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Alcoholism Treatment Quarterly, 27:349 367, 2009 Copyright Taylor & Francis Group, LLC ISSN: 0734-7324 print/1544-4538 online DOI: 10.1080/07347320903209665 Alcoholics Anonymous: Key Research Findings from 2002 2007 SHULAMITH LALA ASHENBERG STRAUSSNER, DSW, CAS Silver School of Social Work, New York University, New York, New York, USA HELGA BYRNE, MA, CASAC, LMHC Greenwich House Chemical Dependency Program, New York, New York, USA Alcoholics Anonymous (AA) and other 12-step programs represent an affordable and widely accessible community-based resource for the estimated 18 million Americans with alcohol-related disorders. While substantiating information regarding 12-step programs remains challenging due to their autonomous structure and emphasis on anonymity, an ever increasing body of research provides a wealth of data regarding AA s efficacy, mechanisms of change, and viability for various special populations. This review presents key empirical findings from 2002 to 2007 in these areas, as well as proposes recommendations for future research. KEYWORDS Alcoholics Anonymous, 12-step program, Narcotics Anonymous, efficacy, dual diagnosis, special populations INTRODUCTION Currently there are more than 2,000,000 members of Alcoholics Anonymous (AA) in 100,000 groups in more than 150 countries (AA website, n.d., AA at a glance ). AA represents an affordable and highly accessible component of treatment for the estimated 18 million Americans suffering from alcohol use disorders (National Council on Alcoholism and Drug Dependence, n.d.). Multiple studies indicate that regular attendance and involvement in 12- step programs is associated with improved drinking outcomes and greater abstinence rates, providing strong empirical evidence in support of partici- Address correspondence to Dr. S. Lala Straussner, Silver School of Social Work, New York University, 1 Washington Square Park, North, New York, NY 10003. E-mail: lala.straussner@ nyu.edu 349

350 S. L. A. Straussner and H. Byrne pation in 12-step programs (Bond, Kaskutas, & Weisner, 2003; Bottlender & Soyka, 2005; Gossop et al., 2003; Gossop, Stewart, & Marsden, 2008; Kissin, McLeod, & McKay, 2003; McCrady, Epstein, & Kahler, 2004; McKellar, Stewart, & Humphreys, 2003; Moos & Moos, 2004, 2006; Timko, Finney, & Moos, 2005; Vaillant, 2003). Theories about how AA facilitates change abound, filtered through the lens of various paradigms such as self-efficacy (Tonigan, Bogenschutz, & Miller, 2006); social support and social network variables (Groh, Jason, & Keys, 2008); self-determination theory (SDT; Kenneally, 2007); positive psychology (Zemansky, 2005); working through grief, loss, and transition issues (Streifel & Servanty-Seib, 2006); and spirituality and meaning (Harber, 2006; Hudson, 2004; Murray, Goggin, & Malcarne, 2006; Poage, Ketzenberger, & Olson, 2004; Piderman, 2004; Robinson, Cranford, Webb, & Brower, 2007; Tonigan, 2007; Tonigan, Miller, & Schermer, 2002). Recent research also explores specific subsets of the general AA population, including women, adolescents, young adults, and undergraduates, and the dually diagnosed. However, surprisingly little empirical research appears to have been conducted in recent years on AA as it relates to ethnic minority groups. Existing studies regarding the Hispanic, Asian, and African American communities and AA generally have small sample sizes and tend to be primarily descriptive and qualitative in nature, providing opportunities for future research. The challenges inherent in substantiating data regarding AA are embedded in its autonomous structure and emphasis on anonymity, as well as ethical considerations, and thus seriously limit rigorous methodological examination. Despite these challenges, there has been a proliferation of 12-step-related research in recent years. Between 1993 and 2001, 118 AArelated empirical studies were published; nearly the equivalent of the total number of AA-related empirical publications for the years 1940 to 1992 (Owen et al., 2003). The purpose of this paper is to review and synthesize key empirically based research findings from 2002 to 2007 regarding AA. For the purposes of this review, research findings have been divided into three broad categories: the efficacy of AA as measured by drinking outcomes and length of abstinence; proposed mechanisms of change; and AA as it relates to special populations. Recommendations for future research are proposed. EFFICACY OF AA Multiple studies evaluating the efficacy of AA both as a stand-alone treatment and in comparison to other treatment models point to the substantial and ever increasing body of literature that suggests that regular posttreatment attendance in 12-step programs significantly improves alcohol and other drug use outcomes (Cloud et al., 2006). AA has been cited as one of the

