An exploration of the effect of onsite 12‐step meetings on post‐treatment outcomes among polysubstance‐dependent outpatient clients

Abstract

Rates of return to active substance use after addiction treatment tend to be high; participation in 12‐step fellowships (e.g., Alcoholics Anonymous) reduces relapse rates but many clients do not attend or attend for a short period only. This quasi‐experimental study uses repeated measurement to explore the role of presence/absence of onsite 12‐step meetings during treatment on post‐treatment outcomes. Polysubstance‐dependent clients (N = 219) recruited at a program with and one without 12‐step onsite, were followed for one year post‐treatment. Onsite 12‐step enhanced 12‐step attendance, especially during treatment, and predicted continuous abstinence for the post treatment year. Holding 12‐step meetings onsite is a low‐cost strategy that programs should consider to foster post‐treatment remission maintenance.

Substance use disorders (SUD) are conceptualized as chronic (e.g., McLellan, Lewis, O’Brien, C., and Kleber, 2000); the chronicity of SUD is empirically supported by findings on addiction and treatment ‘career’ indicating that most SUD‐affected individuals, especially those with severe dependence, make multiple attempts at remission often involving several treatment episodes prior to resolving their alcohol or drug dependence (e.g., Anglin, Hser, and Grella., 1997; Dennis, Scott, Funk, and Foss, 2005; Hser, Anglin, Grella, Longshore and Prendergast, 1997; Laudet, Stanick, Carway, and Sands, 2004). Because of the multiple costs of long chronic addiction ‘careers’ that include the acquisition/transmission of infectious diseases (e.g., HIV, HepC), deterioration in mental and physical health and other functioning impairments (e.g., Smith and Larson, 2003), it is critical to identify strategies that contribute to sustaining remission, thus shortening addition careers and resulting nefarious effects to the individual and to society. A number of therapeutic modalities have proven effective at addressing drug and alcohol dependence and improving related functioning but treatment gains are often short lived (Hser, Grella, Hsieh and Anglin, 1999). Participation in post‐treatment ‘stepped down’ continuing (or after) care is associated with sustained treatment gains (McKay, Alterman, Cacciola, Rutherford and O’Brien, 1997; Mckay 2001). In the currently austere fiscal context of health services provision, few drug and alcohol treatment programs offer continuing care, especially following outpatient treatment, the most prevalent treatment modality in the US. Twelve‐step fellowships such as Alcoholics and Narcotics Anonymous are the most frequently used form of aftercare in the United States (Tonigan, Toscova, and Miller, 1996). Twelve‐step fellowships are particularly well‐suited to provide ongoing recovery support from chronic substance abuse and dependence because, unlike formal services that are limited in time, these groups are widely and consistently available throughout the US and free of charge. As with treatment, 12‐step fellowships are underutilized and have high attrition rates. Fostering consistent attendance at 12‐step meetings especially early in remission, can contribute to remission maintenance. This study explores the usefulness of 12‐step meetings onsite at outpatient treatment programs on post‐treatment outcomes.

RESEARCH ON 12‐STEP PARTICIPATION

Remission from substance use disorders is a challenging process that is facilitated by obtaining professional treatment and support from recovering peers. Mutual aid (‘self‐help’) organizations such as 12‐step fellowships, Secular Organization for Sobriety (SOS), Smart Recovery, and Women for Sobriety (Kaskutas, 1997) hold regular meetings where members can discuss their shared experiences in a non‐judgmental, supporting forum. Most research has been conducted on 12‐step fellowships, perhaps because other organizations are more recently established and less geographically widespread. Attendance at 12‐step meetings fosters reductions in alcohol and illicit drug use (Fiorentine, 1999; Gossop, Harris, Best, Man, Manning, Marshall, Strang, 2003; Humphreys and Moos, 2001; Moos, Schaefer, Andrassy and Moos, 2001; Morgenstern, Labouvie, McCray, Kahler and Frey, 1997; Morgenstern, Bux, Labouvie, Morgan, Blanchard, and Muench, 2003; Project MATCH Research Group, 1997; for review Tonigan et al., 1996). Among individuals concurrently attending treatment, 12‐step meeting attendance produces independent and additive effects on treatment outcomes (Fiorentine and Hillhouse, 2000). The support 12‐step participation offers is especially important after treatment ends: 12‐step meeting attendance after formal treatment, i.e., as aftercare, is a strong predictor of long‐term abstinence (e.g., Johnson and Chappel, 1994; Kissin, McLeod, and McKay, 2003; Troyer, Acampora, and O’Connor, 1995). In several studies, 12‐step meeting attendance was the best single predictor of positive outcome following treatment for substance use disorders (Morgensten et al., 2003), a factor that rises in tandem with addiction severity (Tonigan et al., 1995). Further, the probability of stable remission increases with the number of meetings attended early on (Hoffmann, Harrison, Belille, 1983; Pisani, Fawcett, Clark, and McGuire, 1993; Humphreys, Moos, and Cohen, 1997).

Studies on 12‐step participation traditionally were limited to relatively short‐term follow‐up periods that are inadequate to study remission from chronic disorders (typically under two years); several recent reports have extended the timeframe significantly including a 16‐year follow‐up study of initially untreated alcohol‐dependent persons showing that 12‐step participation in the first year of the study predicted better substance use outcomes at 16 years (Moos and Moos, 2006; also see Kaskutas, Ammon, Delucchi, Room, Bond, and Weisner, 2005; Kelly, Stout, Zywiak, and Schneider, 2006). As with formal treatment, longer duration and higher level of 12‐step meeting attendance are associated with better outcomes (e.g., Fiorentine, 1999; Moos, Schaefer and Moos et al., 2001; Moos, Moos and Timko, 2006). Until recently, relatively little was known of the effectiveness of 12‐step attendance among drug‐dependent samples since most research was conducted among alcohol‐dependent populations. This is gradually changing. Studies among drug‐dependent samples report a positive effect on subsequent outcomes among 12‐step meeting attenders relative to non‐attenders (Christo and Franey, 1995; Etheridge, Craddock, Hubbard, and Rounds‐Bryant, 1999; McKay, Alterman, McLellan, and Snider., 1994; Mckay, 2001; Ouimette, Moos and Finney., 1998). In two studies comparing 12‐step attendance and formal aftercare, 12‐step participation proved more effective at fostering remission (McKay., 2001; Ouimette et al., 1998). In sum, attending 12‐step meetings, a resource that is free of charge and widely available in the U.S., appears to be an effective and cost effective remission resource for persons with a substance use disorder.

Meeting attendance is the most popular and the most researched form of 12‐step participation. Fellowship with other recovering persons at 12‐step meetings is one of the cornerstones of the 12‐step recovery program, cited as a critical source of support by remitting individuals (e.g., Laudet, Savage, and Mahmood, 2002; Margolis, Kilpatrick and Mooney, 2000; Nealon‐Woods, Ferrari, and Jason, 1995). However, the 12‐step program of recovery suggests that members do more than attend meetings. Benefits of meeting attendance (e.g., stable abstinence) can be enhanced through other suggested practices representing 12‐step affiliation, such as having a sponsor, working the 12‐steps, having a home group, reading 12‐step recovery literature and doing ‘service’ (e.g., Caldwell and Cutter, 1998). Meeting attendance alone ‐ i.e., without affiliative behaviors ‐ is associated with high attrition and consequent loss of the potential benefits of 12‐step participation (Walsh, Hingson, and Merrigan, 1991). Moreover, level of 12‐step affiliation may be more predictive of remission outcomes than is meeting attendance alone (Weiss, Griffin, Gallop, Najavits, Frank, Crits‐Christoph et al., 2005). To date, there has been little research on predictors of 12‐step affiliation (Timko, Billow, and DeBenedetti, 2006).

