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Journal of Studies on Alcohol and Drugs logoLink to Journal of Studies on Alcohol and Drugs
. 2023 May 3;84(2):281–286. doi: 10.15288/jsad.22-00042

Relative and Interactive Associations of Psychosocial Intervention and Alcoholics Anonymous Attendance With Alcohol Use Disorder Outcomes

Rory A Pfund a,,*, Dylan K Richards a, Cassandra L Boness a, Frank J Schwebel a, J Scott Tonigan a, Stephen A Maisto b, Katie Witkiewitz a
PMCID: PMC10171249  PMID: 36971717

Abstract

Objective:

Psychosocial intervention and Alcoholics Anonymous (AA)/mutual help organization attendance are both associated with alcohol use disorder (AUD) outcomes. However, no research has explored the relative or interactive associations of psychosocial intervention and AA attendance with AUD outcomes.

Method:

This was a secondary analysis of data from the Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) outpatient arm participants (N = 952), who were randomly assigned to complete 12-session cognitive–behavioral therapy (CBT, n = 301), 12-session 12-step facilitation (TSF, n = 335), or 4-session motivational enhancement therapy (MET, n = 316). Regression analyses tested the association of psychosocial intervention attendance only, AA attendance only (measured as past-90-day attendance immediately after psychosocial intervention, as well as 1 and 3 years after intervention), and their interaction with the percentage of drinking days and percentage of heavy drinking days after intervention, 1 year after intervention, and 3 years after intervention.

Results:

When accounting for AA attendance and other variables, attending more psychosocial intervention sessions was consistently associated with fewer drinking days and heavy drinking days after intervention. AA attendance was consistently associated with a lower percentage of drinking days at 1 and 3 years after intervention, when accounting for psychosocial intervention attendance and other variables. Analyses failed to identify an interaction between psychosocial intervention attendance and AA attendance with AUD outcomes.

Conclusions:

Psychosocial intervention and AA attendance are robustly associated with better AUD outcomes. Replication studies comprising samples of individuals who attend AA more than once per week are needed to further test the interactive association of psychosocial intervention attendance and AA attendance with AUD outcomes.

Multiple forms of treatment are available to individuals with alcohol use disorder (AUD). Comprehensive reviews support time-limited, therapist-conducted psychosocial interventions, such as cognitive–behavioral therapy (CBT), 12-step facilitation (TSF), and motivational interventions (e.g., motivational enhancement therapy [MET]) (Kelly et al., 2020; Lundahl & Burke, 2009; Magill et al., 2019). Reviews also support peer-led, community-based resources, such as Alcoholics Anonymous (AA) and other mutual help organizations (Tonigan et al., 2018).

Two parallel bodies of research suggest that greater engagement in both treatments is associated with more favorable AUD outcomes. One body of research focuses on the association between the number of psychosocial intervention sessions attended and outcomes (e.g., Connors et al., 2002; Dearing et al., 2005), and another body of research focuses on the association between the percentage of days attending AA during a prespecified time frame and outcomes (e.g., Humphreys et al., 2014). Generally, these bodies of research converge on the finding that more sessions attended or higher percentages of days attending AA are significantly associated with more favorable AUD outcomes, including more days abstinent and fewer heavy drinking days (Humphreys et al., 2014; Mattson et al., 1998; Pagano et al., 2013; Pfund et al., 2021). The association between psychosocial intervention attendance and AUD outcomes is important given emerging evidence that the association persists up to 3 years following treatment (Pfund et al., 2021), and AA attendance is associated with AUD outcomes even when accounting for self-selection bias and other variables (Humphreys et al., 2014; Kelly et al., 2013; Ye & Kaskutas, 2009).

Although individuals with AUD commonly participate in both psychosocial interventions and mutual help organizations simultaneously (Marcovitz et al., 2020), most studies examine these attendance-outcome associations separately, leaving a gap in the research. Many studies on the association between psychosocial intervention attendance and outcomes do not statistically account for AA attendance (e.g., Pfund et al., 2021). Similarly, many studies on the association between AA attendance and outcomes do not statistically account for psychosocial intervention attendance (Worley et al., 2012, 2013). The lack of statistical control across these studies is problematic because it obfuscates the relative strengths of the associations of psychosocial intervention attendance and AA attendance with AUD outcomes.

