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«This study focused on the duration of participation in professional treat­ ment and Alcoholics Anonymous (AA) for previously untreated individuals ...»

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Participation in Treatment and Alcoholics Anonymous:

A 16-Year Follow-Up of Initially Untreated Individuals

Rudolf H. Moos and Bernice S. Moos

Center for Health Care Evaluation, Department of Veterans

Affairs, and Stanford University

This study focused on the duration of participation in professional treat­

ment and Alcoholics Anonymous (AA) for previously untreated individuals

with alcohol use disorders. These individuals were surveyed at baseline

and 1 year, 3 years, 8 years, and 16 years later. Compared with individuals who remained untreated, individuals who obtained 27 weeks or more of treatment in the first year after seeking help had better 16-year alcohol- related outcomes. Similarly, individuals who participated in AA for 27 weeks or more had better 16-year outcomes. Subsequent AA involvement was also associated with better 16-year outcomes, but this was not true of subsequent treatment. Some of the association between treatment and long-term alcohol-related outcomes appears to be due to participation in AA. © 2006 Wiley Periodicals, Inc. J Clin Psychol 62: 735–750, 2006.* Keywords: alcohol; treatment; Alcoholics Anonymous; help seeking;

outcome Introduction Most of the extensive literature on the outcome of treatment for alcohol use disorders (Finney & Monahan, 1996; Miller & Wilbourne, 2002) has focused on individuals who have had one or more earlier episodes of treatment. Accordingly, much of the information we have on the outcome of treatment for alcohol abuse is based on studies of individuals who have not responded to prior episodes of care or have relapsed. Relatively little is Preparation of this manuscript was supported by NIAAA Grant AA12718, and by the Department of Veterans Affairs Health Services Research and Development Service. We thank Bianca Frogner, Ilana Mabel, and Chris­ tine Stansbury for their effort in collecting the 16-year follow-up data. John Finney, Keith Humphreys, John McKellar, Alex Sox-Harris, and Christine Timko made helpful comments on an earlier draft of the manuscript.

The views expressed here are the authors’ and do not necessarily represent the views of the Department of Veterans Affairs.

*This article is a U.S. Government work and, as such, is in the public domain in the United States of America.

Correspondence concerning this article should be addressed to: Rudolf H. Moos,Center for Health Care Eval­ uation (152-MPD), 795 Willow Road, Menlo Park, CA 94025; e-mail: rmoos@stanford.edu JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 62(6), 735–750 (2006) © 2006 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20259 736 Journal of Clinical Psychology, June 2006 known about the duration of initial or subsequent episodes of treatment, their long-term outcomes, or the extent to which longer treatment episodes confer a benefit over shorter episodes or over remaining untreated.

Because so many individuals with alcohol use disorders participate in self-help groups, especially Alcoholics Anonymous (AA), another question involves the extent to which treatment has an effect on outcome that is independent of AA. Prior studies have focused on participation in AA as a dichotomous variable and on the amount of participation in relation to short-term outcomes (Emrick, Tonigan, Montgomery, & Little, 1993; Kownacki & Shadish, 1999; Tonigan, Toscova, & Miller, 1996), but there is relatively little prospec­ tive information about the duration of initial and subsequent episodes of participation, the effect of duration on long-term psychosocial as well as alcohol-related outcomes, or the extent to which AA has effects on outcomes that are independent of treatment.

We focus here on participation in professional treatment and AA among previously untreated individuals after these individuals initially sought help for their alcohol use

disorders and address three sets of questions:

1. Is the duration of treatment obtained in the first year after seeking help, and the duration of subsequent treatment, associated with individuals’ long-term (16­ year) alcohol-related and psychosocial outcomes? Is participation in treatment in the second and third years (or the fourth to eighth years) after initiating help seeking associated with additional benefits beyond those obtained from partici­ pation in the first year?

2. Is the duration of participation in AA in the first year, and the duration of sub­ sequent participation, associated with individuals’ long-term (16-year) out­ comes? Is participation in AA in the second and third years (or the fourth to eighth years) associated with additional benefits beyond those obtained from participa­ tion in the first year?

