Examining mechanisms of action in 12-step community outpatient treatment

Twelve-step theory hypothesizes that changes in specific cognitions and behaviors, including adoption of disease model beliefs and involvement in self-help programs, lead to symptom reduction. We examined the role of self-help affiliation in treatment outcome using causal chain analysis. Baseline, end-treatment and follow-up self-help affiliation and substance use were assessed in 252 drug and alcohol abusers attending a community program. Participants were randomly assigned to one of three cognitive-behavioral or 12-Step oriented individual counseling conditions. Participants also were assigned, based on problem severity, to one of three treatment settings (partial hospitalization; intensive outpatient; standard outpatient) that varied according to intensity of additional 12-Step programming. Repeated-measures ANOVA indicated that self-help affiliation increased overall during treatment, particularly in the 12-Step counseling condition (versus cognitive-behavioral), and the partial hospitalization setting (versus standard outpatient). Multiple regression indicated that self-help affiliation was negatively associated with substance use 6 months post-treatment, and that this was not moderated by condition. Self-help affiliation predicted outcome most strongly in the partial hospitalization setting and not at all in outpatient; however, this effect was accounted for by participants' initial problem severity: high-severity patients had poorer outcomes if they failed to increase self-help affiliation, relative to those who increased affiliation and to low-severity patients regardless of affiliation. Results indicate that, in this community-based program, self-help affiliation increased as a function of exposure to 12-Step oriented treatment programming, and significantly predicted better outcome among patients with high levels of problem severity. Implications for future treatment process and dissemination research are discussed. (C) 2003 Elsevier Ireland Ltd. All rights reserved.