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Examining Mechanisms of Action in 12-Step Treatment: The Role of 12-Step Cognitions

Jon Morgenstern, Donald Bux, Erich Labouvie, Kimberly A. Blanchard, Thomas J. Morgan

Objective: Twelve-step treatment appears to be modestly effective in treating alcohol and cocaine dependence, but little is known about its mechanisms of action. The primary aim of this study was to examine the hypothesized mechanism of action of 12-step cognitions. In addition, the psychometric properties of a measure used to assess 12- step cognitions were tested. Method: The psychometric properties of a measure to assess 12-step cognitions were examined in a sample of individuals (N = 370, 61% male) seeking inpatient (n = 118) or outpatient (n = 252) 12-step-oriented community treatment. Additional analyses of data from the inpatient sample examined changes in cognitions from entry to discharge and 12-month follow-up. The univariate and multivariate relationship of cognitions at discharge, and substance use outcomes across the 12-month follow-up were also examined in the inpatient sample. Results: The measure of 12-step cognitions demonstrated good internal consistency. Findings supported some, but not all, of the hypothesized active ingredients of 12-step treatment. Cognitive processes common to many treatment-approaches significantly mediated outcomes, whereas processes unique to the 12-step approach (e.g., spirituality) did not. Overall, some 12-step cognitions at discharge were good predictors of outcome, explaining as much variance in outcome as illness severity factors (e.g., dependence severity). Conclusions: Results provided greater support for 12-step treatment theory than those reported in prior studies. At the same time, findings suggest that diverse treatment approaches may operate through a common set of active ingredients. (J. Stud. Alcohol 63: 665-672, 2002)