The present study prospectively examined the effects of 12-step meeting attendance on substance use outcome for adolescents in the 6 months following inpatient substance abuse treatment and tested a multivariate process model of factors leading to and affected by such attendance. Attendance at 12-step meetings in the first 3 months, both when examined concurrently and when predicting future substance use behavior, was associated with significant reductions in posttreatment substance involvement. This effect held even when other formal treatment factors, such as aftercare session attendance, days in inpatient treatment, and baseline levels of substance use, were taken into account.
The major mechanism identified in our study by which attendance at 12-step meetings seems to operate is by maintaining and enhancing motivation for abstinence, which in turn is associated with abstinence and lower levels of substance use. It may be that the testimony and sharing of past and present experiences, a central component of 12-step meeting process, serves to remind those in attendance of past negative consequences resulting from their own use while emphasizing benefits of remaining abstinent. In this way cognitions supportive of continued abstinence may be reinforced.
Twelve-step meeting attendance was also found to maintain and enhance abstinence-focused coping in the first 3 months posttreatment, but greater coping skills were not associated with lower levels of substance use in the second 3 months after treatment. This may be due to differences observed between adults and adolescents in substance use topography. As mentioned earlier, adolescents have less entrenched patterns of use and present with lower levels of physical dependence compared to adults. Therefore, it may be that motivation is the principal factor that serves as the catalyst for behavioral change in adolescents, overriding the need for specific abstinence-focused skills. Adults presenting for treatment, on the other hand (who possess on average greater dependency), might possess a strong desire to remain abstinent but may be less likely to do so without the acquisition and employment of specific coping skills. Indeed, this notion is captured within the postulates of cognitive-behavioral theories of relapse for adults (e.g., Marlatt & Gordon, 1985
). Findings in this study would suggest a closer fit with self-regulation theory (Kanfer, 1987
) and its derivative motivational enhancement theory (Miller & Rollnick, 1991
). Adolescents with briefer substance involvement histories may be better able to “self-regulate” their behavior once they reach a commitment to do so.
Attendance at 12-step meetings did not affect self-efficacy measured at 3 months. However, self-efficacy did retain unique explanatory power in the equation predicting substance use between 3 and 6 months postdischarge. It may be that testimonials and admonitions from individuals who have relapsed, often heard at 12-step meetings, initially do not enhance confidence. Instead, such dialogue may again serve to increase motivation for continued abstinence and continued attendance. These findings appear to be consistent with the study by Morgenstern and colleagues (1997)
in which adult AA affiliation in the first month after inpatient treatment had strong relations with motivation and active coping efforts but only a small effect on self-efficacy. Longer term follow-up would help elucidate how self-efficacy is affected by continued 12-step attendance over time.
When examined from a temporal-process perspective, the pattern of results suggests that adolescents in treatment who display a greater degree of substance dependency are consequently more motivated to cease their substance use. Motivation for abstinence is related to an increased likelihood of postdischarge attendance at 12-step meetings, but not aftercare meetings. This may be because a greater degree of effort is necessary to find and attend 12-step meetings in the community than to find and attend aftercare meetings, which typically occur at the same facility as the inpatient treatment. Adolescents who attend 12-step groups tend to realize increases in abstinence-focused coping skills and motivation. However, it is a continued commitment to abstain that appears to have the most impact on substance use.
In the present study we measured attendance at 12-step meetings but did not assess the degree of affiliation or acculturation with such groups. Although it seems feasible to assume that attendance may serve as a reasonable proxy for affiliation, prior research with adults has shown that affiliation with 12-step groups is more predictive of successful outcome than mere attendance at meetings (e.g., Montgomery et al., 1995
; Snow, Prochaska, & Rossi, 1994
). Affiliation can be differentiated from attendance when it is understood as active participation in fellowship meetings (e.g., speaking at meetings, receiving and/or giving tokens) and organized activities (e.g., dances and parties) and incorporating 12-step principles and strategies into one's daily life (e.g., meditation and calling a sponsor). This has implications for estimating the effectiveness of 12-step mutual-support groups in reducing substance use problems. A parallel can be made with formal treatment, because many individuals attend but do not become engaged by the treatment process, or actively participate in it. The same has been shown to be true in studies of other psychiatric disorders requiring medication compliance, which have shown that only 50% of individuals who are prescribed medications actually comply with the treatment regimen (Haynes, McKibbon, & Kanani, 1996
). Therefore, to adequately assess whether a medication is effective it would be important to know whether the patient has been actually taking it. Thus, future research would do well to examine any incremental effects of affiliation with 12-step groups and substance use outcomes for adolescents.
