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Development and Initial Validation of a 12-Step Participation Expectancies Questionnaire

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Abstract

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 expectancies regarding 12-step participation, to conduct preliminary analyses on its psychometric properties, and to explore its concurrent and predictive validity. Alcohol-dependent patients (N=48) undergoing 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 following discharge. After examining the internal consistency of the items within each subscale and refining the questionnaire accordingly, an exploratory factor analysis showed that the scales could be combined into a higher-order total score. This total score correlated significantly 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. The measure of attitudes and expectancies regarding 12-step group participation demonstrated good internal consistency, concurrent validity, and predictive validity. The measure may have clinical utility in highlighting patients' expectancies regarding 12-step participation, allowing treatment providers to explore with patients the benefits, concerns, and barriers to involvement that they have endorsed.
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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... Despite these encouraging results and the generally high frequency of referrals to AA/NA by youth treatment programs (Brown, 2004;Drug Strategies, 2003;Kelly, Yeterian, & Myers, 2008), the assessment of patient expectancies and motivation prior to beginning TS or mutual help group treatment is rare (Kahler, Kelly, Strong, Stuart, & Brown, 2006). Although the Downloaded by [Johns Hopkins University] at 09:23 17 August 2015 outpatient SUD treatment that study participants underwent in this study did not include a TS treatment component, study participants were educated on and encouraged to attend such programs and were assessed on their experiences/attendance/expectations regarding TS MHO participation at each time point. ...
... Participants separately rated the importance of not drinking and using drugs in the next 90 days on a scale from 1 (not important) to 10 (very important) at baseline, 6-month, and 12-month assessment points. Additionally, participants' TS expectancies were assessed at each time point using two subscales from the Twelve-Step Participation Expectancies Questionnaire (T-SEQ; Kahler et al., 2006). We used two subscales from this measure; TS motivation (TS-Motivation; focused on AA/NA enhancing or maintaining motivation to stay sober) and positive emotional reactions to TS treatment (TS-Positive emotions; focused on positive emotional experiences related to AA/NA attendance such as social acceptance and hope). ...
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Conduct disorder (CD) commonly co-occurs among adolescents with substance use disorder (SUD) and complicates the clinical course of SUD. Although research has begun to investigate CD's impact on adolescent response to SUD treatment, comparatively little is known about the effects of outpatient SUD treatment on this population. This study examined how co-occurring CD influences SUD treatment response as well as longer-term outcomes. Adolescent outpatients (N = 126; M age = 16.7, 25% female) with (i.e., SUD-CD; n = 52), and without CD (SUD-only; n = 74), were compared at baseline. Multilevel mixed models tested group effects on percent days abstinent (PDA) and other clinical and continuing care variables during and following treatment at 6 and 12 months. At baseline, SUD-CD participants had significantly greater psychiatric symptoms, substance use consequences, problem severity, and comorbid internalizing disorders. Both groups changed similarly on measured variables during treatment; however, the sample overall showed increases in PDA and drops in psychiatric symptoms. Following treatment, there were no differences in PDA between groups (p = .44). Both groups showed lower rates of psychiatric symptoms and arrests in the year following treatment, though SUD-CD still reported more psychiatric symptoms (p = .01) and higher inpatient (p = .02) and outpatient treatment (p = .04) utilization than SUD-only. SUD-CD patients may require a more psychiatrically integrated treatment approach during outpatient SUD treatment and more assertive and aggressive continuing care to reduce psychiatric distress, decrease the risk of further hospitalizations, and increase quality of life.
... Twelve-step expectancies questionnaire (TSEQ): The TSEQ (Kahler et al., 2006) examines attitudes and expectancies about participating in 12-step groups. The intentions to attend 12-step variable was a single reverse-coded item included in the twelve step expectancies questionnaire, stating "I do not want to go to any AA or NA meetings." ...
