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538 JOURNAL OF STUDIES ON ALCOHOL / JULY 2006
Development and Initial Validation of a 12-Step
Participation Expectancies Questionnaire
CHRISTOPHER W. KAHLER, PH.D.,
†
JOHN F. KELLY, PH.D., DAVID R. STRONG, PH.D.,
†
GREGORY L. STUART, PH.D.,
†
AND RICHARD A. BROWN, PH.D.
†
Center for Alcohol and Addiction Studies, Brown University, Box G-BH, Providence, Rhode Island 02912
Received: August 19, 2005. Revision: November 3, 2005.
†
Correspondence may be addressed to Christopher W. Kahler at the above
address or via email at: Christopher_Kahler@Brown.edu. David R. Strong,
Gregory L. Stuart, and Richard A. Brown are with the Brown Medical School
and Butler Hospital, Providence, RI.
538
ABSTRACT. Objective: There are no available instruments that assess
expectancies for participation in 12-step mutual-help groups despite the
impact such expectancies may have on actual participation. The purpose
of the present study was to develop a measure of attitudes and expect-
ancies regarding 12-step participation, to conduct preliminary analyses
on its psychometric properties, and to explore its concurrent and pre-
dictive validity. Method: Alcohol-dependent patients (N = 48) under-
going inpatient detoxification completed a questionnaire that included
subscales assessing expected benefits of, concerns about, and barriers
to 12-step participation. Participants also completed measures of 12-step
group participation and drinking outcomes at 1, 3, and 6 months fol-
lowing discharge. Results: After examining the internal consistency of
the items within each subscale and refining the questionnaire accord-
ingly, an exploratory factor analysis showed that the scales could be com-
bined into a higher-order total score. This total score correlated signifi-
cantly with prior 12-step experience and goals for attending future
12-step meetings. In addition, the Expectancies Total Score at baseline
significantly predicted 12-step group participation during follow-up.
Conclusions: The measure of attitudes and expectancies regarding 12-
step group participation demonstrated good internal consistency, con-
current validity, and predictive validity. The measure may have clinical
utility in highlighting patients’ expectancies regarding 12-step partici-
pation, allowing treatment providers to explore with patients the ben-
efits, concerns, and barriers to involvement that they have endorsed. (J.
Stud. Alcohol 67: 538-542, 2006)
T
WELVE-STEP MUTUAL-HELP GROUPS, such as
Alcoholics Anonymous (AA) and Narcotics Anony-
mous (NA), are attractive as adjuncts or alternatives to ad-
dictions treatment, because they can be attended free of
charge, are easily accessible, and are widely available in
most communities. Increasing evidence regarding the util-
ity of AA-NA (e.g., Emrick et al., 1993; Kelly, 2003; Timko
et al., 2000; Tonigan et al., 2003) has led to widespread
referrals to such groups (Humphreys, 1997). However, many
patients do not attend at all, and others discontinue atten-
dance after some initial exposure (Kelly and Moos, 2003;
Tonigan et al., 2003). Greater understanding regarding which
patients participate in AA-NA, and why, would inform and
help target efforts to facilitate 12-step involvement. Deci-
sion-making theory suggests that individuals engage in a
conscious appraisal of the benefits and drawbacks associ-
ated with a given course of behavior before engaging in
behavior change (Janis and Mann, 1977). Assessment of
beliefs about potential positive and negative outcomes of
AA-NA participation may enhance predictive precision re-
garding who participates in these fellowships and could pro-
vide valuable clinical information by identifying specific
barriers to participation. However, we are aware of no vali-
dated measures that assess beliefs or attitudes regarding
12-step participation.
AA and NA offer a number of potential benefits that
may influence decisions to participate. For example, these
programs may offer abstinence-specific social support and
may act to maintain motivation for recovery through the
sharing of personal testimony (e.g., Kelly et al., 2000). Sto-
ries of recovery may be uplifting and inspiring for attend-
ees, and participation in 12-step programs may enhance
sober living skills and confidence in staying sober (e.g.,
Morgenstern et al., 1997). AA-NA also may provide a way
of structuring sober time, especially during high-risk peri-
ods such as evenings and weekends. Assessing the degree
to which individual patients perceive these potential ben-
efits of 12-step participation as being likely to occur for
themselves may be of predictive value and clinically may
provide a means of highlighting and reinforcing the ben-
efits of increased mutual-help involvement.
