title: Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: a multiple mediator analysis.
abstract: OBJECTIVE
  Evidence indicates that Alcoholics Anonymous (AA) participation reduces relapse risk but less is known about the mechanisms through which AA confers this benefit. Initial studies indicate self-efficacy, negative affect, adaptive social networks and spiritual practices are mediators of this effect, but because these have been tested in isolation, their relative importance remains elusive. This study tested multiple mediators simultaneously to help determine the most influential pathways.
  
  
  METHODS
  Prospective, statistically controlled, naturalistic investigation examined the extent to which these previously identified mechanisms mediated AA attendance effects on alcohol outcomes controlling for baseline outcome values, mediators, treatment, and other confounders.
  
  
  METHODS
  Nine clinical sites within the United States.
  
  
  METHODS
  Adults (n = 1726) suffering from alcohol use disorder (AUD) initially enrolled in a randomized study with two arms: aftercare (n = 774); and out-patient (n = 952) comparing three out-patient treatments (Project MATCH).
  
  
  METHODS
  AA attendance during treatment; mediators at 9 months; and outcomes [percentage of days abstinent (PDA) and drinks per drinking day (DDD)] at 15 months.
  
  
  RESULTS
  Among out-patients the effect of AA attendance on alcohol outcomes was explained primarily by adaptive social network changes and increases in social abstinence self-efficacy. Among more impaired aftercare patients, in addition to mediation through adaptive network changes and increases in social self-efficacy, AA lead to better outcomes through increasing spirituality/religiosity and by reducing negative affect. The degree to which mediators explained the relationship between AA and outcomes ranged from 43% to 67%.
  
  
  CONCLUSIONS
  While Alcoholics Anonymous facilitates recovery by mobilizing several processes simultaneously, it is changes in social factors which appear to be of primary importance.
authors.affiliation: Center for Addiction Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, 02114, USA. jkelly11@partners.org
authors.forename: John F
authors.initials: JF
authors.lastname: Kelly
authors.forename: Bettina
authors.initials: B
authors.lastname: Hoeppner
authors.forename: Robert L
authors.initials: RL
authors.lastname: Stout
authors.forename: Maria
authors.initials: M
authors.lastname: Pagano
mesh_terms: D000328:Adult; D000359:Aftercare / Q000706:statistics & numerical data; D000436:Alcoholics Anonymous; D000437:Alcoholism / Q000534:rehabilitation*; D000553:Ambulatory Care / Q000706:statistics & numerical data; D001521:Behavior Therapy / Q000379:methods*; D003863:Depression / Q000150:complications; D005260:Female; D006801:Humans; D008297:Male; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D012067:Religion; D055502:Secondary Prevention; D020377:Self Efficacy; D012944:Social Support; D029181:Spirituality; D016896:Treatment Outcome