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Addiction Research and Theory
June 2010; 18(3): 316–325
Assessing why substance use disorder patients drop out
from or refuse to attend 12-step mutual-help groups:
The ‘‘REASONS’’ questionnaire
JOHN F. KELLY
1
, CHRISTOPHER W. KAHLER
2
,&
KEITH HUMPHREYS
3
1
Department of Psychiatry, MGH Center for Addiction Medicine, 60 Staniford Street, Boston
02114, USA,
2
Brown University Center for Alcohol and Addiction Studies, Brown University,
Providence, USA, and
3
VA Palo Alto Health Care System and Stanford University School of
Medicine, Stanford University, Palo Alto, USA
(Received 16 March 2009; revised 21 May 2009; accepted 1 August 2009)
Abstract
Substance use disorder (SUD) patients who become involved in 12-step mutual-help groups (MHGs),
such as Alcoholics Anonymous, experience better outcomes and have reduced healthcare costs.
In spite of this, many do not attend at all and other initial attendees drop out. Reasons for non-
attendance and dropout have not been systematically studied, yet such knowledge could enhance the
efficiency of twelve-step facilitation (TSF) efforts or help clinicians decide which patients might prefer
non-12-step MHGs (e.g., SMART Recovery). This study developed and tested a measure of reasons
for non-participation and dropout from 12-step MHGs. Items were generated and clustered into eight
domains using a rational keying approach. Male veterans (N¼60; M age ¼49; 41% African American)
undergoing SUD treatment were asked to complete a brief assessment about prior MHG experiences.
Psychometric analyses produced a 24-item measure containing seven internally consistent, face-valid,
subscales. Co-morbid psychiatric issues and, to a lesser degree, spiritual concerns, were found to be
particularly important dimensions relating to this phenomenon. The measure could serve as a useful
screening tool for barriers to 12-step participation and subsequently focus TSF efforts or inform
referral to non-12 step MHGs.
Keywords: Alcoholics Anonymous, self-help, groups, mutual-help, addiction, substance abuse
Correspondence: John F. Kelly, Center for Addiction Medicine, Department of Psychiatry, Massachusetts General Hospital,
60 Staniford St. Suite 120, Boston, MA 02114, USA. Tel: 617-643-1980. Fax: 617-643-1998. E-mail: jkelly11@partners.org
This article is not subject to U.S. copyright law.
ISSN 1606-6359 print/ISSN 1476-7392 online ß2010 Informa Healthcare Ltd.
DOI: 10.3109/16066350903254775
Participation in 12-step mutual-help groups (MHGs), such as Alcoholics Anonymous (AA)
or Narcotics Anonymous (NA), is associated with remission of substance use disorders
(SUDs), improvements in psychosocial functioning, and decreased health care costs
through reducing patients’ reliance on professional services (e.g., Emrick et al. 1993;
Tonigan 1996; Timko et al. 2000; Humphreys and Moos 2001, 2007; Gossop 2003,
2007; Kissin et al. 2003; Humphreys 2004; Moos and Moos 2004, 2007; Kelly et al. 2008a;
Kelly and Yeterian, 2008a). As these freely available community resources also appear
helpful to many different types of patients (Winzelberg and Humphreys 1999; Kelly et al.
2006; Timko 2006), their use is advocated by clinical practice guidelines of prominent
addiction and mental health focused organizations (e.g., Institute of Medicine 1998;
Veterans Health Administration 2001; American Psychiatric Association 2006) and the vast
majority of individuals treated in the private and public sectors are referred to
12-step MHGs (Humphreys 1997; Roman and Blum 1998; Laudet and White 2005;
Kelly et al. 2008c).
Yet many patients referred to 12-step MHGs do not attend at all and many quickly
discontinue (Godlaski et al. 1997; Kelly and Moos 2003; Tonigan et al. 2003; Kelly et al.
2008a). Given that patients typically undergo several treatment episodes with subsequent
periods of AA/NA participation and discontinuation during their addiction careers (Moos
and Moos 2004; Dennis et al. 2005), by the time they arrive back in some kind of formal
treatment they often have tried AA or other MHGs and discontinued at some point. Because
a common proximal outcome goal of most treatment programs is to have patients reengage
with community MHGs (Humphreys 1997; Kelly et al. 2008c) greater understanding of the
reasons why patients discontinue or never attended would help target MHG facilitation
efforts more efficiently.