Key AA Research Findings 351 few treatment models to demonstrate positive abstinence outcomes (Groh et al., 2008) and appears to be equal or superior to conventional treatments for alcoholism (Vaillant, 2005). Twelve-step programs, for example, have been shown to be more effective than cognitive behavioral skills training for most substance abusers (Brown, Seraganian, Tremblay, & Annis, 2002). Bottlender and Soyka s (2005) study of 103 alcohol-dependent individuals found that after controlling for confounding variables, patients who participated regularly in self-help (or more accurately, mutual-help) groups fared the best, while those who attended infrequently had the highest relapse rates. Likewise, Kissin et al. (2003) demonstrated that continuous self-help participation was associated with the lowest alcohol and other drug use, while nonattendance was linked to the highest use, even after controlling for length of formal treatment and the participant s perceived severity of their alcohol or drug use problem. McCrady et al. s (2004) study of 90 men with alcohol problems also concurred that drinking outcomes were strongly related to AA attendance. The degree of AA participation, in terms of both frequency and duration, has also been shown to be a significant predictor of drinking outcomes and length of abstinence. Bond et al. (2003) estimate that an increase in AA participation in the 12 to 36 months posttreatment increases the odds of abstinence at 3 years by 35%. Vaillant s (2003) study of alcohol abuse among two male cohorts followed from 1940 to 2003 identified participation in AA, as well as severity of alcohol abuse (those having met criteria for alcohol dependence), as the two best predictors of abstinence. Men in the study who demonstrated positive drinking outcomes attended roughly 20 times more AA meetings than men who demonstrated poorer drinking outcomes. A 3-year study of 227 recovering alcoholics funded by the National Institute on Alcohol Abuse and Alcoholism also demonstrated that greater attendance at AA or other self-help meetings posttreatment resulted in increased abstinence rates or in less intensive alcohol consumption in the event of relapse, regardless of religious preferences, gender, mental health disorders, or whether the individual had previously participated in AA or other selfhelp groups (Stout, 2006). Similarly, Gossop et al. s (2003) longitudinal study of 150 alcohol-dependent patients found that individuals who frequently attended AA had superior drinking outcomes to those who did not attend or were infrequent participants. In addition, individuals who attended AA meetings on a weekly or more frequent basis reported greater reductions in alcohol consumption and more abstinent days, even after controlling for confounding variables. McKellar et al. (2003) identified the level of AA participation during the first year posttreatment as a predictor of fewer alcohol-related problems at the second year follow-up (n D 2,319). Gossop et al. (2008) evaluated substance use outcomes after residential treatment (n D 142) relative to

352 S. L. A. Straussner and H. Byrne frequency of attendance at Narcotics Anonymous (NA) and AA meetings. Those who attended more frequent NA or AA meetings were more likely to be abstinent from drugs and alcohol when compared to those who did not attend meetings or those who attended less than weekly. Similarly, a longitudinal study by Timko et al. (2005) of 466 individuals in professional treatment and AA over an 8-year time span demonstrated that a longer duration of AA attendance during the first year, as well as over the course of the entire 8 years, was associated with decreased drinking. Moos and Moos (2004, 2006) have provided a wealth of quantifiable data regarding drinking outcomes and predictors of abstinence through their study of 461 previously untreated individuals with alcohol use disorders in both professional treatment and AA. Study participants were interviewed at baseline and at 1, 3, 8, and 16 years later. Individuals who participated in AA or obtained treatment for 27 weeks or more after seeking help had better 16-year outcomes than those who remained untreated. Subsequent participation in AA was also associated with better 16-year outcomes, although this was not true for subsequent professional treatment. Even individuals who participated in AA for 9 weeks or more had better 16-year alcohol outcomes compared to those who did not attend AA in the first year. Only 34% of individuals who did not participate in AA in the first year were abstinent at 16 years, compared to 67% of those who participated in AA for 27 weeks or more (Moos & Moos, 2006). Moreover, individuals who participated in both formal treatment and AA were more likely to achieve 16-year remission than those who participated only in treatment in the first year. Moos and Moos (2006) concluded that initial professional treatment may have a beneficial effect on drinking outcomes, but participation in mutual-help programs such as AA appear to be a far more important determinant of long-term drinking outcomes. Moos and Moos (2004) also studied the effect of additional and delayed affiliation with AA on drinking outcomes. Relative to individuals who did not participate in AA, those who affiliated with AA quickly and who participated longer had better drinking outcomes at the 1- and 8-year follow-ups than those who discontinued participation. However, individuals who delayed participation in AA did not have better outcomes than those who never participated. Moos and Moos also noted that a longer duration in AA produced a greater likelihood of remission among high-risk than among low-risk individuals. Kaskutas et al. (2005) identified patterns of AA participation as they relate to abstinence using longitudinal data from 349 dependent drinkers interviewed upon entering treatment and at 1, 3, and 5 years. Rates of abstinence at year 5 were 43% for individuals who only participated in AA in the first year following treatment, 73% for those who attended approximately 60 meetings a year at the 3- and 5-year follow-ups, and 79% for those who attended more than 200 meetings a year at the 3- and 5-year follow-ups.

