1. » Empirical Awakening: The New Science
on 12-step Treatment and Related
Addiction Mutual-Help Organization
Participation
John F. Kelly, Ph.D.
President Elect, Society of Addiction Psychology, American Psychological Association
Associate Professor in Psychiatry
Harvard Medical School
Program Director Addiction Recovery Management Service
Associate Director MGH Center for Addiction Medicine
Awakening to the New Science of Mutual Help for Drug Addiction Recovery
San Juan, Puerto Rico, March 15th, 2013

2. » Substance Use Disorders: massive medical, social, and
economic burden
» Mutual-help groups (MHGs) can help offset burden
» MHGs work for many different types of individuals and
produce additional benefit over and above formal
treatment
» MHGs work through mechanisms similar to those
operating in formal treatment
» MHGs can reduce costs by reducing patients’ reliance on
professional services without any detriment to
outcomes, and may even enhance outcomes
» Empirically-supported clinical interventions can increase
patients’ participation in MHGs and enhance treatment
outcomes

3. • #1 public health problem (Institute for Health
Policy, 2011); notably youth (CASA, 2011)
Public health • Of all DALYs lost due to all psychiatric
conditions, alcohol use disorder alone = 36%
• $425 billion in US each year (lost
productivity, criminal justice, medical costs)
Economic • Excessive alcohol consumption costs society $2 per
drink
• SUD leading cause of mortality -alcohol leading risk
factor among males 15-59 yrs worldwide
Mortality • Opiate overdose – leading cause of accidental death
nationwide
• Onset of long-term problems occur during
adolescence/young adulthood
Prevention • 90% adults with dependence start using before age 18
• 50% of adults start using before age 15

4. $450
$400
$350
$300
$250
Economic cost (in billions)
$200
$150
$100
$50
$0
Alcohol/drugs Heart disease Alcohol Drugs Diabetes Smoking Obesity
Source: Bouchery, Harwood, Sacks, Simon, & Brewer (2011); US Department of Justice (2011)

5. Typical Clinical Course for Substance Dependence and Recovery
Addiction Help Full Sustained Relapse Risk
Remission drops below
Onset Seeking 15%
4-5 years 8 years 5 years
Self- 4-5
Treatment Continuing
initiated episodes/ care/
cessation mutual- mutual-
attempts help help

6. » SUDs: massive health, social, and economic burden
» Mutual-help groups (MHGs) can offset that burden
» MHGs work for many different types of individuals over
and above formal treatment
» MHGs work through mechanisms similar to those
operating in formal treatment
» MHGs can reduce costs by reducing patients’ reliance
on professional services without any detriment to
outcomes, and may even enhance outcomes
» Empirically-supported clinical interventions increase
patients’ participation in MHGs and enhance treatment
outcomes

7. » Past 40 years increase in quality and
quantity of SUD treatment in US and
developed countries
» However, professional resources alone
cannot cope; stigma and cost present
further barriers to access
» Addiction often has chronic course (8 yrs
from 1 st tx to achieve FSR; Dennis et
al, 2005); 4-5 yrs before risk of relapse
<15%
» In tacit recognition, most societies seen
increases in MHGs during past 70 yrs
(Kelly & Yeterian, 2008)

8. » Cost-effective -free; attend as intensively, as long as desired
» Focused on addiction recovery over the long haul
» Widely available, easily accessible, flexible
» Access to fellowship/broad support network
» Entry threshold (no paperwork, insurance); anonymous
(stigma)
» Adaptive community based system that is responsive to
undulating relapse risk

9.  1950’s “Minnesota Model”
 >90% of private SUD treatment in US base tx on the 12-step
principles (Roman & Blum, 1998)
 About 80% of VA SUD patients are referred to 12-step groups
(Humphreys et al., 1997)
 84% of youth are referred to AA/NA post-discharge (Knudsen
et al, 2008; Kelly et al, 2008)