Social dynamic forces inherent within groups are likely to present challenges to some
12-step MHG initiates (Sherif and Sherif 1956; Wheelan 1994; Wheelan et al. 2003; Yalom
and Leszcz 2005). A member’s comfort with self-disclosure may vary with the extent of that
individual’s perceived similarity to existing group members in attributes and behavior. From
a group therapy theory perspective, this perceived degree of ‘‘universality’’ (Yalom and
Leszcz 2005) should either strengthen trust and lower resistance, leading to a higher
likelihood of continuing attendance, or exacerbate resistance and diminish trust leading to
dropout. Some members may resist certain 12-step specific group norms and/or perceive
member attributes and behaviors as socially incongruent (Bonney and Foley 1963). For
example, although mostly anecdotal, some frequently cited reasons for discontinuation
include opposition to the spiritual emphasis of 12-step MHGs, repetitiveness of content,
dislike of group meeting formats or other members’ behavior or attitudes, too rigid an
emphasis on abstinence from all substances, and lack of support for, or explicit opposition
to, the use of general psychotropic or addiction specific anti-craving/anti-relapse medications
and negative reactions to the discussion of additional psychiatric concerns (Buxton et al.
1987; Rychtarik et al. 2000; Fletcher 2001; Humphreys 2004; Tonigan and Kelly 2004;
Kelly et al. 2008b; Kelly and Yeterian 2008a). Reasons for discontinuation have lacked
systematic empirical attention. To facilitate a more efficient and systematic way of capturing
such clinically useful information regarding the important reasons why many patients
discontinue AA/NA participation, we sought to develop a brief, psychometrically sound,
twelve-step facilitation (TSF) screening tool with clinical utility. Here we describe the
development of this measure and provide preliminary data regarding its psychometric
properties of reliability, scale independence, and factor structure.
Assessing AA dropout 317
Method
Participants and procedure
The sample for this study comprised sixty, male veterans (Mage ¼49; 41% African
American) entering VA SUD treatment in the Palo Alto area of California. Sixty-eight
patients entering treatment were approached and invited to participate in a brief assessment
interview regarding their prior 12-step attendance and experiences and reasons for non-
participation in, or discontinuation of, MHGs, such as AA. Eight individuals declined to
participate citing lack of time as the main barrier. Participants were paid $20 in compensation
for their time. Patients were asked if they had ever attended 12-step MHGs and if so,
whether they had ever stopped attending for a period of 90 days or longer. All patients
reported attending 12-step meetings at some point in their lives and 95% reported stopping
attendance for a period of 3 months or more. The number of months that patients had
attended 12-step groups prior to stopping varied widely and was positively skewed
(median ¼9; interquartile range ¼16; M¼20, SD ¼30; range 1–132). As part of the
assessment patients were also asked to fill out the Rationales, Explanations, and Summaries
of Non-Attendance at Self-help (REASONS) Questionnaire. Patients were eligible if they
met an ICD-10 diagnosis for SUD and were between the ages of 18 and 65. Exclusion
criteria were current suicidal or homicidal intent, organic impairment, or active psychotic
symptoms. The study was reviewed and approved by the Stanford University Institutional
Review Board (IRB) for the protection of human subjects.
Measures
Instrument constr uction. Items for the REASONS assessment tool were generated and
clustered into eight domains using a rational keying approach based on empirical literature,
clinical expertise, and consultation. An additional informal focus group was held with
addiction clinicians (n¼11) from the Palo Alto, VA Addiction Treatment Services (ATS)
during a staff meeting to discuss and review the constructed items to maximize content
validity and comprehensiveness. Items were constructed from the following commonly
cited potential barriers to 12-step MHG participation: motivation/no perceived need
(e.g., ‘‘I wasn’t that bad in my addiction that I needed to attend’’), spiritual concerns
(e.g., ‘‘The religious/spiritual content of 12-step meetings bothered me’’), social anx-
iety (e.g., ‘‘I feel nervous around people’’), logistics of attending (e.g., ‘‘I didn’t have a car
so getting to meetings was difficult’’), dislike of members (e.g., ‘‘People at meetings were
too uptight or rigid’’), dislike of meeting content and/or format (e.g., ‘‘I didn’t like
hearing the same stories over and over’’), illness (e.g., ‘‘I become too medically ill’’), and
discomfort discussing co-morbid psychiatric issues (e.g., ‘‘People at meetings didn’t like me
talking about my other psychiatric problems’’). The 30 initial items were presented
in the same random order for all study participants. All responses to the items were rated
on a 7-point scale (0–6) with three descriptive anchors given for 0 (‘‘Not at all’’),
3 (‘‘Somewhat’’) and 6 (‘‘A lot’’). The following instructions were provided on the top
of the questionnaire:
Below are some reasons why people do not attend or stop attending 12-step self-help groups.