Key AA Research Findings 353 Specific Activities as Predictors of Abstinence Specific activities within AA that serve as predictors of abstinence have also been identified. Witbrodt and Kaskutas (2005) examined whether specific aspects of 12-step participation differentially affect abstinence based on the individual s specific substance dependence disorder (n D 302). They determined that the number of meetings attended and the number of activities engaged in similarly predicted abstinence regardless of the substance dependence disorder, however, specific activities were associated with abstinence differentially by dependence disorder. Only two AA activities distinguished abstinence for alcoholics having a sponsor and doing service while many activities differentiated abstinence for those dependent on drugs or those who abused both drugs and alcohol. Service work, which the authors do not define but can be understood as executing a task in support of the AA group, was the strongest predictor of abstinence in all categories 12 months after treatment. Bond et al. (2003) identified AA involvement in the last year, the percentage of heavy or problem drinkers in the individual s social network, the percentage of those in the social network encouraging alcohol reduction, and AA-related support for reducing drinking as significant predictors of 90- day abstinence at 1- and 3-year follow-ups (n D 655). Reexamination of Success Rate Very little substantiated data or record keeping exists within AA that validates or refutes its success rates. Arthur S., Tom E., and Glenn C. (2008), however, endeavor to debunk two conflicting statistics from AA s verbal tradition that depict AA as experiencing a 50% 75% success rate in its early years, in contrast to a current success rate of only 5% to 10%. First publicly cited in 1940 by AA s founder Bill Wilson, a 50% C 25% D 75% success rate has remained firmly fixed in AA lore despite its lack of supporting data. What that referred to was the belief that in the initial years of AA when individual cases were tracked, an estimated 50% of the pioneering members of AA who seriously tried the program achieved a successful recovery shortly after affiliating with the program. Of the remaining 50%, 25% were believed to have returned to the program after relapsing, and subsequently were able to successfully achieve and maintain sobriety, accounting for a total recovery success rate of 75%. What was ignored in this statistic was the fact that, in those days, prospective AA members were often prescreened before being admitted, in effect measuring the recovery success rate of only those prequalified as committed to recovery. Bill Wilson was careful to emphasize that this success rate applied solely to those who were serious about AA, and further qualified that this figure applied to the one to two prospects out of five who remained affiliated with AA after their initial exposure (Arthur S. et al., 2008).

354 S. L. A. Straussner and H. Byrne The authors believe that a second conflicting statistic purporting that contemporary AA enjoys a success rate of between only 5% and 10% is erroneous and can be traced to a consistently misconstrued graph in a 1989 1990 AA General Service Organization report. Frequently interpreted as signifying retention or success rates, the graph, correctly interpreted, illustrates the distribution of the amount of time the sample attended AA. In the case of the 1989 1990 report, 56% of those who remained in AA after 3 months remained active members at the end of 1 year. The authors thus contend that recent research discoveries support the 50% C 25% D 75% as a reasonable best estimate of AA s current, as well as prior success rate (Arthur et al., 2008, p. 3). Clearly, empirical data overwhelmingly supports participation in AA and other 12-step groups as a significant predictor of improved long-term drinking outcomes and abstinence rates, independent of professional treatment and regardless of confounding variables. Furthermore, both the promptness of affiliation with AA s program of recovery and the duration of participation therein are strong predictors of drinking outcomes. MECHANISMS OF CHANGE In addition to evaluating and quantifying the efficacy of AA, researchers have also sought to explain how AA is effective by exploring proposed mechanisms of change through various paradigms. These include social support and social network variables; self-efficacy; SDT; positive psychology; working through transition, grief, and loss issues; and spirituality and religion. Groh et al. s (2008) meta-analysis of 24 papers examining the relationship between AA and social network variables, for example, found that involvement in AA is associated with a variety of positive qualitative and quantitative changes in social support networks, with the greatest impact on friends and less impact on family and other networks. Not surprisingly, support from other AA members was determined to be of great value in recovery and those with prior or existing harmful social networks (those supportive of drinking) obtained the greatest benefit. Tonigan et al. (2006) examined the mediational role of self-efficacy on changes in drinking associated with AA attendance in type A and type B alcoholics using data from 1,284 Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity) participants. For both typologies, AA attendance was associated with substantial increases in perceived abstinence self-efficacy, which in turn was a significant predictor of later abstinence. Kenneally (2007) examined AA-related behaviors in the context of SDT, which posits that humans strive to engage in behavior of their own choice, which leads to healthy psychological development. SDT defines this process as requiring regular social experiences and feelings of autonomy, related-