Patients also may perceive 12-step programs in negative
ways. For example, some may dislike the group format of
AA-NA meetings or may perceive meetings as aversive,
causing boredom, embarrassment, or hopelessness. For oth-
ers, barriers may be more logistical such as difficulty ob-
taining transportation. Finally, the explicit spiritual emphasis
of AA-NA may be a concern for some. Assessing these
potential barriers to participation may help clinicians better
understand and manage resistance to engaging in 12-step
mutual-help groups.
KAHLER ET AL. 539
Study aims
The purpose of the present study was to develop a mea-
sure of attitudes pertaining to 12-step participation, to con-
duct preliminary analyses on its psychometric properties,
and to examine its concurrent and predictive validity.
Method
Participants
Participants were 37 men and 11 women recruited from
a private, nonprofit, inpatient detoxification program to par-
ticipate in a randomized clinical trial comparing brief ad-
vice to attend AA-NA with a motivational enhancement
intervention that focused on increasing involvement in 12-
step mutual-help groups (ME-12; Kahler et al., 2004). Al-
cohol-dependent patients ages 18-65 were included.
Exclusion criteria were current suicidal or homicidal intent,
organic impairment, psychotic symptoms or history of psy-
chotic disorder, or use of methadone maintenance. Drug
dependence was diagnosed in 22.9% of participants. The
participants mean (SD) age was 43 (7.4) years, and 50%
had some schooling beyond high school. The sample was
81.2% white, 8.3% black, 6.3% Hispanic/Latino, and 4.2%
of other backgrounds. Participants drank on 65.2% (31.3%)
of days in the 3 months prior to treatment, an average of
23.5 (17.4) drinks per drinking day. The mean on the Alco-
hol Dependence Scale (ADS; Skinner and Allen, 1982) was
23.0 (9.1).
Procedure
Participants were recruited into the study after they had
spent at least 24 hours on the detoxification unit. Research
assistants completed the baseline assessment after obtain-
ing written informed consent. Participants were randomly
assigned to either the brief advice or ME-12 protocol, which
was conducted on the unit. Kahler et al. (2004) provide
complete details of the recruitment procedures and the treat-
ments received. Participants were re-interviewed at 1, 3,
and 6 months; participation rates were 85.4%, 87.5%, and
89.5%, respectively.
At baseline, participants reported the total number of
12-step meetings they had ever attended (sample median =
162 meetings). Lifetime AA-NA involvement was assessed
with five dichotomous items (Tonigan et al., 1996) regard-
ing whether they had ever considered themselves an AA-
NA member (56.2% of the sample); been to 90 meetings in
90 days (39.6%); celebrated an AA-NA sobriety birthday
(31.2%); had a sponsor (50.0%); or had been a sponsor
(16.7%). Following our previous work (Kahler et al., 2004),
attendance and involvement were standardized and summed
to form an AA-NA experience variable. AA-NA attendance
goals were assessed with a single item ranging from every
day or almost every day (n = 20; 42%), four or five times
per week (n = 6; 12.5%), two or three times per week (n =
12; 25%), once per week (n = 3; 6.3%), or monthly or less
(n = 7; 14.6%).
The Timeline Followback interview (TLFB; Sobell and
Sobell, 1996) was used to assess drinking frequency and
quantity for the 90 days prior to study enrollment and at all
follow-up interviews. During the follow-ups, AA-NA at-
tendance data were collected using the TLFB, and percent
days attending AA-NA was calculated for each month. In-
volvement in AA-NA during follow-up was assessed using
the Recovery Interview (Morgenstern et al., 1996).
Twelve-step participation expectancies
Eleven scales were initially constructed using rational
criteria to cover domains that might enhance or detract from
motivation and willingness to be involved in AA or NA.
Four items, all worded in the first person, were constructed
for each scale. Five of these scales focused on expected
benefits of 12-step involvement: social support (items fo-
cus on the positive social aspects of AA-NA), structured
time (items focus on AA-NA meetings providing positive
activity), increased motivation (items focus on AA-NA en-
hancing or maintaining motivation to stay sober), skill learn-
ing (items focus on learning more about how to stay sober),
and positive emotional reactions (items focus on positive
emotional experiences related to AA-NA attendance such
as social acceptance and hope). Three scales assessed po-
tential concerns about 12-step involvement: negative emo-
tional reactions (items focus on negative emotional responses
to attendance), social concerns (items focus on negative
social aspects of AA-NA), and spirituality concerns (items
address concerns about spiritual aspects of AA-NA as well
as reverse-scored potential benefits of spirituality). Two
scales focused on barriers to involvement: program barriers
(items focus on central aspects of the program with which
the participant is uncomfortable or disagrees) and atten-
dance barriers (items focus on access and availability of
meetings and competing commitments). Finally, the social
influences scale assessed the extent to which patients had
received encouragement to attend AA-NA and had heard
positive things about the program from others.