10. Substance Focused Mutual-help Groups
Year of Evidence base*
Name Location of groups in U.S.
Origin Number of groups in U.S. (0-3)
Alcoholics Anonymous 52,651
all 50 States 1, 2, 3
(AA) 1935
Narcotics Anonymous Approx. 15,000
all 50 States 1, 2
(NA) 1940s
Cocaine Anonymous Approx. 2000 groups most States; 6 online meetings at
0
(CA) 1982 www.ca-online.org
Methadone Anonymous 25 States; online meetings at
Approx. 100 groups 1, 2
(MA) 1990s http://methadone-anonymous.org/chat.html
Marijuana Anonymous 24 States; online meetings at
Approx. 200 groups 0
(MA) 1989 www.ma-online.org
No group meetings or mutual
1988 helping; emphasis is on
Rational Recovery (RR) ----------------------------------------------------- 1, 2
individual control and
responsibility
Self-Management and 40 States; 19 online meetings at
Recovery Training 1994 Approx. 250 groups www.smartrecovery.org/meetings/olschedule 1, 3
(S.M.A.R.T. Recovery) .htm
Secular Organization for
all 50 States; Online chat at
Sobriety, a.k.a. Save 1986 Approx. 480 groups 1
www.sossobriety.org/sos/chat.htm
Ourselves (SOS)
Women for Sobriety Online meetings at
150-300 groups 1
(WFS) 1976 http://groups.msn.com/ WomenforSobriety
Moderation Management Approx.16 face-to-face 12 States; Most meetings are online at
1
(MM) 1994 meetings www.angelfire.com/trek/mmchat/;
*0= None 1=Descriptive studies only 2 = Observational (correlational, longitudinal) 3= Experimental (random assignment, controlled).
Source: Kelly & Yeterian, 2008

11. » SUDs: massive health, social, and economic burden
» Mutual-help groups (MHGs) can offset that burden
» MHGs work for many different types of individuals
over and above formal treatment
» MHGs work through mechanisms similar to those
operating in formal treatment
» MHGs can reduce costs by reducing patients’ reliance
on professional services without any detriment to
outcomes, and may even enhance outcomes
» Empirically-supported clinical interventions increase
patients’ participation in MHGs and enhance treatment
outcomes

13.  Emrick et al. 1993 - 107 studies. AA attendance and involvement modest
beneficial effect on drinking behavior
 Tonigan et al., 1996 - 74 studies. Examined moderators of effectiveness (i.e.
outpatient vs. inpatient; study quality)
Studies generally, were “methodological poor” and underpowered
 Kownacki & Shadish, 1999 – 21 studies. Examined controlled trials only
- Randomization confounded with coerced status (justice system required)
- Coerced individuals fared worse than individuals in other treatment or no
treatment
- Coerced individuals may have better outcomes if coerced into other kinds
of treatment
- Found support for 12-step-based tx and non-coerced AA attendance

14. » Attempted to examine RCTs of AA or TSF
» 8 trials involving 3417 people were included.
» Findings:
˃ AA may help patients to accept treatment and keep patients in treatment
more than alternative treatments
˃ AA had similar retention rates
˃ 3 studies compared AA combined with other interventions against other
treatments and found few differences in the amount of drinks and
percentage of drinking days
˃ Peer-led AA participation found to be as effective as other comparison
professionally-delivered interventions to which it was compared
(e.g., CBT)

15.  Clinical concerns member-group fit with 12-step mutual-
help organizations.
 1. Dual-diagnosed (DD)
 Medications
 Clinical syndromes vs. “not working the program”
 2. Non-religious people
 Barriers to 12-step
 3. Women
 “Powerlessness”
 4. Young People
 Developmental barriers

16. Setting
Authors Year N Follow-up (Months) % Female M Age
(No. of sites)
Alford, Koehler, Leonard 1991 157 6, 12, 24 38% 16 Inpatient (1)
Brown 1993 140 12 42% 16 Inpatient (2)
Kennedy & Minami 1993 91 12 23% 16.5 Inpatient (1)
Hsieh, Hoffman, Hollister 1998 2,317 6, 12 35% 17-19 Inpatient (24)
Kelly, Myers, Brown 2000 99 6 60% 16 Inpatient (2)
Kelly, Myers, Brown 2002 74 6 62% 16 Inpatient (2)
Mason and Luckey 2003 95 3, 12 32% 22 Inpatient (2)
2004 810 12 30% 16 Residential (8),STI (6),
Grella, Joshi, Hser
Outpatient (9)
Kelly, Myers, Brown 2005 74 6 62% 16 Inpatient (2)
Kelly, Brown et al 2008 160 6, 12, 24, 48, 72, 96 34% 13-18 Inpatient (2)
Chi, Kaskutas, Sterling et al 2009 419 6, 12, 36 34% 13-18 Intensive outpatient (4)
Kelly, Dow, Yeterian 2010 127 3, 6 24% 16.7 Outpatient (1)
Chi, Sterling, Campbell, 2012 419 12, 36, 60, 72, 84 34% 13-18 Intensive outpatient(4)
Weisner
Kelly and Urbanoski 2012 127 3, 6, 12 24% 16.7 Outpatient (1)
Kelly, Stout, Slaymaker 2012 303 1, 3, 6, 12 27% 20 Residential (1)