Key AA Research Findings 355 ness, and competence and proposes that individuals may develop negative compensatory behaviors if they experience a deficit of these feelings. Kenneally hypothesized that AA acts as a social environment where individuals can experience feelings of relatedness (through identification with similar others), autonomy, and competence (through successful remission of alcohol consumption), leading them to make healthier choices and positive psychological development. Although several of the hypothesized questions, including a correlation between attending AA meetings and well-being, were not supported by the data, progression through the 12 steps was found to have a therapeutic effect and was highly correlated to increased feelings of autonomy, relatedness, and competence, as well as a resulting sense of well-being. Using the paradigm of positive psychology, Zemansky (2005) examined the relationships between optimism, gratitude, meaning and purpose in life, subjective well-being, spirituality, and the process of recovery among active members of AA. Using Internet survey data from 164 AA members, 100 of whom had more than 10 years of continuous sobriety, Zemansky found several associations, including a positive relationship between involvement in AA and gratitude, between having a sponsor and spirituality, and between working all 12 steps and having meaning and purpose in life. AA participants had significantly above average scores on optimism, gratitude, spirituality, and subjective well-being when compared to same-instrument scores from historical reference studies using nonclinical adult populations, providing quantifiable evidence of a positive transformation that occurs in AA above and beyond cessation of alcohol use. Vaillant (2005) proposes four commonly recognized relapse prevention factors as AA s primary mechanisms of change: external supervision, substitute dependency, new caring relationships, and increased spirituality. External supervision can be found in working with a sponsor, engaging in service, and working the 12 steps, and serves as a daily reminder of the effects of alcohol use. Substitute or competing behaviors for addictions can be found in the social and service aspects of AA. New caring relationships in the form of sponsorship and social support offer AA members the opportunity to form connections with people they have not hurt in the past and to whom they are not emotionally indebted. Finally, AA s emphasis on spirituality provides a healthy alternative to the high produced by alcohol and drugs and helps to absolve guilt. Streifel and Servanty-Seib (2006) offer two interconnected theories to help elucidate AA s mechanisms of change: Schlossberg s transition theory (1984) and Rando s (1995) theory of grief and mourning. The authors propose that AA helps individuals manage the transition from active alcoholism to recovery and facilitates processing loss and grief issues associated with recovery, which may include the loss of alcohol itself, relationships with others, and the ability to escape feelings. They believe that participation in

356 S. L. A. Straussner and H. Byrne AA increases an individual s resources in each of the four key areas identified in Schlossberg s theory of transition as key determinants in a person s ability to cope with a major life transition: situation, self, support, and strategies. AA helps individuals learn to control what they can and to change people, places and things (situation); increases an individual s psychological resources, instills hope, and fosters humility and honesty (self); provides acceptance, support, and feedback in friendship networks and communities (support); and helps individuals manage stress through information seeking and direct action (strategies). Rando s (1995) theory of grief and mourning, which Streifel and Servanty-Seib (2006) view as a parallel process to the steps and concepts of AA, seeks to help individuals learn to accommodate loss in a healthy manner by recognizing the loss, reacting to the separation, recollecting and re-experiencing, relinquishing old attachments, readjusting, and reinvesting. The authors encourage clinicians to familiarize themselves with both theories and to incorporate them in treatment. Spirituality and Meaning in AA Research is inconclusive regarding the role of spirituality and religion as a mechanism of change in AA, although various studies have shown that participation in AA produces significant shifts in God beliefs and spirituality. There is conflicting evidence in support of spirituality as a predictor of abstinence; in fact, several studies point to AA attendance as a significant factor in reduced drinking and abstinence regardless of religious or spiritual affiliation. Tonigan s (2007) examination of spirituality and AA appears to mirror the findings of multiple studies; namely, he found little evidence in support of spirituality as a factor in later abstinence, although he postulates that it may have an indirect effect, as initial increases in spirituality appear to promote sustained AA participation, which in turn leads to sustained recovery over time. Robinson et al. (2007) found that increases in religious beliefs occurred in outpatients with alcohol use disorders even after controlling for gender and AA involvement. Using 10 measures of spirituality and religiousness, behaviors, beliefs, and experiences, their study of 123 outpatients with alcohol use disorders examined changes in alcoholics spirituality or religiousness from treatment entry to 6 months later and whether these changes were associated with drinking outcomes. Results showed statistically significant increases in half the spirituality and religious measures over the 6-month time span, as well as statistically significant decreases in alcohol use. Using qualitative and quantitative methods to identify relationships between God image, self-image, and length of abstinence among active AA members, Harber (2006) found no statistically significant relationship between belief in a God/higher power and length of abstinence. In fact, the

