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Introduction: During the COVID-19 pandemic, online video platforms became the primary mode of accessing substance use-focused mutual-help group meetings, which may persist after in-person meetings are available again. This study examined the characteristics (demographic, substance use and recovery, and mutual-help group use) of attendees of online recovery support meetings, and associations of online meeting attendance with substance use outcomes, using national data (without ensured representativeness) collected before the pandemic., Methods: Data were from the Peer Alternatives in Addiction (PAL) Study of attendees of 12-step groups (e.g., Alcoholics Anonymous), Women for Sobriety (WFS), LifeRing Secular Recovery (LifeRing), and SMART Recovery (SMART). The baseline sample, collected in 2015 (pre-pandemic), was 647 adults with lifetime alcohol use disorder who were surveyed online at baseline and 6-month (81%) and 12-month follow-up (83%)., Results: At baseline, 62% (n = 402) had attended an online mutual-help group meeting in their lifetime, and 36% (n = 236) had done so in the past 30 days. Bivariate analyses found that online meeting attendance was more likely among women than men, younger than older participants, and participants with more recent alcohol and drug use, and less abstinence self-efficacy. In addition, online meeting attendance was more likely among respondents who attended two or more different types of mutual-help groups (rather than just one type), and whose primary group was 12-step or WFS rather than LifeRing or SMART. Longitudinal analyses found an interaction between online meeting attendance (yes or no) and time on the outcomes of alcohol and total abstinence such that, compared to those who did not attend online meetings, online meeting attendees were less likely to be abstinent at baseline but were about the same on abstinence at 12 months. However, the interaction effect was attenuated when the model adjusted for mutual-help use characteristics., Conclusions: The findings inform mutual-help groups, providers, and researchers' efforts to sustain and expand this resource by suggesting that online meeting attendance may have appeal and be helpful to mutual-help group members who are earlier in their recovery., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: We examined whether alcohol-dependent individuals with sustained substance use or psychiatric problems after completing treatment were more likely to experience low social status and whether continued help-seeking would improve outcomes., Short Summary: Ongoing alcohol, drug and psychiatric problems after completing treatment were associated with increased odds of low social status (unemployment, unstable housing and/or living in high-poverty neighborhood) over 7 years. The impact of drug problems declined over time, and there were small, delayed benefits of AA attendance on social status., Method: Alcohol-dependent individuals sampled from public and private treatment programs (N = 491; 62% male) in Northern California were interviewed at treatment entry and 1, 3, 5 and 7 years later. Random effects models tested relationships between problem severity (alcohol, drug and psychiatric problems) and help-seeking (attending specialty alcohol/drug treatment and Alcoholics Anonymous, AA) with low social status (unemployment, unstable housing and/or living in a high-poverty neighborhood) over time., Results: The proportion of participants experiencing none of the indicators of low social status increased between baseline and the 1-year follow-up and remained stable thereafter. Higher alcohol problem scores and having any drug and/or psychiatric problems in the years after treatment were associated with increased odds of low social status over time. An interaction of drug problems with time indicated the impact of drug problems on social status declined over the 7-year period. Both treatment-seeking and AA attendance were associated with increased odds of low social status, although lagged models suggested there were small, delayed benefits of AA attendance on improved social status over time., Conclusion: Specialty addiction treatment alone was not sufficient to have positive long-term impacts on social status and social integration of most alcohol-dependent people.

Background: Despite the effectiveness of 12-step groups, most people reporting a prior alcohol use disorder (AUD) do not sustain involvement in such groups at beneficial levels. This highlights the need for research on other mutual help groups that address alcohol problems and may attract those who avoid 12-step groups. The current study addresses this need, offering outcome data from the first longitudinal, comparative study of 12-step groups and their alternatives: The Peer ALlternatives for Addiction (PAL) Study., Methods: Adults with a lifetime AUD were surveyed at baseline (N=647), 6months (81% response rate) and 12months (83% response rate). Members of the largest known secular mutual help alternatives, namely Women for Sobriety (WFS), LifeRing, and SMART, were recruited in collaboration with group directors; current 12-step attendees were recruited from an online meeting hub. Online surveys assessed demographic and clinical variables; mutual help involvement; and alcohol and drug use and severity. Analyses involved multivariate logistic GEEs separately modelling alcohol abstinence, alcohol problems, and total abstinence across 6 and 12months. Key predictors were baseline primary group affiliation (PGA); primary group involvement (PGI) at both baseline and 6months; and the interaction between baseline PGA and 6-month PGI. The critical effects of interest were the interactions, expressing whether associations between changes in PGI from baseline to 6months and substance use outcomes differed by primary group., Results: None of the interactions between baseline PGA and 6-month PGI were significant, suggesting no differences in the efficacy of WFS, LifeRing, or SMART, vs. 12-step groups. Nevertheless, some PGA main effects emerged. Compared to 12-step members, those identifying SMART as their primary group at baseline fared worse across outcomes, and those affiliating with LifeRing showed lower odds of total abstinence. Still, these effects became nonsignificant when controlling for baseline alcohol recovery goal, suggesting that any group differences may be explained by selection of those with weaker abstinence motivation into LifeRing and (especially) SMART., Conclusions: This study makes a valuable contribution in view of the extremely limited evidence on mutual help alternatives. Results tentatively suggest that WFS, LifeRing, and SMART are as effective as 12-step groups for those with AUDs, and that this population has the best odds of success when committing to lifetime total abstinence. An optimal care plan may thus involve facilitating involvement in a broad array of mutual help groups and supporting abstinence motivation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Empirical knowledge is lacking about Al-Anon Family Groups (Al-Anon), the most widely used form of help by people concerned about another's drinking, partly because conducting research on 12-step groups is challenging. Our purpose was to describe a new method of obtaining survey data from 12-step group attendees and to examine influences on initial Al-Anon attendance and attendees' recent life contexts and functioning., Method: Al-Anon's World Service Office sent a mailing to a random sample of groups, which subsequently yielded surveys from newcomers (n = 359) and stable members (n = 264)., Results: Reasons for groups' nonparticipation included having infrequent newcomers and the study being seen as either contrary to the 12 Traditions or too uncomfortable for newcomers. Main concerns prompting initial Al-Anon attendance were problems with overall quality of life and with the Al-Anon trigger (a significant drinking individual), and being stressed and angry. Goals for Al-Anon attendance were related to the following concerns: better quality of life, fewer trigger-related problems, and less stress. Members reported better functioning in some of these domains (quality of life, relationship with the trigger) but did not differ from newcomers on physical and psychological health. Newcomers were more likely to have recently drunk alcohol and to have obtained treatment for their own substance misuse problems., Conclusions: This method of collecting data from 12-step group attendees yielded valid data and also was seen by many in Al-Anon as consistent with the Traditions. Both newcomers and members had aimed to improve their overall quality of life and well-being through Al-Anon, and, indeed, members were more satisfied with their quality of life than were newcomers.

