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10 Year Course of AA Participation and Long-term Outcomes: A follow-up study of outpatient subjects in Project Match

By: Maria E. Pagano Ph.D., William L. White M.A., John F. Kelly Ph.D., Robert L. Stout Ph.D., Rebecca R. Carter B.A. & J. Scott Tonigan Ph.D

ABSTRACT
This study investigates the 10-year course and impact of 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 one year, three years, 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.

INTRODUCTION
Alcoholics Anonymous (AA) has distinguished itself within the alcohol problems arena through its membership size and geographical dispersion (more than 2.1 million members and 100,766 groups in 150 countries), its influence on the modern treatment of alcohol use disorders, and through the volume and growing methodological rigor of research studies on the effects of AA participation (1-3).-analytic reviews of the effects of AA involvement report a positive association between AA participation and abstinence across diverse populations as well as reductions in substance-related health care costs (4-8). Efforts to date to isolate the active ingredients of AA participation have focused primarily on meeting attendance, step-work, and service (9,10).Meeting attendance has been associated with abstinence and a higher number of sober friends (11-13). More step-work at a 3-year follow-up has been associated with decreased alcohol consumption at a 10-year follow-up (14) AA-related helping activities (AAH) are associated with greater abstinence at 1-year and 3-year follow-ups and reduced depression (15-20).

There are several theoretical interpretations of the evolution of service within the 12-step program. First, AAH can be viewed as an application of Riesman's “helper therapy principle (HTP)”; one's own problems diminish through the process of helping others (21). AAH applies the long “wounded healer” tradition whereby survivors of a life-altering disorder or experience develop special sensitivities, insights, and skills to be uniquely helpful to others with the same condition (22,23) —a process AA's co-founder Bill Wilson characterized as “the sublime paradox of strength coming out of weakness”(24). Second, just as an evolutionarily adaptive gene may promote the replication and survival of a particular species (25), AA's primary purpose, to stay sober and help other alcoholics, may have evolved to sustain the program's survival. Service positions such as chairperson or secretary further ongoing AA group functioning. Third, AAH can also be understood within AA's posited theory of self-centeredness as a central factor in the development and maintenance of alcoholism. AA's main textbook is filled with admonitions of the dangers of selfishness, self-centeredness, self-absorption, self-justification, self-pity, and self-deception. The collective experience of AA's original 100 members acknowledges self-knowledge, self-reliance, self-control, and self-sufficiency as failed paths to sustaining sobriety (26). Whereas mutual aid alcoholic societies in the 19th century viewed self-assertion as liberating the alcoholic from the disease (27,28), AA's founders characterized the illness as stemming from the “bondage of self” (26) which could only be broken by personal surrender and self-transcendence.

AA's main textbook emphasizes key exercises for ego reduction, which others reference as the foundation of recovery (29,30).The AA recovery process involves: a) surrender–admission of powerlessness and personal limitations (Step 1) (“…we had to quit playing God”); b) transcendence of self via reliance on a power greater than self (Step 2); c) witnessed confession of wrongs done to others (Step 5); d) repair of family and social relationships through making amends (Step 9); e) carrying a message of hope to other alcoholics (Step 12), which is often done in ritualized storytelling within a community of recovering people; and f) personal anonymity as a spiritual principle–a metaphoric and literal shedding of self (Tradition 4) (31). Seen in this light, AA is not a “self-help” program but a mutual-help program that rests on the premonition that sustained sobriety cannot be achieved alone (32). AAH enacts many of these exercises designed to increase other-orientation and self-transcendence which occurs quickly for some and slowly for others.

