mechanism in 12-step programs. A total of 130 people, early 12-step affiliates with limited Alcoholics Anonymous (AA) histories, were recruited from 2007 to 2008 from AA, treatment, and community centers in a Southwestern city in the United States. A majority of the sample was alcohol dependent. Participants were interviewed at baseline and at 3, 6, and 9 months. Lagged General Linear Modeling analyses indicated that spiritual change as measured by the Religious Background and Behavior (RBB) self-report questionnaire were predictive of increased abstinence and decreased drinking intensity, and that the magnitude of this effect varied across different RBB scoring algorithms. Future research should address study limitations by recruiting participants with more extensive AA histories and by including assessments of commitment to, and practice of, AA prescribed activities. The study's limitations are noted.

White matter volume in alcohol use disorders: a meta-analysis

Atrophy of brain white matter (WM) often is considered a signature injury of alcohol use disorders (AUDs). However, investigations into AUD-related changes in WM volume have yielded complex findings that are difficult to synthesize in a narrative review. The objective of this study was to obtain an averaged effect size (ES) for WM volume reduction associated with AUD diagnosis and to test potential moderators of ES. Study inclusion criteria were: (1) English language; (2) peer reviewed; (3) published before December 2011; (4) use of magnetic resonance imaging (MRI); (5) human participants; (6) inclusion of AUD group; (7) inclusion of non-AUD comparison group; and (8) reporting or testing of total or cerebral WM volume. Moderators included study design, MRI methodology and AUD characteristics. Nineteen studies with a total of 1302 participants (70% male) were included, and calculated ESs were confirmed by the corresponding author for 12 studies. The magnitude of the averaged ES adjusted for small sample bias (Hedges' g) for WM reduction in AUDs was 0.304 (standard error = 0.134, range = -0.57-1.21). Hierarchical linear modeling indicated that the overall ES differed significantly from 0, t(18) = 2.257, P = 0.037, and that the distribution of the 19 ESs showed significant heterogeneity beyond sampling error, χ(2) (18) = 52.400, P < 0.001. Treatment-seeking status and length of abstinence were significant moderators of ES distribution. These results are suggestive of WM recovery with sustained abstinence and point to the need for further investigation of factors related to treatment-seeking status.

Interpersonal Climate of 12-step Groups Predicts Reductions in Alcohol Use

Research has shown that increases in the size of abstinence-based social networks helps explain the association between 12-step attendance and increased abstinence. This study investigated whether the quality of social interaction in 12-step groups also predicts reduced substance use. Participants reported their perceptions of engagedness, avoidance, and conflict in their 12-step groups and their substance use in four assessments. Results showed that perceptions of group engagedness, but not avoidance or conflict, decreased over time. Despite this, engagedness predicted increased 12-step-related behavior and decreased alcohol use. Findings suggest that positive group interaction plays an important role in 12-step affiliates' recovery efforts.

Spirituality and confidence to resist substance use among celebrate recovery participants

Since self-efficacy is a positive predictor of substance use treatment outcome, we investigated whether it is associated with spirituality within a religious 12-step program. This was a cross-sectional survey (N = 91) of 10 different Celebrate Recovery sites held at community churches. The mean spirituality score for those with high confidence was significantly greater than those with low confidence. Spirituality associated with greater confidence to resist substance use (OR = 1.09, 95% CI 1.02-1.17, P < 0.05). So every unit increase of measured spirituality increased the odds of being above the median in self-efficacy by 9%. We conclude that spirituality may be an important explanatory variable in outcomes of a faith-based 12-step recovery program.

