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Substance Abuse
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Alcoholics Anonymous Science Update: Introduction to
the Special Issue
John F. Kelly PhD a
a Center for Addiction Medicine, Massachusetts General Hospital and Harvard Medical
School, Boston, Massachusetts, USA
Accepted author version posted online: 22 May 2012.Version of record first published: 17 Jan
2013.
To cite this article: John F. Kelly PhD (2013): Alcoholics Anonymous Science Update: Introduction to the Special Issue,
Substance Abuse, 34:1, 1-3
To link to this article: http://dx.doi.org/10.1080/08897077.2012.691447
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SUBSTANCE ABUSE, 34: 1–3, 2013
Copyright C
Taylor & Francis Group, LLC
ISSN: 0889-7077 print / 1547-0164 online
DOI: 10.1080/08897077.2012.691447
INTRODUCTION
Alcoholics Anonymous Science Update:
Introduction to the Special Issue
John F. Kelly, PhD
Center for Addiction Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
In most developed nations, alarming increases in the prodi-
gious economic, social, and medical burden attributable to
alcohol and other drug misuse has opened the door for greater
coordination among formal and informal intervention and
support services to help reduce harm, curb health care costs,
and enhance long-term recovery (1–5). Significant increases
in the quantity and quality of professional addiction treat-
ment options has been welcome. In addition, there have been
parallel increases in the emergence and spread of addic-
tion mutual-help organizations (6–8). The most ubiquitous
of these is Alcoholics Anonymous (AA).
In the United States, AA is the most commonly sought
source of help for alcohol-related problems (9–11). In 1990,
AA’s increasing reach and influence led to a call from the
Institute of Medicine of the National Academy of Sciences
for more research on AA and its mechanisms (12). Legit-
imizing serious scientific investigation into the public health
significance of AA and how it works, and underwritten by ap-
propriations through the National Institutes of Health and the
Department of Veterans Affairs, the ensuing 20-year period
witnessed an explosion of investigations on the effectiveness,
efficacy, health care cost offset potential, and mechanisms of
behavior change within AA that attracted some of the addic-
tion fields’ top research teams.
In terms of its verifiable impact, hundreds of published
studies have supported the beneficial effects of AA in help-
ing alleviate alcohol and other drug problems. This body of
scientific literature has been summarized in narrative reviews
as well as quantitatively, through rigorous meta-analyses (6,
13–19). AA has been shown to be associated with producing
and maintaining salutary changes in alcohol and other drug
use that are on par with professional interventions while si-
Correspondence should be addressed to John F. Kelly, PhD, Cen-
ter for Addiction Medicine, Massachusetts General Hospital and Harvard
Medical School, 60 Staniford Street, Boston, MA 02114, USA. E-mail:
jkelly11@partners.org
multaneously reducing reliance on professional services and
thus lowering related health care costs (6, 20–22).
The most recent areas of investigation have been in exam-
ining AA’s mechanisms of behavior change as well as poten-
tial moderators. That is to say, research has been conducted
into determining how exactly AA aids addiction recovery
and whether particular subgroups benefit more or less from
AA (23, 24). It is striking to note that one of the most prolific
and advanced areas for understanding mechanisms of behav-
ior change through which interventions produce beneficial
effects has been in the area of mutual help. Several of the
most prominent of these research teams present their work
here.
Some of the highlights of this special issue include up-
dates on novel mechanisms and potential moderators of AA’s
effects; analyses of whether commonly prescribed AA activ-
ities, such as regular meeting attendance, sponsorship, and
reading and meditation result in increased benefits; and long-
term 7- and 10-year follow-ups examining relations between
AA participation and alcohol and other drug use outcomes
among adolescent and adult samples following treatment.
Dr. Daniel Blonigan and colleagues provide results from
a unique and highly innovative examination of the role of
impulsivity as a mechanism of behavior change in AA. Par-
ticularly intriguing about their contribution is their focus
on understanding whether the mechanisms through which
AA helps individuals recover differ depending on particular
patients’ characteristics (i.e., moderated mediation). Their
finding that AA may lead to improved outcomes through
reductions in impulsivity, but only among young adults, un-
derscores the reality that there are likely many pathways to
recovery even within the same organization.
A further study of the mechanisms of behavior change
mobilized by AA participation is presented by Dr. Scott
Tonigan and colleagues. Their investigation is important in
several ways. The sample is quite novel, since they included
only new AA affiliates with less than 16 weeks of prior life-
time AA participation and recruited these individuals from
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2SUBSTANCE ABUSE
the community, from AA clubhouses, as well as from the
more usual treatment settings. It also examines the effect
of AA participation on the character trait of “selfishness,”
which according to AA is purported to be the most high-risk
personality trait, which if not attenuated, will inevitably lead
to relapse (25). The study found that compared with a large
general population sample, the sample of AA attendees was
substantially higher on selfishness. The sophisticated media-
tional analyses, however, did not find support for AA-related
reductions in this trait and therefore it was not found to
be the mechanism through which AA led to better alcohol
outcomes. The authors are careful to place their findings in
the broader context and note that the measures used in their
study may not be optimal in validly assessing this potentially
important construct. These provocative findings provide im-
portant data that should stimulate the development and use
of more refined measurement to investigate this hypothesis
further.