12‐STEP PARTICIPATION PATTERNS

The demonstrated benefits of 12‐step attendance may be somewhat limited by under‐utilization and high attrition. Although the majority of substance dependent persons report some lifetime attendance (Humphreys, Kaskutas and Weisner, 1998), few maintain stable participation over time, particularly after the first 6‐months (e.g., Fiorentine, 1999; McKay., 2001; Timko, Finney, Moos, Moos, Steinbaum., 1993). Alcoholics Anonymous (1990) has noted “a slow attrition of newcomers during the first year,” and acknowledged this phenomenon as a challenge (for discussion, see McIntire, 2000). Kaskutas and colleagues (2005) examined AA attendance patterns over 5 years after treatment entry and identified four classes of AA "careers:" Individuals who attended only in the first year after treatment entry (the ‘low’ group), medium and high AA attendance groups, characterized by stable attendance at the second and third yearly follow‐ups (60 meetings a year for the medium group, over 200 meetings per year for the high group), followed by slight increases for the medium group and slight decreases for the high group by year five; and a ‘declining’ group whose high level of attendance during the first year declined to about six meetings on average by year five. Overall, a substantial proportion of substance dependent persons actively participate in 12‐step meetings early on after treatment; subsequently, there is “considerable variability in patterns, with some becoming increasingly committed while others gradually slip away” (McCrady, 1998, p.715). The potential benefits of 12‐step attendance to resolve substance dependence are limited not only by high attrition but by underutilization as well. In spite of being encouraged by clinicians to attend 12‐step meetings (Humphreys, 1997; Laudet and White, 2005) and expressing generally positive views about the importance and helpfulness of 12‐step groups (Laudet, 2003), a large minority of treatment clients never attend 12‐step meetings (e.g., Fiorentine, 1999). In sum, 12‐step fellowships have potential usefulness in fostering and solidifying remission but this is somewhat limited by low rate of utilization and early attrition.

PREDICTORS OF 12‐STEP PARTICIPATION

Individual‐level predictors

In light of the demonstrated effectiveness of 12‐step attendance, researchers have sought to identify predictors of 12‐step participation, especially after clients leave treatment. The bulk of that work has examined individual‐level client characteristics. Greater problem severity consistently predicts higher levels of 12‐step attendance (e.g. Humphreys, Huebsch, Finney, and Moos, 1999; McKay, McLellan, Alterman, Cacciola, Rutherford and O’Brien, 1998; Morgenstern et al., 1997; Tonigan et al., 2006). Results for other demographic characteristics including race and gender have been inconsistent across studies (Emrick, Tonigan Montgomery and Little, 1993; Humphreys, 1991; Kessler, Mickelson and Zhao, 1997; Mankowski, Humphreys and Moos, 2001). A comprehensive study examining a large number of potential individual‐level predictors (demographics, personality characteristics, clinical, and cognitive processes) reported that only baseline abstinence and longer substance use significantly predicted subsequent 12‐step attendance levels (McKay et al., 1998). Most research in this area has sought to predict attendance in AA. Only one study has been was conducted among members of Narcotics Anonymous: it examined spiritual beliefs, locus of control and recovery ideology as possible predictors: the strongest predictor of non‐attendance at 6‐month follow‐up was positive attitudes toward drinking at baseline (Christo and Franey, 1995). Overall, seeking to identify individual predictors of 12‐step attendance has been challenging. A unique study tested a multilevel model of predictors of post‐treatment 12‐step attendance that included individual‐level (client demographics and cognitive characteristics) as well as treatment and post treatment socio‐ecological domains ‐ e.g., type of housing, availability of 12‐step meetings in the area (Mankowski et al., 2001). Significant individual‐level predictors were education level, prior 12‐step exposure, abstinence goal, endorsement of the disease model, religious beliefs and behaviors; socio‐ecological predictors were treatment 12‐step orientation, and living in group housing. While the incorporation of socio‐ecological factors in this study represents a significant improvement over studies focusing solely on client characteristics, the model accounted for only 22% of the variance explained in post treatment 12‐step attendance, suggesting that key predictor domains remain unidentified.

Treatment‐level predictors of 12‐step attendance

Individual client characteristics clearly play a part on whether or not clients participate in 12‐step. However, treatment‐related factors are influential as well. Several studies have examined the role of formal treatment on 12‐ step attendance. Project MATCH is the largest study to evaluate the role of treatment orientation on subsequent 12‐step attendance using an experimental design. The Twelve‐Step Facilitation (TSF) treatment condition that encouraged AA attendance and familiarized clients with the first three of the 12‐steps resulted in greater AA attendance and involvement during treatment and at one‐ and three‐year follow‐ups than did the cognitive behavioral or motivational enhancement therapy conditions (Carroll, Connors, Cooney, DiClemente, Donovan, Kadden et al., 1998; Project MATCH Research Group, 1998; Tonigan, Connors and Miller, 2002). Another group of researchers used a naturalistic design to examine how treatment programs' theoretical orientation influences clients' attendance in, and benefit from, 12‐step attendance after treatment ends (Humphreys et al., 1999; Humphreys and Moos 2001 and 2007). Clients in 12‐step and eclectic programs (combined 12‐step and cognitive‐behavioral) had higher rates of subsequent 12‐step attendance than did clients in purely cognitive‐behavioral treatment program; further, program orientation moderated the effectiveness of 12‐step attendance: as the degree of programs' "12‐stepness" increased, the positive relationship between 12‐step attendance and outcome (substance use and psychosocial) became stronger.

A third group of studies in the body of research on treatment‐level factors predicting 12‐step attendance examined the intensity of counselors’ 12‐step referral strategies. A small pilot study compared "simple referral" (i.e., clinician's suggestion that client attend 12‐step and giving client a meeting list) with "intensive referral" whereby clinician and client called an experienced 12‐step member who accompanied the client to a meeting (Sisson and Mallams, 1981). While all clients in the intensive group attended 12‐step meetings, none in the "simple referral" condition did, suggesting that being merely encouraged to attend may not be sufficient to foster attendance. Timko and colleagues (Timko, Debenedetti and Billow, 2006) replicated the study using a large sample of alcohol and drug‐dependent male veterans. Intensive referral did not affect meeting attendance but increased level of 12‐step involvement (e.g., working the 12‐step program) during the 6‐month follow‐up. Taken together, findings reviewed in this section suggest that what happens during treatment (treatment orientation, specific referral protocol) can enhance clients’ post treatment 12‐step attendance and indirectly, help sustain/strengthen remission.

