the influence of posttreatment mutual help group participation on the friendship networks of...

American Journal of Community Psychology, Vol. 25, No. 1, 1997

The Influence of Posttreatment Mutual HelpGroup Participation on the Friendship Networksof Substance Abuse Patients1

Keith Humphreys2 and Jennifer M. NokeVeterans Affairs Pah Alto Health Care System and Stanford University School of Medicine

The effect of 12-step mutual help groups (e.g., Narcotics Anonymous) onmembers' friendship networks has received little attention. This 1-yearlongitudinal study examined such effects in a sample of 2,337 male substanceabuse inpatients, 57.7% of whom became significantly involved in 12-stepactivities (e.g., reading program literature, attending meetings) after treatment.An a priori model of the interplay of 12-step involvement and friendshipnetworks was tested using structural equation modeling, and found to haveexcellent fit to the data. Twelve-step group involvement after treatment predictedbetter general friendship characteristics (e.g., number of close friends) andsubstance abuse-specific friendship characteristics (e.g., proportion of friendswho abstain from drugs and alcohol) at follow-up. Results are discussed interms of how mutual help group involvement benefits patients and how theself-help group evaluation paradigm should be broadened.

1An earlier version of this paper was presented at the 1995 Meeting of the Society forCommunity Research and Action, Chicago. Preparation of this paper was supported by theDepartment of Veterans Affairs Mental Health Strategic Health Group and Health ServicesResearch and Development Service. Thomas Horvath, Richard Suchinsky, and Karen Boiesprovided general guidance and administrative support. This project also benefited from theinvaluable contributions of the local coordinators, project assistants at each site, and the staffof the Program Evaluation and Resource Center. Rudolf Moos, Kurt Ribisl, and KathleenSchutte provided helpful comments on a draft of this manuscript.

2Al1 correspondence should be addressed to Keith Humphreys, Center for Health CareEvaluation, Veterans Affairs, Palo Alto Health Care System (152-MPD), 795 Willow Road,Menlo Park, California 94025.

KEY WORDS: self-help groups; mutual help organizations; social networks; friendships;substance abuse; treatment outcome.

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0091-0562/97/0200-0001$12.50/0 C 1997 Plenum Publishing Corporation

In the United States, 12-step groups (e.g., Narcotics Anonymous) are boththe most prevalent type of self-help group and the most common sourceof help sought by people with substance abuse problems (Kurtz, 1990;Room & Greenfield, 1993). The popularity of 12-step groups is partiallydue to many treatment professionals encouraging substance abuse patientsto attend groups after treatment (Makela et al., 1996). Thus, it is not sur-prising that significant attention has been focused on the effects of post-treatment 12-step group attendance on substance abuse outcomes (Emrick,Tonigan, Montgomery, & Little, 1993; McKay, Alterman, McLellan, &Snider, 1994). This paper address a complementary issue that has receivedrelatively less attention: the effects of posttreatment mutual help group in-volvement on friendship networks.

Evaluation of the effects of self-help group participation on friendshipnetworks is driven by the recognition that mutual help groups may haveimportant benefits that are not examined when evaluators conceptualizethem solely as treatments (e.g., when research examines whether groupsproduce improvement in the "presenting problem"). Mutual help groupshave "treatment-like" features, but they also have aspects common tochurch groups, social networks, and voluntary organizations in general(Humphreys, Finney, & Moos, 1994; Kurtz & Powell, 1987). For example,Alcoholics Anonymous (AA) members may stay in the organization longafter they stop drinking, incorporating AA into daily life as an ongoingsocial resource (e.g., going to AA dances) and opportunity for communityservice (e.g., sponsoring newcomers). Indeed, 12-step organizations valuebuilding community with others so highly that more of the 12 steps addressimproving relationships than abstaining from substances (AA, 1953; Nar-cotics Anonymous, 1992).