Key AA Research Findings 357 number of mean days sober was 68% longer for those active AA members who had at one time quit AA for religious reasons than for those who had quit for all other reasons. Those who reported no religious affiliation remained sober longer (8.3 years) than those with religious affiliation (Protestant 7.32 years, Catholic 5.6 years, other religions 5.02 years). Tonigan, Miller, and Schermer s (2002) study of atheists and agnostics in AA (n D 1,526 Project MATCH participants) likewise demonstrated that AA attendance was strongly correlated with greater abstinence and reductions in drinking, regardless of God belief. Although atheist and agnostic clients attended AA considerably less often than individuals who identified themselves as spiritual or religious, no differences in the percentage of days abstinent and drinking intensity were found between atheist and agnostic versus spiritual and religious clients. Using the paradigm of spirituality-related control beliefs, Murray et al. (2006) assessed study participants perceptions of the role of God/higher power in recovery from alcoholism through the Alcohol-Related God Locus of Control (AGLOC) scale, a 12-item self-report measure. Administered to 144 recovering alcoholics attending AA meetings, results showed that attributions of God control were correlated to cessation of drinking, but not necessarily to maintenance of abstinence. Piderman (2004), however, found an association between scores of spiritual well-being and abstinence self-efficacy in her study of 49 alcohol-dependent individuals. In addition, Poage et al. s (2004) examination of length of sobriety, spirituality, stress, and contentment in a sample of AA participants found that length of sobriety was significantly associated with spirituality. Hudson (2004) examined the relationship among alcohol-problem adversity and the combined variables of spiritual awareness, AA membership patterns, and involvement in AA. Using the Drinker Inventory of Consequences and the General Alcoholics Anonymous Tools of Recovery (GAATOR) 2.1, analysis of data from 172 study participants found that those who reported greater AA attendance also had higher spirituality or GAATOR scores. Greater AA attendance was also significantly related to fewer negative drinking-related consequences, and higher GAATOR scores had a significant correspondence to fewer consequences. In sum, research suggests that significant increases in religious or spiritual beliefs occur in persons in recovery, although these increases do not necessarily appear to be directly linked to AA attendance or affiliation. Further research is suggested regarding the causality of the relationship between spirituality/religious beliefs and AA. SPECIAL POPULATIONS Research encompassing a variety of special populations within AA such as young adults, undergraduates, and adolescents; the dually diagnosed;