For several reasons, the present findings must be interpreted cautiously. The small sample size may mean that obtained estimates do not truly reflect population parameters. This work should be replicated with larger samples. Also, given the high dropout rate and missing data, there are obvious generalizability issues. However, these concerns are ameliorated by a failure to find any systematic differences on important baseline variables. The correlational nature of the study may mean that unspecified variables may account for observed relations. However, the present study did control for possible demographic, problem severity, and treatment experience confounds, which adds to the validity of the conclusions. Also, the data collected in this study relied primarily on a monomethod, self-report, which may possibly bias estimates of population parameters (Campbell & Fiske, 1959
). However, other possible reporting bias was minimized through collateral informants (parents) and biological assays. The follow-up period was also relatively short (6 months). However, this initial posttreatment phase is of critical clinical importance, because it requires an acute and demanding adjustment, and prior research has shown that, during this time, relapse for both adults and adolescents is most likely to occur (e.g., Brown, 1993
). More lengthy prospective follow-ups are needed, however, to help elucidate the impact of these relations in the long term. In addition, only a single outcome was measured (days abstinent). Broader psychosocial domains of functioning, such as school and work performance, interpersonal relationships, and familial and emotional difficulties, would be useful to assess in future studies to examine the relative effects of 12-step attendance in these domains. A further limitation is the measure of self-efficacy used herein. Although such measures are in keeping with the literature in general, this may nevertheless over-simplify the construct. Also, the future time frame in relation to this measure was not limited to the next 3-month period but rather to “future use.” Finally, the modest explanatory power of 12-step attendance and the specified mediators imply other factors at work not specified in this model.
Of clinical importance is the fact that just over one fourth of the individuals treated did not attend any 12-step meetings during the first 3 months, and during the second 3-month period the number of adolescents not attending any 12-step meetings increased to almost 41% while the average number of meetings attended decreased. Given the importance attributed to meeting attendance within the chronic, disease model perspective of 12-step treatment philosophy, such nonattendance may diminish its effectiveness. According to Finney (1995)
, this could represent a “program failure” in that a weakness in the treatment chain occurs between treatment implementation and an intended proximal outcome (attendance at 12-step meetings). It would then follow that either more intensive treatment should be offered or a different therapeutic approach be taken. Given that motivation was only indirectly related to substance use outcome by means of 12-step attendance, use of motivational enhancement strategies proposed by Miller and Rollnick (1991)
may prove useful in helping adolescents reflect on their current substance use status and its relation to current difficulties creating in turn a state of internal imbalance or dissonance sufficient to increase the likelihood of attendance at 12-step meetings. Alternatively, given that participants with a less severe substance abuse problem appear less motivated for abstinence and less likely to attend 12-step meetings, a different therapeutic focus on the interpersonal consequences of use rather than on the “disease”-related aspects may be a more fitting way to effect changes in those whose substance abuse is less severe. As Tober (1991)
pointed out, use of a motivational enhancement approach may increase self-esteem and give adolescents a belief in their ability to have some control in their lives. More research is needed to determine the possibility of such attribute-treatment matching effects for this age group.
As explained earlier, it is also possible that adolescent nonattendance at 12-step groups may be due to developmentally specific logistical barriers not faced by adults (e.g., dependence on other people for transportation, adult composition of most groups). Thus, the effects of initial levels of motivation on subsequent attendance may be moderated by contextual factors, such as family support and resources. Future studies are needed to assess the impact of such differences on adolescent relapse.
In summary, these findings indicate that post-discharge attendance at 12-step meetings is associated with reductions in posttreatment substance involvement for adolescents. The modest salutary effect appears to operate primarily through maintaining and enhancing motivation to remain abstinent. In spite of this, many adolescents do not attend such groups, either because they are not convinced of the need to do so or because of environmental constraints related to their developmental status. In addition, unlike adults, the acquisition of specific abstinence-focused coping skills for youth, although a consequence of attendance at 12-step meetings, is not as crucial in effecting substance use behavior change for youth, at least in the early postdischarge months.
A multitude of studies in adult populations reveal that there is no uniformly right or optimal approach to treating psychoactive substance use disorders that is suitable in every case. This may be even more evident for adolescents. These results underscore the need for further studies with larger samples to examine more complex models of moderated mediation to begin to diagnose weak links in the causal chains of substance abuse treatments and determine which individuals, in particular, are vulnerable at these junctures.