3. Many of the individuals who participate in one modality of help (professional treatment or AA) also participate in the other modality. Accordingly, we focus on whether the associations between the duration of participation in treatment and AA and 16-year outcomes are independent of participation in the other modality of help. We also consider interactions between the duration of treatment and AA in that, for example, one modality could compensate for or amplify the influence of the other.

Duration of Participation in Treatment and Outcome Patients with substance use disorders who receive more extended episodes of outpatient care tend to have better short-term outcomes (Fiorentine & Anglin, 1996; Moos, Finney, Federman, & Suchinsky, 2000; Moos, Schaefer, Andrassy, & Moos, 2001; Ouimette, Moos, & Finney, 1998), and are more likely to be remitted 2 years after discharge from residential care (Ritsher, Moos, & Finney, 2002) than are patients who have outpatient care for a shorter interval. Prior studies of variations in the duration of care have focused primarily on individuals with severe and chronic substance use disorders. Many of these patients likely need longer episodes of care, whereas individuals who enter treatment for the first time and have less chronic disorders may respond more quickly and experience good outcomes with briefer treatment (Moyer, Finney, Swearingen, & Vergun, 2002).

Another issue is that prior studies have examined relatively short-term outcomes. Here, we consider the long-term contribution of the duration of treatment among initially untreated individuals with alcohol use disorders in the first few years after they first sought help.

Journal of Clinical Psychology DOI 10.1002/jclp 737 Treatment and Alcoholics Anonymous Duration of Participation in Alcoholics Anonymous and Outcome Self-help groups play a key role in contributing to positive alcohol-related outcomes (Fiorentine, 1999; Humphreys, 2004; Watson et al., 1997). For example, in all three Project MATCH treatments, participation in AA in the first few months after treatment was associated with a higher likelihood of abstinence in the subsequent 6 months (Con­ nors, Tonigan, & Miller, 2001; Tonigan, Connors, & Miller, 2003). In two other multisite studies, patients who attended more self-help group meetings had better 1-year outcomes than did patients who were less involved in such groups (Moos et al., 2001; Ouimette et al., 1998). Patients who attended more self-help groups in the first year after acute treatment were more likely to be in remission at 2 years (Ritsher, Moos, & Finney, 2002) and 5 years (Ritsher, McKellar, Finney, Otilingam, & Moos, 2002).

These studies indicate that participation in 12-step self-help groups and, up to a point, the number of meetings attended, are associated with abstinence and remission.

However, little is known about the association between the duration of participation in 12-step self-help groups and individuals’ outcomes, or about whether the duration of initial and subsequent episodes of participation makes a long-term contribution to alcoholrelated and psychosocial outcomes.

Independent Contribution of Treatment and Alcoholics Anonymous Patients who participate in both self-help groups and treatment tend to have better out­ comes than do patients who are involved only in treatment (Fiorentine, 1999; Fiorentine & Hillhouse, 2000). According to Moos et al. (2001), patients with substance use dis­ orders who attended more self-help group meetings had better 1-year outcomes after controlling for continuing outpatient mental health care. Similarly, among patients dis­ charged from intensive substance use care, participation in self-help groups was associ­ ated with better 1-year (Ouimette et al., 1998), 2-year, and 5-year (Ritsher, Moos, & Finney, 2002; Ritsher, McKellar, et al., 2002) outcomes, after controlling for outpatient mental health care. We focus here on whether the duration of participation in one modal­ ity of help (treatment or AA) contributes to long-term outcomes beyond the contribution of participation in the other modality.

Prior Findings With This Sample In prior work with the current sample, we found that individuals who entered treatment or AA in the first year after seeking help had better alcohol-related outcomes and were more likely to be remitted than were individuals who did not obtain any help. Individuals who participated in treatment and/or in AA for a longer interval in the first year were more likely to be abstinent and had fewer drinking problems at 1-year and 8-year follow-ups (Moos & Moos, 2003; 2004a; 2005b; Timko, Moos, Finney, & Lesar, 2000). In this article, the distinctive focus is on associations between the duration of participation in treatment and AA and 16-year outcomes. We also consider the independent contribution of participation in treatment and AA to 16-year outcomes.

