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Try out PMC Labs and tell us what you think. Learn More. Alcoholics Anonymous AA began as a male organization, but about one third is now female. Studies have found that women participate at least as much as men and benefit equally from AA, but it is unclear whether women benefit from AA in the same or different ways as men. This study tested whether gender moderated the mechanisms through which AA aids recovery.
Multiple mediator models tested whether purported mechanisms i. Both men and women were found to benefit from changes in social factors but these mechanisms were more important among men. Again, men benefitted mostly from social changes. Independent of AA's effects, negative affect self-efficacy was shown to have a strong relationship to outcome for women but not men. The recovery benefits derived from AA differ in nature and magnitude between men and women and may reflect differing needs based on recovery challenges related to gender-based social roles and Aa female for aa male contexts.
In most developed nations, alarming increases in the prodigious economic, social, and medical burden attributable to alcohol and other drug misuse has opened the door for greater coordination among formal and informal intervention and support services to help reduce harm, curb health care costs, and enhance long term recovery Bouchery et al. ificant increases in the quantity and quality of professional addiction treatment has been paralleled by increases in the spread of addiction mutual-help organizations Humphreys, ; Kelly et al.
The most ubiquitous of these is Alcoholics Anonymous AA. The most recent areas of investigation have been in examining AA's mechanisms of behavior change as well as potential moderators of its effects; specifically, increasing research has been conducted on the psychological and social change processes that are mobilized by AA and which subsequently lead to recovery i.
Research has also begun to combine these two types of analytic questions to examine whether the mechanisms through which AA works depend on certain characteristics of patients i. Another important characteristic of patients that is particularly intriguing when it comes to AA is gender, as the appropriateness of AA for women has been questioned. About one third of AA members are women, placing them in minority status in a predominantly male organization Alcoholics Anonymous, Moreover, during AA's formative years, the organization was almost entirely composed of Aa female for aa male.
Consequently, it has remained somewhat unclear whether a program derived from its successful application to male alcohol dependent cases, would cater to and be as effective for women. Also, much of the literature on which AA is based is written using the male pronoun i. These concerns, however, have not been borne out empirically. Studies that have examined whether women engage and benefit from AA as much as men have found that women become as, or more, involved, as their male counterparts, and also benefit as much or more than men Del Boca et al.
Unclear, however, is whether women benefit from AA in the same or different ways as men. For example, recent findings suggest AA le to enhanced alcohol outcomes by mobilizing recovery-supportive social changes in the networks of its members i. As noted above, AA participation has been shown also to lead to better outcomes by reducing depression symptoms and by increasing spiritual practices, particularly for more severely alcohol-impaired individuals Kelly et al.
However, given gender differences in the prevalence of depression among men and women Maier et al. Greater knowledge in this regard would help reveal the nature of any gender-specific benefits related to AA participation and also inform the broader field about the mechanisms through which men and women may recover from alcohol addiction Potenza et al.
Based on prior mediational findings Kelly et al. We did not have strong directional hypotheses about gender differences. However, based on the relatively higher prevalence of depression among women than men Piccinelli et al.
Subjects were randomly ased to 1 of 3 individually-delivered, psychosocial interventions: cognitive behavioral therapy CBT; Kadden et al. This study focused on baseline, 3- 9- and month follow-ups because only these time points contained the necessary variables needed for our fully lagged analyses.
Alcohol consumption was assessed using the Form 90 Miller et al. Two drinking outcomes were based on the past 90 days: percent days abstinent PDA and of drinks per drinking day DDD. AA attendance was also assessed using the Form 90, which captured the of AA meetings attended during the past 90 days at intake and 3, 9, and 15 months. The proportion of days attending AA was created by dividing the of days attended by total of days in period. Negative affect assesses an individual's confidence in their ability to successfully abstain when experiencing negative emotions; social self-efficacy assesses confidence in an individual's ability to abstain when encountering a high risk social drinking situation.