Aims: Investigators of the COMBINE (Combining Medications and Behavioral Interventions for Alcoholism) study examined whether combining medications with a behavioral intervention would improve outcomes over monotherapies. Unexpectedly, the combination did not offer any advantage over either treatment alone. This study aimed to explain the lack of incremental benefit offered by the combination over either monotherapy by assessing the role of cravings as a treatment mediator and moderator., Design: Secondary mediation and moderation analyses of COMBINE study data., Setting: Eleven United States academic sites., Participants: A total of 863 patients randomized to one of four treatment groups: naltrexone (100 mg/day; n = 209), the combined behavioral intervention (CBI, n = 236), naltrexone and CBI combined (n = 213) and placebo naltrexone (n = 205)., Measurements: Percentage of days abstinent (PDA) measured between 13 and 16 weeks post-baseline. Cravings, the potential mediator/moderator, were measured at baseline, weeks 4 and 12 using the Obsessive-Compulsive Drinking Scale., Findings: Compared with placebo, naltrexone, CBI and the combination all increased PDA by an additional 6-10 percentage points for those with high cravings (P < 0.05 for all three treatment groups). None had significant effects on PDA for those with low cravings. The effects of all three treatments were mediated at least partially by cravings; craving reduction explained 48-53% of treatment effects (P < 0.05 for all three treatment groups). Furthermore, naltrexone appeared to reduce cravings at 4 weeks, while CBI did not reduce cravings until 12 weeks., Conclusions: The Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) naltrexone + CBI combination may not be more beneficial than either monotherapy because craving reduction is a common mechanism of both., (© 2013 Society for the Study of Addiction.)

A trial of "Making Alcoholics Anonymous Easier" (MAAEZ), a group-format 12-step facilitation program, showed significantly higher odds of past 30-day abstinence after 12 months among those who had been treated in MAAEZ compared to usual care, especially for clients with high prior AA/NA/CA meeting attendance (>90 prior meetings; OR = 2.94, p = .02). We examined whether MAAEZ effects for this group were mediated by social support for sobriety and comfort with the 12-step fellowship. Among those with high prior AA/NA/CA attendance, we performed tests of multiple mediation to estimate MAAEZ effects attributable to the combined effect of social network support for sobriety, comfort being at AA/NA/CA meetings, and comfort speaking at AA/NA/CA meetings. To gain some understanding of sustaining these behaviors, we also examined each potential mediating variable measured both prior to, and concurrent with, 12-month outcomes. Having support for sobriety at 6 months emerged as a mediator of 12-month MAAEZ effects, when controlling for comfort being and speaking at AA/NA/CA meetings at 6 months. The effect remained when controlling for mediator values at 12 months, and explained 44% of the MAAEZ effect. Results highlight the value of studying specific, modifiable 12-step activities, and demonstrate the importance of exploring subgroups to determine behaviors and attitudes to target for optimal treatment. For example, increasing support for sobriety among those with high prior AA/NA/CA attendance may be especially pertinent., (2013 APA, all rights reserved)

This study grouped treatment-seeking individuals (n = 1825) by common patterns of 12-step attendance using 5 waves of data (75% interviewed Year 9) to isolate unique characteristics and use-related outcomes distinguishing each class profile. The "high" class reported the highest attendance and abstention. The "descending" class reported high baseline alcohol severity, long treatment episodes, and high initial attendance and abstinence, but by Year 5, their attendance and abstinence dropped. The "early-drop" class, which started with high attendance and abstinence but with low problem severity, reported no attendance after Year 1. The "rising" class, with fairly high alcohol and psychiatric severity throughout, reported initially low attendance, followed by increasing attendance paralleling their abstention. Last, the "low" and "no" classes, which reported low problem severity and very low/no attendance, had the lowest abstention. Female gender and high alcohol severity predicted attendance all years. Consistent with a sustained benefit for 12-step exposure, abstinence patterns aligned much like attendance profiles., (Copyright © 2012 Elsevier Inc. All rights reserved.)