Article
Background Opioid misuse and dependence rates among emerging adults have increased substantially. While office-based opioid treatments (e.g., buprenorphine/naloxone) have shown overall efficacy, discontinuation rates among emerging adults are high. Abstinence-based residential treatment may serve as a viable alternative, but has seldom been investigated in this age group Methods Emerging adults attending 12-step-oriented residential treatment (N = 292; 18-24yrs, 74% Male, 95% White) were classified into opioid dependent (OD; 25%), opioid misuse (OM; 20%), and no opiate use (NO; 55%) groups. Paired t-tests and ANOVAs tested baseline differences and whether groups differed in their during-treatment response. Longitudinal multilevel models tested whether groups differed on substance use outcomes and treatment utilization during the year following the index treatment episode Results Despite a more severe clinical profile at baseline among OD, all groups experienced similar during-treatment increases on therapeutic targets (e.g., abstinence self-efficacy), while OD showed a greater decline in psychiatric symptoms. During follow-up relative to OM, both NO and OD had significantly greater Percent Days Abstinent, and significantly less cannabis use. OD attended significantly more outpatient treatment sessions than OM or NO; 29% of OD was completely abstinent at 12-month follow-up Conclusions Findings here suggest residential treatment may be helpful for emerging adults with opioid dependence. This benefit may be less prominent, though, among non-dependent opioid misusers. Randomized trials are needed to compare more directly the relative benefits of outpatient agonist-based treatment to abstinence-based, residential care in this vulnerable age-group, and to examine the feasibility of an integrated model.
... There are a number of recently developed measures that can assist the practitioner in determining where the individual is in his or her readiness to engage in 12-Step groups (Cloud & Kingree, 2008). These include measures of factors such as readiness to participate in 12-Step programs, which includes the perceived severity of substance use disorder, and the perceived benefits of and barriers to 12-Step involvement (Kingree, Simpson, Thompson, McCrady, & Tonigan, 2007;Kingree et al., 2006); common attitudes and expectancies about participating in 12-Step mutual-help groups (Kahler, Kelly, Strong, Stuart, & Brown, 2006;Morgenstern, Frey, McCrady, Labouvie, & Neighbors, 1996); the potential negative aspects of 12-Step groups, including risks of participation, the limitations of such groups in relationship to different stages of readiness to change, the concepts of powerlessness and the spiritual emphasis of such groups, and the lack of professional leadership of the groups (Laudet, 2003). Additionally, there are multidimensional measures of 12-Step affiliation, which incorporates meeting attendance and engagement in recovery-related activities that can serve as indicators of participation and involvement, as well as measures of the outcomes related to 12-Step participation (Greenfield & Tonigan, 2012;Humphreys, Kaskutas, & Weisner, 1998;Kelly, Urbanoski, Hoeppner, & Slaymaker, 2011;Klein, Slaymaker, & Kelly, 2011;Tonigan, Connors, & Miller, 1996). ...
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Social workers and other behavioral health professionals are likely to encounter individuals with substance use disorders in a variety of practice settings outside of specialty treatment. 12-Step mutual support programs represent readily available, no cost community-based resources for such individuals; however, practitioners are often unfamiliar with such programs. The present article provides a brief overview of 12-Step programs, the positive substance use and psychosocial outcomes associated with active 12-Step involvement, and approaches ranging from ones that can be utilized by social workers in any practice setting to those developed for specialty treatment programs to facilitate engagement in 12-Step meetings and recovery activities. The goal is to familiarize social workers with 12-Step approaches so that they are better able to make informed referrals that match clients to mutual support groups that best meet the individual's needs and maximize the likelihood of engagement and positive outcomes.
... relatively high levels of intention to participate, but attendance and involvement were not assessed (Kahler, Kelly, Strong, Stuart, & Brown, 2006). ...
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Little is known about detoxification (detox) history as a risk factor for poor treatment outcomes among dually diagnosed (substance use and other mental health disorders) patients. We compared patients with a detox history with those who had never received detox on baseline characteristics, subsequent treatment and mutual-help group participation, and substance use and related outcomes at 6-month, 1-year, and 2-year follow-ups. Having a detox history was associated with poorer status at treatment intake, but detoxed patients were functioning as well as never-detoxed patients on alcohol and drug use severity 2 years later. However, having a detox history at baseline was associated with poorer psychological and legal functioning at follow-ups. Assessing detox history in mental health programs would be feasible to implement routinely. Targeting more comprehensive mental health, case management, and 12-step facilitation services to dually diagnosed patients with a history of detox may improve mental health and criminal involvement status.
... 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. ...
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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 (N = 60; M age = 49; 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.
... Strong endorsement by treatment programs of 12-step participation has been found to influence the likelihood that patients will attend AA/NA post-treatment (Humphreys, 2004;Kelly and Moos, 2003;Tonigan et al., 2003). It is unclear, however, whether adolescent programs adapt and utilize strategies, such as Twelve-Step Facilitation (TSF), which have been shown to be helpful among adults (Kahler et al., 2006;Kaskutas et al., 2009;Litt et al., 2009;Timko and DeBenedetti, 2007;Timko et al., 2006;Tonigan et al., 2003;Walitzer et al., 2009). This gap should be addressed in future research. ...