At baseline, the 44 initial items were presented in the
same random order for all participants. All responses to the
items were on a 6-point scale from 1 = strongly disagree to
6 = strongly agree. The top of the questionnaire read: “The
following statements reflect opinions that some people have
about getting involved in Alcoholics Anonymous (AA) or
Narcotics Anonymous (NA). Please indicate how much you
agree with each statement by circling ‘strongly disagree,’
‘disagree,’ ‘tend to disagree,’ ‘tend to agree,’ ‘agree,’ or
‘strongly agree.’”
540 JOURNAL OF STUDIES ON ALCOHOL / JULY 2006
TABLE 1. Internal consistencies, sample means, and standard deviations for each subscale of the 12-Step Participation
Expectancies Questionnaire and its associated items (n = 48)
Subscales and associated items Mean (SD)
Social support (α = .83) 5.0 (0.7)
Going to AA/NA meetings is a good way to meet “sober” friends. 5.1 (0.9)
People at AA/NA could give me a lot of support. 4.9 (0.8)
I don’t think people at AA/NA could be of any help to me.
a
1.9 (0.9)
Getting a sponsor through AA/NA would help me in my recovery. 4.9 (1.1)
Structured time (α = .82) 4.6 (1.0)
Going to AA/NA meetings can help me use some of my free time. 4.5 (1.3)
Going to AA/NA meetings would keep me out of situations where I might be tempted to drink. 4.6 (1.3)
I have much better things to do with my time than go to AA/NA meetings.
a
2.2 (1.2)
Going to AA/NA meetings would give me something to look forward to. 4.5 (1.3)
Increased motivation (α = .82) 4.8 (0.8)
Going to AA/NA meetings would help me remember why I want to stay sober. 5.0 (0.8)
Going to AA/NA meetings would motivate me to stay sober. 5.1 (.0.9)
I would feel inspired to stay sober by seeing people at AA/NA who have been successful. 5.0 (0.8)
Whether or not I go to AA/NA meetings will not affect how I feel about drinking.
a
2.7 (1.6)
Skill learning (α = .80) 4.8 (0.8)
Through AA or NA, I could learn some useful skills to help me stay sober. 4.9 (0.8)
I could learn a lot by working on the Twelve Steps of AA or NA. 5.0 (0.8)
I don’t see how AA or NA could teach me anything new about recovery.
a
2.2 (1.1)
I could learn a lot by hearing about other people’s experiences in getting sober. 4.6 (1.2)
Positive emotional reactions (α = .87) 4.7 (1.0)
I think that AA/NA meetings could be uplifting. 4.7 (1.2)
Being part of AA/NA would make me feel more hopeful. 4.8 (1.1)
I would feel proud to be an AA or NA member. 4.7 (1.2)
Negative emotional reactions (α = .66) 2.8 (1.0)
I would get bored easily at AA/NA meetings. 3.0 (1.5)
I would feel embarrassed going to an AA/NA meeting. 2.0 (1.1)
Going to AA or NA would depress me. 2.9 (1.5)
I would feel very nervous going to an AA/NA meeting. 3.3 (1.7)
Social concerns (α = .64) 2.8 (0.8)
I would not want to speak in front of a group at an AA/NA meeting. 2.4 (1.8)
I would not want people at AA or NA to know about my personal problems. 2.2 (1.5)
I think I would fit in well with most of the people who go to AA/NA.
a
3.7 (0.9)
I do not think I would like the people I meet at AA/NA. 2.7 (1.1)
I don’t want people at AA or NA telling me how I should lead my life. 3.4 (1.7)
I don’t want to hear other people talk about their problems at AA/NA meetings. 3.2 (1.2)
Spirituality concerns (α = .66) 2.5 (1.0)
I like that AA and NA are “spiritual” programs.
