A randomized trial of treatment options for alcohol-abusing workers. Issues in the implementation of a randomized clinical trial that includes Alcoholics Anonymous: studying AA-related behaviors during treatment. Process and outcome changes with relapse prevention versus 12-Step aftercare programs for substance abusers. Matching alcoholism treatments to client heterogeneity: treatment main effects and matching effects on drinking during treatment. Project MATCH Research Group. A trial of "standard" outpatient alcoholism treatment vs. a minimal treatment control. What is Alcoholics Anonymous affiliation? In 12-step groups, helping helps the helper. Motivational enhancement for 12-step involvement among patients undergoing alcohol detoxification.
Employee-assistance programs sponsored by companies or labor unions identify workers who abuse alcohol and refer them for care, often to inpatient rehabilitation programs. Yet the effectiveness of inpatient treatment, as compared with a variety of less intensive alternatives, has repeatedly been called into question. In this study, anchored in the work site, we compared the effectiveness of mandatory in-hospital treatment with that of required attendance at the meetings of a self-help group and a choice of treatment options.
                We randomly assigned a series of 227 workers newly identified as abusing alcohol to one of three rehabilitation regimens: compulsory inpatient treatment, compulsory attendance at Alcoholics Anonymous (AA) meetings, and a choice of options. Inpatient backup was provided if needed. The groups were compared in terms of 12 job-performance variables and 12 measures of drinking and drug use during a two-year follow-up period.
                All three groups improved, and no significant differences were found among the groups in job-related outcome variables. On seven measures of drinking and drug use, however, we found significant differences at several follow-up assessments. The hospital group fared best and that assigned to AA the least well; those allowed to choose a program had intermediate outcomes. Additional inpatient treatment was required significantly more often (P less than 0.0001) by the AA group (63 percent) and the choice group (38 percent) than by subjects assigned to initial treatment in the hospital (23 percent). The differences among the groups were especially pronounced for workers who had used cocaine within six months before study entry. The estimated costs of inpatient treatment for the AA and choice groups averaged only 10 percent less than the costs for the hospital group because of their higher rates of additional treatment.
                Even for employed problem drinkers who are not abusing drugs and who have no serious medical problems, an initial referral to AA alone or a choice of programs, although less costly than inpatient care, involves more risk than compulsory inpatient treatment and should be accompanied by close monitoring for signs of incipient relapse. The purpose of this study is to examine implementation of a randomized clinical trial and within treatment behavior when AA is included as an element of treatment. Special attention is given to the measurement of compliance, use of treatment skills, and the nature and extent of involvement with AA during the active phase of treatment.
                Subjects, 90 male alcoholics and their female partners seeking conjoint, outpatient behavioral alcoholism treatment, were randomly assigned to one of three treatments: alcohol-focused behavioral marital therapy (ABMT), ABMT plus AA/Alanon (AA/ABMT), or ABMT plus relapse prevention (RP/ABMT). Within treatment data are reported for the 68 couples who completed at least five treatment sessions. Measures included: treatment attrition, number of treatment sessions, attendance at AA and Alanon, use of AA and Alanon skills, compliance with homework assignments and drinking during treatment.
                Several aspects of within treatment behavior were examined: (1) Attrition: There was no differential attrition across treatment conditions, with 24.4% of couples discontinuing treatment prior to the fifth session. (2) AA and Alanon attendance: Subjects in the AA/ABMT treatment were more likely to attend AA (91.7% attended at least one AA meeting; 58.3% attended at least one Alanon meeting) than were subjects in the other treatment conditions (18% attended at least one AA meeting and 14% at least one Alanon meeting). Subjects in the AA/ABMT condition attended significantly more AA and Alanon meetings than did subjects in the other treatment conditions. (3) Homework compliance: Subjects generally showed no differences in compliance with homework assignments, but spouses in the AA/ABMT condition completed less condition-specific homework (37.2%, versus 67.8% for the RP/ABMT spouses) because of low utilization of Alanon. (4) Use of AA-related skills: Subjects reported using AA-related skills more frequently in the AA/ABMT condition than in the other treatment conditions. (5) Patterns of attendance: Analyses of AA attendance during treatment revealed three patterns: positive attendance, characterized by regular AA attendance or increasing use of AA across treatment; negative attendance, characterized by decreased AA attendance over time; and nonattendance, characterized by none or infrequent and erratic attendance.
                Randomized clinical trials can be used to study AA. Use of multiple measures of treatment compliance and examination of patterns of AA utilization use over time provide more complex views of the patterns of involvement with AA than do simple descriptive reports of attendance. Presumptive support was sought for mechanisms of action whereby two conceptually distinct aftercare programs, relapse prevention (RP) and 12-Step facilitation (TSF), impact upon substance abusers.
                Adults who had just completed intensive treatment were assigned randomly to either RP (n=61) or TSF (n=70) aftercare programs.
                Three residential treatment facilities.
                Trained counselors delivered to small groups a manualized aftercare program which focused either upon the utilization of cognitive-behavioral processes to orchestrate change through an individualized treatment plan (i.e. RP) or which sought to facilitate utilization of AA's 12 Steps (i.e. TSF).
                Process measures developed specifically to quantify either: (a) the changes in self-efficacy process in RP or (b) the utilization of AA's principles in TSF, as well as psychosocial and substance abuse indices were administered to all patients pre- and post-aftercare and at 6-month follow-up.