Long-term, prospective study of the course of AA participation across major programmatic activities and impact on behavior is limited. Of the few studies with 5-years or more follow-up post-treatment, Kaskutas and colleagues (33) delineated four long-term patterns regarding AA meeting attendance: 1) low, 2) medium, 3) descending, and 4) high, with highest meeting attendance occurring in the first year following treatment. Long-term participation patterns in other program activities such as step-work and AAH are less clear. While higher meeting attendance in the initial post-treatment period is associated with more improved drinking outcomes (7,34-49), few have studied the long-term influence of other major components on decreased substance use. Further, long-term alcohol investigations of AA's impact on clinical outcomes beyond drinking are rare. A handful of early studies considered the potential effect of AA participation on a transformation from self-centeredness to increased other-orientation (29,50).Reinert and colleagues (51,52) hypothesized a decline in self orientation with increased years in recovery, but did not find such declines over short periods of time in a sample of AA members.However, increased other-regard, if it occurs through such mechanisms as step-work or AAH, may span years of AA participation.

This paper builds upon prior prospective AAH research to explore the course and impact of AA participation across three major programmatic activities: meeting attendance, step-work, and AAH. In this study, we examine: 1) the 10-year course of AA participation, drinking, and other-oriented behavior, 2) the influence of 12-step facilitated treatment (TSF) on AA programmatic activities and outcomes over time, and 3) the influence of time-varying participation in AA programmatic activities on subsequent drinking and other-oriented behavior.

MEASURES
Background characteristics were assessed at baseline. Time-varying variables (percent days abstinent, 3 indices of AA participation, other-oriented interest) were assessed at baseline, 3-, 15-, 39-, and 120-months post-randomization.

Background Characteristics. Baseline demographic and clinical characteristics included gender, race, marital status, full-time employment status, age, years of education, anti-social personality disorder (ASPD), chemical dependency treatment history, and receipt of Twelve-step Facilitation (TSF). Receipt of TSF versus no TSF (Cognitive Behavioral Therapy, Motivational Enhancement Therapy) was ascertained from Project MATCH's randomized treatment assignment (42).

Alcohol Use. Alcohol use was defined as percent days abstinent (PDA) using the semi-structured Form 90 (59). The Form 90 is a calendar-based daily drinking estimation method that incorporates a grid-averaging approach to provide a comprehensive and efficient assessment of a person's drinking over a designated period of time (90 days in this study). It has demonstrated test-retest reliability for treatment-seeking alcoholics (60) and problem use of illicit drugs (61). Given the negatively skewed distribution, PDA variables received an arcsine transformation, as was done in the primary MATCH outcome analyses (54).

AA Participation. Three indices of AA participation variables were measured: 1) AAH, 2) AA meeting attendance (MTG), and 3) step-work. AAH was assessed with the 13-item Alcoholics Anonymous Involvement (AAI) questionnaire (62), a well-validated measure of AA affiliation developed for use in Project MATCH (62). Using criterion from prior work (9), AAH was defined by endorsement of two AAI items: being a sponsor and/or completion of the 12th step in the last 90 days.MTG was assessed from one item on the Form 90, “How many AA meetings have you attended in the past 90 days?” and converted into percent of days attending AA (number of days attending AA/ number of days in the assessment period), for a score ranging from .00-1.00. Because of a positively skewed distribution, MTG was log transformed. Step-work was measured from the continuous AAI item ascertaining completed steps (0-11) in the assessment period, and summed. Using Cohen's effect size r estimates (63), there was a small correlation between AAH and MTG at any assessment (r = .18-.24, P < .001), a moderate correlation between AAH and step-work (r = .26-.43, P < .001), and a moderate correlation between MTG and step-work (r = .42-.60, P < .001).

Other-Oriented Interest (OOI). One item from the Beck Depression Inventory (BDI;64) was used as an index of AA's espoused behavior towards others (i.e., “…trying each day to be a little more thoughtful and considerate to those with whom we came in contact” (65; p356). With regard to interest in others in the past week, participants rated the OOI item from 0 (no loss of interest) to 3 (lost all interest). Similar single-item measures have been used in other alcohol investigations (66,67).