This item measure assesses past-week depression symptom severity; higher values indicate greater depression severity. The measure is well established psychometrically, with good internal consistency, test-retest stability and construct validity Beck et al. In the IPA, patients name the four most important people of the past 6 months, and rate how each reacts to their abstinence or drinking.
The of each type of network members was summed to produce a scale range 0—4. Someone could list four people all neutral about drinking, in which case they would get a count of 0 for both measures. Based on research Kelly et al. At intake, demographic information and the of prior alcohol treatments were recorded. Gender, marital status, and employment status were coded binary variables; race was coded as a 3-level categorical variable dummy-coded in the SEM see Table 1.
Compared to men, women tended to be more depressed, and had fewer prior alcohol treatments, a higher PDA, a lower of DDD, lower negative affect self-efficacy, and higher religiosity Table 1. The majority of participants To reduce the influence of these outliers, the of prior alcohol treatments was capped at four range The dependent variables i. To avoid temporal confounding among the predictor variable i. In addition, to help rule out other causes of change in the mediators and outcomes i.
Path diagram of the mediational model fit for men and women. Baseline covariates are included to help rule out other causes of change in the mediators and outcomes i. We Aa female for aa male a structural equation modeling multi-group approach to test for gender differences in the mediational paths in the ly tested multiple mediator model Kelly et al.
That is, we fit the multiple mediator model Figure 1 simultaneously but separately for men and women. We had considered including interaction terms i. Thus we opted for the less complicated separate models. To assess the overall equivalence of the model for men and women, we first fit a model in which we constrained all parameter estimates to be equal for men and women, and compared it to a model in which all parameter estimates could differ.
Then, because we were interested in gender differences in specific parameter estimates, we used the second model to conduct planned comparisons of mediational paths. Based on this second model, we tested mediation separately for men and women using the product-of-coefficients approach Sobel, This approach extends directly to multiple mediator models, where the total indirect effect is simply the sum of the mediator-specific indirect effects Mackinnon, ; Preacher et al.
We fitted models for both alcohol outcomes i. Missing data were observed for 3. To address missing data, the maximum likelihood estimation approach was used Schafer et al. We first estimated the variance-covariance matrix using all available data using the iterative expectation-maximization EM algorithm [SAS 9.
Prior to mediational analyses, we tested if Aa female for aa male was an overall effect of AA attendance on alcohol outcomes. Here, the effect of self-efficacy in negative affect situations on alcohol outcomes was larger in women than men, while the reverse was true for self-efficacy in high risk social situations see Table 2.
A positive difference between parameter estimates indicates that the effect was stronger for men than for women; a negative difference indicates that the effect was stronger for women than for men. The proportion of the total effect of AA on alcohol use outcomes ed for by the six mediators ranged from Direct effects were not always ificant given indirect effects, but the total effect of AA attendance on drinking outcomes was. The total effect i. Not all of the specific mediators were ificant Table 5. To better understand the nature of the non-ificant mediations, we examined Aa female for aa male standardized parameter estimates of the mediational paths Table 5 together with the tests of mediation of the specific mediators Table 4.
Partioning of the standardized effect of AA on drinking outcome: Total, direct and indirect effects. Test of mediation for specific indirect i. For PDA, greater self-efficacy in high-risk social situations and a higher of pro-abstinence social network members were ificant mediators of lower PDA for both men and women.
These two mediators appeared to be more influential in men than women, as indicated by the higher percentage of the overall effect that was mediated in men Figure 2. A higher of pro-drinking social network members was a similarly important mediator of lower PDA in men and women, though it was only statistically ificant in men.
Inspection of the standardized path estimates Table 5 revealed that in women, the effect of AA attendance on this mediator was not ificant, while the effect of pro-drinking social network members on PDA was, in both men and women. The mediation through self-efficacy in negative affect situations ed for Here as well, the effect of AA on this mediator was not ificant, but the effect of self-efficacy in negative social situations on PDA was.
In women, none of the specific mediators were statistically ificant. In women, either the effect of AA on the mediator was present, or the effect of the mediator on DDD, but not both. Judging by the percentages of the effect of AA attendance that was mediated by each mediator Table 4it appears as though women had similar though not statistically ificant effects for the social network mediators as men.