A recent trial (n=508) of "Making Alcoholics Anonymous Easier" (MAAEZ), a group-format 12-step facilitation program, showed that MAAEZ participants had increased odds of abstinence (OR=1.58; p=0.063). Effects were especially marked in several subgroups, including those with more prior AA/NA/CA exposure, and those with severe psychiatric problems. This paper examines whether the effects of MAAEZ were explained by higher engagement in particular Alcoholics Anonymous (AA) and other 12-step organization activities. Mediation analyses were performed, estimating MAAEZ effects attributable to AA/NA/CA meeting attendance, overall AA/NA/CA involvement, having a sponsor, and engaging in 12-step service. The only variable that appeared to mediate MAAEZ effects in the sample overall was doing service at either 6 months or at both 6 and 12 months. Among those with high prior AA/NA/CA attendance, both having a sponsor and doing service emerged as mediators, with having a sponsor explaining approximately 25% of the MAAEZ effect. Doing service also partially explained the MAAEZ effect among those with high psychiatric severity. Results highlight the value of studying specific AA/NA/CA activities as mediators of treatment effects, and demonstrate the importance of exploring subgroups when trying to understand treatment mechanisms. Findings also suggest that treatment programs should emphasize specific activities for particular clients. For example, individuals may have attended many AA/NA/CA meetings, but never known how to ask for a sponsor or get involved in service; doing service may represent a non-threatening way of connecting with 12-step members for clients with psychiatric problems such as social anxiety., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: Much of what we know about the course of alcohol consumption in problem and dependent drinkers comes from studies of in-treatment populations. Less is known about the natural course of alcohol consumption among such drinkers in the general population and what predicts how much they drink., Method: This study examined alcohol consumption over the course of 11 years in a randomly selected sample of 672 problem and dependent drinkers from a single, heterogeneous U.S. county., Results: Alcohol consumption declined and leveled off over time but did not decrease to the average general U.S. population level. Several indicators of ongoing problems with drinking are associated with high levels of drinking over time: having a heavy-drinking network, receiving suggestions to do something about one's drinking, and going to treatment. Factors associated with less drinking include having contact with community agencies and going to Alcoholics Anonymous (AA)., Conclusions: Results suggest that problem and dependent drinkers continue to drink at an elevated level over the course of years. Gatekeepers, family members, and policymakers should encourage and facilitate contact with social service agencies and with AA for problem drinkers. Suggestions from others to do something about one's drinking and seeking specialty care occur more often in those with more severe problems and do not appear to be linked to less drinking over time.

Although many members of Alcoholics Anonymous (AA) are introduced to AA during treatment, the relationship between treatment and AA attendance over time is unknown. This paper describes four latent classes of AA attendance among 586 dependent alcoholics interviewed by telephone 1, 3, 5 and 7 years after baseline, and models the relationship between treatment exposure and AA attendance in each class. There was a low AA group (averaging fewer than 5 meetings at most follow-ups), a medium AA group (about 50 meetings a year at each follow-up), a descending AA group (about 150 meetings year 1, then decreasing steeply), and a high AA group (about 200 meetings at 1 year, then decreasing gradually by year 7). Declines in meeting attendance were not always accompanied by decreases in abstinence. After accounting for the effect of time on AA attendance (i.e., the "ups-and-downs" that occur over time), treatment exposure was minimally related to AA attendance in all but the descending AA group, where it was negatively associated (p<0.001). Considering AA patterns over time highlights a different role for treatment in AA attendance than what is gleaned from analyses at single timepoints.

Most treatment programs recommend clients attend 12-step groups, but many drop out posttreatment. The effectiveness of Making Alcoholics Anonymous [AA] Easier (MAAEZ ), a manual-guided intervention designed to help clients connect with individuals encountered in AA, was tested using an "OFF/ON" design (n = 508). MAAEZ effectiveness was determined by comparing abstinence rates of participants recruited during ON and OFF conditions and by studying the effect of the number of MAAEZ sessions attended. At 12 months, more clients in the ON condition (vs. OFF) reported past 30-day abstinence from alcohol (p = .012), drugs (p = .009), and both alcohol and drugs (p = .045). In multivariate analyses, ON condition participants had significantly increased odds of abstinence from alcohol (odds ratio [OR] = 1.85) and from drugs (OR = 2.21); abstinence odds also increased significantly for each additional MAAEZ session received. MAAEZ appeared especially effective for those with more prior AA exposure, severe psychiatric problems, and atheists/agnostics. MAAEZ represents an evidence-based intervention that is easily implemented in existing treatment programs.