17. Any, Monthy, and Weekly AA/NA Attendance across 8 Years
Following Inpatient Treatment
100%
90%
80%
% Attending AA/NA
70%
Any
60% Monthly
50% Weekly
40%
30%
20%
10%
0%
0-6m 6m-1yr 1-2yr 2-4yr 4-6yr 6-8yr
Follow-Up
Source: Kelly, J.F., Brown, S. A., Abrantes, A., Kahler, C. H., & Myers, M. (2008) Social Recovery Model: An 8-
year Investigation of adolescent 12-step group participation following inpatient treatment. Alcoholism:
Clinical and Experimental Research.

18. Percent of Youth in Each Trajectory Outcome Group attending AA/NA at least Weekly
across 8 Years
100
% Attending AA/NA weekly
90
80
70
Abstainers
60
Infrequent User
50
worse with time
40
Frequent User
30
20
10
0
6m 12m 24m 48m 72m 96m
Time

19. Parameter Estimate Standard Error 95% Confidence Z P
Limits
Intercept 37.3071 6.9601 23.6656 50.9486 5.36 <.0001
Time 1.4424 0.8693 -0.2614 3.1462 1.66 0.0971
Gender -9.3380 2.6605 -14.5526 -4.1234 -3.51 0.0004
Pre-treatment PDA -0.0811 0.0490 -0.1772 0.0150 -1.65 0.0980
Moderate use -1.8816 0.9646 -3.7722 0.0090 -1.95 0.0511
Aftercare1 6m 0.4349 0.5158 -0.5761 1.4460 0.84 0.3991
Formal Treatment2 5.5669 3.2856 -0.8727 12.0065 1.69 0.0902
AA/NA2 1.9517 0.4512 1.0674 2.8360 4.33 <.0001
PDA2 0.5030 0.0371 0.4304 0.5757 13.56 <.0001
1= Sq root transformed; 2= Time varying covariate
Kelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of Youth Treatment Outcome in
Relation to 12-step Group Involvement. Alcoholism: Clinical and Experimental Research, 2008, 32, 8 1468-1478.

20. 20
Kelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of Youth
Treatment Outcome in Relation to 12-step Group Involvement. Alcoholism: Clinical and Experimental
Research, 2008, 32, 8 1468-1478.

21. Moderators: Might Age Composition of AA/NA meetings
100
moderate participation and derived benefits?
95
90
85
80
75
70
65
60
55 Days Abstinent (3m)
50 Days Abstinent (6m)
All adults Mostly adults Even mix Mostly teens All teens
Kelly JF, Myers, MG Brown SA (2005). The effect of age composition of 12-step meetings on adolescent attendance and outcomes
Journal of Child and Adolescent Chemical Dependency.

22. » SUDs: massive health, social, and economic burden
» Mutual-help groups (MHGs) can offset that burden
» MHGs work for many different types of individuals over
and above formal treatment
» MHGs work through mechanisms similar to those
operating in formal treatment
» MHGs can reduce costs by reducing patients’ reliance
on professional services without any detriment to
outcomes, and may even enhance outcomes
» Empirically-supported clinical interventions increase
patients’ participation in MHGs and enhance treatment
outcomes

23. » Studies of treatment are often theory-based
(e.g, Longabaugh and Morgenstern, 2002;
Moos, 2007)
» However, studies of SUD remission and recovery
are very seldom theory-based
» But, there are empirically supported theories that
help explain the onset of substance use and SUD
» These same theories may be useful in helping
explain SUD remission and recovery…

24. Parallels in the onset and offset of SUD
People want to use
substances for 4 main
reasons (NIDA, 2005):
To feel good
To feel better
To do better
Because others are
doing it

25. Parallels in the onset and offset of SUD
People want to use People want to stop using
substances for 4 main substances and recover for
reasons (NIDA, 2005): the same 4 main reasons:
To feel good To feel good
To feel better To feel better
To do better To do better
Because others are Because others are
doing it doing it