Two aspects shared by all the strategies used in these studies are encouraging 12‐step attendance and familiarizing clients with the 12‐step recovery philosophy (e.g., commitment to abstinence, reliance on a Higher Power, needing to work the 12‐step program), a system of beliefs that predicts subsequent abstinence independently of meeting attendance (e.g., Fiorentine and Hillhouse, 2000). Most clients entering treatment have had prior exposure to both treatment and to 12‐step, and many have had a series of recursive cycles between active substance use and attendance in treatment and/or 12‐step (e.g., Dennis, Scott, Funk and Foss, 2005; Laudet and White, 2004). The decision to make significant changes in substance use behaviors is fraught with ambivalence; most clients enter treatment at least in part because of external pressure (be it from the legal system, their family or employer). Recovery initiation requires significant behavioral, social and cognitive changes (e.g., changing social network, acquiring adaptive coping strategies to deal with stress without turning to drugs), in addition to keeping on a schedule and adhering to program rules and requirements when enrolled in treatment. For individuals who may not be highly internally motivated to change early on, all these demands likely represent stumbling blocks and so many reasons to disengage. In this context, as demonstrated by findings from the two referral intensity studies described above, the effectiveness of merely encouraging clients to attend 12‐step meetings is likely to be limited. Although intensive referrals may be effective, these interventions need to be delivered in individual counseling sessions while today, the majority of substance abuse treatment services in the U.S. are delivered in group format (Mckay, 2001). Other strategies shown to enhance 12‐step attendance, such as TSF (see above), may be somewhat burdensome to treatment programs as they require implementing a new intervention and training of staff, all requiring time and financial resources that an agency may not have. There have been calls for research to examine service delivery in a range of real world settings (Lamb, Greenlick, and McCarty, 1998) and the National Institute on Drug Abuse’s Blue Ribbon Task Force on Health Services has emphasized the importance of identifying research and community‐derived practices that are practical, cost‐effective, and self‐sustaining (NIDA, 2004; Compton, Stein, Robertson, Pintello, Pringle and Volkow., 2005).

On‐site twelve‐step meetings

Both Alcoholics and Narcotics Anonymous maintain a Hospitals and Institutions (H & I) program that “brings” 12‐step meetings to agencies requesting it. Meetings are facilitated by experienced 12‐step members who are independent of the treatment agency; meetings are typically held weekly at times that do not conflict with treatment services such as during a general staff meeting or during early evening after the treatment day has ended. Following a number of relatively recent court decisions, most notably DeStefano v. Emergency Housing Group (2001), 12‐step meeting attendance cannot be made compulsory at publicly‐funded programs in New York State. Thus the current practice of treatment programs under such guidelines is to “strongly encourage” (but not “require”) 12‐step meetings attendance, no matter where their location, on‐site or otherwise.

Holding an onsite 12‐step meeting may be an effective and cost‐efficient strategy to enhance 12‐step attendance. Convenience (“getting there”) has been cited as a reason for not attending 12‐step (Laudet, 2003; Laudet et al., 2004) and Mankowski et al. (2001) found a significant association between “geographical density” of 12‐step meetings and greater levels of attendance. While there are typically numerous 12‐step meetings held throughout the week in most US cities, convenience is a plausible reason not to attend for some (e.g., individuals who lack time or transportation) and a plausible excuse for others (persons who are ambivalent about attending, perhaps because of low motivation to enter remission). Theories of social ecology view attendance in self‐help groups as an issue of environmental transition (Felner, Ginter, and Primavera, 1982; Hanson, Foreman, Tomlin, and Bright, 1994); “becoming involved in self‐help groups requires the navigation of border points between groups, organizations or institutions. Barriers may exist at these border points that may increase the difficulty in gaining needed assistance or services” (Mankowski et al., 2001, p. 539). Onsite meeting availability may minimize some of the barriers to attendance at a critical transition period‐ i.e., early remission ‐ and contribute to initiating the engagement process. This is important since 12‐step attendance patterns established early during treatment tend to be maintained (Weiss et al., 2000a); further, initiating 12‐step attendance during treatment is associated with better outcomes than later initiation (Moos and Moos, 2006).

STUDY OBJECTIVES

At this writing, the potential usefulness of holding a 12‐step meeting onsite on subsequent client outcomes has not been empirically examined. The present study represents a first step toward filling that gap. We explore the effect of attending an outpatient treatment program with or without onsite 12‐step meetings on subsequent 12‐step attendance and on remission outcomes. We hypothesize that (1) controlling for relevant individual‐level variables, attending a program holding 12‐step meetings onsite (TSO) will be associated with significantly greater levels of 12‐step participation during and after treatment (at 3, 6‐ and 12‐months after treatment ends) compared to attending a program without 12‐step onsite (N‐TSO); that (2) TSO will predict higher likelihood of abstinence 12‐months after treatment ends compared to N‐TSO; and that (3) the effect of TSO on abstinence will be mediated by enhanced 12‐step attendance during treatment.

METHODS

SETTING AND PROCEDURES

The study was designed to investigate predictors and effectiveness of 12‐step participation as aftercare among outpatient substance abuse treatment clients. Recruiting took place at two publicly funded New York state licensed programs; the programs had been selected because they were comparable in terms of therapeutic orientation, services offered, planned length of stay, census size and types of clients served (e.g., referral source, clinical profile) and combined, gave access to large pools of African American and Hispanic clients ‐ one program is in a Latino‐dense neighborhood, the other serves primarily African Americans. Both programs are located in underserved communities in New York City; they meet the definition of an “eclectic” orientation, incorporating both 12 step and cognitive behavioral principles (Humphreys et al., 1999); the programs are relatively intensive and highly structured: Clients are required to attend 5 days a week from 9:00 am to 3:00 pm for groups and individual counseling sessions as well as for relapse prevention classes, special topic groups (e.g., men/women groups, AIDS education, domestic violence prevention), and vocational training.

When the study was proposed to the funding agency, both programs held a 12‐step meeting onsite once a week. Shortly before data collection started, the meeting at one of the programs was discontinued for logistics reasons (changes in program scheduling). We interviewed administrative and clinical staff at all levels, reviewed services provided and typical client schedules before and twice after the 12‐step group was eliminated over the duration of data collection (in case gradual changes had been introduced) to determine whether other program changes had been introduced that may constitute a confound in our study. Based on the information we were able to collect, we determined that no other services or aspect of the program appeared to have changed (staff remained unchanged including the program’s administrative and clinical directors), nor were significant administrative changes noted (e.g., a change in funding source, umbrella organization, department head). We proceeded with data collection and identified this unplanned opportunity to explore the effect on holding on onsite 12‐step meeting on subsequent client outcomes after a literature search revealed that this issue had not been systematically examined. Analyses were conducted to determine whether clients at the two programs differed on dimensions previously identified as predictors of post treatment 12‐step attendance and treatment outcomes (see later section).

The study was introduced to new clients during their first orientation session (immediately after official admission). Clients who expressed interest in participating met with the research interviewer who explained the voluntary nature of the study and what participation in the study entailed; the signed informed consent procedure was then administered and the interview was conducted, lasting two and a half hours on average. The first interview (baseline ‐ BL) was conducted within two weeks of admission and participants received $30 for their time. Clients were re‐interviewed when services ended regardless of the reason for ending treatment (treatment completion, transfer or dropping out), then again 3, 6 and 12‐months after treatment had ended. The study was reviewed and approved by the NDRI Institutional review Board (IRB) and by the review boards of the two participating service agencies and we obtained a certificate of confidentiality from the funding agency.

STUDY SAMPLE

Three hundred and fourteen consecutive admissions were recruited into the study between September 2003 and December 2004 (96% of those asked). Thirty‐six clients stayed in treatment for under thirty days and were not followed (19 from the N‐TSO program, 17 from the TSO program): the study examined treatment participation as a potential predictor of 12‐step meeting attendance during and after treatment, therefore a minimum treatment exposure was deemed necessary. Of the 278 clients who attended treatment for thirty days or longer, 250 were interviewed at the end of treatment (89.9% of the valid study cohort of 278 participants) and constituted the prospective cohort that we sought to re‐interview. Of these, 216 were re‐interviewed three months post‐treatment end (86.4% retention), 221 at six‐month post‐treatment end (88.4% retention) and we obtained one year post treatment end data from 219 participants (87.6% retention) who constitute the sample for this study. The one‐year post‐treatment interview was conducted a mean of 350 days after treatment ended (St, Dev = 51 days). Attrition analyses were conducted to assess differences between participants who did and did not provide full data for the study (see later section).