Another gap in the research is that studies do not test the interactive association of psychosocial intervention attendance and AA attendance with AUD outcomes. In a subgroup analysis, Kaskutas and colleagues (2009) found that attending more sessions of TSF was significantly associated with more favorable AUD outcomes among individuals who attended more than 90 mutual help meetings (including but not limited to AA), and this association was not significant for individuals who attended 90 or fewer meetings. These findings suggest a possible interaction between psychosocial intervention attendance and AA attendance where attending both treatments confers more benefits than attending one treatment alone. Furthermore, these findings were limited in that the authors used a categorical variable to represent AA meeting attendance rather than a continuous variable.

The purpose of the present study was to explore the relative and interactive associations of psychosocial intervention attendance and AA attendance with AUD outcomes. Specifically, these associations were examined across several distinct forms of psychosocial interventions (i.e., CBT, TSF, and MET) and two outcomes (i.e., abstinence and heavy drinking). Associations were also examined following termination of psychosocial interventions (i.e., 1- and 3-year follow-up) because psychosocial intervention attendance remains significantly associated with outcomes after termination (e.g., Dearing et al., 2005; Pfund et al., 2021). That association may be confounded by the significant association between AA attendance and AUD outcomes after psychosocial intervention termination (McCrady et al., 2004).

Method

Participants

The present study was a secondary analysis of data collected from Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), a randomized clinical trial comparing three forms of psychosocial interventions among patients with “alcohol dependence” or “alcohol abuse” according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (American Psychiatric Association, 1987). Participants were randomly assigned to attend 12 sessions of CBT (Kadden et al., 1994), 12 sessions of TSF (Nowinski et al., 1995), or 4 sessions of MET (Miller et al., 1994). In all conditions, treatments were intended to be conducted over a 12-week period; in the MET condition, treatment sessions were intended to occur at Weeks 1, 2, 6, and 12.

The present sample was restricted to the 952 participants in the outpatient arm of Project MATCH. Participants in the aftercare arm were excluded because it was not possible to determine how much treatment was received before participating in Project MATCH and because only the outpatient arm was re-assessed at 3-year follow-up. The outpatient sample represented multiple research sites including Albuquerque, NM; Buffalo, NY; Farmington, CT; Milwaukee, WI; and West Haven, CT. Of the 952 recruited participants, 871 (91.5% retention) reported drinking data at the 1-year follow-up and 806 (84.7% retention) reported drinking data at the 3-year follow-up.

Measures

Psychosocial intervention attendance. Psychosocial intervention attendance was defined as the total number of psychosocial intervention sessions attended in each treatment arm of Project MATCH.

AA attendance. Based on the Form-90 (Miller et al., 1995), the percentage of days attending AA or other 12-step groups in the past 90 days was calculated immediately after intervention, 1 year after intervention, and 3 years after intervention. The percentage of days attending AA after intervention therefore reflected the percentage of days attending AA during the assigned psychosocial intervention.

AUD outcomes. AUD outcomes included abstinence and heavy drinking after intervention (3 months after baseline), 1 year after intervention (15 months after baseline), and 3 years after intervention (39 months after baseline). Abstinence and heavy drinking were assessed using the Form-90 (Miller et al., 1995). Specifically, abstinence was defined as the percentage of drinking days (PDD) in the previous 90 days, and heavy drinking was defined as the percentage of heavy drinking days (PHD, i.e., ≥4/5 drinks in a day for women/men) in the previous 90 days.