Having good friends is probably a universal human need, but it alsohas a particular importance to substance abuse patients. Substance abusetreatment is typically of short duration, and long-term substance abuse andpsychosocial outcomes are predicted heavily by the social context to whichpatients return (Edwards, 1989; Humphreys, Moos, & Cohen, 1997; Moos,Finney, & Cronkite, 1990). For example, alcoholic patients whose posttreat-ment friendship networks are conflictual and unsupportive are more likelyto experience continued alcohol problems after treatment (Booth, Russell,Soucek, & Laughin, 1992; Humphreys, Moos, & Finney, 1996; Rosenberg,1983). Thus, if 12-step group participation increases the quantity and qual-ity of members' friendships, this may produce better substance abuse out-comes in addition to the inherent benefits of friendship.

Only a handful of studies have provided data on how 12-step groupparticipation affects friendship networks. Two longitudinal studies of alco-holic individuals have examined the influence of 12-step group involvement

2 Humphreys and Noke

on composite social functioning measures that included friendship charac-teristics as a component. Vaillant (1983) found that AA involvement overan 8-year period increased the likelihood of having "stable psychosocialadjustment," which he defined as not living as a skid row social isolate.Similarly, Finney, Moos, and Chan (1981) reported that the number of AAmeetings attended during residential alcoholism treatment positively pre-dicted a composite measure of posttreatment social functioning that incor-porated time spent with friends.

Other research has focused directly on how 12-step involvement af-fects friendships. A qualitative study of 20 upper middle-class, gay alcoholicmen indicated that AA involvement often produces a rift between new AAmembers and former drinking companions, resulting in a decrease in thesize of friendship networks (Kus, 1991). However, this finding must be in-terpreted in the context of other research on the social networks of sub-stance-dependent individuals who attempt to stop using alcohol and otherdrugs. For example, a study of 467 (77% African-American, 73% male)dual-diagnosis patients treated in a public hospital found steady decreasesin the size of social networks over time (Ribisl, 1997). Hence, Kus's findingsmay be attributed to cessation of alcohol consumption rather than to AAaffiliation per se. In fact, self-help groups may be able to minimize or elimi-nate the erosion in friendship network size that often attends cessation ofsubstance abuse. In a study of 253 African-American men and womentreated in public substance abuse treatment programs, individuals who werenot participating in 12-step groups experienced an average decline of 18%in their number of friends, whereas self-help group attenders had an iden-tical number of friends at intake and 1-year follow-up (Humphreys, Mavis,& Stoffelmayr, 1994).

In terms of friendship quality, Kus (1991) suggests that ongoing 12-step group involvement is associated with increased trust, respect, and sup-port in members' friendships. Some support for this conjecture comes froma study of 439 alcohol-abusing individuals (50% male, 82% Caucasian),which found that AA involvement after baseline predicted greater friend-ship quality at 3-year follow-up (Humphreys, Finney, & Moos, 1994).

Collectively, these studies provide modest support for the generalproposition that mutual help participation can improve friendship networks.However, more specific conclusions cannot be drawn because of the smallresearch base and because each study measured different aspects of friend-ship. If this research area is to move forward, the components of substance-abusing individuals' friendships must be delineated and consistentlyexamined across studies. One promising framework that can be applied tothis task has been offered by Beattie and Longabough (1996). Followingdistinctions in the social support literature on structural versus functional

Mutual Help Group Participation and Friendship 3

features of social relationships, they suggest that substance abuse re-searchers maintain a distinction between general aspects of friendships(e.g., number of friends, frequency of contact, overall supportiveness) andsubstance abuse-specific aspects (e.g., degree to which friends support ef-forts to quit, proportion of friends who have a drug or alcohol problem).General aspects may contribute more to quality of Me as a whole, whereassubstance abuse-specific aspects are probably more important for maintain-ing abstinence from substances (Beattie & Longabough, 1996).

In this paper, we adopt the distinction between substance abuse-spe-cific and general features of friendships as we attempt to understand theinterplay between friendship networks and posttreatment participation in12-step mutual help organizations. We also examine the important questionof whether mutual help group participation can prevent erosion in numberof friends and increase friendship quality after treatment. Finally, we pro-vide information on how friendship networks composed of 12-step groupmembers differ from those composed of nonmembers.