MEASURES

Client background and clinical status at treatment entry

The following domains were used in subgroup comparisons (attrition analyses and comparison of subsample across the two study conditions) and/or represent control variables used in the analyses (see later section).

Dependence severity

We used the Lifetime Non‐alcohol Psychoactive Substance Use Disorders subscale of the Mini International Neuropsychiatric Interview (M.I.N.I.), a short structured diagnostic interview developed to diagnose DSM‐IV and ICD‐10 psychiatric disorders (Sheehan, Lecrubier, Harnett‐Sheehan, Amorim, Janavs, Weiller, et al., 1998). The M.I.N.I. has been validated against the much longer Structured Clinical Interview for DSM diagnoses (SCID‐P) and against the Composite International Diagnostic Interview for ICD‐10 (CIDI). The 14‐items answered in a yes/no format yield a single score that can range from 0 to 14. Alpha = .89.

Legal pressure to enter treatment

At baseline, participants were asked “Was your coming to drug treatment at this time required or recommended by the criminal justice system (judge, probation/parole, etc.)?”

Treatment history

(1) Ever received addiction treatment services prior to the index episode (yes/no); if yes, (2) number of prior episodes including the following modalities: Detoxification (drug or alcohol), Methadone Maintenance, Therapeutic Community, 21/28 day Inpatient Rehab, Outpatient Treatment or Day Treatment, Treatment in jail or prison (alcohol or drugs), any other.

Twelve‐step attendance history

Participants were asked (1) whether they had ever attended Alcoholics, Narcotics and/or Cocaine Anonymous; if yes, (2) whether they attended 12‐step in the year before being starting the index treatment episode; and (3) total number of meetings attended during that period.

Substance use

At baseline, drug and alcohol use history was collected using a list of 13 substances based on the ASI (McLellan, Kushner, H., Metzger et al., 1992). For each substance ‘ever’ used once or more, participants provided the last date of use; at each interview, a variable was computed for clean time from each substance ever used; length of abstinence represents time since most recent use of any illicit drug ever used, in months (i.e., if a participant last used heroin 4 years ago and marijuana 5 months ago, length of abstinence is 5 months).

Attitudes and beliefs

Perceived helpfulness of 12‐step fellowships

In addition to comparing clients in the two study conditions in terms of history of 12‐step exposure, we also wanted to compare participants on how favorably they felt about 12‐step fellowships at treatment entry as this may have represented a confound. We used the Positive Attitude subscale of the Twelve‐step Beliefs Inventory (Laudet, 2003) consisting of six items rated on a 4‐point Likert‐type scale from 1 (strongly disagree) to 4 (strongly agree); Cronbach Alpha in this dataset = .91. Sample item: “12‐step groups help you gain insight into your issues.”

Embracement of Higher Power

The spiritual dimension of 12‐step recovery is among its most controversial aspects of and an obstacle to 12‐step attendance for some (Chappel and DuPont, 1999; Klaw and Humphreys, 2000; Laudet, 2000); participants in the two study groups were compared on this dimension using the relevant subscale of the Addiction Treatment Questionnaire (Morgenstern and McCrady 1993; Morgenstern, Kahler, Frey and Labouvie, 1996) consisting of eight items each rated for level of agreement on a Likert‐type scale ranging from 1 (strongly disagree) to 4 (strongly agree); Alpha in this dataset = .86. Sample item: “I need to let my Higher Power run my life, with no strings attached.”

Commitment to abstinence

This dimension of motivation has been shown to predict better substance use outcome (e.g., Morgenstern et al., 1997). The Commitment to Abstinence subscale of the Addiction Treatment Questionnaire (Morgenstern and McCrady 1993; Morgenstern et al., 1996) consists of five items each rated for level of agreement as described in the preceding section; Alpha in this dataset = .81. Sample item: “I can never use drugs again, not even once.”

Outcome domains

Twelve‐step participation

Measures included at each follow‐up: a) Meeting attendance: The number of AA, NA or CA meetings attended since the previous interview and in the past thirty days. b) 12‐step Involvement: The sum of nine 12‐step activities practiced in the past 30 days: Having a sponsor; sponsoring someone; considering oneself a member of AA, NA or CA; having a home group; working the steps; doing service; contacting other 12‐step members outside of meetings; reading 12‐step or recovery literature outside of meetings; and socializing with 12‐step members outside of meetings (e.g., coffee before/after a meeting).

Substance use

At each follow‐up interview, proceeding as described earlier, we calculated length of abstinence from all drugs since previous interview as well as a dichotomous summary variable (used since the previous interview: yes/no); a summary variable was also computed for the entire post treatment period: Did not use at all in the year following treatment ” (sustained abstinence).

COMPARISON OF PARTICIPANTS BETWEEN THE TWO PROGRAMS

The study explores the effect of attending a program with or without a 12‐step meeting onsite on 12‐step participation and substance use outcomes. The research questions presuppose a quasi‐experimental design where initially, the two groups of participants do not differ significantly on relevant dimensions other than the program they attended (and the two programs do not differ significantly aside from presence/absence of 12‐step meeting on site). As explained earlier, this was not a planned intervention study so that program and sample characteristics that would ideally be matched across study conditions in an intervention study were outside of our control. In addition to conducting a program review to assess differences between the two sites (see Setting and Procedures), we compared participants from the two programs on key domains identified from a review of the extant literature (e.g, Cloud, Ziegler and Blondell, 2004; Emrick et al., 1993; Horgan, Reif, Ritter, Lee, and Strickler., 2003; Timko, Billow and DeBenedetti., 2006; Weiss, Griffin, Gallop, Luborsky, Siqueland, Frank et al., 2000). We used chi‐squares and t‐tests to compare the two groups on age, gender, race/ethnicity, education; addiction severity, drug and alcohol history, legal, employment and psychological problems as measured by the Addiction Severity Index (ASI, McLellan et al., 1992), prior exposure to treatment and to 12‐step groups, belief in the need for a Higher power, commitment to abstinence, and positive attitudes toward 12‐step groups. Results from these analyses (Table 1) indicate that the two groups differed in (a) race/ethnicity (larger percentage of African Americans and fewer Hispanics in the TSO group) an expected finding since the two programs had been chosen based on the race/ethnicity representation of their client pool; and (b) education: TSO clients had an average of a half year more education than the N‐TSO participants (10.9 years vs. 10.3). The domains were entered as control variables in the multivariate analyses reported below. Other parameters were statistically equivalent between the two groups.

Table 1.