358 S. L. A. Straussner and H. Byrne women; and ethnic and racial minorities has shed light on the specific needs of these groups and how they may or not be met by 12-step programs. This section examines the research literature regarding these populations. Young Adults, Undergraduates, and Adolescents A study by Mason and Luckey (2003) of 98 young adults age 18 25 years within a sample of 1,022 individuals in alcohol treatment showed that young adults attended about half as many AA meetings as other members and were less likely to have attended an AA meeting before. The older sample was also more likely to have experienced a conversion experience in AA and to consider themselves AA members. Mason and Luckey propose having young adults meetings and suggest that young adults may gravitate more toward NA rather than AA, given the likelihood that they may have polydrug issues. Colleges and universities may be one of the most challenging environments in which to moderate drinking, given that many social activities are organized around alcohol consumption (Cleveland, Harris, Baker, Herbert, & Dean, 2007). Morrison s (2006) evaluation of 40 undergraduates between the ages of 18 and 25 years who were engaged in AA or NA demonstrated that substance abuse recovery can be successfully experienced in conjunction with a productive academic career and that their most frequently expressed desire was to connect with similar others. Adolescents face specific barriers to participation in AA and other 12- step programs, including lower substance use problem recognition, less addiction severity and related sequelae, a significant age discrepancy relative to other members, logistical issues such as transportation and parental permission, and possible uncertainty about the spiritual aspects of 12-step fellowships (Kelly & Myers, 2007). Appropriate and effective treatment resources for adolescents are particularly important, as substance use disorders are the most prevalent cause of adolescent mortality in the United States (Conason, Oquendo, & Sher, 2006). A 5-year longitudinal study of 315 adolescents in three treatment groups demonstrated that the 12-step-based treatment group showed consistent and significantly lower levels of drug use (Winters, Stinchfield, Latimer, & Lee, 2007). Analysis of data from the Drug Treatment Outcome Studies for Adolescents (n D 810) also indicates that participation in 12-step programs was positively associated with posttreatment abstinence among dually diagnosed adolescents (Grella, Joshi, & Hser, 2004). Kelly, Myers, and Brown s (2002) study of 74 adolescent inpatients found that adolescents with greater substance use problem severity were more likely to attend and affiliate with 12-step groups. A greater frequency of meeting attendance and, to a smaller degree, a higher level of affiliation with 12-step groups was associated with improved posttreatment substance use outcomes; however, affiliation did not predict outcomes beyond frequency of attendance. Kelly, Myers, and

Key AA Research Findings 359 Brown s (2005) study using the same sample also found that greater age similarity positively influenced attendance rates among adolescents and was associated with increased step work and a decrease in substance use. Dually Diagnosed Community-based resources to augment recovery support both during and after treatment have become more critical in recent years due to the emergence of managed care and subsequent decreases in the duration and intensity of substance abuse treatment, particularly for dually diagnosed individuals, who may require a greater level of support for a longer duration than single-disorder substance users (Laudet et al., 2004). Participation in 12-step programs is associated with improved outcomes for individuals with comorbid disorders (Bogenschutz, 2007). For example, Timko and Sempel s (2004) study of 230 dually diagnosed individuals found that a greater frequency of 12-step attendance during treatment was associated with better psychiatric outcomes, while a longer duration of 12-step attendance during treatment was associated with better alcohol use outcomes. Another study of 112 dually diagnosed individuals assigned to either a Cognitive Behavioral Therapy (CBT) approach (SMART Recovery) or a 12-step approach found the 12-step approach to be more effective in decreasing alcohol use and increasing social interactions, although an increase in medical problems and psychiatric hospitalizations were associated with the 12-step intervention (Brooks & Penn, 2003). Dually diagnosed individuals demonstrate similar 12-step attendance rates and have been found to receive similar benefits as non dually diagnosed individuals, although attendance rates may vary by diagnosis (Bogenschutz, 2007). An evaluation of the AA and NA attendance rates of 351 dually diagnosed individuals showed that 10 months posthospitalization, study participants had similar rates of attendance as those with substance use disorders but no comorbid severe mental illness ( Jordan, Davidson, Herman, & BootsMiller, 2002). Those with schizophrenia or schizoaffective disorders, however, reported significantly fewer days of AA or NA meeting attendance. In recent years, specialized dual-focus 12-step groups, such as Double Trouble in Recovery (DTR) and Double Trouble Anonymous (DTA), have emerged to address the specific needs of dually diagnosed individuals. Traditional 12-step meetings may have an unspoken bias against the use of medications despite AA s official stance that no AA member plays doctor (Alcoholics Anonymous, n.d., The AA member Medications and other drugs ). These specialized groups provide dually diagnosed individuals an opportunity to discuss substance use and mental health issues in a safe, accepting, and socially supportive forum. A 2-year longitudinal study of 310 DTR members demonstrated that DTR attendance was significantly associated with a greater probability of absti-