Please rate with the scale on the right the degree to which each of the reasons applies to you.
318 J. F. Kelly et al.
Analysis plan
Given that our long-term goal is to develop a tool that is both clinically useful and that can be
useful for future research purposes, we employed a psychometric as well as a descriptive
approach. As a first step, we calculated Cronbach’s alpha (i.e. internal consistency) for each
of the eight subscales of the REASONS assessment tool. We required the alpha level to
exceed 0.60. If the presence of any one item on a scale was detracting from the internal
consistency of that scale, the item was removed. Otherwise, if the removal of items did not
yield an acceptable alpha, we considered the scale to be unreliable and dropped it from
further consideration. We examined also the relationship between the length of attendance
prior to discontinuing 12-step MHG participation and each subscale to determine whether
reasons differed significantly along this dimension. We then examined the correlations
among the scales. In order to determine the underlying empirical structure of the measure
and whether scales could be combined meaningfully into a higher order total score, we
conducted an exploratory factor analysis using a robust principal axis factoring extraction
procedure and oblique rotation method (Promax). The latter allows for correlations among
factors, and conform to ‘‘best practice’’ methods in factor analysis for psychosocial research
(Costello and Osborne 2005).
Results
Analyses with all 30 original items within the 8 subscales revealed adequate initial internal
consistencies for five of eight subscales using a cutoff criterion of 0.60. Further analysis of
the item-total statistics revealed two items detracting from alpha in the motivation/no
perceived need subscale, which were removed and the new subscale alphas were
re-computed. This changed the alpha from 0.53 to a more satisfactory 0.67. Similarly,
the dislike of meeting content/format subscale was re-computed after removing a poorly
performing item increasing the internal consistency estimate from 0.54 to 0.74. The medical
illness subscale performed poorly, did not meet the threshold inclusion criterion (¼0.44)
and was subsequently dropped. The average alpha across the seven retained subscales was
0.77 (range ¼0.67–0.86). The 24 retained items and subscales along with their means and
standard deviations and alphas can be seen in Table I. Shown in the last column of Table I is
the correlation between the duration of attendance prior to discontinuation and each
subscale. We did not observe any significant associations between the particular reasons for
discontinuation and length of time participants had attended, with the exception of the
‘‘logistical barriers’’ subscale: patients who had attended longer were significantly less likely
to have dropped out for logistical reasons (r¼0.34, p< 0.001).
Interscale dependence
We examined the inter-correlations among subscales using Pearson product moment
correlations. As shown in Table II, results revealed some moderate interdependence. The
highest degree of overlap was between dislike of other meeting attendees and dislike of
meeting content/format (r¼0.43, p< 0.001). Furthermore, the more the individuals
reported social anxiety as a reason for discontinuation, the more strongly they endorsed
lack of support or discomfort in talking about psychiatric issues as a reason for dropping out
(r¼0.38, p< 0.001).
Assessing AA dropout 319
Table I. Subscales with internal consistency coefficients and items with means and standard deviations.
Scale Items
Item M
(SD)
Scale M
(SD)
Scale internal
consistency ()
Pearson r(Months
attending AA/NA
prior to discontinuation)
Motivation/no
perceived need
I wasn’t that bad in my addiction that I thought I needed to attend 2.3 (2.7) 10.5 (6.6) 0.67 0.13
I wasn’t ready or motivated to change my drinking/drug use 2.8 (2.3)
I thought I could change and do it myself 3.3 (2.3)
I wanted to cut down, but not stop drinking/taking drugs completely 2.1 (2.4)
Dislike of other
meeting
attendees
People at meetings were too rigid about things 2.6 (2.3) 6.8 (6.1) 0.78 0.08
People never spoke to me 1.2 (1.8)
People at meetings were too bossy 2.0 (2.1)
People at 12-step self-help meetings weren’t very friendly 1.3 (1.7)
Spiritual barriers The religious/spiritual content of 12-step meetings bothered me 1.2 (1.9) 3.1 (4.5) 0.73 0.06
I didn’t like the praying at meetings 1.2 (2.1)
I don’t believe in God 0.7 (1.6)
Social anxiety
barriers
I didn’t like having to speak at meetings 2.7 (2.6) 9.9 (7.8) 0.83 15
I don’t like crowds or large groups 2.5 (2.5)
I feel nervous around people 2.4 (2.2)
It was hard to connect with people 2.5 (2.2)
Logistical barriers I didn’t have a car so getting to meetings was difficult 1.5 (2.3) 3.3 (5.3) 0.86 0.34
I didn’t have a drivers license so getting to meetings was hard 0.8 (1.8)
It was a long way to the nearest meeting or a meeting that I liked 1.1 (1.9)
Dislike of meeting
content/format
Meetings were just the same thing over and over again 2.7 (2.3) 7.2 (5.3) 0.74 0.03
I didn’t like hearing the same stories over and over again 2.9 (2.3)
I didn’t like the format of the meetings 1.7 (2.0)
Psychiatric barriers People at meetings weren’t supportive of me taking my medications 0.9 (1.8) 2.9 (4.9) 0.81 0.18
People at meetings didn’t like me talking about my other psychiatric
problems
0.6 (1.5)
I didn’t feel comfortable talking at meetings about my medication
issues and other psychiatric problems
1.4 (2.3)
Note:
p< 0.01
320 J. F. Kelly et al.
Factor structure
We factor analyzed the measure data at the subscale level using principal axis factoring
procedures in SPSS 17.0 with an oblique promax rotation (Castello and Osborne
2005). A Kaiser normalization was also employed to adjust for the influence of
varying communalities (Afifi and Azen 1979; Afifi and Clark 1996). We first conducted
some preliminary tests to examine the suitability of the data for structure detection.
A Kaiser–Meyer–Olkin test of sampling adequacy revealed that 64% of the variance was
attributable to the underlying factors indicating data were suitable for structure detection.
Similarly, a Bartlett’s test of sphericity revealed that variables were significantly related and
suitable for structure detection (
2
¼51.05, p< 0.0001).
We then conducted the factor analysis extraction and rotation. The analysis extracted
two factors with eigenvalues greater than one. The initial solution accounted for 49%
of the variance (32% and 17% for the first and second factors, respectively). The rotated
factor matrix is shown in Table III. The subscale most highly correlated with factor 1
was ‘‘psychiatric barriers’’ (0.82) followed by ‘‘dislike of other meeting attendees’’ (0.44)
and ‘‘social anxiety barriers’’ (0.43), suggesting a ‘‘social-fellowship’’ discontinuation
dimension, whereas the subscale most highly correlated with factor 2 was ‘‘spiritual barriers’’
Table III. Extracted factor loadings.
Rotated factor matrix
a
Factor
12
No perceived need/motivation 0.126 0.403
Dislike of other meeting attendees 0.435 0.328
Spiritual barr iers 0.060 0.538
Social anxiety barriers 0.432 0.123
Logistical barriers 0.292 0.188
Dislike of meeting content/format 0.146 0.413
Psychiatric barriers 0.823 0.262
Note: Extraction method: Principal axis factoring. Rotation method: (Oblique)
Promax with Kaiser normalization. Bolding represents the highest loading on
that factor.
a. Rotation converged in 3 iterations. N¼60.
Table II. Subscale inter-correlation matrix.
Scale 1 2 3 4 5 6 7
1. Motivation/no perceived need –
2. Dislike of other meeting attendees 0.09 –
3. Spiritual barriers 0.15 0.23 –
4. Social anxiety barriers 0.04 0.28
0.33
–
5. Logistical barriers 0.02 0.33
0.26
0.16 –
6. Dislike of meeting content/format 0.16 0.43
0.25 0.14 0.16 –
7. Psychiatric barriers 0.04 0.32
0.03 0.38
0.20 0.21 –
Note:
p< 0.05,
p< 0.01, N¼60.
Assessing AA dropout 321
(0.54), followed by ‘‘dislike of meeting format/content’’ (0.41) and lack of motivation (0.40)
suggesting a potential ‘‘program-content’’ discontinuation dimension. However, within
these broader dimensions, psychiatric barriers (e.g., ‘‘People at meetings weren’t supportive
of me taking my medications’’) appear most strongly associated with the social-fellowship
discontinuation influence, and spiritual concerns (e.g., ‘‘I didn’t like praying at meetings’’)
appear most strongly associated with the program-content dropout influence. Participants’
extracted factor scores were also examined with regard to length of prior 12-step MHG
participation. Correlation estimates were non-significant ( p’s > 0.22), suggesting these
broad influences on dropout could occur at any point during an individuals’ involvement.