Baseline sample characteristics for total sample and by study condition

		12‐step meeting onsite
	Total sample	No	Yes
	(N = 219)	(N = 122)	(N = 97)
Men	55.3%	52.5%	58.8%
Age (mean years)	39.4	38.9	40
African American	62.6%	53.3%	74.2%***
Latino/Hispanic	33.9	43.8	21.6***
Education (mean years)	10.6	10.3	11.0*
Primary income
Government assistance	77.1	77.5	76.6
Work	5.6	5.9	5.3
Criminal justice involvement (no)	61.2	61.5	60.8
Medical ASI composite score	.29	.28	.30
Psychological ASI composite score	.31	.31	.30
Employment ASI composite score	.64	.64	.65
Legal ASI composite score	.22	.21	.24
Addiction severity (range: 0 – 14)	7.6	7.2	7.9
Polysubstance (mean # substances cited as problem)	3.6	3.8	3.4
Crack	43.8	47.1	41.8
Alcohol	19.2	18.2	21.1
Heroin	14.2	17.2	11.9
Marijuana	13.7	12.0	14.7
Legally pressure to enter treatment	24.2%	25.4%	22.7%
Prior treatment (yes)	80.4%	82.8%	77.3
Number prior treatment episodes	5.8	6.2	4.7
Ever attended 12‐step (yes)	81.7%	80.3	83.5
12‐step year before current treatment	44.3%	41%	46.4%
Attitudes and beliefs
Commitment to abstinence (range: 0 – 5)	4.1	4.1	4.1
Positive attitudes towards 12‐step (range: 1 – 5)	2.75	2.75	2.76
Embracement of Higher Power (range: 1 – 5)	3.9	3.9	3.9

^*p < .05

^**p < .01

^***p < .001

ATTRITION ANALYSIS

We compared participants included in the analyses (n = 219) with those who were not (n = 31) on key individual‐level variables previously reported to predict 12‐step participation and/or substance use outcome: Age, gender, race/ethnicity, primary substance, lifetime addiction severity, substance use status at baseline (whether used in the previous month), prior exposure to treatment and to 12‐step treatment mandated status (whether or not mandated into treatment). The only variable on which the two groups differed significantly (<.05) was age, whereby individuals who provided full data were older at baseline by 3.6 years than those who did not (mean = 39.4 vs. 35.8; F = 4.35, p<.05).

STATISTICAL ANALYSES

Descriptive analyses were conducted first to examine patterns of 12‐step participation and of substance use over the course of the post treatment year. Next we conducted bivariate comparisons (ANOVAs and Chi‐square tests) to compare the two groups (TSO and N‐TSO) on levels of 12‐step affiliation, number of 12‐step meetings attended and substance use since the last interview between the two groups (TSO and N‐TSO) at each data collection point. Finally, regression analyses were conducted to test the study hypotheses with type of program as the independent variable. In analyses where a measure of 12‐step participation was the dependent variable, the individual‐level domains on which the two groups had been found to differ (Hispanic ethnicity, African American race and education) as well as treatment duration and 12‐step participation prior to baseline were forced‐entered in the first block; for analyses where abstinence from substance use was the outcome, the control variables were Hispanic ethnicity, African American race, education level, treatment duration, 12‐step participation prior to baseline, addiction severity and length of abstinence at baseline. The significance level for all statistical tests was set at p<05.

RESULTS

SAMPLE DESCRIPTIVES

Participants were members of under‐served, minority groups, 55% males with an average age of 39 years (Table 1); most reported prior exposure to formal treatment (a mean of 5.8 prior episodes) and to 12‐step: 76.7% had previously attended Narcotics Anonymous and 46.6% Alcoholics Anonymous., 44% had attended 12‐step in the year before entering treatment. Three quarters (77%) reported government assistance as their primary income source, fewer than 6% derived primary income from work (on‐ or off‐the books), Almost all (93.7%) cited multiple problem substances with a mean of 3.6 problem substances reported, including crack (43.8%), alcohol (19.2%), heroin (14.2%), and marijuana (13.7%); 61.2% had no involvement with the criminal justice system.

TREATMENT AND POST‐TREATMENT OUTCOMES

Treatment and post treatment outcomes for the total sample and by program are reported in Table 2. Four out of ten clients (42.2%) completed treatment with an average length of stay of five months. There was no statistical difference between the two groups (TSO and N‐TSO) in treatment retention or completion rates.

Table 2.

Post‐treatment 12‐step participation and substance use as a function of presence/absence on 12‐step meeting onsite

		12‐step meeting onsite
	Total sample	No	Yes
	(N = 219)	(N = 122)	(N = 97)
Length in index treatment episode (mean days)	148	155	141
Completed treatment (yes)	42%	37.7%	47.4
End of treatment
Attended 12‐step since baseline	54.3%	45.1	66%**
Number of meetings past month	5.1	3.2	7.4*
12‐step involvementa	2.3	1.9	2.9*
No substance use since baseline	40%	30.5%	52.2**
Three‐month post treatment end
Attended 12‐step since previous interview	40.3%	33.3%	50%*
Number of meetings past month	3.7	2.3	5.4*
12‐step involvementa	1.9	1.6	2.4†
No substance use since previous interview	52.2%	45%	64.6%**
Six‐month post treatment end
Attended 12‐step since previous interview	39.3%	35.1%	44.4%
Number of meetings past month	4.0	2.9	5.4*
12‐step involvementa	2.0	1.5	2.6**
No substance use since previous interview	55.4%	49.1%	63.2%*
Twelve‐month post treatment end
Attended 12‐step since previous interview	29.7%	24.6%	36.1%
Number of meetings past month	3.5	2.6	4.7†
12‐step involvementa	1.8	1.4	2.3*
Attended 12‐step continuously since discharge	16.7%	14%	20.2%
No substance use since previous interview	48.6%	43%	58.9%**
Continuous abstinence since end of treatment	21.5%	12.2%	33.3***

^†p < .1

^*p < .05

^**p < .01

^***p < .001

^apossible range 0 to 9

Substance use outcomes

One half (55%) or fewer of study participants reported no drug use since the prior interview at any assessment point and only one in five (21.5%) sustained abstinence continuously throughout the one year post treatment period (Table 2).

Twelve‐step participation patterns

Twelve step meeting attendance was moderate at treatment end (54.3% ‐ Table 2, left col.) and declined steadily through the post end of treatment year to less than one third of participants reporting attendance in the six months preceding the one year post discharge interview (29.7%). Fewer than one in five participants (16.7%) reported continuous 12‐step attendance through the post treatment year. Of note, the intensity of attendance increased among those who did attend 12‐step after treatment, from a mean of 7.8 meetings in the month prior to the three month follow‐up, to 9.1 meetings in the month prior to the 6‐ months interview and 11.9 in the month prior to the one‐year post treatment end assessment (not shown in table).

Twelve‐step attendance during treatment was significantly associated with continued attendance at each post treatment follow‐ups as well as with continuous attendance for the entire year following treatment end: 30% of those who attended during treatment attended continuously for the entire subsequent year, compared to 3% of those who did not attend during treatment (Chi sq = 32.6, p <.0001), emphasizing the importance of fostering 12‐step attendance during treatment. Number of meetings attended during treatment was positively correlated with number of meetings attended since the previous interview at each follow‐up (r = .14, .37 and .18, respectively, all p<.05). In logistic regression, pre‐treatment 12‐step attendance (during the year before entering treatment) was associated with greater likelihood of 12‐step attendance during but not after treatment (Table 3). Attendance during treatment was associated with a 5.3 times greater likelihood of attending 12‐step in the second half (6 months) of the year post discharge (B = 1.67, p<.01, 95% CI = 2.54– 11.07 ‐ Table 3).

Table 3.

Logistic regression results of 12‐step onsite predicting 12‐step attendance at 3‐, 6‐ and 12‐months follow‐ups.

