1. AA Effectiveness – Faith Meets Science Lee Ann Kaskutas, Dr.P.H. Alcohol Research Group, Emeryville, CA School of Public Health, UC Berkeley Presented at the Annual Meeting and Conference of the Federation of State Physician Health Programs (FSPHP) April 25, 2012 Fort Worth, TX

2. Perspectives on AA Effectiveness AA members: I know AA works and there is no need for research to prove that

3. Perspectives on AA Effectiveness AA members: I know AA works and there is no need for research to prove that AA critics: AA is a cult that relies on God as mechanism of action

4. Perspectives on AA Effectiveness AA members: I know AA works and there is no need for research to prove that AA critics: AA is a cult that relies on God as mechanism of action Cochrane Review: no experimental evidence of effectiveness

5. Perspectives on AA Effectiveness AA members: I know AA works and there is no need for research to prove that AA critics: AA is a cult that relies on God as mechanism of action Cochrane Review: no experimental evidence of effectiveness Moos: first send people to AA, not treatment

6. Criteria to establish causation Strength of association Dose-response relationship Consistency of association Temporally-correct association Specificity of the association Coherence with existing information Mausner & Kramer, Epidemiology -- text 1985

7. Criteria to establish causation Strength of association Dose-response relationship Consistency of association Temporally-correct association Specificity of the association Coherence with existing information Mausner & Kramer, Epidemiology -- text 1985

8. Abstinence & AA exposure Ouimette et al., J Stud Alcohol 1998 Thurstin et al., Int J Addict 1987 male VA inpatients 1 yr n = 3018; 18 mo n = 91

9. Criteria to establish causation Strength of association Dose-response relationship Consistency of association Temporally-correct association Specificity of the association Coherence with existing information Mausner & Kramer, Epidemiology -- text 1985

10. Abstinence & meeting amount Moos et al., J Clin Psychol 2001 Male VA residential patients n = 2376

11. Fiorentine, Am J Drug Alcohol Ab 1999 Abstinence & meeting frequency LA Target Cities, outpatients n = 262

12. Abstinence & sustained attendance Moos & Moos, J Clin Psychol 2006 Also see Moos & Moos, JSAT 2004 meetings Previously untreated problem drinkers n = 461 ☼

13. AA meeting trajectories Kaskutas et al., ACER 2005 Dependent treatment seekers n = 349

14. Abstinence and meeting trajectories Kaskutas et al., ACER 2005 Dependent treatment seekers n = 349

15. Criteria to establish causation Strength of association Dose-response relationship Consistency of association Temporally-correct association Specificity of the association Coherence with existing information Mausner & Kramer, Epidemiology -- text 1985

16. a Ouimette et al., J Stud Alcohol 1998 b Timko et al., J Stud Alcohol 2000 Consistency across samples & time a b b a Male VA inpatients b Previously untx prob drnkrs n = 3018n = 466

17. Consistency across samples (Dawson, Addiction 2006) NESARC; dependent Tx12-stepbothnothing n = 4422 n=239n=138n=829n=3217

18. Consistency across time AA involvement over 10 years Abstinence at 10 years Cross et al., ACER 1990 Inpatients n=158 significant

19. Criteria to establish causation Strength of association Dose-response relationship Consistency of association Temporally-correct association Specificity of the association Coherence with existing information Mausner & Kramer, Epidemiology -- text 1985

20. Substance use following AA/NA 12-step activities mos. 1-3 Alcohol and drug use mos. 4-6 12-step meetings mos. 1-3 No Yes Weiss et al., Drug Alcohol Depen 2005 Cocaine-dependent outpatients n = 336

21. Alcohol abstinence following AA Percent days abstinent mos. 7-12 AA involvement mos. 1-6 Outpatient β =.29 Connors et al., J Stud Alcohol 2001 Aftercare β =.34 Project MATCH n = 480 outpatients, n = 434 aftercare

22. Criteria to establish causation Strength of association Dose-response relationship Consistency of association Temporally-correct association Specificity of the association Coherence with existing information Mausner & Kramer, Epidemiology -- text 1985

23. Randomizing to AA to remove selection effect Walsh et al., New Engl J Med 1991 Alcohol abusers + EAP referred n = 227: n=73 hospital; n=83 AA; n=71 choice