Background: Drop-out from 12-step groups is notoriously high, yet the field lacks strong models and scales for addressing this problem. We aim to determine whether the theory of planned behavior (TPB) can be applied to 12-step involvement, and to develop and validate a scale of 12-step readiness based on that theory: the Alcoholics Anonymous Intention Measure (AAIM)., Method: Data were from a longitudinal trial of a manual-guided 12-step facilitation intervention called Making AA Easier (MAAEZ) involving two treatment programs in California (N=508). Participants completed surveys at baseline, 7 weeks, 6 months, and 12 months. Surveys included the preliminary AAIM, a 12-step involvement measure, other readiness measures, and substance use outcomes., Results: The final, 17-item AAIM measured Attitude (5-item alpha's=.75-.83), Subjective Norm (4-item alpha's=.56-.81), Perceived Control (5-item alpha's=.78-.85), and Intention (3-item alpha's=.80-.95) regarding attendance at 12-step groups. Components were correlated with each other and other readiness measures as expected, supporting the AAIM's validity. Scale components predicted 31% of the variance in Intention to attend 12-step groups at 6 months and 41% of the variance in 12-step involvement at 12 months. Social factors were among the strongest predictors of 12-step involvement. Results did not support the expectancy-value formulation of the TPB, as unweighted (vs. weighted) belief items performed optimally., Conclusions: Results generally support the TPB as a model of 12-step involvement and suggest specific targets for 12-step facilitation interventions within attitude, norm, and control components. Findings also support the AAIM as a tool for identifying drop-out risks and tailoring individual interventions.

Background: The effectiveness of Alcoholics Anonymous (AA) is difficult to establish. Observational studies consistently find strong dose-response relationships between AA meeting attendance and abstinence, and the only experimental studies favoring AA have been of 12-step facilitation treatment rather than of AA per se. Pending future randomized trials, this paper uses propensity score (PS) method to address the selection bias that potentially confounds the effect of AA in observational studies., Method: The study followed a treatment sample for 1 year to assess post-treatment AA attendance and abstinence (n=569). Propensity scores were constructed based on known confounders including motivation, problem severity, and prior help-seeking. AA attendance during the 12-month follow-up period was studied as a predictor of alcohol abstinence for 30 days prior to the follow-up interview. PS stratification and PS matching techniques were used to adjust for the self-select bias associated with respondents' propensity to attend AA., Results: The overall advantage in abstinence initially observed narrowed when adjusted. The odds ratio associated with AA attendance reduced from 3.6 to 3.0 after PS stratification and 2.6 after PS matching to AA-attenders. Support for AA effectiveness was strengthened in the quintile with lower propensity scores and when AA-nonattenders were matched as the target group, but was weakened among those in the higher PS quintiles and when matching to AA-attenders., Discussion: These results confirm the robustness of AA effectiveness overall, because the results for higher abstinence associated with AA attendance following propensity score adjustment remained significant, and the reduction in the magnitude of AA's effect was moderate. However, the effect modification by propensity scores in both PS stratification and PS matching approaches seems to suggest that AA may be most helpful, or matter more, for those with a lower propensity to attend AA. Conversely, for those with a high propensity to go to AA (operationalized as higher motivation, greater problem severity, more prior AA and treatment exposure, etc.), attending AA may not make as much of a difference. It will be important that future studies replicate our results, as this is the first paper to use propensity score adjustment in this context.

Objective: Evidence suggests that people misjudge the size of their drinks, calling into question the validity of data from surveys and screening instruments assessing alcohol quantity in terms of standard drinks. This article studied the validity of photographs of glasses to assess drink size., Method: In a U.S. national sample of 323 drinkers, respondents were mailed a measuring beaker and a set of photographs of wine, beer, and other drinking glasses for use in a subsequent telephone survey. In the interview, they were asked to pick the glass most similar to what they use at home and to identify the letter associated with their usual pour level. Then, a protocol where subjects measured the actual number of ounces in their typical drink, by pouring water into their usual glass and measuring this volume using the measuring beaker, gave a direct measure of home drink volume. We compared drink sizes using the two approaches., Results: Photographs worked well for certain groups, including women, young people, and nonwhites (for wine) and whites (for beer). The greatest magnitude of error arising from the use of photographs was for wine drinks among those age 50 and older, those with a 4-year degree, frequent 5+ drinkers in general, and heavy-volume wine drinkers. Average drink size based on the most popular wine and beer glasses in the photographs were 0.62 oz (18 ml) and 1.62 oz (48 ml) larger than beaker pours, respectively. Error between actual drinks and photographs was especially high for a large balloon-shaped wine glass, chosen by only 3% of wine drinkers., Conclusions: Whenever possible, researchers and clinicians should incorporate protocols that allow for some type of direct measurement using the actual vessels from home. When this is not viable, photographs represent a solution that is practical, shows promise for beer and wine drinks, and is relevant to any drinking context.

This chapter draws on AA membership surveys, US general population surveys, and longitudinal treatment data to compile profiles of those ever exposed to AA in their lifetime, those who no longer report AA meeting attendance, and those who attend AA meetings currently. We consider demographics (gender, age, ethnicity, marital status), receipt of specialty treatment, and short- and long-term abstinence rates among these AA exposure groups. Results suggest stability in the representation of women and minorities among the AA membership, but a decline among youth. Fully one-half of those completing AA's most recent membership survey reported that they had been abstinent for more than 5 years. Those receiving specialty treatment any given year are likely to report AA exposure that year. Disengagement from AA does not appear to necessarily translate to loss of abstinence among those with initial high levels of AA exposure, but long-term abstinence is more likely among those with continued engagement.