Variable	B	S.E.	Sig.	Odds ratio	95% CI
				(Exp B)	(Exp B)
Independent variable: 12‐step onsite
Dependent variable: 12‐step attendance during treatment (assessed at treatment end)
Latino	−1.02	.53	.06	.36	(.13–.1.02)
African‐American	−.65	.52	.20	.52	(.19–1.44)
Education	.11	.08	.17	1.12	(.95–1.32)
Treatment duration	.00	.002	.00	1.00	(1.00–1.01)
Prior 12‐step (year before baseline)	1.49	.33	.00	4.45	(2.17–8.05)
12‐step onsite	1.06	.34	.00	2.89	(.35–24.09)
Independent variable: 12‐step attendance during treatment
Dependent variable: 12‐step attendance since 6 month follow‐up (assessed at 12 months follow‐up)
Latino	−.33	.55	.54	.71	(.25–2.10)
African‐American	−.18	.51	.71	1,20	(.45–3.24)
Education	.15	.09	.09	1.16	(.97–1.37)
Treatment duration	.00	.00	.43	1.00	(1.00–1.01)
Prior 12‐step (year before baseline)	.43	.34	.21	1.54	(.78–3.01)
12‐step during treatment	1.67	.38	.00	5.30	(2.54–11.07)
Dependent variable: Continuous abstinence from substance use over 12‐months post‐treatment end
Independent variable: 12‐step onsite
Severity	.08	.06	.14	1.09	(.97–1.22)
Abstinent time at discharge	.00	.00	.00	1.00	(1.00–1.01)
Treatment duration	.00	.00	.02	1.01	(1.00–1.01)
Latino	−1.10	.69	11	.33	(.08–1.28)
African‐American	.17	.61	.78	1.19	(.36–3.97)
Education	.11	.11	.32	1.11	(.90–1.38)
12‐step onsite	1.75	.46	.00	5.79	(2.32–14.50)
Mediation model with 12‐step attendance during treatment added as independent variable ‐ Sobel’s Z = 2.31, p<.05
Severity	.05	.06	.41	1.05	(.94–1.18)
Abstinent time at discharge	.00	.00	.00	1.00	(1.00–1.01)
Treatment duration	.00	.00	.06	1.00	(1.00–1.01)
Latino	−1.14	.73	.12	.32	(.08–1.34)
African‐American	.01	.64	.97	1.02	(.29–3.56)
Education	.10	.11	.36	1.11	(.89–1.39)
12‐step onsite	1.42	.48	.00	4.10	(1.60–10.54)
12‐step during treatment	.00	.00	.01	1.01	(1.00–1.01)

Levels of involvement in 12‐step suggested activities (e.g., reading 12‐step recovery literature, working the steps) were consistently low in this sample, with an average of two or fewer out of nine possible activities reported at any of the data collection points. Throughout the study period, the most frequently reported 12‐step activities at any and all interviews (not shown in table) were reading recovery literature, identifying as a member of a 12‐step fellowship, socializing with other 12‐step members before or after meetings and contacting other members outside of meeting times. However the overall rate of participation in any of these activities was consistently low: the highest rate of participation in any 12‐step activity at any time point was reading recovery literature (36% at the end of treatment assessment). Moreover even the most frequently reported activities declined consistently over the follow‐up period with only one quarter of participants reading literature and considering oneself a 12‐step member at the one year follow‐up (26.5% for each).

DOES ATTENDING A TREATMENT PROGRAM WITH 12‐STEP ONSITE PREDICT GREATER 12‐STEP PARTICIPATION DURING AND AFTER TREATMENT?

In bivariate analyses, compared to those in the N‐TSO program, TSO clients had significantly higher rates of 12‐step participation: they attended more meetings and had higher levels of involvement in 12‐step activities at each of the four post‐treatment assessment points (Table 2). We then conducted multivariate analyses to quantify the role of TSO on 12‐step participation. We first examined the role of TSO on 12‐step attendance during treatment: Controlling for relevant individual variables (see Statistical Analyses section), TSO was independently associated with a 2.89 times greater likelihood of having attended 12‐step meetings during the index treatment episode (B = 1.06, p <.01, 95% CI = .35 – 24.09‐ Table 3). Moreover, among those who did attend 12‐step during treatment, TSO was significantly associated with higher level of meeting attendance during treatment (B = 42.18, p<.001) after controlling for individual‐level predictors (not shown in table). The association did not hold for 12‐step involvement.

Next, we examined the association between TSO and post treatment 12‐step participation (not shown in table). We repeated the analyses described above with number of meetings attended between each of the post‐treatment interviews. In linear regression, TSO significantly predicted greater number of meetings attended between the 3‐ and 6‐month post‐treatment end period (B = 17.05, SE (B) = 5.89), however the total model accounted for only 6% of the variance in 12‐step attendance assessed at 6 months with TSO alone accounting for 4% in increased variance. TSO did not significantly predict 12‐step attendance in the first three month post‐treatment or in the second half of the post treatment year. A similar pattern of results was obtained when we repeated these analyses with 12‐step involvement level as the dependent variable: again, controlling for other relevant individual‐level variables, TSO significantly predicted involvement level during the 3 months preceding the 6‐months assessment point (i.e. the elapsed time between 3‐ and 6‐month post‐treatment end interviews) only, where TSO was associated with greater levels of 12‐step involvement (B= .84, p= .05).

Finally, we were interested in exploring whether TSO was associated with starting to attend 12‐step meetings during treatment among participants who had no prior 12‐step exposure at treatment entry. The analyses are exploratory as the sample size was too small to yield statistical significance. Of the forty participants who had reported no prior 12‐step exposure, 11 (27.5%) initiated attendance during treatment: 37.5% of these 11 participants attended the TSO program vs. 20.8% who were in the N‐TSO program, the finding was not statistically significant but indicates a trend consistent with other findings reported here.

DOES ATTENDING A TREATMENT PROGRAM WITH 12‐STEP ONSITE PREDICT SUSTAINED ABSTINENCE AFTER TREATMENT?

In bivariate analyses, compared with N‐TSO, TSO was associated with significantly higher rates of abstinence since the previous interview at each of the four post‐treatment assessment points, as well as with continuous abstinence during the entire year following treatment end (TSO = 33.3% vs. N=TSO = 12.2%, chi sq = 13, p<.001 ‐ Table 2). In logistic regression with “no use since end of treatment’ (i.e., in the entire one year follow‐up period) as the dependent variable, after controlling for relevant variables, TSO participants were 5.79 times more likely than the N‐TSO group to have maintained abstinence for the entire study year (B = 1.75, p < 0.001; 95% CI = 2.32 – 14.5; Table 3). Moreover, in linear regression, TSO was associated with significantly longer abstinence at one year follow‐up compared to the N‐TSO group controlling for length of treatment, addiction severity and length of abstinence at baseline.

DOES 12‐STEP ATTENDANCE MEDIATE THE EFFECT OF ONSITE MEETINGS ON SUBSEQUENT ABSTINENCE?

We tested the mediation hypothesis using procedures described by Kenny and colleagues (Kenny et al., 1998) and most recently used in the intensive referral effectiveness study reported earlier (Timko et al., 2006) and by Moos and Moos (2007) in their investigation of the role of professional treatment in amplifying protective resources and supporting long‐term remission. The first two conditions of the mediation test were fulfilled ‐ TSO predicted 12‐step attendance during treatment, the hypothesized mediator, and abstinence, the outcome (Table 3). The next step involved determining whether, controlling for other relevant variables, 12‐step attendance during treatment predicts continuous abstinence during the one year post treatment period: findings were moderate but statistically significant (B = .011, Exp(B) = 1.1, p <.0001, 95% CI = .98 – 1.08). The last step in the mediation test involves entering study condition and 12‐step attendance during treatment together in a regression to predict abstinence in the post‐treatment year (Table 3). Study condition was a weaker although still significant predictor of continuous abstinence (B = 1.42, p <.05, compared to B = 1.75, p < 0.001 when TSO was the single independent variable) when 12‐step attendance during treatment was also entered in the analysis (B = .00 p <.01). Inclusion of 12‐step attendance during treatment in the regression equation predicting continuous abstinence for one year after treatment ended reduced the beta estimating the effect of TSO on the dependent variable from 1.75 to 1.42, indicating that 12‐step attendance during treatment accounted for about 18.8% of the influence of TSO on continuous abstinence at one year follow‐up. The indirect effect of TSO on abstinence via 12‐step attendance was significantly different from zero according to the Sobel test (Z = 2.31. p<.05 ‐ Sobel, 1982; Table 3).