a
4.5 (1.4)
I feel very uncomfortable with the religious (or spiritual) aspects of AA/NA. 2.4 (1.4)
In AA/NA meetings, there’s too much talk about spirituality and “Higher Powers” for me. 3.4 (1.7)
I think that prayer or meditation could be very helpful in my recovery.
a
5.2 (1.0)
Attendance barriers (α = .60) 2.3 (0.9)
I don’t have enough time to attend AA/NA meetings. 2.2 (1.0)
There are plenty of AA/NA meetings in my area that I could go to.
a
5.1 (0.9)
It would be hard for me to get transportation to AA/NA meetings. 2.8 (1.6)
Social influences (α = .70) 4.7 (1.0)
Many people have encouraged me to go to AA or NA. 4.8 (1.3)
I don’t know many people who were helped by AA or NA.
a
2.2 (1.2)
I know a number of people who really like the AA/NA program. 4.7 (1.4)
Total expectancies score (the mean of subscales with reverse scoring for negative scales) 4.6 (0.7)
Notes: Response options for the items range from 1 = strongly disagree to 6 = strongly agree.
a
Item is reverse scored when
creating the subscale mean.
Analysis
As a first step in the analysis, we calculated Cronbach’s
alpha (i.e., internal consistency) for each subscale of the
12-step participation expectancies measure. We required α
to exceed .60. If the presence of any one item on a scale
was detracting from the internal consistency of that scale,
the item was removed. If the removal of one item did not
yield an acceptable alpha, we considered the scale unreli-
able and dropped it from further consideration. We then
examined the correlations among the scales and conducted
an exploratory principal axis common factor analysis to
determine whether the scales could be combined meaning-
fully into a higher-order total score. To assess concurrent
validity, we correlated the scales with AA-NA experience
and goals for AA-NA attendance. For predictive validity,
we tested the measure’s ability to predict both AA-NA at-
tendance and involvement after discharge.
KAHLER ET AL. 541
Results
Internal consistency analyses revealed that two scales
had alphas below the desired cut-off: social concerns (α =
.53) and program barriers (α = .33). Within program barri-
ers, two items focused on social aspects of the program.
Given the scale’s low alpha, we combined these two so-
cially focused items with the social concerns items. For
this revised six-item social concerns subscale, α = .64 with
no item detracting from internal consistency.
Three scales had one item that detracted from the scale’s
alpha but had adequate internal consistency when that one
item was removed. The remaining six four-item scales all
had adequate internal consistency, with α ranging from .66
to .83. Each retained item, along with its mean and stan-
dard deviation, are presented Table 1, along with the means,
standard deviations, and alphas for each subscale. Partici-
pants, on average, tended to agree or agreed with positive
aspects of AA-NA and tended to disagree or disagreed with
negative aspects.
The correlations among the subscales are presented in
Table 2. The five scales tapping potential benefits of 12-
step participation were highly positively correlated with each
other and with the social influences scale. The three scales
measuring negative aspects of 12-step participation were
negatively correlated with the benefit-related scales and posi-
tively correlated with each other and with the attendance
barriers scale. All but four correlations among subscales
were significant, with three of those four involving spiritu-
ality concerns.
Results of a principal factors analysis of the 10 subscales
indicated a very strong unidimensional structure account-
ing for 83.8% of the common variance with an eigenvalue
of 5.25. The second factor had an eigenvalue of only 0.51.
The smallest loadings on the first factor in absolute terms
were for spirituality concerns (-0.45) and social influences
(0.54), and the largest were for social support (0.90) and
positive emotional reactions (0.89). Based on these results,
we created a 12-step participation expectancies total score
by reverse scoring the negative emotional reactions, social
concerns, spirituality concerns, and attendance barriers scales
and taking the mean of all 10 subscales (mean = 4.6 [0.7]).
Correlations between this composite score and each subscale
are presented in Table 2.
Validity analyses
As shown in the bottom of Table 2, most subscales and
the composite score showed modest correlations with AA-
NA experience, with 7 of 11 being significant. All correla-
tions but one with AA-NA attendance goals were larger
than .35 and significant at p < .01.
We used mixed model analyses to test the effect of 12-
step participation expectancies on AA-NA attendance over
time, with a square-root transformation to correct positive
skewness. Percent days attending AA-NA ranged from 41.2
(38.0) in Month 1 to 29.4 (34.7) in Month 6. We included
in the analysis the 45 participants who provided at least 4
months of outcome data and examined only the 12-step
expectancies total score given that testing the effects of
each subscale would inflate risk of Type I error. The main
effect of expectancies on AA-NA attendance was signifi-
cant (B = 1.81, SE = 0.59, p = .004), and the Expectancies
× Time interaction was nonsignificant (p > .80), indicating
that expectancies predicted the overall level of attendance
during follow-up but not changes in attendance over time.