This study compares peer helping and 12-step involvement among participants receiving chemical dependency treatment at day hospital (N = 503) and residential (N = 230) programs, and examines relationships between both variables and outcomes. Findings show that residential (vs. day hospital) participants reported significantly more peer helping and 12-step involvement during treatment, and marginally more 12-step involvement at 6 months. Both peer helping and 12-step involvement predicted higher odds of sobriety across follow-ups; helping showed an indirect effect on sobriety via 12-step involvement. Results contribute to the 12-step facilitation literature; confirm prior results regarding benefits of mutual aid; and highlight methodological issues in helping research. The study's limitations are noted.

Background: Helping others is evident in the philosophy of Alcoholics Anonymous, and is emphasized in formal treatment. However, helping among recovering alcoholics has not been studied, in part because of a lack of helping measures., Methods: This study developed a Brief Helper Therapy Scale to capture helping among individuals with varying lengths of recovery. The 26-item long version of the Helper Therapy Scale was developed from qualitative interviews (n = 21) and item analysis of responses from 200 recovering alcoholics with differing lengths of recovery. Three subscales assessed Recovery, Life, and Community Helping. This brief version was created using an iterative process of item analysis designed to yield good internal consistency and representation of different types of helping. Helping was assessed as a continuous measure of how much time had been spent on each activity in the past week., Results: The resulting 9-item Brief Helper Therapy Scale demonstrated strong internal consistency (alpha = 0.83), but did not correlate well with psychological and spirituality measures used to assess construct validity. The Brief Helper Therapy Scale can be completed in about 5 minutes. Those in early recovery reported move involvement in recovery helping, with service in AA a notable exception. Those with the longest recovery focused more on community helping., Conclusions: Findings suggest that persons more stable in recovery move beyond a singular focus on recovery helping and demonstrate that people in recovery do contribute to society - potentially dispelling some of the stigma associated with alcoholism.

Background: Most formal treatment programs recommend Alcoholics Anonymous (AA) attendance during treatment and as a form of aftercare, but we know very little about treatment seekers' patterns of AA involvement over time and how these relate to abstinence., Method: This paper applies latent class growth curve modeling to longitudinal data from 349 dependent drinkers recruited when they were entering treatment and were re-interviewed at one or more follow-up interviews one, three and five years later, and who reported having attended AA at least once., Results: Four classes of AA "careers" of meeting attendance emerged: The low AA group mainly just attended AA during the 12 months following treatment entry. The medium and high AA groups were characterized by stable attendance at the second and third follow-ups-at about 60 meetings a year for the medium group and over 200 meetings per year for the high group, followed by slight increases for the medium group and slight decreases for the high group by year five. The declining AA group doubled its meeting attendance postbaseline, to almost 200 meetings during the year following treatment entry, but by year five they were only attending about six meetings on average. Decreases in AA meetings did not necessarily signal disengagement from AA; at the five-year follow-up, a third of the low AA group and over half of the declining AA group said they felt like a member of AA. Activities other than meeting attendance, such as having a sponsor, otherwise paralleled the meeting careers, but social networks were similar by year five. Rates of abstinence by year five (for the past 30 days) were 43% for the low AA group, 73% for the medium group, 79% for the high group and 61% for the declining group. Rates of dependence symptoms and social consequences of drinking did not differ between the groups at year five., Conclusions: The prototypical AA careers derived empirically are consistent with anecdotal data about AA meetings: some never connect; some connect but briefly; and others maintain stable (and sometimes quite high) rates of AA attendance. However, contrary to AA lore, many who connect only for a while do well afterwards.

Aims: To compare representative general population and treated samples on their reasons for drinking less and whether particular reasons were related to sustained remission from problem drinking for either group., Participants and Design: A total of 659 problem drinking adults in a Northern California county identified through a probability survey in the general population (n = 239) and a survey of consecutive admissions to public and private alcohol and drug programs (n = 420), who reported drinking less at the one-year follow-up and provided reasons for reducing their drinking, were assessed 1-, 3-, and 5-years post-baseline regarding their problem drinking status., Measurements: Logistic regression models were used to predict sustained remission from problem drinking., Results: While the treated sample endorsed a majority of reasons in significantly higher proportions than the general population sample, the same three reasons were significant for both groups in predicting sustained remission from problem drinking: hitting rock bottom, experiencing a traumatic event and undergoing a spiritual awakening. Interventions by medical personnel and family members were either non-significant predictors or significantly negatively related to sustained improvement for both general population and treated problem drinkers., Conclusions: General population and treatment samples have similar reasons for cutting down as they relate to sustained remission from problem drinking.