Do changes in selfishness explain 12-step benefit? A prospective lagged analysis

12-Step attendance is associated with increased abstinence. A strong claim made in 12-step literature is that alcoholics are pathologically selfish and that working the 12 steps reduces this selfishness, which, in turn, leads to sustained alcohol abstinence. This study tested this assumption by investigating the linkages between 12-step attendance, pathological narcissism, and drinking. One hundred thirty early Alcohol Anonymous (AA) affiliates with limited AA and treatment histories were recruited from treatment and community-based AA. A majority of the sample was alcohol dependent and reported illicit drug use before recruitment. Participants were interviewed at intake and at 3, 6, and 9 months. A majority of participants attended AA meetings throughout follow-up and such attendance predicted increased abstinence and reduced drinking intensity. 12-Step affiliates were significantly higher on pathological narcissism (PN) relative to general population samples and their PN remained elevated. Contrary to predictions, PN was unrelated to 12-step meeting attendance and did not predict later abstinence or drinking intensity. The findings did not support the hypothesis that reductions in PN explain 12-step benefit. An alternative function for the emphasis placed on pathological selfishness in 12-step programs is discussed and a recommendation is made to use unobtrusive measures of selfishness in future research.

The general alcoholics anonymous tools of recovery: the adoption of 12-step practices and beliefs

Working the 12 steps is widely prescribed for Alcoholics Anonymous (AA) members although the relative merits of different methods for measuring step work have received minimal attention and even less is known about how step work predicts later substance use. The current study (1) compared endorsements of step work on an face-valid or direct measure, the Alcoholics Anonymous Inventory (AAI), with an indirect measure of step work, the General Alcoholics Anonymous Tools of Recovery (GAATOR); (2) evaluated the underlying factor structure of the GAATOR and changes in step work over time; (3) examined changes in the endorsement of step work over time; and (4) investigated how, if at all, 12-step work predicted later substance use. New AA affiliates (N = 130) completed assessments at intake, 3, 6, and 9 months. Significantly more participants endorsed step work on the GAATOR than on the AAI for nine of the 12 steps. An exploratory factor analysis revealed a two-factor structure for the GAATOR comprising behavioral step work and spiritual step work. Behavioral step work did not change over time, but was predicted by having a sponsor, while Spiritual step work decreased over time and increases were predicted by attending 12-step meetings or treatment. Behavioral step work did not prospectively predict substance use. In contrast, spiritual step work predicted percent days abstinent. Behavioral step work and spiritual step work appear to be conceptually distinct components of step work that have distinct predictors and unique impacts on outcomes.

Community Reinforcement and Family Training: a pilot comparison of group and self-directed delivery

In a randomized clinical pilot study, 40 concerned significant others (CSOs) of treatment-refusing alcohol- and drug-using individuals were randomized to either Community Reinforcement and Family Training (CRAFT) conducted in a group format (Group CRAFT) or a Self-Directed CRAFT condition. Although results indicated no significant between-group difference in engaging treatment-refusing substance-using individuals (referred to as identified patients or IPs) into treatment, the engagement rate in Group CRAFT was similar to rates previously reported with individual CRAFT. For the intent-to-treat analysis, 60% of Group CRAFT CSOs engaged their loved one into treatment, as compared with 40% in Self-Directed CRAFT. Of CSOs in the Group condition who received at least one session of group therapy, 71% engaged their IP into treatment. CSOs in both conditions reported improvements in family cohesion and conflict at the 3- and 6-month follow-up, replicating prior CRAFT findings.

Attachment avoidance and anxiety as predictors of 12-step group engagement

OBJECTIVE

Twelve-step mutual help groups such as Alcoholics Anonymous (AA) rely heavily on social interactions and support to reduce drinking, but little is known about how individual differences in social behavior tendencies, such as adult attachment, affect 12-step group engagement and resulting benefits. This prospective study investigated relationships between the anxiety and avoidance dimensions of adult attachment and subsequent 12-step meeting attendance, program behaviors, sponsorship, and alcohol use.

METHOD

Early 12-step group affiliates (N = 253) were recruited from community-based AA and from outpatient treatment. Participants completed baseline interviews that included the Relationship Questionnaire, measures of motivation and professional treatment, and measures of 12-step meeting attendance, practices, and sponsorship. Follow-up interviews were conducted at 3, 6, 9, 12, 18, and 24 months.

RESULTS

At baseline, participants reported elevated attachment anxiety relative to a college population. Lagged analyses demonstrated that, as predicted, high attachment avoidance was related to lower rates of 12-step meeting attendance, practice of behaviors prescribed by 12-step organizations, and lower probability of acquiring a sponsor. Attachment anxiety did not predict any of these aspects of subsequent 12-step group engagement. Contrary to predictions, baseline attachment avoidance did not moderate the relationship between early sponsorship and alcohol use.