26. Theory Key process mechanisms for…
Substance use Recovery
Social Lack of strong bonds with family, Goal-direction, structure and monitoring,
Control friends, work, religion, other aspects shaping behavior to adaptive social bonds
traditional society
Social Modeling and observation and Social network composed of individuals
Learning imitation of substance use, social who espouse abstinence, reinforce negative
reinforcement for and expectations expectations about effects of substances,
of positive consequences from use; provide models of effective sober living
positive norms for use
Stress and life stressors (e.g., Effective coping enhances self-confidence
coping social/work/financial problems, and self-esteem
phys/sex abuse) lead to substance
use especially those lacking coping
and avoid problems; substance use
form of avoidance coping, self-
medication
Behavioral Lack of alternative rewards provided Effective access to alternative, competing,
economics by activities other than substance rewards through involvement in
use educational, work, religious,
social/recreational pursuits
Source: Moos, RH (2011) Processes the promote recovery from addictive disorders.

27. Theory Key process mechanisms for…
Substance use Recovery
Social Lack of strong bonds with family, Goal-direction, structure and monitoring,
Control friends, work, religion, other aspects shaping behavior to adaptive social bonds
traditional society
Social Modeling and observation and Social network composed of individuals
Learning imitation of substance use, social who espouse abstinence, reinforce negative
reinforcement for and expectations expectations about effects of substances,
of positive consequences from use; provide models of effective sober living
positive norms for use
Stress and life stressors (e.g., Effective coping enhances self-confidence
coping social/work/financial problems, and self-esteem
phys/sex abuse) lead to substance
use especially those lacking coping
and avoid problems; substance use
form of avoidance coping, self-
medication
Behavioral Lack of alternative rewards provided Effective access to alternative, competing,
economics by activities other than substance rewards through involvement in
use educational, work, religious,
social/recreational pursuits
Source: Moos, RH (2011) Processes the promote recovery from addictive disorders.

28. How might MHGs like AA reduce relapse risk and sustain the
recovery process?
Cue Induced
Stress Induced RELAPSE
Drug Induced
AA-related social network changes may
help avoid cues, reduce and tolerate
distress, and maintain abstinence
minimizing drug-induced relapse risks
AA
Kelly JF, Yeterian, JD, (In 28
press). Mutual help groups. In McCrady and Epstein. Comprehensive Textbook on Substance Abuse.

29. (15-mo) Alcohol Outcomes
(3-mo) AA attendance
(PDA or DDD)
Baseline (BL) Covariates
Age
Race
Sex
Marital Status
Employment Status
Prior Alcohol Treatment
MATCH Treatment group
MATCH study site
Alcohol Outcomes (PDA/DDD)
(BL) Self-efficacy (9-mo) Self-efficacy
Negative Affect Negative Affect
(BL) Self-efficacy (9-mo) Self-efficacy
Positive Social Positive Social
(BL) Religious/Spiritual (9-mo) Religious/Spiritual
Practices Practices
(BL) Depression (9-mo) Depression
(BL) Social Network (9-mo) Social Network
“pro-abstinence” “pro-abstinence”
(BL) Social Network (9-mo) Social Network
“pro-drinking” pro-drinking”
Source: Kelly, Hoeppner, Stout, Pagano (2012) , Determining the relative importance of the mechanisms of behavior change within Alcoholics
Anonymous: A multiple mediator analysis. Addiction 107(2):289-99

30. Aftercare (PDA) effect of AA on Aftercare (DDD)
Self-efficacy
alcohol use for
(NA) Depression AC was explained
5% 3%
by social factors
but also by S/R
Self-efficacy
and through SocNet: pro-drk.
(NA)
SocNet: pro-drk. 16%
24%
negative affect SocNet:
20%
Spirit/Relig
23%
(DDD only) pro-abst.
11% Depression
SocNet: pro- 11%
abst.
Self-efficacy
16% Self-efficacy (Soc)
(Soc) Spirit/Relig
21%
34% 21%
Majority of effect
Outpatient (PDA) of AA on alcohol Outpatient (DDD)
Self-efficacy
Self-efficacy Depression use for OP was (NA) Depression
(NA) 2% Spirit/Relig
6% explained by 1% 5%
1%
social factors
Spirit/Relig
9%
SocNet: pro-drk.
29%
SocNet: pro-drk. Self-efficacy
33% (Soc)
27%
Self-efficacy
SocNet: pro- (Soc)
SocNet: pro- abst. 39%
abst. 17%
31%
Source: Kelly, Hoeppner, Stout, Pagano (2012) , Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous:
30
A multiple mediator analysis. Addiction 107(2):289-99