24. Randomize to TSF to remove selection effect: Outpatient sample PMRG, J Stud Alcohol 1997 PMRG, ACER 1998 p =.0024p <.007 Project MATCH n = 806 outpatients at yr 3

25. Randomize to TSF to remove selection effect: Aftercare sample PMRG, J Stud Alcohol 1997 Project MATCH aftercare n = 714 at 1-year follow-up

26. AA Meeting Attendance by Project MATCH Sample And Treatment Assignment Outpatient* Aftercare** % Days AA Mtgs Green = 12-step Yellow = Motiv Grey = Cog Beh Green = 12-step Yellow = Motiv Grey = Cog Beh Intake 15 Month Tonigan et al., Tx Match Alcohol 2003 Project MATCH *n = 952 Outpatients, **n = 774 Aftercare

28. Timko’s results for 12-step involvement at 6 months Standard Referral Intensive Referral P Value # of meetings5764ns Did service45%56%<.05 Had awakening39%52%<.01 Had a sponsor38%48%<.05 Timko, Addiction, 2006

29. Groups where Intensive referral mattered in that study The low prior AA group attended significantly more meetings in IR (vs. SR) at 6 months. Differences in meeting attendance were non- significant in the high prior AA group.

30. Specificity: Randomizing to MAAEZ (Making AA Easier) 12-month Outcomes Usual care MAAEZ % Clean7179 % Sober8392 % Clean & Sober 7282

31. Groups where MAAEZ dose seems to really matter Unmarried Had prior treatment Attended 91+ prior AA meetings in lifetime Has high ASI psychiatric problem severity Drug dependent Atheist, agnostic, unsure No heavy drinkers or drug users in social network

32. Statistical models to study selection effect Motivation negative Alcohol problems AA involvement Psychopathology negative no difference Baseline2 years1 year McKellar et al., J Consult Clin Psych 2003 Male VA inpatients N=2,319

33. Example Using Propensity Score Method to Remove Selection Effect: Odds of Abstinence before adjustment * p<0.05, ** p<0.01, *** p<0.01

34. Odds of Abstinence after propensity score stratification * p<0.05, *** p<0.01

35. Criteria to establish causation Strength of association Dose-response relationship Consistency of association Temporally-correct association Specificity of the association Coherence with existing information Mausner & Kramer, Epidemiology -- text 1985

36. Consistency with theory: MEETINGS What you do –Place to go instead of bar –Talk about your problems What you hear –Others had similar experiences –Ways people coped instead of drinking What happens –Your mood changes –Don’t drink a day at a time Cog BehSoc LrnPsy alternativecue need succeed skills mood alternativeefficacy

37. Consistency with theory: FELLOWSHIP Friendship –Adds sober people supportive of your abstinence –Role models of new behavior –Helps learn how to have fun sober Sponsorship –Someone to call –Someone to provide emotional support Cog BehSoc LrnPsy cue model alternativecueneed emerg plan need

38. Consistency with theory: STEPS Change how you treat others, or you will drink –Personal inventory; amends Key to sobriety is helping others –Helping gets you to relinquish negative self focus Cog BehSoc LrnPsy need mood

39. Evidence of mechanism: cognitive behavioral Abstinence AA involvement Coping skills** Self-efficacy* * 1 Morgenstern et al., J Consult Clin Psych 1997 * 2 Kelly et al., J Stud Alcohol 2002 ** 1 Timko et al., ACER 2005 ** 2 Humphreys et al., Ann Behav Med 1999 * 1 Resi or IOP *2 asolescent inpatients ** 1 initially untx PDs ** 2 male VA inpatients n = 100 n=74 n=466 n=2,337

40. Evidence of mechanism: social learning Abstinence AA involvement Enhanced friendship networks** Fewer pro-drinking influences* More friends † # who support abstinence from AA ‡ *Kaskutas et al., Addiction 2002 **Humphreys et al., Ann Behav Med 1999 † Timko et al., ACER 2005 ‡ Bond et al., J Stud Alcohol 2003 * treated ** male VA inpat. † init. untx. PDs ‡ treated n = 722 n=2,337 n=466 n=655