CONCLUSIONS

Findings support the hypothesis that social demands of behaviors prescribed by 12-step groups may deter high-avoidance individuals from fully engaging in them. Perhaps because of instability in attachment avoidance in this population, however, baseline attachment avoidance did not predict drinking outcomes or moderate sponsor benefits.

Impressions of Alcoholics Anonymous (AA) Group Cohesion: A Case for a Nonspecific Factor Predicting Later AA Attendance

Social support for abstinence in Alcoholics Anonymous (AA) has been reported to be a consistent factor accounting for AA benefit. However, the nonspecific or unintended effects of such support remain poorly understood and rarely investigated. This prospective study investigated how one nonspecific factor-perceived AA group cohesiveness-predicted increased practice of AA-related behaviors. Findings indicated that impressions of AA group cohesion predicted increased AA attendance, the practice of prescribed AA activities, and self-reported AA usefulness. It appears that a sense of belongingness predicts subsequent engagement in the AA social network that, in turn, is predictive of increased abstinence.

Does Pathway into 12-Step Programs Influence 12-Step-Related Benefit?

Most 12-step research recruits participants who are seeking treatment (cf. Kaskutas, Turk, Bond, & Weisner, 2003; Robinson, Cranford, Webb, & Brower, 2007), leaving open the question of how non-treatment-seeking individuals respond to 12-step involvement. The current study examined whether participants recruited from community-based Alcoholics Anonymous (AA) clubs or via advertisement/word-of-mouth differed in their 12-step attendance rates, substance use, and the association between these constructs compared to participants recruited from substance abuse treatment. Multilevel analyses showed that while associations between 12-step attendance and improved substance use did not differ by recruitment group, participants recruited from community-based AA clubs had higher 12-step attendance rates and a higher proportion of alcohol abstinent days than did all other participants. Results indicate that using diverse recruitment strategies may be necessary to obtain samples that are representative of the actual population of 12-step affiliates and to achieve results that estimate the true magnitude of 12-step effects.

Do social networks explain 12-step sponsorship effects? A prospective lagged mediation analysis

Sponsorship is a basic and important part of the 12-step approach to recovery from substance abuse (Alcoholics Anonymous, 2005) and research has shown that having a sponsor is associated with increased involvement in 12-step programs and improved outcomes (Bond, Kaskutas, & Weisner, 2003; Tonigan & Rice, 2010). However, little is known about how sponsorship improves outcomes. Given research demonstrating bivariate associations between sponsorship and social support for abstinence (Majer, Jason, Ferrari, Venable, & Olson, 2002), we hypothesized that the association between having a sponsor and increased abstinence outcomes would be explained by increases in one's abstinence-based social network. Prospective fully lagged mediational analyses did not support this hypothesis and these results ran counter to findings of five previous studies (cf. Groh, Jason, & Keys, 2008). A review of these studies showed that researchers often used cross-sectional or partially lagged methods to test mediation and the mediational effect of the social network was small in magnitude. Results suggest that the prospective association between sponsorship and abstinence is not explained by increases in the abstinence-based social network and demonstrate the need for future studies to use rigorous and time-lagged methods to test social support for abstinence as a mediator of the effects of 12-step involvement.

Twelve-step program attendance and polysubstance use: interplay of alcohol and illicit drug use

OBJECTIVE

The primary aim of this study was to advance understanding of the efficacy of 12-step programs by determining the temporal relationships between alcohol and illicit drug use among 12- step program affiliates.

METHOD

A total of 253 early 12-step affiliates without extensive histories of Alcoholics Anonymous (AA) attendance were recruited from substance use treatment and community-based AA. A majority of the sample met criteria for a diagnosis of alcohol dependence, reported lifetime use of illicit drugs, and reported illicit drug use in the 90-day period before recruitment. After informed consent, participants were interviewed at intake and in 3-month increments for 1 year.