31. effect of AA on
Aftercare (PDA) Aftercare (DDD)
alcohol use for
Self-efficacy
(NA) Depression AC was explained
5% 3% by social factors
but also by S/R
Self-efficacy
and through SocNet: pro-drk.
(NA)
16%
SocNet: pro-drk. negative affect 20%
24% SocNet:
Spirit/Relig (DDD only) pro-abst.
23%
11% Depression
SocNet: pro- 11%
abst.
Self-efficacy
16% Self-efficacy (Soc)
(Soc) Spirit/Relig
21%
34% 21%
Majority of effect
Outpatient (PDA) of AA on alcohol Outpatient (DDD)
Self-efficacy Depression use for OP was Self-efficacy
(NA) Depression
(NA) 2% Spirit/Relig
1% 6% explained by 1% 5%
social factors
Spirit/Relig
9%
SocNet: pro-drk.
29%
SocNet: pro-drk. Self-efficacy
33% (Soc)
27%
Self-efficacy
SocNet: pro- (Soc)
SocNet: pro- abst. 39%
abst. 17%
31% 31
Source: Kelly, Hoeppner, Stout, Pagano (2012) , Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous:
A multiple mediator analysis. Addiction 107(2):289-99

32. 32

33. CONCLUSIONS
˃ Recovery benefits derived from AA differ in nature and magnitude between
more severely alcohol involved/impaired and less severely alcohol
involved/impaired; and between men and women
˃ These differences reflect differing needs based on recovery challenges related
to differing symptom profiles, degree of subjective suffering and perceived
severity/threat, recovery challenges, and gender-based social roles & drinking
contexts
˃ Similar to psychotherapy literature (Bohart & Tollman, 1999) rather than
thinking about how AA or similar organizations work, better to think how
individuals use or make these organizations work for them – to meet their
most urgent needs at any given phase of recovery

34. » SUDs: massive health, social, and economic burden
» Mutual-help groups (MHGs) can offset that burden
» MHGs work for many different types of individuals over
and above formal treatment
» MHGs work through mechanisms similar to those
operating in formal treatment
» MHGs can reduce costs by reducing patients’ reliance
on professional services without any detriment to
outcomes, and may even enhance outcomes
» Empirically-supported clinical interventions increase
patients’ participation in MHGs and enhance treatment
outcomes

39. HEALTH CARE COST OFFSET POTENTIAL OF MHGS (1)
CBT VS 12-STEP RESIDENTIAL TREATMENT
Cost per patient over 1 year *
Cost per patient over 1 year *
CBT Resulted
in $4,729 $12,129.00
greater costs
$7,400.00
per patient with
sig. worse
outcomes
CBT TSF
Compared to CBT-
treated
Cost per patient over 1-2 year patients, 12-step
CBT Resulted in treated patients
Cost per patient
$3,295 greater more likely to be in
costs per patient
$5,735.00 recovery, at a
with sig. worse $8,000 lower cost
outcomes in Yr 2 per pt over 2 yrs
$2,440.00
Follow up (about $15M for
entire sample)
CBT TSF
Source: Humphreys & Moos (2001; 2007) Alcoholism: Clinical Experimental Research

40. » The first study to examine how 12-Step participation affects
medical costs in adolescents with SUD
» 4 intensive outpatient programs
» N = 403 adolescents, age 13-18
 66% male; mean age 16.1; 49% White
 Comorbid ADHD: 17%, depression: 36%
» Follow-up: 6 months, 1, 3, 5, and 7 years
» Difference-in-difference model was used
Source: Mundt, Parthasarathy, Chi, Sterling, Campbell (2012)

41. » Avg annual medical costs for all participants
over 7 years: $3085 per person per year
» 4.7% decrease in medical costs with each
additional 12-step meeting attended = $145
annual savings per 12-step meetings attended
Source: Mundt, Parthasarathy, Chi, Sterling, Campbell (2012)

42. » SUDs: massive health, social, and economic burden
» Mutual-help groups (MHGs) can offset that burden
» MHGs work for many different types of individuals over
and above formal treatment
» MHGs work through mechanisms similar to those
operating in formal treatment
» MHGs can reduce costs by reducing patients’ reliance
on professional services without any detriment to
outcomes, and may even enhance outcomes
» Empirically-supported clinical interventions increase
patients’ participation in MHGs and enhance
treatment outcomes