DISCUSSION
This study provides a snapshot of what can be expected of outpatients’ AA participation in the decade following their index treatment and highlights the importance of meeting attendance and AAH to long-term behavioral change. Meeting attendance during treatment and in the following decade parallels patterns reported in other prospective 12-step investigations (76,77) meeting attendance was highest during treatment and steadily declined thereafter. In contrast, a relatively stable rate of AAH (9%) and low levels of step-work were observed during and following treatment. Despite a lowered rate of AAH at the 15-month assessment, AAH participants did more step-work and attended more meetings than non-AAH participants at any study interval. TSF treatment significantly boosted AAH participation and step-work relative to the other treatment conditions, but effects were lost after the initial year post-treatment. Extended effects of TSF beyond the initial year post-treatment may be seen with coordination of other 12-step facilitation approaches such as “Bridging the Gap” (78,79), or periodic booster sessions post-treatment, such as Case Monitoring (R01 AA009907; 80).
We next explored the relationship between participation in 3 AA programmatic activities on subsequent drinking and other-oriented behavior over time. Consistent with prior work (6-8,15,16,62), results showed direct effects of meeting attendance and AAH on greater abstinence across time, but not differential benefit of TSF. Controlling for pretreatment levels of OOI, those engaged in AAH were significantly more likely to report higher interest in others. These findings suggest the importance of meeting attendance to abstinence as a newcomer and in long-term recovery, and support AA's suggestion to help others as way to stave off an urge to drink and increase interest in others.

There are several limitations of this study that warrant attention. This outpatient sample was representative of other outpatient sites in Project MATCH with exception to age and education. Findings may not generalize to non treatment-seeking populations or those with more severe addiction. However, alcohol consumption patterns were similar to 10-year course patterns observed in other samples of problem drinkers (34). Second, treatment effects in this study are limited to the randomized index treatment. Third, our estimates of AAH and OOI are likely to be on the low end of true rates given their 1-2 item assessments.

Limitations aside, this study is the first to explore the 10-year course of meeting attendance, step-work, and AAH and their concurrent influence on long-term outcomes. Psychometrically sound measures employed in Project MATCH were consistently collected at each study interval, with 10-years of month-to-month estimates of drinking outcomes reliably assessed with the Form-90. Other strengths of this study include: a high representation of Hispanic problem drinkers seeking outpatient treatment; an 82% retention rate at 10-years post-treatment; and advanced statistical techniques including multiple imputation that produced robust parameter estimates. The HLM methods employed controlled for all stable measured and unmeasured characteristics of subjects correlated with model covariates (69), thereby eliminating potentially large sources of bias.

Treatment provides a time-limited opportunity during which patients may be receptive to professional input and advice. The significant correlation in our study between worse alcohol outcomes and less interest in others suggests that clients may benefit from increasing other-oriented behaviors as part of their recovery program. The current practice of encouraging meeting attendance could be honed by encouraging service involvement at meetings that do not require extended sobriety time (e.g. helping setup chairs, tables, or coffee). Step-work activity during and following treatment was low; on average, two out of three alcoholics worked no steps during treatment and in the decade following. Formal step-work exercises, a common practice of treatment programs, may require more clinician guidance to increase clients’ understanding of steps worked and their completion. Future studies are warranted to explore the impact of working all 12-steps on behavioral change as well as sequencing of AAH activities in relation to length of time sober.

ACKNOWLEDGEMENTS
We would like to thank Stefan Padfield for his helpful comments regarding this manuscript.The authors acknowledge that the reported results are, in whole or in part, based on analyses of the Project MATCH Public Data Set and 10-year outcomes collected by an outpatient site in Project MATCH.These data were collected as part of a multisite clinical trial of alcoholism treatments, which was supported by a series of grants from NIAAA, and were made available to the authors by the Project MATCH Research Group.This paper was not reviewed or endorsed by the Project MATCH Research Group and does not necessarily represent the opinions of its members, who are not responsible for the contents.
This research was funded in part by a John Templeton Foundation grant awarded to Dr. Pagano, and National Institute on Alcohol Abuse and Alcoholism (NIAAA) grants awarded to Drs. Pagano (K01 AA015137), Stout and Kelly (R21 AA016762), and Tonigan (K02 AA00326).

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