That is to say, in both men and women an increase in social network members advocating abstinence and a reduction of social network members advocating drinking was related to a reduction in DDD. Men and women differed in the effects of self-efficacy on DDD.
Meanwhile, self-efficacy in negative affect situations was important for women With the aid of a uniquely large, and geographically diverse, U. In line with prior studies, we found ificant independent beneficial effects of AA attendance on alcohol use outcomes that did not differ between men and women. Also, the effect of AA on the mediators did not differ by gender. In terms of the ways in which AA helped increase abstinence, ificant mediation was found for both men and women through social self-efficacy and pro-abstainer pathways. As shown in Table 4 and illustrated in Figure 2however, the magnitude of these effects differed, with a substantially larger proportion of AA's effect ed for by these mediators for men While these mechanisms also appear to be some of the ways in which women benefit from AA, for women these risky social contexts may be less frequently encountered, and, consequently, women do not benefit as much in this way.
In terms of the full mediational paths through which AA helped reduce drinking intensity, there were differences found between men and women.
For men, AA attendance led to ificant reductions in heavier drinking by increasing social abstinence self-efficacy, decreasing depression, increasing pro-abstinent network members, and by reducing pro-drinking network members. However, for women, none of the full mediational paths were ificant. As with the findings for PDA, the majority of the effect of AA on reducing drinking intensity for men was by facilitating recovery-supportive social- changes and may reflect the greater need for men to find new ways of coping with common social risks.
Women at this life-stage i. This indicates that other AA mechanisms not specified in the current model are playing an important role in reducing women's levels of drinking intensity. These will need to be delineated and tested in future research. Despite not being a mediational pathway AA was not ificantly related to it noteworthy was the importance of negative affect self-efficacy on both abstinence and drinking intensity among women, but not men.
Women's alcohol use outcomes appear to be strongly related to their ability to cope with negative affect. Such gender-based differences are reflected too in the differences in the meditational effects on abstinence discussed above. Viewed more broadly, these findings suggest there may be gender-related differences in relapse precipitants with women generally more susceptible to negative affect and men more susceptible to cue-induced social precursors.
Difference in sample sizes between men and women may have resulted in some findings being statistically ificant for men but not women despite similar effect size. The sample, although large, is treatment—seeking, mostly White and middle-aged and reflect changes early in recovery. Caution should be taken when extrapolating these findings to others. There were long time lags between measures; future research should examine relationships using finer temporal resolutions i.
It is likely that AA participants attend to, and use, whichever of a variety of helpful aspects that may be on offer in AA that have the most salience and relevance at that particular time in their phase of recovery. Men may use AA more than women to help them buffer socially-relevant relapse risks. Women appear to benefit in similar ways, but more work is needed to understand the additional ways women derive recovery benefit from AA. The pattern of findings underscores some gender-based differences that may have broader implications for the addiction treatment and recovery field.
For women between the ages of 30 and 50, a focus on finding alternative ways to cope with negative affect may yield recovery benefits, while among men in the Aa female for aa male life-stage, a relatively greater focus on coping with high risk social situations may yield recovery related benefits. NIAAA and NIDA had no further role in study de; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
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Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Contributors Authors Kelly and Hoeppner deed the study and wrote the protocol. Author Kelly managed the literature searches and summaries of related work.
Author Hoeppner undertook the statistical analysis, and authors Kelly and Hoeppner wrote the first draft of the manuscript. Both authors contributed to and have approved the final manuscript. Conflict of interest The authors have no conflict of interest, including specific financial interests and relationships and affiliations relevant to the subject of this manuscript. National Center for Biotechnology InformationU. Drug Alcohol Depend. Author manuscript; available in PMC Jun 1. John F.Aa female for aa male
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DOES ALCOHOLICS ANONYMOUS WORK DIFFERENTLY FOR MEN AND WOMEN? A MODERATED MULTIPLE-MEDIATION ANALYSIS IN A LARGE CLINICAL SAMPLE