The current study examined a multivariate process model of 12-step attendance and affiliation by adolescents following treatment for alcohol and other drug problems, and assessed factors that influenced and were influenced by such behaviors. We examined the effects of 12-step affiliation on substance use outcomes over and above measures of 12-step attendance during the first 6 months following inpatient treatment. In addition, mechanisms theorized to explain the relapse process (i.e., coping, motivation and self-efficacy; Marlatt and Gordon, 1985
) were investigated as possible mediators of any such effects.
Similar to findings with adults (Emrick et al., 1993
; Tonigan et al., 1996a
; Weiss et al., 2000
), those adolescents studied here who had greater substance-use problem severity were more likely to attend the abstinence-focused 12-step groups. Knowledge of substance use severity and motivation for abstinence could enhance the specificity and efficiency of intervention strategies used in treatment settings. For youths with less severe problems, focus could be placed on increasing motivation for abstinence and 12-step group attendance. As an alternative, emphasis could be placed on ways of sustaining substance use behavior change (i.e., relapse prevention) that do not involve 12-step group attendance. Examples are family therapies, extrication from substance-using peer group, or functional analysis of substance use and discovery of likely alternatives to meet needs formerly met with substances (Brown, 1993
Both a higher frequency of 12-step meeting attendance and, to a lesser extent, greater affiliation with 12-step groups were associated with better posttreatment substance use outcome, as predicted. The measure of affiliation used here, however, derived from adult studies, did not predict adolescent substance use outcome over and above simple measures of 12-step group attendance. This is in keeping with some adult studies (e.g., Tonigan et al., 2000
) that found that affiliation did not add to the prediction of substance use outcome following early treatment; however, it contradicted other findings that had revealed unique outcome effects for measures of affiliation. The degree of collinearity between attendance and the composite measure of affiliation observed in this study was considerably higher than in the Montgomery et al. (1995)
study and the Snow et al. (1994)
study with adults. This high degree of overlap suggests that adolescents who attend more often are also likely to be those with greater 12-step affiliation. Explanations for the greater degree of overlap between attendance and affiliation among adolescents in this study and the lack of unique predictive ability for affiliation found here could reflect measurement issues, life stage or some combination of the two. For example, 12-step affiliation has been measured using an array of variables assessing a range of behavioral and subjective indices (see Emrick et al., 1993
). These range from single-item measures to longer multidimensional assessments (Gilbert, 1991
; Humphreys et al., 1998
; Tonigan et al., 1996b
). For adolescents, other measures may also be important (e.g., perceived similarity to other group attendees) (Vik et al., 1992
). In addition, the proportion of female subjects in this study sample was larger than in the adult studies; thus, gender may interact with indices of attendance and affiliation. An alternative explanation is that these findings may reflect developmental differences. Given the additional logistical barriers facing adolescents in getting to 12-step meetings, for example (e.g. lack of personal transport, finances, permission from parents), those who do attend more frequently are likely those who place higher value on the importance of such attendance. These youths may also be more likely to follow program suggestions regarding such aspects of affiliation as sponsorship and working the steps. Since adults face fewer logistical barriers, and because some 12-step attendance is legally mandated (Speiglman, 1997
), a greater number of adults may attend but not feel the wish to become actively involved. This greater variability among adult 12-step attendees regarding affiliation could account for the unique predictive power of measures of affiliation observed in several adult studies.
Level of 12-step affiliation was shown to account for unique variance (above 12-step attendance) in motivation measured at 3 months, and also fully mediated the effect of 12-step attendance on motivation. This suggests greater 12-step affiliation is the mechanism through which attendance maintains and enhances adolescents' motivation for abstinence. From an operant behavioral perspective, contact with a sponsor and engagement in social activities with other members may provide youths the opportunity to observe and begin to experience a lifestyle devoid of substance use that may be both negatively (through the absence of former substance-related problems) and positively (through praise and support from family and other fellowship members) reinforcing. From a social-cognitive perspective, work on the 12 steps, which often includes indepth appraisal of past substance-related consequences, may influence and support cognitions supportive of abstinence.
The finding that self-efficacy and coping predicted substance use outcome in this study is in keeping with earlier work, which found these factors to be similarly predictive (Myers et al., 1993
; Richter et al., 1991
). In the current study, however, coping lost its significance once abstinence motivation was taken into account. This change may reflect selection criteria; the earlier study only included individuals who were deemed to be motivated for abstinence at treatment intake. Thus, a possible reason for these discrepant findings is that, in the current study, motivation is a specified measured variable, whereas in the earlier studies it was a constant (i.e., an inclusion criterion). Dimensional measurement of the motivational construct may further enhance explanatory models of the maintenance of substance use behavior change for adolescents.
