Faculty Bibliography

BACKGROUND: Existing data indicate that 12-step program involvement is associated with improved outcomes in the dually diagnosed, but there are questions concerning the magnitude and mechanisms of this effect in various dually diagnosed populations. METHODS: Publications identified in a comprehensive review of the literature pertaining to 12-step programs and patients with addictions and co-occurring psychiatric disorders were reviewed for any content relevant to understanding the process of change involving dually diagnosed patients involved with 12-step programs. RESULTS: Dually diagnosed individuals attend 12-step programs at rates comparable to the nondually diagnosed, although specific diagnoses may have some effect on attendance. The benefits of 12-step attendance do not appear to be markedly different for those with psychiatric disorders. Specialized 12-step programs could have benefits for the dually diagnosed over and above those of traditional 12-step programs. Existing data suggest that nonspecific change mechanisms (self-efficacy, social support) are similar to those found in the general AA literature. CONCLUSIONS: Based on existing data, the change mechanisms are broadly similar to those found in the general 12-step literature, but additional factors related to mental illness may also play a significant role. Further work is necessary to test the components of this model and to achieve a firm empirical foundation for understanding the processes of 12-step recovery in the dually diagnosed.

INTRODUCTION AND AIMS: The aim of this study was to develop a comprehensive annotated public-domain bibliography of the literature on spirituality and addictions to facilitate future research and scholarship. DESIGN AND METHODS: A search was conducted of all citations listed in the MEDLINE, PsychINFO and ALTA Religion databases covering a period from 1941 to 2004 using the following search terms: substance abuse, substance dependence, addiction, religion, spirituality. A group of experts in the field then classified each citation according to empirically derived categories. RESULTS: A total of 1353 papers met the search parameters and were classified into 10 non-exclusive categories: (1) attitudes toward spirituality and substance use, (2) commentaries, (3) spiritual practices and development in recovery, (4) spiritual and religion variables in the epidemiology of substance abuse, (5) psychoactive substances and spiritual experiences, (6) religious and spiritual interventions, (7) literature reviews, (8) measurement of spirituality and addictions, (9) 12-Step spirituality and (10) youth and development. DISCUSSION AND CONCLUSIONS: The literature is voluminous, but has focused primarily in a few areas. Common findings included an inverse relationship between religiosity and substance use/abuse, reduced use among those practising meditation and protective effects of 12-Step group involvement during recovery. Although sound instruments are available for measuring spirituality, studies have tended to use simplistic, often single-item measures.

OBJECTIVE: Existing research indicates that increased self-efficacy to sustain abstinence is a strong causal mechanism explaining later reduction of drinking. Little is known about how mechanisms of change may differ among distinct subgroups of alcoholics. The purpose of this study was to evaluate the mediational role of self-efficacy on changes in drinking associated with Alcoholics Anonymous (AA) attendance in Type-A and Type-B alcoholics. METHOD: Analysis of covariance and structural equation modeling were used to model 6-, 9-, 12-, and 15-month data from Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) participants who were classified as Type-A or Type-B alcoholics (N=1,284; 72% male). Measures of AA attendance and percent days abstinent were taken from the Form 90. Self- efficacy was assessed with the Alcohol Abstinence Self-Efficacy Scale. RESULTS: Alcoholism typology and AA attendance were independent predictors of later self-efficacy, but there was no interaction between typology and AA attendance. Abstinence self-efficacy mediated a modest proportion of the effect of posttreatment AA attendance on later abstinence in both Type-A and Type-B alcoholics. The strength of this mediation did not differ by typology. CONCLUSIONS: Self-efficacy for abstinence has a strong direct relationship to abstinence across treatment conditions and typologies. Increases in self-efficacy mediate some of the beneficial effects of AA for Type-A and Type-B alcoholics. Further work is necessary to determine whether self-efficacy plays a different role in the recovery of Type-A versus Type-B alcoholics.

Twelve Steps (TS) has demonstrated effectiveness; induction into Alcoholics Anonymous (AA) is a primary objective of TS and is a pivotal mechanism explaining its effectiveness. However, evidence suggests that, after treatment, dropout from AA is high. This study investigated whether alcohol problem severity predicted both AA affiliation and disaffiliation among clients receiving TS. This study of a Project MATCH sample included 453 alcohol-dependent clients randomly assigned to TS who reported AA attendance during treatment. Greater alcohol problem severity predicted AA attendance; opposite to prediction, less alcohol-impaired clients were more than twice as likely to discontinue AA attendance after treatment. When sustained AA attendance is desired, the evaluation of client pretreatment alcohol involvement may be useful for identifying potential AA dropout after TS treatment. Findings also indicate that, among treatment-seeking problem drinkers, AA dropout and disaffiliation are distinct, albeit correlated, constructs that require future investigation.

The authors reviewed the empirical literature concerning the use of twelve-step programs and treatments by patients with co-occurring substance use disorders and other psychiatric disorders. Strong evidence was found that dually diagnosed individuals (DDI), with the possible exception of those with psychotic disorders, attend twelve-step programs at rates comparable to non-DDI. Twelve-step involvement is consistently associated with improved substance use outcomes. Although there have been numerous clinical trials involving twelve step-oriented interventions for DDI, most of the studies suffered from substantial methodological limitations. More work is needed to determine what kinds of twelve-step treatments and programs are effective for various types of patients and elucidate the mechanisms by which these approaches facilitate recovery.