Data analysis plan

To mirror past studies on the association between psychosocial intervention attendance and AUD outcomes (e.g., Pfund et al., 2021), all analyses were conducted separately for participants in the CBT, TSF, and MET conditions. Correlation analyses were conducted in IBM SPSS Statistics for Windows, Version 23 (IBM Corp, Armonk, NY) to examine the associations between the number of psychosocial intervention sessions attended and the percentage of days attending AA and other 12-step groups. Regression analyses with full-information maximum likelihood estimation, which accounts for missing data by computing the variance–covariance matrix for all available data that is subsequently used in analyses, were then performed in R 4.0.5 (R Core Team, 2021) using the lavaan package (Rosseel, 2012). These regression analyses tested the following associations with AUD outcomes (i.e., PDD and PHD) after intervention, 1 year after intervention, and 3 years after intervention: (a) psychotherapy attendance only, (b) AA attendance only, and (c) interaction effect between attendance in psychotherapy and AA in the prediction of AUD outcomes. For AUD outcomes immediately after intervention, the number of psychotherapy sessions attended and the percentage of days attending AA in the past 90 days after intervention, as well as their interaction, were entered as predictors. For AUD outcomes 1- and 3-years after intervention, the number of psychotherapy sessions attended during the 12-week intervention period (because no psychotherapy was attended thereafter), the percentage of days attending AA at 1 and 3 years after intervention, respectively, and their interaction were entered as predictors. In all analyses, we controlled for Project MATCH site and baseline readiness to change (as measured by the University of Rhode Island Change Assessment; DiClemente & Hughes, 1990). We also controlled for baseline drinking using baseline PDD when the outcome was PDD and baseline PHD when the outcome was PHD. A Bonferroni correction was applied to account for the 18 regression tests, and a p value of .002 was used to determine statistical significance.

Results

Sample characteristics

Across the three treatment conditions, participants attended an average of 6.13 (SD = 4.00) psychosocial intervention sessions. The mean number of sessions attended in the CBT condition was 7.99 (SD = 3.99); in the TSF condition, 7.26 (SD = 4.12); and in the MET condition, 3.12 (SD = 1.26). Participants attended significantly different percentages of sessions across the three psychosocial intervention assignments, F(2, 949) = 23.41, p < .001, with 78% of sessions completed in MET, 66% in CBT, and 60% in TSF. There were no significant differences in the percentage of total possible sessions attended among the multiple research sites in Project MATCH, F(5, 948) = 0.73, p = .60.

Participants attended AA or other 12-step groups on 11.0% of days during psychosocial interventions, 7.7% of days at 1 year after intervention, and 6.4% of days at 3 years after intervention. The percentage of days attending AA during psychosocial interventions was significantly different based on psychotherapy assignment, F(2, 921) = 80.11, p < .001, with more AA attendance in the TSF condition (21.5% of days) than in the CBT (3.8% of days) and MET conditions (6.8% of days). There were no differences in AA attendance by treatment assignment at 1 year after intervention (p = .12) or 3 years after intervention (p = .70). The percentage of days attending AA and other 12-step groups significantly varied by Project MATCH research site after intervention, F(4, 861) = 3.21, p = .012); 1 year after intervention, F(4, 865) = 3.24, p = .012; and 3 years after intervention, F(4, 801) = 4.24, p = .002.

Associations between psychosocial intervention attendance and AA attendance

There was no correlation between the number of CBT sessions attended and the percentage of days attending AA during CBT (r = .01), at 1 year after CBT (r = -.13) or 3 years (r = -.11). There was a moderate association between the number of TSF sessions attended and the percentage of days attending AA during TSF (r = .31) but no correlation at 1 year after TSF (r = .07) or 3 years (r = .08). There was no correlation between the number of MET sessions attended and the percentage of days attending AA during MET (r = .02), at 1 year after MET (r = -.02), or at 3 years (r = -.05).

Associations of psychosocial intervention and AA attendance with AUD outcomes

Table 1 presents results of regression analyses on the relative and interactive associations of various forms of psychosocial intervention attendance and AA attendance with abstinence and heavy drinking at various follow-up time points.

Table 1.