Expectancies also significantly predicted AA-NA involve-
ment as measured by the Recovery Interview (B = 0.47, SE
= 0.20, p = .02). The total expectancies score did not pre-
dict either percent days abstinent or drinks per drinking
day during follow-up, all p > .70.
TABLE 2. Correlations among 12-step participation expectancies subscales (n = 48)
Measure 1 2 3 4567 891011
1. Social support .–
2. Structured time .73 .–
3. Increased motivation .79 .74 .–
4. Skill learning .58 .58 .67 .–
5. Positive emotional reactions .86 .75 .74 .51 .–
6. Negative emotional reactions -.53 -.39 -.46 -.35 -.56 .–
7. Social concerns -.64 -.68 -.61 -.60 -.73 .57 .–
8. Spirituality concerns -.23 -.36 -.51 -.36 -.32 .26 .32 .–
9. Attendance barriers -.48 -.41 -.41 -.31 -.39 .29 .47 .33 .–
10. Social influences .57 .34 .45 .35 .54 -.31 -.25 -.17 -.44 .–
11. 12-step expectancies total score .87 .82 .87 .73 .89 -.66 -.79 -.53 -.52 .60 .–
Concurrent measures
Prior AA-NA experience .32 .39 .41 .28 .40 -.17 -.24 -.35 -.45 .27 .42
AA-NA attendance goals .59 .58 .53 .27 .74 -.37 -.46 -.36 -.39 .45 .65
Note: Correlations greater than .28 or less than -.28 are significant at p < .05.
542 JOURNAL OF STUDIES ON ALCOHOL / JULY 2006
Discussion
This study represents a first step in developing a mea-
sure of attitudes and expectancies regarding participation
in mutual-help groups, the 12-Step Participation Expectan-
cies Questionnaire (TSPEQ). Our findings suggest that the
TSPEQ may be a useful assessment tool. Subscales for a
variety of expected benefits and barriers as well as expected
concerns and social incentives to 12-step participation were
found to be internally consistent. Factor analyses indicated
that subscales loaded on a higher order attitudinal disposi-
tion toward 12-step participation rather than to a larger num-
ber of dimensions, suggesting that a more brief assessment
of attitudes toward AA-NA involvement may be feasible.
Aggregating the subscales produced a total score that had
good concurrent and predictive validity. However, factor
analyses on the item level could not be conducted given
the small sample. Such analyses may identify whether ad-
ditional dimensions exist within the TSPEQ and whether a
higher-order structure is supported in which items load on
specific subscales, which in turn load on a single factor.
The sample used in this initial study was limited to pa-
tients in alcohol detoxification who were participating in a
clinical trial. Patients reported relatively high levels of in-
tention to participate in AA-NA. A sample with greater
diversity of intentions might increase variability in responses
and reduce potential ceiling or floor effects. Although the
TSPEQ is relatively comprehensive, the measure did not
contain items addressing medication usage. There may be
explicit or implicit opposition to the use of general psycho-
tropic or anti-relapse/craving medications in 12-step fel-
lowships (Tonigan and Kelly, 2004). In future work, we
plan to develop an additional scale to assess whether indi-
viduals believe that AA-NA members will disapprove of
their use of psychotropic medication. It also would be useful
to examine patient characteristics that predict attitudes to-
ward 12-step participation and changes in attitudes toward
12-step participation over time.
The TSPEQ developed in this study was designed to
survey common attitudes that patients with alcohol depen-
dence may have about participating in 12-step mutual-help
groups. In addition to providing a global index of patients’
attitudes toward such groups, the TSPEQ can provide po-
tentially useful information regarding specific facilitators
and barriers to AA-NA participation that can be discussed
when patients are considering 12-step mutual-help group
involvement. Better understanding of specific factors af-
fecting attitudes toward 12-step participation ultimately may
help guide clinical practice. At a minimum, the assessment
of expectancies for 12-step participation may provide a rela-
tively robust predictor of the level of future participation.
Future research that builds upon this initial work can help
to refine further a psychometrically sound assessment of
attitudes regarding AA-NA involvement.
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