Discussion
Findings from these preliminary psychometric analyses of the REASONS questionnaire
revealed a measure consisting of 24 items, clustered into seven internally consistent and
face-valid subscales. The highest average subscale endorsement of the reasons for
discontinuation was ‘‘no perceived need/lack of motivation’’ followed by ‘‘social anxiety
barriers’’. Neither of these seems particular to 12-step groups per se; the same individuals
may well dislike any MHG. In contrast, psychiatric concerns and spirituality do seem
specific to 12-step MHGs. Exploratory factor analysis results suggested that these domains
accounted for much of the variance in the two primary factors underlying self-reported
reasons for dropout. Thus, clinicians may wish to pay particular attention to endorsement to
scores at the high end of these subscales on this screening tool; high scores may be rare but
may be of particular importance. Such patients should be informed of more secular
alternatives to 12-step MHGs, for example SMART Recovery, which may prove a better
fit as a recovery support. Alternatively, if other MHGs are not available in the community,
a knowledgeable clinician may be able to help the patient find meetings within the local
12-step network in which concerns about spiritual and psychiatric issues are less prominent
(Humphreys 2004). Also, dual-diagnosis specific groups (e.g., double trouble in recovery,
dual-diagnosis anonymous) although 12-step-based, may be particularly helpful for those
individuals needing to take medications to manage other psychiatric disorders (Laudet et al.
2000; Magura et al. 2003; Kelly and Yeterian 2008). The internet may be a further resource
as many mutual-help organizations now also have online meetings. These online resources
could serve as an alternative for those unwilling to attend face-to-face meetings or for those
who wish to attend non-spiritually-orientated groups, but who live in communities without
such meetings.
With the exception of logistical barriers, length of attendance prior to discontinuation
did not correlate with specific subscales or extracted factors. This casts doubt on the notion
of temporally related developmental changes in the reasons why individuals discontinue
12-step MHGs; a variety of intrinsic or extrinsic barriers to attendance may manifest at any
time in individuals’ exposure to 12-step MHGs. However, this conclusion is limited by the
fact that the study sample was somewhat restricted in length of attendance with two-thirds
reporting attending 12-step MHGs for less than 12 months, and half the sample reporting
eight months or less of attendance prior to discontinuing. A larger sample that includes
a broader range, including long-term attendees, may reveal temporally related reasons,
including positive reasons, such as the achievement of stable remission and long-term
recovery.
322 J. F. Kelly et al.
The factor analysis suggested two broad dimensions that captured a substantial proportion
of the variance in 12-step MHG discontinuation. These fell along the lines of the two
principal dimensions of 12-step organizations: a social or ‘‘fellowship’’ aspect, and a content
or ‘‘program’’ aspect (Alcoholics Anonymous 1953). However, within these broader
dimensions, psychiatric barriers appear most strongly associated with the social-fellowship
discontinuation influence, and spiritual concerns appear most strongly associated with the
content-program discontinuation influence. Thus, perceptions of others’ lack of support
or discouragement of talking about medication or psychiatric concerns and discomfort
in overt spiritual aspects, such as reciting the Serenity Prayer at the close of meetings, may be
particularly important factors in non-attendance and dropout.
The study findings should be considered in light of important limitations. First, the
sample is relatively small and consisted of all male adult veterans, who typically have severe
addiction problems and often also have comorbid physical and mental health problems.
Thus, generalizations to women, youth, and non-VA populations should be made with
caution. Reasons for discontinuation were constructed rationally based on clinical
experience, common anecdotes, and informal focus group with clinical addiction staff.
There may be other reasons for non-attendance or dropout not captured in our measure.
Importantly, given the cross-sectional design, we do not know how these past reasons for
discontinuation will relate to future 12-step participation.
This study constructed and tested a measure of common reasons for discontinuation from
12-step MHGs. In prior research, we developed and tested a 12-step participation
expectancies questionnaire (TSPEQ) that examined alcohol dependent patients’ beliefs
about participation in AA, which was found to have good psychometric properties and
predictive validity (Kahler et al. 2006). That study supported a single dimension measuring
favorable beliefs about participation. Although this too is a preliminary, and not a conclusive
or definitive examination of the measure or construct, the REASONS questionnaire may
serve as an additional brief and clinically efficient multidimensional tool to screen for
common reasons for dropout that could subsequently form the basis for focused TSF efforts
(e.g., Kahler et al. 2004) or for exploring with patients the growing range of non-12 step
MHGs that are available (Humphreys 2004; Kelly and Yeterian 2008).
Acknowledgment
This study was funded by the Department of Veterans’ Affairs Health Services Research and
Development Department.
Declaration of interest: The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the article.
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