Article
A major barrier to youth recovery is finding suitable sobriety-supportive social contexts. National studies reveal most adolescent addiction treatment programs link youths to community 12-step fellowships to help meet this challenge, but little is known empirically regarding the extent to which adolescents attend and benefit from 12-step meetings or whether they derive additional gains from active involvement in prescribed 12-step activities (e.g., contact with a sponsor and other fellowship members). Greater knowledge in this area would enhance the efficiency of clinical continuing care recommendations. Adolescent outpatients (N = 127; M age 16.7; 75% male; 87% white) enrolled in a naturalistic study of treatment effectiveness were assessed at intake and 3, 6, and 12 months later using standardized assessments. Mixed-effects models, controlling for static and time-varying confounds, examined the concurrent and lagged effects of 12-step attendance and active involvement on abstinence over time. The proportion attending 12-step meetings was relatively low across follow-up (24 to 29%), but more frequent attendance was independently associated with greater abstinence in concurrent and, to a lesser extent, lagged models. An 8-item composite measure of 12-step involvement did not enhance outcomes over and above attendance, but separate components did; specifically, greater contact with a 12-step sponsor outside of meetings and more verbal participation during meetings. The benefits of 12-step participation observed among adult samples extend to adolescent outpatients. Community 12-step fellowships appear to provide a useful sobriety-supportive social context for youths seeking recovery, but evidence-based youth-specific 12-step facilitation strategies are needed to enhance outpatient attendance rates.
... Since then, research, particularly on AA but also on other large 12-step organizations, has substantially increased in quantity and level of scientific sophistication (for reviews see Humphreys, 2004; Kelly, Magill, & Stout, 2009; Kelly & Yeterian, 2008 ). This line of research has given rise to a number of measures of 12- step attendance and involvement (Caldwell, 1999; Gilbert, 1991; Humphreys, Kaskutas, & Weisner, 1998; Kahler, Kelly, Strong, Stuart, & Brown, 2006; Kelly, Humphreys, & Kahler, 2006; McKay, Alterman, McLellan, & Snider, 1994; Morgenstern, Kahler, Frey, & Labouvie, 1996; Snow, Prochaska, & Rossi, 1994; Tonigan, Conners, & Miller, 1996). This proliferation in measures has facilitated important new insights into the nature and benefits of 12-step group activities in relation to recovery (Humphreys, 2004; Kelly, 2003). ...
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Existing measures of 12-step mutual-help activity typically capture only a narrow range of experiences and combine fellowships with explicitly different substance-specific emphases (e.g., Alcoholics versus Narcotics Anonymous). To help expand our knowledge in this important area, we report on the development and use of a comprehensive multidimensional measure of 12-step experiences in two clinical samples of young adults and adolescents (N=430). One-week test-retest reliability was verified on a subsample. Results indicated high content validity and reliability across seven dimensions of experience (meeting attendance, meeting participation, fellowship involvement, step work, mandated attendance, affiliation, and safety), and the measure successfully discriminated between samples on anticipated activity levels. This measure provides rich data on mutual-help activities and deepens our understanding of individuals' experiences across different 12-step organizations.
... Longitudinal naturalistic studies have documented significant improvements in motivation, self-efficacy, coping skills, and commitment to 12- step groups, as well as decreases in psychological distress (Feeney et al., 2006; Finney et al., 1998; Kelly et al., 2005; Morgenstern et al., 1997; Young et al., 2011). In many cases, authors have noted fairly high sample means for constructs such as motivation, self-efficacy, and 12-step-related beliefs and intentions at treatment entry (Finney et al., 1998; Kahler et al., 2006; Morgenstern et al., 1996), and pre-treatment levels of self-efficacy, motivation, coping, and psychological symptoms have consistently predicted post-treatment outcomes (Adamson et al., 2009; McKay and Weiss, 2001; Project MATCH Research Group, 1997). However, we are aware of no studies examining processes of change among young adults. ...