Cognitive–behavioral therapy, 12-step facilitation, motivational enhancement therapy, and Alcoholics Anonymous attendance as predictors of alcohol use disorder outcomes at various follow-up points

graphic file with name jsad.22-00042tbl1.jpg

Model PDD PHD
βSE p Model R2 βSE p Model R2
Cognitive–behavioral therapy
 After intervention .26 .27
  CBT no. of sessions -3.20 (0.39) <.001 -2.91 (0.33) <.001
  % days attending AA -0.10 (0.14) .50 -0.00 (0.12) .98
  CBT × AA -0.00 (0.04) .93 -0.02 (0.04) .62
 1 year after intervention .18 .13
  CBT no. of sessions -1.00 (0.50) .04 -1.43 (0.42) .001
  % days attending AA -0.40 (0.13) .002 -0.28 (0.11) .009
  CBT × AA -0.02 (0.03) .51 -0.00 (0.02) .88
 3 years after intervention .18 .12
  CBT no. of sessions -0.60 (0.53) .26 -0.94 (0.47) .05
  % days attending AA -0.46 (0.14) .001 -0.26 (0.13) .04
  CBT × AA 0.03 (0.03) .28 0.04 (0.03) .09
12-Step facilitation
 After intervention .34 .26
  TSF no. of sessions -2.83 (0.34) <.001 -2.19 (0.31) <.001
  % days attending AA -0.17 (0.06) .004 -0.10 (0.05) .06
  TSF × AA 0.02 (0.01) .07 0.02 (0.01) .34
 1 year after intervention .23 .15
  TSF no. of sessions -1.67 (0.43) <.001 -1.05 (0.36) .003
  % days attending AA -0.37 (0.09) <.001 -0.21 (0.07) .004
  TSF × AA 0.02 (0.02) .26 0.01 (0.02) .39
 3 years after intervention .17 .12
  TSF no. of sessions -0.73 (0.46) .11 -0.59 (0.38) .12
  % days attending AA -0.56 (0.13) <.001 -0.34 (0.11) .002
  TSF × AA 0.06 (0.03) .06 0.03 (0.02) .22
Motivational enhancement therapy
 After intervention .19 .16
  MET no. of sessions -3.07 (1.28) .02 -4.28 (1.07) <.001
  % days attending AA -0.10 (0.09) .29 -0.05 (0.08) .48
  MET × AA -0.02 (0.09) .81 0.01 (0.08) .89
 1 year after intervention .21 .12
  MET no. of sessions -3.28 (1.58) .04 -3.24 (1.37) .02
  % days attending AA -0.42 (0.11) <.001 -0.26 (0.09) .005
  MET × AA -0.01 (0.09) .88 0.01 (0.08) .88
 3 years after intervention .21 .15
  MET no. of sessions -0.66 (1.64) .69 -1.22 (1.46) .40
  % days attending AA -0.44 (0.13) .001 -0.32 (0.12) .006
  MET × AA -0.06 (0.11) .56 -0.03 (0.10) .79
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Notes: P values in bold indicate significant associations after a Bonferroni correction for the 18 regression analyses (p < .002). Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) site, baseline readiness to change, and baseline PDD/PHD were controlled for in these analyses. PDD = percentage of drinking days in past 90 days; PHD = percentage of heavy drinking days in past 90 days; CBT = cognitive–behavioral therapy; AA = Alcoholics Anonymous; no. = number; TSF = 12-step facilitation; MET = motivational enhancement therapy.

CBT. After intervention, more CBT sessions significantly predicted lower PDD and PHD. One year after intervention, more CBT sessions significantly predicted lower PHD. Three years after intervention, higher percentages of days attending AA significantly predicted lower PDD.

TSF. After intervention, more TSF sessions attended significantly predicted lower PDD and PHD. One year after intervention, more TSF sessions attended and higher percentages of days attending AA significantly predicted lower PDD. Three years after intervention, higher percentages of days attending AA significantly predicted lower PDD.

MET. After intervention, more MET sessions attended significantly predicted lower PHD. One year after intervention, higher percentages of days attending AA significantly predicted lower PDD. Three years after intervention, higher percentages of days attending AA significantly predicted lower PDD.

Discussion

The purpose of the present study was to explore the relative and interactive associations of psychosocial intervention attendance and AA attendance with AUD outcomes after intervention and various follow-up time points. Analyses consistently supported that when accounting for AA attendance (as well as Project MATCH site, baseline readiness to change, and baseline drinking), more psychosocial intervention sessions attended was significantly associated with fewer drinking days and heavy drinking days after intervention.