Dr. Amy Krentzman and colleagues tackle the intriguing
issue of spirituality as a mechanism of behavior change in
AA using a sophisticated fully lagged prospective design. Of
note, the authors provide a thorough critical analysis of prior
work in this area, placing their own work within this broader
picture. They also examine the effects of active AA involve-
ment in addition to AA attendance on 6 different facets of
spirituality and 2 drinking outcomes (percent days abstinent
and drinks per drinking day). Employing state-of-the-art mul-
tiple mediator analyses, they carefully unravel some of the
complexities and find support for a distinct spiritual pathway
through which AA participation leads to better outcomes.
Their sensitivity to important nuances in this area offers sev-
eral compelling additional hypotheses to be tested in future
work.
Felicia Chi and colleagues and Matthew Worley and col-
leagues each provide quite different examples of the influ-
ence of psychiatric comorbidity on the derived benefits from
AA. First, Chi and colleagues provide results from an unusu-
ally long 7-year follow-up of a diverse adolescent treatment
sample examining whether, compared with youth suffering
from substance use disorder (SUD) only, youth suffering
from both SUD and a comorbid psychiatric condition par-
ticipate as much in 12-step groups and derive equal benefit.
Across the follow-up period, adolescents in the comorbid
group attended more 12-step meetings and were more ac-
tive in these organizations at 1- and 3-year follow-ups; the
groups were equivalent at the 5- and 7-year follow-ups. Also,
the comorbid group attendees were found to benefit as much
from 12-step mutual-help group meetings as those with SUD
only. Among 12-step attendees in either group, abstinence
rates were at least 3 times higher than nonattendees, high-
lighting the potential recovery-related benefits that might be
obtained from these resources by young people across the
challenging transitional life stage of young adulthood where
support for abstinence and recovery may be lower than at any
other time in the adult life span (26).
Matthew Worley and colleagues provide results from an
18-month investigation of 12-step meeting attendance and
affiliation, and their effects on alcohol and other drug use out-
comes in a sample of veterans with comorbid substance de-
pendence and major depression initially assigned to receive
6 months of either a group-delivered Twelve-Step Facilita-
tion (TSF) intervention or an integrated cognitive-behavioral
treatment (ICBT) intervention. In keeping with other studies
examining TSF interventions (e.g., Tonigan et al. 27), those
participants assigned to TSF had greater community 12-step
meeting attendance and involvement during treatment. How-
ever, this declined following the withdrawal of the TSF inter-
vention. Also, similar to other study findings, greater 12-step
participation was associated with better outcomes indepen-
dent of treatment group. In terms of treatment main effects,
although there were not differences between treatment con-
ditions on drug use outcomes, patients assigned to the TSF
condition has significantly worse alcohol use outcomes over
time. Further analyses indicated that the greater relative in-
creases in alcohol use for the TSF patients were mediated
by their greater relative decreases in 12-step participation.
These findings provide valuable information on potentially
important moderators of the benefits derived from both TSF
interventions and community 12-step meeting participation.
Specifically, as found in prior work with individuals with
psychotic spectrum illness and among other samples of mili-
tary veterans (28), the presence of major depressive disorder
(MDD) in addition to substance dependence may attenuate
12-step related benefits for this important population.
In a rare long-term follow-up, Dr. Maria Pagano and col-
leagues present 10-year alcohol use outcomes in relation
to AA attendance, AA helping (AAH), and working AA’s
12 steps. Using data from the New Mexico subsample of
outpatients initially participating in Project MATCH—a ran-
domized controlled trial in which patients were randomly
assigned to receive either individually delivered cognitive-
behavioral therapy (CBT), motivational enhancement ther-
apy (MET), or Twelve-Step Facilitation (TSF) therapy, the
authors found that, overall, AA meeting attendance, AA help-
ing, and working AA’s 12 steps was apparent in only a mi-
nority of participants. However, in keeping with prior reports
showing that clinicians can make a difference in the like-
lihood of patients’ AA engagement, patients receiving the
Project MATCH TSF treatment showed more AA attendance
and greater AA involvement. The well-controlled prospec-
tive analyses conducted by Pagano and colleagues found
support for significant beneficial effects from AA meeting
attendance and AA-related helping on drinking outcomes
over the 10-year period. The sophisticated prospective de-
sign and analyses covering such a long time frame adds valu-
able information to our understanding of the clinical course
for those suffering from alcohol use disorder in relation to
12-step activities.
Finally, Dr. Sarah Zemore and colleagues tackle the highly
practical issue of which particular 12-step activities, such as
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INTRODUCTION 3
having and using an AA sponsor, having more 12-step mem-
bers among your friends, and reading AA literature, impact
outcomes and therefore might be more strongly prescribed
in professionally delivered TSF interventions. Using the data
from the MAAEZ intervention study (29), the authors found
that whereas some 12-step activity variables were associated
with outcomes at various follow-up points, it was only AA
meeting attendance and using an AA sponsor that consis-
tently predicted better outcomes over the 12-month follow-
up period. These findings highlight the importance of both
AA meeting attendance and the close social relationship,
oversight, and accountability that a sponsor may provide
for many seeking recovery. Findings raise further questions
about whether certain other types of 12-step activities may
have critical periods of influence (e.g., reading AA litera-
ture may be important early on to increase basic knowledge,
understanding, and acceptance) exerting more or less effect
depending on when in the recovery process such activities are
performed.
Collectively, this special issue contains a unique collection
of complementary papers examining both controversial and
novel mechanisms and moderators of behavior change within
AA as well as long-term prospective analysis regarding how
AA may foster enduring recovery among both adolescents
and adults. The result is an intriguing and provocative set
of findings that is sure to stimulate debate and inform novel
areas for investigation.
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