43. Risk Treatment Settings High Supportive Treatment Low supportive Treatment
Factors Combined milieu milieu
n Dropout Rate n Dropout Rate n Dropout Rate
0 261 30 % (77) 151 30 % (45) 110 29 % (32)
1 548 30 % (163) 274 29 % (79) 274 31% (84)
2 582 38 % (221) 269 38 %(103) 313 38 % (118)
3 512 43 % (218) 176 40 % (70) 336 44% (148)
4 381 51 % (193) 119 42 % (50) 262 55% (143)
5 150 54 % (81) 36 47 % (17) 114 56% (64)
6-7 78 65 % (51) 16 50 % (8) 62 70% (43)
•Dropout rate = 40%
•AA dropouts had 3x higher odds of relapse to alcohol/drug use
Source: Kelly & Moos (2003) Dropout from 12-Step Groups: Prevalence, Predictors and Counteracting Treatment
Influences, Journal of Substance Abuse Treatment,24, 241-250

44. Source: Kelly & Moos (2003) Dropout from 12-Step Groups: Prevalence, Predictors and Counteracting Treatment
Influences, Journal of Substance Abuse Treatment,24, 241-250

45. » 20 patients randomly selected from outpatient tx
program for alcohol use disorder
» Randomly assigned to:
˃1: Standard referral
- given information about AA including time, date, location of
meetings, encouraged to attend meetings
˃2: Systematic encouragement and community access
- In addition to standard procedure, clients had phone conversation with AA
member during a session - client and AA member met before first
meeting, member provided client with ride; client also received a reminder
phone call from the member

46. » Results:
˃0% clients in standard referral attended a meeting during the
target week
˃100% clients in systematic encouragement and community
access group attended meeting during target week
˃Mean AA meeting attendance rate for 4 week period:
+ 0 for standard referral group vs 2.3 for systematic encouragement
group

47. T O
S T
F H
Stand alone Integrated into an existing Component of a treatment
Independent therapy therapy package (e.g., an
additional group)
As Modular add-on
linkage component

48. » Multisite randomized clinical trial of alcohol dependent
individuals
 2 arms
• Aftercare (n=774)- recently finished inpatient treatment
• Outpatient (n=952)
 3 conditions, all with ultimate goal of abstinence
• Twelve Step Facilitation
- Therapist took firm stance against any drinking
• Cognitive Behavioral Therapy
- Therapist assisted in building skill set to maintain abstinence
• Motivational Enhancement Therapy
- Therapist aimed to build clients motivation to accept abstinence as
objective

49. » Individuals randomly assigned to TSF attended AA more frequently and had
higher rates of continuous abstinence (71% more) 1yr following tx
(TSF=24%, CBT=15%, MET=14%) than those assigned to CBT or MET; similar
on continuous outcomes (PDA/DDD)
» Social support for drinking
˃ 3 yrs post treatment, clients whose social networks were more
supportive of drinking prior to treatment had higher abstinence and
lower drinks per drinking day in TSF than in MET (clients in CBT did not
show a significant advantage over those in MET)

50.  Effects mediated by ongoing AA attendance
 Across txs, those who attended AA groups had better outcomes (Tonigan
et al, 2002)
 AA valuable adjunct to SUD treatment - even when not formally
emphasized

51. T O
S T
F H
Stand alone Integrated into an existing Component of a treatment
Independent therapy therapy package (e.g., an
additional group)
As Modular add-on
linkage component

52. » Approaches to assist in involvement in AA
» 169 adult alcoholic outpatients randomly assigned to
one of three treatment conditions
» All clients received treatment that included:
˃12 sessions
˃Focus on problem-solving, drink refusal, relaxation
˃Recommendation to attend AA meetings

53. » Treatment varied between 3 conditions in terms of how the therapist discussed AA and how
much information about AA was shared
˃ Condition 1: Directive approach
- Therapist directed
- Client signed contract describing goals to attend AA meetings
- Therapist encouraged client to keep a journal about meetings
- Reading material about AA provided to client
- Therapist informs client about skills to use during meetings and about using a
sponsor
- 38% total material covered in sessions was about AA
˃ Condition 2: motivational enhancement approach (more client centered)
- Therapist obtains clients feelings and attitudes about AA
- Therapist describes positive aspects of AA, but states that it is up to the client how
much they will be involved
- Therapist intends to assist the client in making a decision in favor of AA
- 20% total material covered in sessions about AA
˃ Condition 3: CBT treatment as usual, no special emphasis on AA
- Throughout treatment, therapist briefly inquires about AA and encourages client to
attend AA
- 8% total material covered in sessions about AA
Walitzer, Dermen & Barrick, 2009