METHOD

Sample

Participants were drawn from a sample of 3,699 male veterans whowere admitted to inpatient substance abuse treatment programs and con-sented to participate (88% consent rate) in a longitudinal study (seeOuimette, Finney, & Moos, 1997; for a detailed description of the overallstudy). This paper focuses on the 2,868 participants who had no or minimalinvolvement in 12-step groups at baseline. Participants who had attendeda few 12-step group meetings during pretreatment detoxification or in thefirst few days of treatment were included in the study, but individuals whohad a 12-step sponsor or had attended 10 or more meetings at baselinedata collection (n = 831) were excluded from the present sample.

Of these participants, 2,337 (81.5%) were successfully followed-up 1year after discharge. Chi-square and t-test analyses were conducted to as-sess factors associated with attrition over the course of the study. With asignificance criterion of p < .01, power to detect small differences betweengroups was .9 or greater for each comparison (Cohen, 1992; Kraemer &Thiemann, 1987). Those successfully followed (n = 2,337) were not signifi-cantly different than those not followed (n = 531) on race, marital status,age, education, religious affiliation, number of close friends, frequency ofcontact with friends, friends' alcohol use, friends' drug use, friends' hin-drance of efforts to abstain, or friendship quality.


Most of the 2,337 participants were African American (49.0%) ornon-Hispanic Caucasian (45.2%). At baseline, participants had an averageage of 42.9 years (SD = 9.6) and average education of 12.7 years (SD =1.7). The most common marital status was divorced or separated (55.9%).A slight majority (58.0%) of participants reported their religious affiliationor preference as Protestant. The most common primary DSM-III-R AxisI clinical diagnoses in the sample were alcohol dependence (61.1%) andcocaine dependence (25.5%).

Procedure

Within 3 days of entering treatment at one of 15 Veterans Affairs(VA) medical centers, inpatients were asked to participate in a follow-upstudy and complete a baseline inventory. Clinical diagnoses were drawn byresearch staff from participants' patient record. One year after participants'discharge from treatment, a research staff member readministered a nearlyidentical follow-up version of the inventory by mail or telephone. The in-take and follow-up inventory covered demographic information as well asother areas described below.

General Friendship Network Characteristics. Participants reported onthe number of close friends with whom they "felt at ease with and can talkto about personal matters," and on how often they were in contact withthese close friends. Friendship quality was assessed using the 6-item friend-ship resources scale from the Life Stressors and Social Resources Inventory(a = .80, range = 0-24, higher scores indicate friendships with more sup-port, trust, and respect, see Moos & Moos, 1994). This scale did not specifyclose friends, so individuals who had friends but were not particularly closeto them could still complete the scale.

Substance Use-Specific Network Characteristics. Friends' hindrance ofefforts to stop using substances was measured by four items adapted fromthe Social Network Social Influence Scale (Collins, Emont, & Zywiak,1990). These items use a 5-point response format ranging from 0 (never)to 4 for (often) (a = .74) to tap the extent to which friends' belittle orundermine respondent's efforts to quit using drugs and alcohol. Friends'use of alcohol and drugs were assessed by asking about use by "Most ofyour close friends." Friendship networks were thus characterized with twodichotomous variables for alcohol and other drugs (0 = Most friends donot use, 1 = Most friends use). Finally, participants reported on the pro-portion of their friends who were members of AA, Narcotics Anonymous(NA), or Cocaine Anonymous (CA).


Posttreatment 12-Step Involvement. The construct and predictive valid-ity of measures of 12-step group involvement can be enhanced by supple-menting assessment of meeting attendance with questions related to"working the 12 step program" (Tonigan, Connors, & Miller, 1996). Hence,the follow-up measure of 12-step substance abuse mutual help group in-volvement (AA/CA/NA) after treatment tapped both of these dimensionsof participation. The 3 items employed were number of 12-step meetingsattended in the past 3 months, frequency of reading 12-step materials suchas "24 hours a day" and "The Big Book" (response range from never toseveral times a week), and the number of the 12 steps that participants hadtried to incorporate into their daily lives in the past year. Examples of stepsare "Made a decision to turn our will and our lives over to the care ofGod as we understood him" and "Made a list of all persons we had harmed,and became willing to make amends to them all."

RESULTS

Because Fisherian null hypothesis testing in large samples can pro-duce many statistically significant but substantively meaningless findings(Meehl's, 1967, "crud factor"), we use them sparingly here. Instead, wefocus more heavily on the size of effects or the amount of variance ex-plained in each analysis.