Discussion

REPRISE OF KEY FINDINGS

We identified an unplanned opportunity to explore the role of 12‐step meetings onsite at treatment programs (TSO) on subsequent client outcomes; to our knowledge this is the first study to examine this question empirically. We hypothesized that TSO would be associated with greater levels of 12‐step participation and with less substance use after treatment and that the association between TSO and subsequent abstinence would be mediated by 12‐step attendance during treatment. TSO was associated with a nearly three times greater likelihood of attending 12‐step during treatment and that in turn, enhanced by more than five‐fold, the likelihood of post treatment 12‐step attendance. TSO participants were four times more likely than non‐TSO participants to maintain abstinence continuously for one year after treatment and the effect was partially mediated by the number of meetings attending during treatment.

RATES OF 12‐STEP PARTICIPATION

The finding that TSO enhances 12‐step attendance during treatment is significant for at least two reasons. First, 12‐step patterns established early on in treatment may be fairly consistent throughout the treatment episode (Weiss et al 2000a); moreover, clients who initiate 12‐step attendance during treatment attend longer and more frequently after treatment (Horgan et al., 2003; Kelly and Moos, 2003) and are more likely to achieve remission (Moos and Moos, 2005). The presence of an onsite meeting may convey to newly admitted clients that 12‐step attendance is an integral part of the treatment program (even if attendance is not mandated), resulting in greater attendance during treatment than if programs merely encourage 12‐step attendance in the community as is the case where there is no on‐site meeting. Second, recent findings from a long‐term study of alcohol dependent persons suggest that 12‐step attendance early on in the remission process (e.g., in the first half of the first year) is associated with better long‐term outcomes at the 16‐year follow‐up including lower substance use and lower mortality (Moos and Moos, 2006; Timko, Debenedetti, Moos and Moos, 2006; also see Masudomi, Isse, Uchiyama, and Watanabe., 2004).

Post‐treatment 12‐step attendance findings were on par with those of other studies reporting that under half of participants attend after discharge (e.g., Horgan et al., 2003). Twelve‐step attendance participation was significantly higher during the first three months after treatment end among TSO than non‐TSO participants. However even in the TSO program, during that period, only half participants attended 12‐step and attendance rates at subsequent follow‐ups declined steadily. Few studies report rates of continuous attendance over a period longer than a few months; one exception is a study of cocaine dependent treatment clients whose post‐treatment 12‐step attendance pattern was tracked over two years: 40% attended continuously, 26% attended in the first six months then dropped out, 26% never attended, and 9% initiated attendance during the follow‐up period (Fiorentine, 1999); in the present study, only 20.2% of TSO participants attended continuously over the first post‐treatment year. The two study samples, one in California and in New York State, are not significantly different in terms of sociodemographics so possible factors associated with continuous 12‐step attendance rate are not clear and conclusions are difficult to draw from two studies only; more information about longitudinal continuous patterns of 12‐step attendance among drug‐dependent populations is clearly needed and future studies must adopt a longer term perspective than the one year follow‐up used here.

Overall in this sample, rates of 12‐step participation were low. One of the unique aspects of this study is its use of a repeated measures that allowed us to examine patterns of 12‐step participation at intervals over the first year after treatment ended, a critical period for solidifying remission. During that period, 12‐step attendance declined over time. This is unfortunate since longer post‐treatment 12‐step attendance plays a critical role in maintaining treatment gains (e.g., Fiorentine, 1999). Underutilization and high attrition rates in 12‐step fellowships have been widely noted but there has been little research seeking to elucidate their possible causes. While most work on 12‐step participation has been conducted among alcohol‐dependent samples until recently, a study comparing views about 12‐step among alcohol‐ and drug‐dependent clients found that compared to alcohol‐dependent persons, drug dependent treatment clients expressed more positive views and more willingness to attend 12‐step meetings (Best, Harris, Gossop, Manning, Man, Marshall et al, 2001); participants in this study expressed highly positive views of 12‐step meetings at intake. Findings from studies on reasons for attrition and non‐engagement in 12‐step point to problem denial, active substance use, not recognizing the need for help (”I can do it on my own’) and low motivation to change as critical obstacles to 12‐step attendance (Laudet, 2003; Laudet et al., 2004). Many of these obstacles are similar to those cited by substance dependent persons for not seeking help and for disengaging from treatment when enrolled, suggesting that motivation for change and information about the critical need to seek support for recovery are important loci of intervention when working with clients who are resistant to engaging in treatment and/or in 12‐step.

Although post‐treatment 12‐step attendance rates declined overall, the intensity of attendance among attenders increased by 50% over the follow‐up year. This is consistent with McCrady’s observation of “considerable variability in patterns, with some becoming increasingly committed while others gradually slip away” (1998, p.715). Because 12‐step attendance during treatment was strongly associated with attendance post treatment, clients who go on to become engaged in 12‐step after treatment are likely to have already established substantial engagement during treatment. Treatment providers may be able to enroll clients who attend regularly during treatment as ‘peer mentors’ or educators to those who do not; this could take a number of forms including group discussions where 12‐step attenders share with other clients, the types of benefits they derive from attending 12‐steps, and address reservations expressed by non‐attenders.

Involvement in 12‐step recovery activities was very low in this sample, declined after treatment and the effect of TSO on 12‐step involvement was not significant in multivariate analyses. Reading 12‐step literature and having contact with other 12‐step members were the most frequently reported activities; contact with other members may provide social support and role models, both critically needed in early recovery. However other important aspects of the 12‐step recovery program, aspects that can be regarded as representing more commitment to recovery such as obtaining a sponsor and working the steps were reported by a minority of participants only. This low 12‐step involvement finding is perhaps not surprising in the present sample of chronically dependent persons with long addiction and treatment careers, since 12‐step involvement is generally interpreted as representing stronger engagement in 12‐step recovery than meeting attendance alone. However, paired with the report of low and declining attendance over time, this finding underlines the critical need for additional research to identify effective means of involving chronically substance dependent persons in 12‐step recovery activities during treatment. It is not surprising that TSO did not have a strong effect on involvement, and in particular on the forms of involvement that represent a stronger commitment to 12‐step recovery such as working the 12‐steps, having a sponsor or considering oneself a member of a 12‐step group. These affiliative behaviors develop over time in the context of regular meeting attendance. The low and declining rates of 12‐step attendance over time may not have afforded sufficient opportunities for participants to ‘buy into’ 12‐step recovery.