Objective: To address unanticipated results from randomized trials, researchers often focus on client-level data about services received during treatment. Program-level observations can also be helpful, especially in understanding treatment delivered in groups. Using both approaches, this article strives to better understand inconsistent results from a trial comparing medical and nonmedical group-format day treatment., Method: Dependent treatment seekers were randomized to a hospital-based medical day-treatment program or to one of two community-based nonmedical day treatment programs. Services received during treatment were captured from clients using the Treatment Services Review (N = 230 subjects; 78 women), and group sessions were observed to measure therapeutic style using an Event Form (N = 48 observations)., Results: The trial had found better medical outcomes at the hospital than at either nonmedical program, but most other tests had demonstrated similar outcomes at day hospital and one of the nonmedical sites and worse outcomes (psychiatric, family/social and employment) at the other nonmedical study site. Our analysis of services reported by study participants found a pattern of fewer substance misuse-oriented groups and less serious discussions about medical, psychiatric and family/social problems at the same nonmedical site that had worse outcomes. The way that services were delivered at that site further helped to explain the poorer outcomes there: Groups tended to be more didactic, classroom-like and less discussion-oriented., Conclusions: Although services received are helpful in explaining treatment outcome, treatment observation adds explanatory value. Without increasing the cost of service provision, programs that rely heavily on didactic approaches might improve their outcomes simply by encouraging more interactive discussions that engage the clients.

Objective: The purpose of this study is to examine how helping activities and spirituality--perhaps key influences on sobriety--change over recovery. The study also explores interrelations among Alcoholics Anonymous (AA), helping and spirituality., Method: Questionnaires were administered to recovering alcoholics (118 men, 80 women) recruited at AA and Women for Sobriety meetings, treatment programs and through personal connections. A helping scale measured Recovery Helping (8-item alpha = 0.78), Life Helping (12-item alpha = 0.62), and Community Helping (6-item alpha = 0.60). The Daily Spiritual Experiences scale assessed two components of spirituality identified by factor analysis: Theism and Self-Transcendence. Two components of an AA scale, Involvement and Achievement, were also treated separately on the basis of factor analysis., Results: Structural equation modeling revealed that longer sobriety predicted significantly more time spent on Community Helping, less time spent on Recovery Helping and higher levels of Theism, Self-Transcendence and AA Achievement. Model covariances revealed that both AA components were related to more Recovery Helping and higher Theism. Both spirituality components related to all forms of helping, with one exception., Conclusions: The findings highlight important changes in helping with length of sobriety. As their sobriety accumulates, recovering alcoholics seem to devote less time to informal helping and more time to organized community projects--perhaps indicating evolving needs and abilities. The results also suggest roles for AA and spirituality in encouraging helping, and they indicate that some forms of spirituality relate to AA affiliation. Future work might establish whether and when helping in different domains contributes to the maintenance of abstinence and to other drinking-related outcomes.

This expert consensus statement reviews evidence on the effectiveness of drug and alcohol self-help groups and presents potential implications for clinicians, treatment program managers and policymakers. Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies. Policies described here that could be implemented by clinicians and program managers include making greater use of empirically-validated self-help group referral methods in both specialty and non-specialty treatment settings and developing a menu of locally available self-help group options that are responsive to client's needs, preferences, and cultural background. The workgroup also offered possible self-help supportive policy options (e.g., supporting self-help clearinghouses) for state and federal decision makers. Implementing such policies could strengthen alcohol and drug self-help organizations, and thereby enhance the national response to the serious public health problem of substance abuse.

Aims: To compare representative treatment and untreated samples of alcohol-dependent individuals in rates of abstinence and non-problematic use at 1-year follow-up., Participants and Design: A total of 482 alcohol-dependent adults in a northern California county identified through a probability survey of problem drinkers in the general population (n = 111) or a survey of consecutive admissions to public and private substance abuse programs (n = 371) were interviewed in person at baseline and by telephone at 1 year., Measurements: Logistic regression models were used to predict 30-day abstinence and 12-month non-problematic alcohol use., Results: At follow-up, alcohol-dependent individuals in the treatment sample had higher abstinence rates and non-problematic use outcomes than those in the untreated general population sample. In logistic regression models of the merged samples, being in the treatment sample was related strongly and positively to abstinence and non-problematic use. Having more drug users and heavy drinkers in one's social network, higher psychiatric comorbidity, and more social consequences were inversely related to abstinence and non-problematic use in the treatment sample. The number of drug users and heavy drinkers in one's social network was also inversely related to abstinence in both the treatment and untreated general population samples. Results predicting non-problematic use were similar., Conclusions: These results are consistent with other studies that examine treatment effectiveness in the absence of a controlled trial. Although natural recovery also occurs, alcohol-dependent individuals benefit from treatment. Co-occurring psychiatric problems continue to be major barriers to treatment effectiveness. An emphasis on changing social networks to be conducive to recovery could heighten both clinical effectiveness and prevention efforts within communities.