360 S. L. A. Straussner and H. Byrne nence after controlling for variables such as mental health symptoms (Laudet et al., 2004). A quasi-experimental study comparing two cohorts receiving psychiatric day treatment, one exposed to DTR, the other not exposed, found that the DTR cohort had fewer days of substance use, higher attendance at external 12-step meetings, and greater psychiatric mediation compliance (Magura et al., 2008). In Magura, Laudet, Mahmood, Rosenblum, and Knight s (2002) study of 240 DTR members, consistent DTR attendance was identified as one variable associated with improved medication compliance, which in turn was associated with a lower severity of psychiatric symptoms at a 1-year follow-up and an absence of psychiatric hospitalizations during the follow-up period. A related study using the same sample demonstrated that abstinence among study participants increased from 54% at baseline to 72% at the 1-year follow-up (Magura et al., 2003). Laudet, Magura, Cleland, Vogel, and Knight (2003) also identified retention predictors using a sample of 276 members of a dual-focus group. Results identified older age, a greater incidence of lifetime arrests, abstinence, a greater level of psychiatric symptoms in the prebaseline year, medication noncompliance, being more concerned with substance use than mental health, and greater self-efficacy for recovery as baseline characteristics associated with higher retention 1 year later. Women Several recent studies have evaluated how women affiliate with AA and whether they are hindered by the male-dominated culture and language of AA. Sanders (2006), for example, argues against a feminist critique of AA as patriarchal and male dominated in her examination of how women in AA approach, interpret, and utilize the 12 steps. Through survey and narrative data from 167 women in AA, Sanders findings suggest that women working AA s 12 steps become empowered and change for the better in spite of the culture and language of the 12 steps and regardless of any difficulty they have in completing the steps. Sanders concludes that AA does not represent a threat to feminist empowerment, but instead is a particular and powerful contemporary form of women s empowerment. Bradley (2005), in her dissertation examining women s experiences in AA, also found that although the noninclusive language of AA literature and male God images were troublesome to some women, particularly some lesbian study participants, these factors were inconsequential for most women and did not affect their feelings about the appropriateness of the program for women. Study participants made gender-specific modifications, such as changing pronouns in the AA literature, using a female God image, and participating in women s meetings. As in Sanders study (2006), participants also reflected that they found the process of recovery in AA very empowering. Rush (2002) investigated dimensions of perceived social support among 125 women in AA using the Social Support Network Inventory. Results of

Key AA Research Findings 361 this correlational study indicated that women with a sponsor had significantly higher scores in social and personal support. Availability was the strongest contributor to personal and overall perceived social support, leading Rush to conclude that sponsorship and availability are critical components of a supportive environment for females in sobriety. Ethnic and Racial Minorities Although numerous studies exist prior to 2005 that specifically address AA in relation to ethnic minorities such as Hispanics, African Americans, and Native Americans, recent studies regarding these populations and AA appear to be limited and are primarily descriptive and qualitative in nature, indicating the need for further research. In one larger-scale empirical study, Roland and Kaskutas (2002) investigated the effect of AA involvement and spirituality and religiousness on sobriety within three ethnic groups: Hispanics (n D 60), African Americans (n D 253), and Caucasians (n D 538). Results indicated that African Americans self-identified as more religious and were less likely to substitute church attendance for AA participation. In addition, African American participants who reported greater AA participation and church attendance at the end of the first year were more likely to report sobriety than African American participants reporting only greater church attendance. For Hispanics and Caucasians, participants who reported primarily greater AA attendance were more likely to have more than 30 days of sobriety. Research regarding the Hispanic community also includes Arroyo, Miller, and Tonigan s (2003) study of 105 non-hispanic White participants and 100 Hispanic participants at a Project MATCH treatment site. The authors hypothesized that 12-step facilitation therapy (TSF) would be less effective than CBT or Motivational Enhancement Therapy (MET) for Hispanic clients, particularly those with low acculturation, based on prior research suggesting that Hispanic clients are less likely to affiliate with AA. Although results showed that Hispanics responded similarly to the three treatment conditions, Hispanics in TSF had significantly poorer outcomes than non-hispanic Whites in TSF, including more intense and more frequent drinking, even though Hispanics drank less frequently than non-hispanic Whites pretreatment. AA attendance was also considerably lower among Hispanic clients, although Hispanics who did attend AA reported a higher level of participation than non-hispanic Whites. The authors concluded that self-identified ethnicity mediated treatment response as measured by frequency and intensity of alcohol consumption. Contrary to prediction, however, the level of acculturation did not predict differential response to treatment. Moreover, the authors suggest that ethnic self-identification interacts with treatment outcomes in complex ways that are not directly linked to factors associated with traditional measures of acculturation.