At follow-up, 84.4% (n = 1972) of participants had become involvedin at least one type of 12-step activity after treatment, and 57.7% (« =1,349) of participants were involved in at least two 12-step activities. Themost common 12-step activity was attempting to incorporate the 12 stepsinto daily life (76.5% of sample, M = 7.0 steps, SD = 3.8). Just over half(51.1%, n = 1,194) of participants went to at least one meeting of AA,NA, or CA after treatment, with 17.3% going to 20 or more meetings.Similarly, 52.4% of participants (n = 1,225) read at least some 12-step ma-terials, with 25.6% doing so at least weekly. Descriptive data on friendshipnetwork characteristics at baseline and follow-up are presented in Table I.

Figure 1 presents a structural equation model of the interplay offriendship networks and self-help group participation which is based on ananalytic framework described in detail elsewhere (see Humphreys, Finney,& Moos, 1994). Variables enclosed in rectangles are observed (or "mani-fest") variables, and variables enclosed in circles are latent variables. Ar-rows connecting latent variables indicate hypothesized causal pathways.Dotted lines connecting latent variables indicate hypothesized correlations.The scale of each latent variable in a structural equation model has to beestablished using one of its observed variables. The paths denoted with a


Mutual Help Group Participation and Friendship

Fig. 1. Proposed model of interplay of friendship network characteristics and 12-stepgroup involvement.

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Table I. Friendship Network Characteristics of 2,337 Substance Abuse Patients atBaseline and 1-Year Follow-Up

No. of close friends (%)01234 or more

Frequency of contact with friends (%)NeverLess than once a monthOnce or twice a monthOnce a weekSeveral times a week

Substance use of most of friendsUse alcohol (% yes)Use drugs (% yes)

Friends' hindrance of efforts to quit [M (SD)]Friend resources [M (SD)]

Intake

20.418.524.315.521.2

16.917.520.418.726.5

75.044.84.2 (3.4)

13.0 (5.7)

Follow-up

17.216.524.815.625.8

13.513.017.620.335.6

57.830.13.9 (3.4)

14.0 (5.9)

1 indicate observed variables selected for this purpose because they seemedto represent best their respective latent construct (Joreskog & Sorbom,1989).

General friendship characteristics is a latent variable defined by threeobserved variables at each wave: number of close friends, frequency of con-tact with close friends, and friendship resources (quality). The latent vari-able for friends' support for substance use is also defined by three observedvariables: alcohol use of friends, drug use of friends, and friends' hindranceof efforts to abstain from substances. When a path between an observedand latent variable was estimated at each wave (e.g., the path from generalfriendship characteristics to number of close friends), these paths were con-strained to be equal across waves. Finally, the observed variables for post-treatment 12-step group involvement were number of 12-step meetingsattended, frequency of reading 12-step materials, and number of steps in-corporated into daily life.

The model was analyzed using LISREL VII (Joreskog & Sorbom,1989). Due to the presence of ordinal variables, LISREL analysis was basedon the polychoric correlation matrix. Some of the variables analyzedshowed slight departures from normality. Hence, as recommended byJoreskog and Sorbom, Browne's (1984) asymptotically distribution-free pro-cedure was used to estimate the model. Autocorrelation (i.e., the correla-tion in measurement error resulting from repeated measurement of thesame observed variables) was addressed by specifying parameters for allobserved variables to predict themselves. These paths were specified to im-prove overall fit and reduce bias in parameter estimates.

The strategy for assessing fit was as follows. First, the sample wasrandomly divided into two halves. The a priori model was fit on the firsthalf of the data. Overall fit was assessed using the Goodness of Fit Index(GFI), and specific hypothesized parameters were assessed based on t-val-ues (absolute values of t greater than 1.96 correspond to p < .05). Thechi-square statistic was not used because of its extreme sensitivity to samplesize and deviations from normality (Joreskog & Sorbom, 1989). After non-significant parameters had been removed, the trimmed model was then fiton the second half of the data. Final parameter estimates were based onthe total sample.