54. » Participants exposed to the Directive TSF approach reported
significantly more:
˃attendance of AA meetings
˃more active involvement in AA
˃higher percent days abstinent in comparison to the
motivational and treatment as usual groups
» Evidence suggests AA involvement partially mediated the
effects of the directive approach

55. T O
S T
F H
Stand alone Integrated into an existing Component of a treatment
Independent therapy therapy package (e.g., an
additional group)
As Modular add-on
linkage component

56. » Making AA Easier- manual guided - designed to help clients prepare for AA
» Goal: to prepare for AA (encourage participation in AA, minimize resistance
to AA, and educate about AA)
˃ MAAEZ intervention is conducted in a group format to help prepare for
group dynamic of AA
» Facilitator goal: to inform clients about AA and facilitate group interaction
˃ Facilitator recommended to be an active member of AA, NA, or CA
» Discussion format: MAAEZ allows and encourages feedback (referred to as
“cross-talk” in MAAEZ), unlike AA which does not allow feedback

57. » Structure of Program:
» Six, weekly, 90-minute sessions
˃Homework assigned at the end of each session
- List of texts for reading assignments provided in
manual
- List of articles that discuss effectiveness of AA
provided in manual
- Each homework assignment includes going to at least
one AA meeting in the 7 days following that
session, making connections with other people in
AA, and completing reading assignments

58. » Spirituality: provides clients with range of “spirituality” definitions that do
not all require religious orientation. The homework assignment after that
session is to talk to someone longer sober, after a meeting.
» Principles Not Personalities: deals with AA myths, types of
meetings/etiquette. Homework- ask someone for phone number and
speak on the phone before next session.
» Sponsorship: explains function of AA sponsor, offers guidelines for picking
someone, and includes role-playing to practice asking for a sponsor and
overcoming a rejection. Homework that week is to get a temporary
sponsor.
» Living Sober, tools for staying sober are tackled: relapse
triggers, service, and avoiding “slippery” people, places, and things.
Homework for this session is to socialize with someone in AA who has
more sobriety.

59. » Abstinence:
˃ TSF participants significantly more past 30 day alcohol
abstinence, drug abstinence, and both alcohol and drug abstinence at
12 month time period
˃ Increased odds of continuous abstinence in general and for each
additional MAAEZ session attended
» Prior AA Exposure:
˃ MAAEZ found to be more effective in participants with AA previous
experience (differs from outcomes found in Project MATCH), possibly
because MAAEZ gives clients new perspective of AA
Kaskutas et al 2009

61. T O
S T
F H
Stand alone Integrated into an existing Component of a treatment
Independent therapy therapy package (e.g., an
additional group)
As Modular add-on
linkage component

64.  Evaluation of procedures to effectively refer patients to 12-step meetings
 Individuals with SUDs entering a new outpatient treatment program randomly assigned
to a treatment condition and provided self reports on meeting attendance and
substance use
 Condition 1: standard referral
• Patients given locations and schedules of meetings and encouraged to attend
 Condition 2: intensive referral
• Patients give locations and schedules of meetings, with the meetings
preferred by previous clients indicated
• Therapist reviews a handout about program including introduction to 12-step
philosophy and common concerns
• Therapist arranged a meeting with a current member and client had a phone
conversation with this member during a session
• Therapist and client agreed on which meetings client will attend and client
kept a journal of meetings attended and experiences

65. » At 6m, patients in intensive referral who had relatively less
previous 12-Step experience had:
˃higher meeting attendance
˃better substance use outcomes
» At both the 6 and 12 month follow up, patients in intensive
referral:
˃more likely to attend at least one meeting per week
˃had higher rates of attendance and had higher rates of
abstinence

66. » Timko et al. (2011; N=287): standard vs. intensive referral
condition
» Patients in the intensive referral group were more likely to
attend and be involved in dual-focused mutual-help groups
(DFGs) and substance-focused mutual-help groups
(SFGs), and had less drug use and better psychiatric
outcomes at follow-up
» Only 23% of patients in the intensive-referral group
attended a DFG meeting during the six-month follow-up
period, while 85% attended a SFG