Studies of Alcoholics Anonymous (and similar self-help group) affiliation in longitudinal samples of treated and untreated problem and dependent drinkers in the U.S. and Sweden
Sammanfattning: Background AA has become an important adjunct to alcoholism treatment worldwide. As well, many persons turn to AA as a first (sometimes only) source of help for a drinking problem. Thus, these groups represent a significant resource for the handling of alcohol problems, both at the system level and the individual level. The primary aim of this thesis is to further the knowledge on who benefits from AA (and similar self- help group) affiliation, both proximally and distally. This research is framed by a widely utilized behavioral help-seeking model of health care utilization (as adapted to alcohol treatment research) that considers the roles of contextual (aggregate or system wide) and individual factors that act to either facilitate or impede help-seeking. Method A two-pronged analytical stategy is used. First, a cross-cultural comparative study of the role and impact of self-help groups under two different treatment systems (Swedish and U.S.) was conducted using treatment samples interviewed at baseline and 1 year later (proximal outcomes) to assess who attends and who benefits. The Swedish and U.S. studies, which collected data at the countywide level, used tha same research methodolgies and collected comparable measures. Next, long-term trajectories analyses were conducted to explore more specific aspects of AA as a program and the relationship of these aspects to distal drinking outcomes (with follow-ups at 1, 3, 5, and 7 years) using a U.S. sample of treated and untreated problem drinkers. Gender was considered in all Papers. Results Some differences were found between the two samples at treatment entry. In general, the Swedish sample was older, more male, and with denser using social networks relative to the U.S. sample. In contrast, the U.S. sample reported greater drug and psychiatric severity. In terms of gender, both Swedish and U.S. women were more likely than their male counterparts were to be in a marital-like relationship and to have care of children under the age of 18 years at treatment initiation, and they presented with higher family/social, medical, and psychiatric problem severity. Males in both samples initiated treatment with greater legal severity. Though male-to-female ASI severity scores were in the same direction in the both samples, the magnitude of most ASI scores was noticeably greater for the U.S. sample (except ASI alcohol severity scores which were similar). Paper I showed that even though mutual help played a more significant role in post-treatment help seeking in the U.S. than in Sweden, for the most, similar factors predicted attendance at year 1. In both samples having an abstinence goal, having a high self-perceived need of treatment, being both alcohol and drug dependent, having prior self-help, and getting employment suggestions to seek treatment predicted 1-year self-help attendance. Factors predicting drinking outcomes in Paper II revealed younger age, female gender, abstinence goal, and less prior treatment predicted either abstinence or moderate (vs. heavy) drinking for both samples. Non-using social networks and drink severity predicted drinking outcomes in the Swedish sample. Paper III revealed a greater proportion of marginalized persons are found in the Swedish than U.S. treatment. In both countries, these individuals used more inpatient treatment and more social services and community mental-health services. However, the role of the Swedish social service system as a referral or social pressure institution was more apparent than in the U.S., as was the role of police. Paper IV found that gender did not differentiate practice of specific AA behaviors. For both genders, greater problem severity and a greater number of negative consequences predicted greater AA affiliation over time, as did having an abstinence goal and more social network support to not drink. Though higher AA affiliation was a predictor of ￼￼￼￼￼ abstinence for both genders, males were less likely than women to be abstinent over time. Men were also more likely to reduce their AA participation across time. Latent class analyses in Paper V results found heterogeneity in patterns of AA attendance and sponsorship (supporting the value of using clustering analyses). Any pattern of AA attendance, even if it declined or was never high for a particular 12-month period, was better than little or no attendance in terms of abstinence. Having a sponsor had added value above the positive value of attendance in increasing abstinence, suggesting there is a benefit for maintaining a sponsor over time above that found for attendance. Conclusion AA (similar self-help) groups can play a legitimate role in the handling of alcohol-dependent individuals seeking help for their problem. They provide a social context and recovery assistance at no cost in any system. Contextual factors (i.e., aggregate level or countrywide variables were not empirically tested) suggest that these groups are relied upon more in the U.S. than Sweden (consistent with the history of treatment/handling of alcohol problems in the two countries). Individual level predisposing, enabling, and need variables differentiated who initiates and who stays involved over time (especially severity and social factors), and these were influenced by contextual characteristics in the comparative analyses. Women use AA at least equal to men and their outcomes are as good (or better) as for men who affiliate with these groups (U.S. results). While heterogeneity was found in how U.S. individuals use self-help groups over time, any level of affiliation was better than little or no attendance in terms of increasing the changes of abstinence over 7 years. Still, some individuals with little or no affiliation reported abstinence at all follow-ups. These results are worth consideration when making referrals to self-help groups. It is advised that these groups not replace but instead complement an array of services within an overall system of care for problem drinkers.
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