RESULTS

Preliminary analyses indicated that 12-step attendance was predictive of reductions in substance use and that such reductions were not moderated by illicit substance use disorder diagnosis or alcohol problem severity. Lagged hierarchical linear models indicated that illicit drug use was a robust predictor of later use of alcohol, although the frequency and intensity of drinking were contingent on whether participants sustained 12-step program affiliation. Alcohol use did not predict later illicit drug use among participants who sustained 12-step program participation.

CONCLUSIONS

Findings suggest that 12-step participation may serve as a protective factor after substance use occurs. Although our results suggest that the initiation of illicit drug use may undermine efforts to achieve and sustain abstinence from alcohol, our findings do not suggest that alcohol use necessarily mobilizes relapse across different substances among 12-step program affiliates.

The role of Alcoholics Anonymous in mobilizing adaptive social network changes: a prospective lagged mediational analysis

OBJECTIVE

Many individuals entering treatment are involved in social networks and activities that heighten relapse risk. Consequently, treatment programs facilitate engagement in social recovery resources, such as Alcoholics Anonymous (AA), to provide a low risk network. While it is assumed that AA works partially through this social mechanism, research has been limited in rigor and scope. This study used lagged mediational methods to examine changes in pro-abstinent and pro-drinking network ties and activities.

METHOD

Adults (N=1726) participating in a randomized controlled trial of alcohol use disorder treatment were assessed at intake, and 3, 9, and 15 months. Generalized linear modeling (Generalized linear modeling) tested whether changes in pro-abstinent and pro-drinking network ties and drinking and abstinent activities helped to explain AA's effects.

RESULTS

Greater AA attendance facilitated substantial decreases in pro-drinking social ties and significant, but less substantial increases in pro-abstinent ties. Also, AA attendance reduced engagement in drinking-related activities and increased engagement in abstinent activities. Lagged mediational analyses revealed that it was through reductions in pro-drinking network ties and, to a lesser degree, increases in pro-abstinent ties that AA exerted its salutary effect on abstinence, and to a lesser extent, on drinking intensity.

CONCLUSIONS

AA appears to facilitate recovery by mobilizing adaptive changes in the social networks of individuals exhibiting a broad range of impairment. Specifically by reducing involvement with pro-drinking ties and increasing involvement with pro-abstinent ties. These changes may aid recovery by decreasing exposure to alcohol-related cues thereby reducing craving, while simultaneously increasing rewarding social relationships.

Spirituality in recovery: a lagged mediational analysis of alcoholics anonymous' principal theoretical mechanism of behavior change

BACKGROUND

Evidence indicates Alcoholics Anonymous (AA) can play a valuable role in recovery from alcohol use disorder. While AA itself purports it aids recovery through "spiritual" practices and beliefs, this claim remains contentious and has been only rarely formally investigated. Using a lagged, mediational analysis, with a large, clinical sample of adults with alcohol use disorder, this study examined the relationships among AA, spirituality/religiousness, and alcohol use, and tested whether the observed relation between AA and better alcohol outcomes can be explained by spiritual changes.

METHOD

Adults (N = 1,726) participating in a randomized controlled trial of psychosocial treatments for alcohol use disorder (Project MATCH) were assessed at treatment intake, and 3, 6, 9, 12, and 15 months on their AA attendance, spiritual/religious practices, and alcohol use outcomes using validated measures. General linear modeling (GLM) and controlled lagged mediational analyses were utilized to test for mediational effects.

RESULTS

Controlling for a variety of confounding variables, attending AA was associated with increases in spiritual practices, especially for those initially low on this measure at treatment intake. Results revealed AA was also consistently associated with better subsequent alcohol outcomes, which was partially mediated by increases in spirituality. This mediational effect was demonstrated across both outpatient and aftercare samples and both alcohol outcomes (proportion of abstinent days; drinks per drinking day).

CONCLUSIONS

Findings suggest that AA leads to better alcohol use outcomes, in part, by enhancing individuals' spiritual practices and provides support for AA's own emphasis on increasing spiritual practices to facilitate recovery from alcohol use disorder.