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Young adulthood represents a key developmental period for the onset of substance use disorder (SUD). While the number of young adults entering treatment has increased, little is known about the mechanisms of change and early recovery processes in this important clinical population. This study investigated during-treatment change in key therapeutic processes (psychological distress, motivation, self-efficacy, coping skills, and commitment to AA/NA), and tested their relation to outcome at 3 months post-treatment. Young adults undergoing residential treatment (N=303; age 18-24; 26% female; 95% Caucasian) were enrolled in a naturalistic prospective study and assessed at intake, mid-treatment, discharge, and 3 months following discharge. Repeated-measures and regression analyses modeled during-treatment change in process variables and impact on outcome. Statistically significant medium to large effect sizes were observed for changes in most processes during treatment, with the exception of motivation, which was high at treatment intake and underwent smaller, but still significant, change. In turn, these during-treatment changes all individually predicted 3-month abstinence to varying degrees, with self-efficacy emerging as the sole predictor in a simultaneous regression. Findings help to clarify the mechanisms through which treatment confers recovery-related benefit among young adults. At treatment intake, high levels of abstinence motivation but lower coping, self-efficacy, and commitment to AA/NA, suggests many entering treatment may be "ready and willing" to change, but "unable" to do so without help. Treatment appears to work, in part, by helping to maintain motivation while conferring greater ability and confidence to enact such change.
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Background: Thousands of individuals in the United States seek alcohol treatment each year, typically in outpatient settings. Partial hospital programs provide a high level of structured, individualized outpatient care for individuals who are in treatment for alcohol use disorder. Previous research in other outpatient and inpatient settings has found that psychological distress, pain, and aftercare utilization are associated with treatment outcomes. Objectives: The current study evaluates baseline characteristics and aftercare utilization predictors of alcohol use outcomes of individuals in a week-long partial hospital program. Methods: The 113 participants (59.3% male) were interviewed during their time in the program and then were reassessed one month post-discharge. Results: Results indicated that a greater number of mental health provider visits and 12-step attendance were associated with abstinence at follow-up such, while baseline characteristics did not consistently predict outcomes. Conclusions: Findings highlight the importance of aftercare planning, particularly in our more severe, clinical sample.
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Al-Anon Family Groups, commonly known as Al-Anon, is a mutual-help organization for relatives and friends of people misusing alcohol and other substances. We first summarize Al-Anon's history and current membership and then describe its theoretical basis and helping approach. We review evidence for Al-Anon's active ingredients and outcomes and present a conceptual model to guide future research. Research opportunities include understanding Al-Anon newcomers, specifying Al-Anon's active ingredients, and examining potential synergistic influences between Al-Anon participation and identified substance misusers' participation in mutual-help groups such as Alcoholics Anonymous. We suggest that mutual-help and professional communities work together to facilitate early participation in Al-Anon by shortening the time between problem recognition and seeking help from the fellowship.
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The aim of this study was to examine how the type and timing of help received over 8 years by previously untreated problem drinking individuals were linked to drinking and functioning outcomes. At the time of the 8-year follow-up, individuals (N= 466, 51% male) had self-selected into four groups: no treatment (n = 78), Alcoholics Anonymous (AA) only (n = 66), formal treatment only (n = 74), or formal treatment plus AA (n = 248). Individuals who received some type of help--AA, formal treatment or both--were more likely to be abstinent at 8 years than were untreated individuals. Although the AA only group was better off than the formal treatment only group at 1 and 3 years, the informally and formally treated groups were equivalent on drinking outcomes at 8 years. Similarly, despite the formal treatment plus AA group having been better off at 1 and 3 years than the formal treatment only group, the two formal treatment groups were comparable on drinking at 8 years. Both helped and untreated individuals improved between baseline and 1 year on drinking outcomes, but only formally treated individuals showed continued improvement over 8 years on drinking indices. Participation in AA or formal treatment during Year 1 of follow-up was associated with better drinking outcomes at 8 years. Individuals who obtain help for a drinking problem, especially relatively quickly, do somewhat better on drinking outcomes over 8 years than those who do not receive help, but there is little difference between types of help on long-term drinking outcomes.
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A common recommendation for youth treated for substance abuse is to attend 12-step groups. However, little is known regarding the effects of this adult-derived prescription on substance use outcomes for teens. This study examined (a) the relation between 12-step attendance and substance use outcome in the 6 months postdischarge from inpatient care and (b) a process model of how 12-step attendance during the first 3 months postdischarge affects proximal outcomes of motivation, coping, and self-efficacy, measured at 3 months, and how these, in turn, affect ultimate substance use outcome in the following 3 months. Adolescent inpatients (N = 99) were assessed during treatment and 3 and 6 months postdischarge. Results revealed modest beneficial effects of 12-step attendance, which were mediated by motivation but not by coping or self-efficacy. Findings suggest that closer attention be paid to motivational factors in the treatment of adolescent substance abuse.