Twelve step participation and remission

Rates of abstinence increased slightly from the end of treatment to the 12‐months post treatment follow‐up. However, only one in five participants maintained abstinence during the full post treatment year. Published studies typically report abstinence rates bearing on one to three months prior to each of the follow‐up interviews (Kaskutas et al., 2005; Moos and Moos, 2007; Scott, Foss and Dennis, 2005) rather than continuous abstinence rates which is rather unfortunate as sustained remission is arguably the goal of treatment (and of 12‐step step participation); there is virtually no information available on rates of continuous abstinence among drug dependent persons. As a result, determining how representative our findings of post‐treatment substance use patterns is challenging. While the overall reported effect of TSO on 12‐step attendance and on subsequent remission is encouraging and significant, the effect of TSO on remission may have been stronger had it extended to enhancing 12‐step involvement, a stronger predictor of substance use outcomes than is attendance alone (Weiss, Griffin, Gallop, Najavits, Frank, Crits‐Christoph et al., 2005).

STRENGTHS AND LIMITATIONS

This exploratory study has several strengths including the use of four assessment points over the one post‐treatment year, the use of total abstinence from all illicit drugs (compared to abstinence from primary substance only), the assessment of continuous abstinence and continuous 12‐step attendance over the study period, the examination of the role of 12‐step attendance on subsequent (rather than concurrent) substance use, and the use of multivariate analyses that control for known predictors of outcomes domains other than those under study. The study also has several limitations. The primary limitation is the non‐randomized nature of the independent variable (onsite 12‐step meeting). Although we found few significant statistical differences on key variables measured at baseline and included these variables as control in the analyses, there may be other variables or non‐observable confounds between the two programs influencing the results; therefore findings must be interpreted with great caution. The research providing data for this study called for analyzing data in the aggregate across the two programs; we did not collect in‐depth individual program information using standardized scales (e.g., therapeutic orientation, program climate). We relied on interviews with administrative and clinical staff and on review of the two program’s curricula (e.g., services offered, clients’ schedule) when the study was being planned and again after data collection started to determine whether the two programs were comparable. Future studies designed to further examine the role of on‐site 12‐step meetings on subsequent outcomes should include more rigorous program‐level data collection than we obtained to rule out as many program confounds as possible. Second, the sample is relatively small. Replicating this study using an experimental design and a larger sample with balanced racial/ethnic representation in both study conditions would be useful to rigorously assess the efficacy of 12‐step onsite, a potentially useful recovery resource. Third, participants retained in the study were older by nearly four years on average, than those lost to follow‐up; while none of study outcomes (abstinence and 12‐step participation) were associated with age, older age may coincide with being further along in one’s addiction career so that outcomes may be somewhat different (poorer) with younger cohorts.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Most research on 12‐step participation has been conducted among alcohol‐dependent samples. Present study participants were under‐served inner city polysubstance users with long addiction and treatment ‘careers’ typical of client populations served in publicly‐funded outpatient programs in large cities such as New York City where the project is based. They had long chronic addiction career as well as long treatment careers with on average, six previous treatment episodes (similar to findings reported by Dennis et al., 2005); 42% completed treatment; across assessment periods, half or fewer attained a few months of abstinence over the post treatment year, and one in five only maintained continuous abstinence over one year. These figures illustrate the critical need to identify factors that promote initiation and especially maintenance of remission from drug dependence. Addiction is increasingly conceptualized as a chronic, relapse prone disorder (e.g., McLellan et al., 2000) and most substance dependent individuals require multiple treatment episodes before they are able to attain and maintain abstinence from illicit drugs (e.g., Anglin et al., 1997; Dennis et al., 2005). A number of addiction scientists have argued that research in this area adopt a life course, developmental perspective to assess the role of treatment on substance use outcomes. Multiple treatment episodes may generate cumulative effects (Powers and Anglin, 1993) and be best understood as cyclical, incremental and interactive in nature rather than discreet episodes (e.g., Anglin et al., 1997; Hser et al., 1997). For instance, in outpatient drug‐free programs, individual counseling and program compliance has greater impact on abstinence among treatment repeaters than for first‐timers (Hser et al., 1999). From a developmental perspective, multiple treatment episodes (and relapses) may be viewed as part of the recovery process rather than as failed efforts to achieve complete and enduring abstinence (Anglin, et al, 1997).

As multiple treatment episodes are often required before remission is attained, multiple ‘episodes‘ of 12‐step participation may be necessary for affiliation to develop and for 12‐step recovery ideology to be embraced. We have documented patterns of multiple 12‐step attendance/attrition episodes in this sample: Nearly all participants with prior 12‐step exposure at treatment entry had dropped out of 12‐step meetings at least once for a month or longer; participants reported an average of six such episodes with no difference between patterns of AA and NA attendance (Laudet et al., 2004). The same life course cumulative approach that has proven useful to elucidate the role of treatment processes over time is likely to extend to the effects of 12‐step participation as well, although little research has been conducted in this area. Comparing 12‐step fellowships and formal treatment, Vaillant observed “[The individual] belongs to the first, he only visits the latter (…) unlike visits at a treatment program, affiliation with 12‐step groups, if it develops, is often measured in hundred of meetings and spread over years” (1995, p. 257; also see Humphreys et al., 1997). This points to the need to adopt a life course approach to investigating patterns of 12‐step attendance and their effectiveness over time (independently as well as in combination with formal treatment attendance patterns), including change and periods of transition between engagement and disengagement. Moos and colleagues adopted a life course perspective to study the effects of patterns of 12‐step attendance over multiple years among alcohol dependent persons (Moos and Moos, 2006 and 2007; Timko, Moos, Finney and Lesar, 2000) but the field lack a similar body of work among drug dependent persons. This is critically needed, particularly because drug (vs. alcohol) dependent persons tend to have exhausted more of their social capital by the time they seek remission (Blomqvist, 2002), suggesting that the ongoing support, recovery strategies and role models available in 12‐step over time may be especially relevant to this population. Adopting a prospective life course perspective to studying the cumulative effects of multiple treatment and/or 12‐step episodes over time is likely to remain challenging for researchers; in addition to the logistic difficulties of following the same, often unstable individuals over long periods of time, current research funding mechanisms do not lend themselves easily to a life course approach. When long‐term follow‐ups are not feasible, combining retrospective and prospective information on 12‐step attendance and substance use patterns may represent a suitable alternative.

The most important implication of present findings for treatment programs is that holding a 12‐step meeting on site may represent a promising, effective and cost effective strategy to fostering post‐treatment recovery by providing clients with low‐threshold opportunity to attend a meeting. Moreover, because our findings show that some clients become engaged in 12‐step and others do not, it is critical to initiate and maintain an open dialogue with clients starting at intake, about their beliefs, concerns and experiences with 12‐step meetings, and to redress any misconception that clients may have. When clients do not appear to engage, alternative community‐based sources of recovery support should be identified although this is often challenging as non 12‐step support groups (e.g., Rational Recovery) tend to be geographically dispersed and limited in availability. Finally, clinicians, like researchers, would serve clients well by adopting a developmental approach to clinical care: the intensity and pattern of previous exposure to both treatment and 12‐step is likely to have a residual cumulative effect that may ‘prime’ clients to be more (or less) receptive to the current treatment episode (depending on their previous experience).

CONCLUSIONS

As access to and duration of formal services continue to decrease due to fiscal austerity and aggressive managed care, clinical outcomes may be increasingly influenced by the degree to which treatment programs actively support clients’ transition into the post‐treatment phase of recovery, including participation in 12‐step or alternative mutual aid structures (Humphreys et al., 1999; Mankowski et al., 2001). Holding a 12‐step meeting onsite at a treatment program is a low cost strategy that is available to any agency that wishes to implement it. Our findings suggest that it may also be an effective strategy to enhance the likelihood of 12‐step attendance and, more importantly, the likelihood of sustaining abstinence from drugs after treatment. We hope that these exploratory findings will stimulate further investigation of this potentially useful recovery‐promoting strategy.