Objective: The role of changes in Alcoholics Anonymous (AA) involvement and social networks in relation to abstinence following substance abuse treatment is studied. Specifically, the role of AA and network support for abstinence are examined in relation to their effect on changes in abstinence states between follow-ups., Method: Study sites were 10 representative public and private alcohol treatment programs in a northern California county. A recruitment of 367 men and 288 women seeking treatment were interviewed at intake and re-interviewed 1 and 3 years later to collect information about alcohol consumption, dependence symptoms, social support for reducing drinking, number of heavy drinkers in the social network and AA involvement., Results: Significant predictors of 90-day abstinence at both the 1- and 3-year follow-up interviews included AA involvement in the last year, percentage of heavy or problem drinkers in the social network, percentage encouraging alcohol reduction and AA-based support for reducing drinking. Panel models estimated an increase in AA participation between 12 and 36 months posttreatment increased the odds of abstinence at 3 years by 35% above those at 12 months. The only significant mediator of AA's effect on abstinence was the number of AA-based contacts supporting reduced drinking, which reduced the magnitude of the relationship by 16%., Conclusions: AA involvement and the type of support received from AA members were consistent contributors to abstinence 3 years following a treatment episode. The enduring effects observed from supportive networks demonstrate the importance of ongoing mechanisms of action that contribute to an abstinent lifestyle.

Aims: This study tested the hypothesis that the relationship between Alcoholics Anonymous (AA) involvement and reduced substance use is partially explained (or 'mediated') by changes in social networks., Design: This is a naturalistic longitudinal study of the course of alcohol problems., Setting: Study sites were the 10 largest public and private alcohol treatment programs in a northern California county., Participants: Three hundred and seventy-seven men and 277 women were recruited upon seeking treatment at study sites., Measurements: At baseline and 1-year follow-up, we assessed alcohol consequences and dependence symptoms, consumption, social support for abstinence, pro-drinking social influences and AA involvement., Findings: In the structural equation model, AA involvement was a significant predictor of lower alcohol consumption and fewer related problems. The size of this effect decreased by 36% when network size and support for drinking were included as mediators. In logistic regression models predicting abstinence at follow-up, AA remained highly significant after including social network variables but was again reduced in magnitude. Thirty-day abstinence was predicted by AA involvement (OR=2.9), not having pro-drinking influences in one's network (OR=0.7) and having support for reducing consumption from people met in AA (versus no support; OR=3.4). In contrast, having support from non-AA members was not a significant predictor of abstinence. For alcohol-related outcomes other than abstinence, significant relationships were found for both AA-based and non-AA-based support., Conclusions: The type of social support specifically given by AA members, such as 24-hour availability, role modeling and experientially based advice for staying sober, may help to explain AA's mechanism of action. Results highlight the value of focusing on outcomes reflective of AA's goals (such as abstinence) when studying how AA works.

Despite public health campaigns and clinical interventions that encourage women to abstain from alcohol during pregnancy, some women continue to drink while pregnant. To provide a more in-depth understanding of how at-risk women regard--and emotionally react to--warnings about drinking alcohol during pregnancy, we conducted focus groups in 1997 with 11 pregnant and recent postpartum Native American and African American women in Los Angeles, California. The main objective of these groups was to uncover relevant aspects of women's beliefs and opinions about drinking during pregnancy that may not have been elicited by other research instruments. Results would then be used to shape a large survey of pregnant at-risk women. Analysis of the transcripts revealed three emergent themes, which had the greatest impact on our subsequent survey. These were women's exposure to and perceived believability of messages, their perception of risk associated with drinking, and the barriers to cutting down on alcohol consumption during pregnancy. Questions added to our survey instrument because of these findings included whether women think that some alcohol beverages are safer to drink than others; how they value cutting back alcohol use; their views on the irreversibility of fetal alcohol syndrome; and what pressures they feel from peers and family to drink during pregnancy. Given the small sample size associated with focus groups, these results cannot be generalized to larger populations; however, these women's words revealed important underlying issues and barriers that should be considered in studying and intervening with larger representative samples.

Policy research assesses how outside forces affect alcohol treatment services. In this primer, we examine a range of effective methods that can be brought to bear by researchers and address the issues involved in conceptualizing and conducting studies of policy formation, implementation and policy implications. Because there is no single superior methodology for studying policy change, researchers have relied on five broad methodologies for studying policy context, formation, change and implications. We provide specific examples of each approach, addressing the following issues: data sources and samples; the problems, challenges, strengths, and limitations of the approach; and whether (and how) the method has been used in the alcohol field. The five methods are archival studies; key informant studies; ethnographic and observational studies; surveys; and meta-analyses. The strongest research designs in alcohol services research often combine methods and sources to get different vantage points on questions about policy change.

Affiliation with Alcoholics Anonymous (AA) is an important variable to measure in many clinical and research activities. This paper reports on the development of an AA affiliation scale, and demonstrates its utility in a sample of 927 alcohol treatment seekers and 674 untreated problem drinkers. The scale is short (9 items), covers a range of AA experiences, and is internally consistent across diverse demographic groups, multiple health services settings, and treated and untreated populations. The validity of the scale is supported by the findings that treatment seekers report significantly higher AA affiliation than do untreated problem drinkers, and inpatients report higher affiliation than outpatients. Potential clinical and research applications of the scale are proposed.