–  –  –

contact with the alcoholism treatment system via an Information and Referral (I&R) center or detoxification (detox) program. The four I&R centers involved in the study provided services over the telephone or in person during information and referral ses­ sions. The three detox programs provided detoxification services to individuals in the three counties in which they were located. One program was for women only, and the other two admitted both women and men.

At baseline, data were collected from 628 eligible individuals. After providing informed consent, these individuals completed a baseline inventory described below. The initial data collection process is described in Finney and Moos (1995). Individuals who entered the study had an alcohol use disorder, as determined by one or more substance use prob­ lems, dependence symptoms, drinking to intoxication in the past month, and/or percep­ tion of alcohol abuse as a significant problem.

At 1, 3, 8, and 16 years after entering the study, participants were located and con­ tacted by telephone and asked to complete an inventory that was essentially identical to the baseline inventory. One hundred twenty-one of the 628 baseline participants (19.3%) had died by the 16-year follow-up. At baseline, compared with the individuals who sur­ vived, those who died were older (40.1 vs. 33.4 years, t = 7.39, p.01), less likely to be married (13.2% vs. 22.9%, t = 2.35, p.05), and consumed more alcohol (14.9 vs. 12.7 ounces of ethanol on a typical drinking day; t = 1.99, p.05).

Of the remaining 507 individuals, 422, 391, 408, and 405 completed the 1-year, 3-year, 8-year, and 16-year follow-ups, respectively. We focus here on the 461 (90.9%) surviving individuals who completed two or more follow-ups or the 16-year follow-up.

Compared with the remaining 46 surviving individuals, these 461 individuals were more likely to be women (50.3% vs. 32.6%; t =2.30, p.05) and to be employed at baseline (44.3% vs. 21.7%; t =2.97, p.01).

The 461 previously untreated individuals were almost evenly divided between women (50.3%) and men (49.7%). Most were White (80.0%), unmarried (76.4%), and unemployed (55.7%). On average, at baseline, these individuals were in their mid-30s (M = 33.5;

SD = 8.8) and had 13 years of education (M = 13.1; SD = 2.2) and an annual income of $12,800. They consumed an average of 12.5 ounces of ethanol (SD = 11.2) on a typical drinking day, were intoxicated on an average of 13.0 days (SD = 10.8) in the last month, and had an average of 5.0 dependence symptoms (SD = 2.9) and 4.8 drinking problems (SD = 2.4).


At baseline and at each follow-up, we assessed respondents’ drinking patterns and prob­ lems, self-efficacy to resist pressure to drink, depression, and social functioning. In addi­ tion, we obtained information about respondents’ participation in treatment and AA. We dichotomized the baseline and follow-up values of the outcomes to provide more clini­ cally meaningful indices of functioning.

–  –  –

Collaterals and participants showed significant agreement at baseline on these two alcoholrelated indices (Finney & Moos, 1995).

Psychological functioning. Information was obtained on two indices. Self-efficacy to resist alcohol was assessed with 10 items (Cronbach’s alpha at baseline =.93) adapted from the Situational Confidence Questionnaire (Annis & Graham, 1988). The items cov­ ered situations involving negative and positive emotions, interpersonal conflict, and test­ ing one’s self-control. Each item was rated on a 6-point scale varying from 0 = not at all confident to 5 = very confident. Based on evidence that maximum levels of self-efficacy are the strongest predictors of alcohol-related outcomes (Ilgen, McKellar, & Tiet, in press), respondents were considered to be self-confident if they rated themselves as con­ fident or very confident on all 10 of the items; otherwise they were classified as not self-confident.

Depression was based on a measure included in the HDL and derived from the Research Diagnostic Criteria (Spitzer, Endicott, & Robins, 1978). Respondents rated how often (on a 5-point scale with 0 = never and 4 = often) they experienced each of nine symptoms of depression in the last month, such as feeling sad or blue; feeling guilty, worthless, or down; thoughts about death or suicide (Cronbach’s alpha at baseline =.92). This measure is relatively stable (rs =.54,.52, and.49 over 3-year, 5-year, and 8-year intervals, respec­ tively). Based on the criteria for minor depression in the Diagnostic and Statistical Man­ ual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994), respondents were considered to be experiencing depression if they answered “often” or “fairly often” to four or more items; otherwise they were classified as not depressed.

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