However, psychosocial intervention attendance was inconsistently associated with AUD outcomes at 1 year after intervention and not associated with AUD outcomes at 3 years after intervention when accounting for AA attendance and other variables. Collectively, these results extend the findings from previous studies in that they support the robustness of the association between psychosocial intervention attendance and outcomes during intervention (Mattson et al., 1998) but call into question the robustness of the association between psychosocial intervention attendance and outcomes following termination (Pfund et al., 2021). Given that approximately 26% of individuals prematurely discontinue psychosocial interventions for AUD (Lappan et al., 2020), clinicians should focus on retaining individuals in treatment. Furthermore, clinicians may suggest that individuals who are nearing termination of psychosocial interventions could attend AA or an aftercare program to improve outcomes after psychosocial interventions (Blodgett et al., 2014; McCrady et al., 2004).

After psychosocial intervention termination, the percentage of days attending AA was consistently associated with fewer drinking days, but not heavy drinking days, when accounting for psychosocial intervention attendance (as well as Project MATCH site, baseline readiness to change, and baseline drinking). These results are consistent with prior findings on the association between AA attendance and AUD outcomes (Humphreys et al., 2014; Ye & Kaskutas, 2009). However, none of the analyses supported interactive associations between psychosocial intervention attendance and AA attendance with AUD outcomes. The failure to identify this interactive association may be because of the low participation in AA across all psychosocial interventions. The percentage of days attending AA ranged between 5% and 11% of days across all interventions and all assessment time points. These percentages translate to attending AA at a frequency lower than the recommended once per week (Kelly et al., 2008; Krentzman et al., 2011). Future studies should replicate the present findings in samples of individuals who attend at least one meeting per week.

Another possible explanation that relative and interactive associations could not be identified is that AA attendance is not ideal for capturing AA engagement. Prior research contends that AA involvement (e.g., having a sponsor, socializing with other group members, service) is more strongly associated with AUD outcomes than AA attendance (Montgomery et al., 1995; Walitzer et al., 2009). The AA involvement variable was not included in the present study because it provides an uneven comparison to psychosocial intervention attendance. Future studies should therefore incorporate an AA involvement variable and examine its relative and interactive associations with an equivalent psychosocial intervention involvement variable (e.g., homework completion).

Limitations

The findings of the present study should be considered in context of the following limitations. First, Project MATCH was conducted almost three decades ago, and the sample comprised mostly middle-age White men. Thus, the results may not generalize to more recent and racially, ethnically, and gender diverse samples. Second, it is difficult to disentangle TSF and AA attendance as unique predictors of AUD outcomes. However, correlation analyses indicated that these variables were only modestly correlated (r = .31). Third, the present study could not capture other treatments received in the years after terminating psychotherapy, and additional unmeasured treatment attendance may have further affected the outcomes at 1 and 3 years after intervention. Fourth, the present study used different units to represent psychosocial intervention attendance (number of sessions) and AA attendance (percentage of days attending AA). This decision was made to remain consistent with how they are typically measured in the literature (Dearing et al., 2005; Humphreys et al., 2014). Nonetheless, future studies should examine how these different units may affect attendance-outcome associations.

Conclusions

Despite these limitations, the present study provided initial evidence on the robustness of the associations of psychosocial intervention attendance and AA attendance with AUD outcomes. Importantly, this study supported that attending more psychosocial intervention sessions was significantly associated with more favorable AUD outcomes (both abstinence and heavy drinking) after intervention when accounting for AA attendance. This study also supported that attending greater percentages of AA meetings was significantly associated with more favorable abstinence (but not heavy drinking) outcomes when accounting for psychosocial intervention attendance. Replication studies are needed to understand the interactive association of psychosocial intervention and AA attendance.

Footnotes

This work was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health, award numbers L30AA029551, T32AA018108, R01AA022328, K05AA016928, and F32AA028712. The content is the sole responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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