Objective: This article considers the predictors of help-seeking behavior, and the types of help sought among the general population., Method: Longitudinal data are used, collected during in-person interviews with 2,234 (1190 female) individuals in 1984 and again in 1992. The focus is on help seeking during the follow-up interval, with an emphasis on baseline alcohol-related problems as predictors of seeking help for one's drinking over the 8-year period. Correlates of help seeking are shown separately for respondents who at baseline had already experienced, in their lifetime, three or more dependence-related symptoms, and those who had not., Results: Significant predictors of help seeking during the longitudinal follow-up period include male gender, younger age. Hispanic ethnicity, and having already (at baseline) experienced three or more alcohol-related social consequences. Alcoholics Anonymous (AA) was the most frequent treatment experience that was reported among those seeking help during the study period., Conclusions: Longstanding social consequences appear to play a key role in decisions to seek help for one's drinking, even when dependence-related symptoms are also considered. In this study Hispanics had an increased likelihood to seek help for their drinking (compared to whites), but blacks did not. AA continues to attract the largest number of help-seekers when compared to other alternatives.

This paper reports changes in drinking problems among Whites, Blacks, and Hispanics between 1984 and 1992. A probability sample including 1,777 Whites. 1,947 Blacks, and 1,453 Hispanics in the United States adult household population was interviewed in 1984. In 1992 a subsample consisting of 788 Whites, 723 Blacks, and 703 Hispanics was reinterviewed. Results show a decrease in problem prevalence among Whites, stability among Blacks, and an increase among Hispanics. Problem incidence was higher among Hispanics than among Whites and Blacks, put problem remission was higher among Whites. Women had a lower problem incidence but a higher problem remission than men, independent of ethnicity. The two best predictors of problem status in 1992 were reporting a problem in 1984 and reporting a high level of consumption in 1984.

Women for Sobriety represents a self-help option oriented toward positive thinking and behavior modification. Formed in 1975, there are now approximately 125 active WFS groups holding weekly meetings in the United States and Canada. Using data collected from a 1991 membership survey (n = 600, response rate = 73%), this paper chronicles WFS members' pathways to recovery. We describe turning points in seeking help, things women tried at first to contain their drinking, exposure to other treatment approaches, and referrals to WFS from formal treatment programs. Only 15% of the respondents sought treatment because they had been confronted about their drinking, while physical symptoms or emotional problems represented the turning point for over half the women. Another fifth said their life had gotten out of control, and these were the ones to achieve sobriety most quickly. Almost all WFS members had sought professional help for their drinking, and three-fourths have undergone individual therapy-suggesting that WFS members are fairly open to a psychological approach such as WFS offers. WFS philosophy is based on the belief that behavior is predicated on thoughts, so the program teaches members that maintaining sobriety must involve the realization that negative emotions are destructive-and that members can control how much they allow problems to bother them. Goals of membership include abstinence, improved self-esteem, and spiritual and emotional growth. About a third of the respondents currently attend AA, and no differences in length of sobriety associated with current AA attendance were found within the WFS membership. However, women who sought professional help in response to the turning point experience but who also attended AA that year were most likely to have achieved sobriety within a year of the turning point.

Objective: This article reports a longitudinal study of drinking patterns among whites, blacks and Hispanics between 1984 and 1992., Method: A probability sample including 1,777 whites, 1,947 blacks and 1,453 Hispanics in the U.S. adult household population was interviewed in 1984. In 1992 a subsample consisting of 788 whites, 723 blacks and 703 Hispanics was reinterviewed. Interviews averaging 1 hour in length were conducted in respondents' home by trained interviewers., Results: Abstention increased in all groups with the exception of Hispanic women, among whom it remained stable. Heavy drinking decreased only among white men (from 19% to 12%). Among men, the incidence of heavy drinking was 7% among whites, 10% among blacks and 17% among Hispanics. The stability of heavy drinking was greater among black (51%) and Hispanic men (43%) than among white men (32%). The best predictor of drinking in 1992 was drinking in 1984., Conclusions: Reductions in heavy drinking observed among whites were not observed among blacks and Hispanics. The greater stability of heavy drinking in the minority groups helps to explain higher rates of problems reported in the literature for these two groups. Prevention efforts targeting drinking and heavy drinking among blacks and Hispanics must be renewed and intensified.

It has been variously argued in the literature on women and alcohol that there is insufficient evidence to determine whether there is a need for women to be treated separately and differently from alcoholic men; that the findings are mixed; that the treatment characteristics that are more or less effective with women still are not known; and that some types of treatment are indeed best for women. This paper considers reasons for distinct treatment approaches for alcoholic women and considers in depth one such solution: Women For Sobriety (WFS). Using data from the first comprehensive survey of the WFS membership (response rate = 73%, n = 600), the reasons given by respondents for attending WFS and Alcoholics Anonymous (AA), and for not attending AA, are presented. Respondents said they attend WFS for support and nurturance (54%), for a safe environment (26%), for sharing about women's issues (42%), and because of its positive emphasis (38%) and focus on self esteem (39%). They attend AA primarily as insurance against relapse (28%), for its wide availability (25%), and for sharing (31%) and support (27%). Women who do not attend AA mentioned feeling as though they never fit in at AA (20%), finding AA too negative (18%), disliking the drunkalogs (14%) and their focus on the past (14%), and feeling that AA is geared to men's needs (15%). To provide a context for understanding what WFS members get out of attending WFS that they do not get out of AA, a brief description of WFS and a comparison between WFS and AA are provided. Implications for treatment referral are also discussed.