                A significant relationship between changes in measures of self- efficacy for RP participants as well as a trend for a relationship between process-specific change for TSF participants partially satisfied the first condition for presumptive support. The fact that the intervention-specific mediators covaried with several outcome indices, and that removal of such mediators attenuated prediction of outcome met, respectively, the second and third conditions for presumptive support.
                Carefully orchestrated RP and TSF aftercare programs yield process changes that are related positively to improved outcome. This article examines client drinking and related psychosocial functioning during the course of alcoholism treatment. It focuses on (1) the main effects of the three Project MATCH treatments, (2) the prognostic value of client attributes employed in the matching hypotheses, and (3) the attribute by treatment interaction effects.
                Clients recruited from outpatient settings (n = 952) or from aftercare settings (n = 774) were randomized to one of the following treatments: Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT) and Twelve-Step Facilitation (TSF). Alcohol consumption and psychosocial functioning during treatment were assessed at the end of the 12-week treatment phase.
                During the treatment phase, small but statistically significant differences among treatments were found only in the outpatient arm on measures of alcohol consumption and alcohol-related negative consequences. Forty-one percent (41%) of CBT and TSF clients were abstinent or drank moderately without alcohol-related consequences, compared with 28% of MET clients. Tests of 10 a priori primary client-treatment matching hypotheses failed to find any interaction effects that had an impact on drinking throughout the treatment phase.
                In the outpatient setting there appears to be a temporary advantage to assigning individuals to CBT or TSF rather than MET. When there is a need to quickly reduce heavy drinking and alcohol-related consequences, it appears that CBT or TSF should be the treatment of choice. This study sought to examine the effectiveness of a "standard" outpatient alcoholism treatment (ST) program. An outpatient alcoholism treatment as it is commonly practiced in the US (with group and individual therapy, and an emphasis on Alcoholics Anonymous [AA]), was compared with a minimal treatment (MT) approach (weekly alcohol education movies). At 6 months, ST patients surpassed those in MT in terms of complete abstinence, reduction in amount of alcohol consumed, length of sobriety at follow-up, improvement in employment status, number of AA meetings attended, and lower initial drop-out. It is concluded that a ST approach is more helpful than MT in treating severely alcohol-dependent individuals who have not been able to cut down drinking on their own. Those already drinking less appeared to be helped by MT. An increasing body of research evidence supports the use of 12-step program affiliation as an effective adjunct and aftercare for formal treatment. Recently, three brief (9- or 10-item) measures of affiliation have been developed. However, the brief scales are difficult to interpret, and the question of exactly what is affiliation (or disaffiliation) remains unclear. This analysis examines the question of what is the essence of affiliation vs. disaffiliation. Data from the Project MATCH 1-year posttreatment Alcoholics Anonymous Involvement (AAI) scale (N=1506) are used to identify the most salient items of Alcoholics Anonymous (AA) affiliation predicting 1-year posttreatment drinking outcomes. Analysis using stepwise regression suggests that a three-item solution can explain a similar amount of variance in the proportion of days abstinent in months 9 through 12 posttreatment, as does using the nine items. These three "core items predicting recovery" include AA attendance, sum of steps completed, and identifying self as an AA member. As an affiliation composite scale, these three items are easier to interpret and administer than the full AAI scale, and when combined, possess adequate reliability (alpha=0.72). The helper therapy principle suggests that, within mutual-help groups, those who help others help themselves. The current study examines whether clients in treatment for alcohol and drug problems benefit from helping others, and how helping relates to 12-step involvement.
                Longitudinal treatment outcome.
                An ethnically diverse community sample of 279 alcohol- and/or drug-dependent individuals (162 males, 117 females) was recruited through advertisement and treatment referral from Northern California Bay Area communities.
                were treated at one of four day-treatment programs.
                A helping checklist measured the amount of time participants spent, during treatment, helping others by sharing experiences, explaining how to get help and giving advice on housing and employment. Measures of 12-step involvement and substance use outcomes were administered at baseline and a 6 month follow-up.
                Helping and 12-step involvement emerged as important and related predictors of treatment outcomes. In the general sample, total abstinence at follow-up was strongly and positively predicted by 12-step involvement at follow-up, but not by helping during treatment; still, helping positively predicted subsequent 12-step involvement. Among individuals still drinking at follow-up, helping during treatment predicted a lower probability of binge drinking, whereas effects for 12-step involvement proved inconsistent.
                Findings support the helper therapy principle and clarify the process of 12-step affiliation. Forty-eight patients undergoing inpatient detoxification for alcohol dependence were assigned to either brief advice (BA) to attend Alcoholics Anonymous or a motivational enhancement for 12-step involvement (ME-12) intervention that focused on increasing involvement in 12-step self-help groups. Attendance at 12-step groups did not differ significantly by treatment condition over 6 months of follow-up, nor did drinking outcomes. There was a significant interaction between 12-step experience and treatment condition, indicating that ME-12 was associated with relatively better alcohol outcomes at the low ends of 12-step experience, whereas BA was associated with relatively better outcomes at the high ends of 12-step experience. Results indicate that among patients undergoing alcohol detoxification, ME-12 may be beneficial only for those who have little experience with 12-step groups.
No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems. One large study focused on the prognostic factors associated with interventions that were assumed to be successful rather than on the effectiveness of interventions themselves, so more efficacy studies are needed.