Abstinence-focused self-efficacy of this sample appeared to be least affected by 12-step involvement. This is in keeping with the Morgenstern et al. (1997)
study, which also found that self-efficacy, although a significant mediator in the adult sample studied, was least affected by 12-step involvement. It may be that testimonials and admonitions from individuals who have relapsed, often heard at 12-step meetings, initially thwarts confidence, despite behavioral change.
When examined from a dynamic process perspective, the pattern of results suggests that adolescents in treatment who display more severe alcohol and drug problems are also more motivated to cease their substance use. Motivation for abstinence is related to an increased likelihood of attendance at 12-step meetings. Adolescents who attend 12-step groups regularly are also likely to follow 12-step program suggestions (e.g., acquisition of a sponsor and working the steps), participate in the social aspects of the fellowship and rate highly the importance of 12-step attendance in their recovery efforts. Those who are more affiliated with 12-step groups, in turn, are more likely to realize maintenance of or increases in motivation, coping and self-efficacy. However, whereas self-efficacy and coping measured at 3 months are both associated with substance use in the ensuing 3 months, it is motivation to abstain that appears to have the most impact on future use. This finding appears consistent with adult studies that show a similar influence of motivation for change on future substance use behavior regardless of treatment orientation (Project MATCH, 1997
Findings reported here, if replicated in other studies of adolescents, have important theoretical implications. The cognitive-behavioral model of adult relapse proposed by Marlatt and Gordon (1985)
provides reasonably good fit in helping explain factors in adult relapse (Miller et al., 1996
). Findings with this cohort of substance abusing youth suggest, however, a closer fit with self-regulation theory (Kanfer, 1987
) and its derivative, motivational enhancement theory (Miller and Rollnick, 1991
). Alcohol- and drug-abusing adolescents (who typically possess briefer substance use histories and less severe substance dependence) may be better able to “self-regulate” their behavior once they reach a commitment to do so. The applied implications of these findings suggest greater attention be paid to cognitive factors (e.g., motivation) when attempting to influence adolescent substance use behavior. It has been noted that few, if any, youths voluntarily enter alcohol and drug treatment programs (Brown, 1993
). As a consequence, a nonconfrontive empathic therapist style, a focus on problems youth are concerned about and acknowledgement of a reluctance to be in treatment may be critical early on, in order to form a therapeutic alliance and improve treatment retention and motivation for change (Jackson-Gilfort and Liddle, 1999
; Wagner et al., 1994
For several reasons, the current findings must be interpreted cautiously. The small sample size may mean that obtained estimates do not truly reflect population parameters and should be replicated with larger samples. Also, given the relatively high dropout rate, there are obvious generalizability issues. These concerns are ameliorated, however, by a failure to find any systematic differences on important baseline variables. Although structural modeling analyses undertaken in this study often assume the name “casual modeling,” the lack of experimental control may mean that unspecified variables may account for observed relationships. The current study did control for possible demographic, substance use problem severity and treatment experience confounds, however, which support the validity of the conclusions. We focused on only a single outcome measure (days abstinent). Broader psychosocial domains (e.g., school/work performance, familial/interpersonal relations and emotional difficulties) would be useful to assess (Brown, 1993
). In addition, the explanatory power of 12-step variables and the specified mediators, although able to explain about one third of the substance use outcome variance, implies other important factors need to be included in models of youth alcohol and drug treatment outcome. Measurement and inclusion of other theoretically important factors (e.g., family and peer variables) will likely help further explain changes in substance use and 12-step involvement.
Do adolescents affiliate with 12-step groups? Findings here suggest that youths with more severe alcohol and other drug problems do and that, for those who do, there appear to be benefits. Many youths, however, do not affiliate and others attend briefly before dropping out. Given the widespread treatment recommendations for adolescent 12-step involvement, more study is needed to determine what kinds and what aspects of 12-step groups and fellowships are helpful to adolescent change efforts and what alternatives should be developed. In addition, longer-term follow-up is needed to determine the dynamic relations between 12-step attendance and affiliation and outcomes for youth with substance use disorders and how these, in turn, might impact development trajectories into adulthood.