362 S. L. A. Straussner and H. Byrne Using the same sample and treatment conditions as Arroyo et al. (2003), Tonigan, Miller, Juarez, and Villanueva (2002) evaluated how commitment to AA behaviors posttreatment differs between Hispanics and non-hispanic Whites. Their findings indicated that Hispanics in TSF reported attending significantly fewer AA meetings 6 months after treatment than did the non- Hispanic Whites in TSF. No differences in AA attendance rates were found between Hispanics who were encouraged to attend AA and those who were not, and no ethnic differences were found in rates of specific AA behaviors, although Hispanics reported a significantly higher level of God consciousness posttreatment. Similar to the findings of Arroyo et al. (2003), Hispanics showed increased AA commitment compared to non-hispanic Whites despite less frequent AA attendance, leading Tonigan et al. (2002) to conclude that the difference in commitment to AA does not explain why Hispanics report less frequent AA attendance but equal benefits relative to non-hispanic Whites. Very few empirical studies were found regarding Asian Americans and AA. In one study, Lee, Law, and Eo (2003) examined beliefs about treatment and help-seeking preferences in the Asian American community using a sample of 425 Chinese, Korean, Indian, and Vietnamese respondents. Their findings suggested a tendency for Asian Americans to use personal resources instead of professional services or formal treatment programs, as well as a lack of interest to utilize self-help groups. In another, Morjaria & Orford (2002) explored the spiritual aspects of recovery of South Asian men through interviews and comparative analysis of five South Asian men recovering from alcohol use disorder and five White AA members. Spirituality and religion played an important role in the recovery experiences of both the Caucasian AA members and the South Asian participants. Their experiences differed, however, in that the South Asian participants described a reaffirmation of existing beliefs rather than the conversion experience described by the Caucasian AA members. FUTURE RESEARCH Multiple studies point to participation in AA and other self-help groups as a significant predictor of improved drinking outcomes and abstinence, fostering increases in self-efficacy, social networks, social support, and well-being. These results are consistent across many variables, including gender, religious preferences, and mental health disorders, and are independent of professional treatment. Despite this significant body of research, further research is warranted in a number of areas, including special populations, specifically with regard to ethnic minorities; factors that mediate and influence dropout rates; the role of substitution therapies in AA; and how specific aspects of AA, such as sponsorship, service, and slogans, may act as mechanisms of change.

Key AA Research Findings 363 Existing research on special populations within AA is enlightening and varied in its approaches, but is limited in scope. For example, additional research is warranted regarding dually diagnosed individuals perceptions and experiences of 12-step groups, particularly how the use of psychiatric medication may impact the participation and experience of AA for individuals with comorbid mental disorders. As minority populations in the United States continue to grow, research regarding ethnic minorities in AA will become increasingly important. Hispanics, for example, are the fastest growing minority group in the United States. Rates of heavy drinking increased among Hispanic males between the mid-1980s and mid-1990s, suggesting that there will be an increased need for alcohol treatment among Hispanics in the future (Arroyo et al., 2003). Suggestions for future research regarding ethnic and minority groups include additional large-scale quantitative studies to identify cultural barriers to AA affiliation; examine how cultural issues affect minority groups perceptions of and experience in 12-step groups; determine whether cultural background differentially affects mechanisms of change; and determine proportional representation, attendance, and attrition rates of ethnic minorities. Analysis of Project MATCH data indicates that regular 12-step attendance is practiced by a minority, deteriorates across time, and stabilizes at 6 months following treatment (Cloud et al., 2006). Kelly and Moos (2003), for example, reported a 40% dropout rate in the year following treatment in a sample of 3,660 participants from 15 Veterans Administration treatment sites. Additional research delineating factors that impact and mediate affiliation and dropout from 12-step programs is needed and may help guide clinicians to more effective interventions to increase or maintain 12-step attendance. Studies exploring specific aspects of AA and other 12-step groups, such as the role of sponsorship, service, literature, and slogans, may provide additional information regarding mechanisms of change. For example, what scientific evidence has been found to support specific behavioral recommendations in AA, such as attending 90 meetings in 90 days? Or in the example of the AA slogan First Things First, do alcoholics have poor multitasking skills or low tolerance to stress, and are these a result of alcoholism or one of the contributing factors that led to alcohol use? As previously noted, further research is needed regarding the causality of the relationship between spirituality and religious beliefs and AA, as well as how gender differences impact AA affiliation. In addition, examination of how involvement in AA is qualitatively different than involvement in other 12-steps groups such as NA or Cocaine Anonymous could prove fruitful (Kingree & Sullivan, 2002). Finally, few empirical studies were found regarding the use of substitution therapies. Given the relatively recent introduction of new relapse prevention medications onto the U.S. market, additional studies addressing the use of substitution therapies among members of AA and other 12-step groups are needed.

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