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This study investigated client attitudes about AA participation and the use of medications for drinking and emotional problems. The sample (N = 133) was Project MATCH clients recruited in Albuquerque, New Mexico, who were interviewed 10 years after outpatient alcohol treatment. Three self-selected AA-exposed groups of clients were identified in the 10-year interviews, and perceptions of AA and medications were divided according to whether clients reported continuous AA participation for 10 years, limited AA attendance, or no AA attendance over 10 years. Planned comparisons showed that the three groups of AA-exposed clients did not differ in their perceptions about AA and the use of medications to prevent drinking, alcohol craving, and to alleviate emotional problems. In general, client perceptions were not favorable about the use of such medications. Secondary analyses, however, suggested that current AA members may be modestly more favorable about the use of such medications, but this finding requires replication.
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Alcoholics Anonymous (AA) participation often is of interest in alcoholism treatment research, but few measures of this variable have been developed with known psychometric properties. It is common for measures of AA participation to blur the important distinction between frequency of AA attendance and AA involvement. This study provides psychometric findings for the Alcoholics Anonymous Involvement (AAI) scale, a 13-item self-report inventory that measures lifetime and recent attendance and involvement in AA. Normative data are provided based on a national sample of alcoholic participants in treatment ( N = 1,625), and AAI response stability is reported by using a test-retest sample ( N = 76). Findings indicate that the AAI can serve as a reliable and useful instrument for assessing AA attendance and involvement. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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disciplines encountered [in this review] included anthropology, sociology, psychology, medicine, theology, and philosophy / participant-observational studies, epidemiological surveys, public opinion surveys, ethnographic investigations, and psychotherapy outcome studies were among the research strategies used in the sources (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Findings from alcohol treatment studies have had limited impact on clinical practice, in part because they have failed to accurately model treatment factors. This study attempted to model initial response to 12-step substance abuse treatment using a treatment theory-guided evaluation paradigm. A theory-guided measure of 12-step behaviors was constructed. Participants (N = 103) from two traditional substance abuse treatment programs were assessed at intake, discharge, and 1 month after discharge from intensive treatment. Results indicated that the measure of 12-step behaviors had adequate psychometric properties, and a one-factor solution best fit the data. Participants demonstrated substantial variability in their initial response to treatment. A cluster analysis of 12-step behaviors yielded three distinct groups of responders: optimal responders, partial responders, and nonresponders. Descriptive features and differences in relapse rates for groups are reported. Implications for matching patients to 12-step treatment and for clarifying the specific effects of this widely used treatment model are discussed.
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Relatively little is known about how substance abuse treatment facilitates positive outcomes. This study examined the therapeutic effects and mechanisms of action of affiliation with Alcoholics Anonymous (AA) after treatment. Patients (N = 100) in intensive 12-step substance abuse treatment were assessed during treatment and at 1- and 6-month follow-ups. Results indicated that increased affiliation with AA predicted better outcomes. The effects of AA affiliation were mediated by a set of common change factors. Affiliation with AA after treatment was related to maintenance of self-efficacy and motivation, as well as to increased active coping efforts. These processes, in turn, were significant predictors of outcome. Findings help to illustrate the value of embedding a test of explanatory models in an evaluation study.
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The clinical practice guidelines for substance use disorders from the American Psychiatric Association (APA) recommend referral of some patients to self-help groups. The purpose of this study was to determine current patterns of referral to self-help groups in substance abuse treatment programs in the United States and compare them with referral recommendations in APA guidelines. Directors of all 389 substance abuse treatment programs in the Department of Veterans Affairs health care system completed a mailed survey on posttreatment self-help referral practices. Survey responses indicated that a large proportion of substance abuse patients were referred to Alcoholics Anonymous (79.4 percent), with other self-help organizations receiving a smaller but significant number of referrals. Referrals to 12-step self-help organizations were more common in programs that endorsed a 12-step treatment orientation and that employed a higher proportion of staff members in recovery from substance use disorders. Consistent with APA practice guidelines, clinicians were less likely to make a referral to a 12-step self-help group if a patient was an atheist, had a comorbid psychiatric disorder, or had less severe substance abuse problems. In deciding whom to refer to self-help groups, clinicians also considered other variables that are not addressed in current practice guidelines, such as age and previous involvement in 12-step groups. Clinicians make extensive use of self-help groups for their patients, as recommended in APA practice guidelines. However, some differences between current practice and recommended practice warrant further investigation.