41. Evidence of mechanism: social learning? AbstinenceMAAEZ Sponsor Service 6+12mos; high psych Comfort speak; be @ meetings # who support abstinence Kaskutas et al., JSAT 2009

42. Evidence of mechanism: psychodynamic Abstinence AA involvement Motivation for abstinence** Life meaning* *White & Laudet, CPDD 2006 **Kelly et al., J Stud Alcohol 2002 *In recovery**adolescent inpatients n = 354 n = 74

43. Evidence of mechanism: spirituality Abstinence AA involvement Spiritual awakening Δ religious beliefs & behaviors Zemore, ACER in press Day Hosp & Residential, managed care n = 537

44. Criteria to establish causation Strength of association Dose-response relationship Consistency of association Temporally-correct association –Specificity of the association Coherence with existing information Mausner & Kramer, Epidemiology -- text 1985

45. Getting People to AA Making AA Easier (MAAEZ) Six 90-minute manual-guided GROUP sessions led by recovering counselor Goals: To reduce patients’ immediate rejection of AA, and to help them connect with the AA fellowship Manual available now (lkaskutas@arg.org) Kaskutas & Oberste, MAAEZ 2002

46. Why care about AA facilitation? AA is the most widely-used source of help for alcoholism Over time, those who attend AA have higher rates of abstinence than those who drop-out Drop-out from AA is very high –Over half drop-out within their first year

47. Goal of MAA*EZ To prepare clients to engage in the culture of AA/NA/CA –Making it easier to connect with AA members Changing social networks is a mechanism of AA’s effect on abstinence 5,6 –Helping clients fill a purposeful role early on Helping helps the helper (Reissman’s Helper Therapy Principle) 7,8 and is consistent with AA’s stated goal 9 5 Kaskutas et al, Addiction 2002;97(7):891-900 6 Bond et al, JSA 2003;64(4):579-588 7 Riessman, Social Policy 1976;7:41-45 8 Zemore, Southern Medical Journal, forthcoming 9 Alcoholics Amonymous, 1939

48. Structure of MAA*EZ 6-week intervention –Six sessions, attended 1-week apart Need time for doing weekly homework Intro session –First and Last session attended For newcomers and graduates 4 core sessions –Spirituality, sponsorship, principles not personalities, living sober Attended in any order

49. Introduction Graduate vignettes of their AA and MAA*EZ experience How do you pick a meeting? –Meeting directories are passed-out Rules of the road at meetings Homework: go to a meeting –Pick meeting now using directory

50. Spirituality AA is spiritual, not religious program –Things to think about when you hear ‘God as we understood Him” Spirituality in AA –It’s about your behavior and taking responsibility for it “Act your way into good thinking” Get outside yourself; do service Homework –Talk to someone at a meeting who you don’t know, who has more sobriety than you

51. Principles, not Personalities Common objections to AA –It is a cult No single person speaks for AA Homework –Ask someone you don’t know at meeting, for their phone # Telephone them (and talk to them) before next session

52. Sponsorship Who should you ask? –You’re not imposing Role playing to ask someone to be temporary sponsor; 4 vignettes: –Asking someone you went to coffee with –Ask someone whose phone # you got –Ask speaker at meeting whose talk you liked –Ask someone who said something you connected with, but they said ‘no, they’re too busy’ Homework: ask somebody to be your temporary sponsor

53. Living Sober Sober fun: or, Is there life after sobriety? –What are some things you are worried about being able to do without the help of alcohol or drugs? Homework: do something with one or more people from AA who have more sobriety than you

54. Acknowledgements: Funding NIAAA grants –R01 AA 11279 (Kaskutas, PI) –R21 AA 13066 (Kaskutas, PI) –R01 AA 14688 (Kaskutas, PI) –R01 AA 9750 (Weisner, PI) –P50 AA 5595 (Greenfield, PI) NIDA grant –R01 DA 12297 (Kaskutas, PI) CSAT contract –#270-94-0001 (Kaskutas, PI)

55. Acknowledgements: People Eddie Oberste –co-developed MAAEZ Thomasina Borkman, Constance Weisner, David Pating –expert panel on MAAEZ development Ann Munoz, Sarah Zemore, Jane Witbrodt, Mina Subbaraman –fieldwork and analysis for MAAEZ study