The a priori model had excellent fit (GFI = .997) in the first half ofthe data. However, the path connecting baseline general friendship char-acteristics with posttreatment 12-step involvement was nonsignificant (p =-.04, t = -1.09). This path was therefore deleted. All other specified pa-rameters were significant and hence were carried forward to the secondhalf of the data. The trimmed model was well supported by the secondhalf of the data (GFI = .976), with all specified parameters being statisti-


cally significant and similar to their companions in the first half of the data.Figure 2 presents the reduced model results for the full sample (GFI =.998).

Baseline friendship characteristics were poor predictors of posttreat-ment mutual help group involvement. There is a statistically significant (p< .01) relationship between higher baseline support for substance use byfriends and lower posttreatment 12-step involvement, but the size of theeffect is modest (P = -.07). The friendship latent variables predict them-selves well at follow-up, and are moderately negatively correlated with eachother at each time point. That is, better general friendship characteristicswere associated with less support for substance use by friends.

Greater posttreatment 12-step involvement predicted better generalfriendship characteristics at follow-up and lower support of substance useby friends. The parameters for these pathways indicate that 12-step groupinvolvement explains about 6-7% of the variance in each outcome, evenafter accounting for the baseline values of the outcomes.

Fig. 2. Structural equation model results in a sample of 2,337 substance abuse patients.


Friendship Erosion Analysis

Erosion in the size of friendship networks was examined using re-peated measures analysis of variance to compare the number of closefriends at baseline with the number at follow-up for individuals who didand did not have significant involvement in 12-step activities after treat-ment. Significant 12-step involvement was defined as being involved in atleast two of the three measured 12-step activities (57.7% of participants,n = 1,349) versus one or no 12-step activities (42.3% of participants, n =988). Secondary analyses showed that changing the definition of participa-tion (e.g., defining it as 1 or 3 of the measured activities) had little effecton the results presented here.

In contrast to previous studies, there was no evidence of overall ero-sion. But the results do tell an interesting story: At baseline, both 12-stepattenders and nonattenders had a virtually identical number of closefriends, but by follow-up only the 12-step attenders increased the size oftheir close friendship network (Table II). The average increase in size was16%. This finding was explored further by comparing attenders and nonat-tenders on number of 12-step friends. The attenders showed a sharp in-crease in number of 12-step friends, in fact, one larger than their increasein total number of friends. This indicates that 12-step attenders must havereplaced non-12-step friends with 12-step friends in the year following theirentry into treatment.

Because some previous research on social network erosion was onpredominantly or entirely African American samples (e.g., Ribisl et al.,1997), the analyses in Table II were reconducted separately for African


Table II. Repeated Measures Analysis of Variance for Friendship Network Size Among2,337 Substance Abuse Patients at Baseline and 1-Year Follow-Up

No. of close friendsSignificantLittle or none

No. of 12-Step friendsSignificantLittle or none

Intake

M

2.001.96

0.860.48

SD

1.341.45

1.341.01

Follow-up

M

2.321.95

2.060.48

SD

1.371.47

1.651.06

Fb

Group

17.69

494.60

Time

21.05

317.46

G x Tc

25.21

318.53

aSignificant = Participated in at least two 12-step activities after treatment (n = 1,349). Littleor none = Participated in no more than one 12-step activity after treatment (n = 988).

bAll F statistics significant at p < .001.Interaction of Group and Time effects.

American (n = 1,144) and non-Hispanic Caucasian (n = 1,056) partici-pants. Results were virtually identical for both racial groups.

Differences Between 12-Step and Non-12-Step Friendship Networks

The final issue we examined is the difference between close friendshipnetworks composed primarily of 12-step group members versus non-12-stepgroup members. This analysis excludes those 405 participants who reportedthat they had no close friends at follow-up. Within the remaining 1,932participants, the data on composition of friendships had a pronounced bi-modal distribution. About half of the sample (n = 964, 49.9%) had almostno 12-step group members among their close friends (M = 2.7% of friends,SD = 8.5), whereas the other half (n = 968, 50.1%) had close friendshipnetworks composed almost entirely of 12-step group members (M = 90.9%of friends, SD = 17.9). The two types of friendship networks were stronglyassociated with personally having significant 12-step involvement (83.9%for those with 12-step friendship networks vs. 37.8% of those with non-12-step friendship networks).

In terms of friendship quality, close friendship networks composedprimarily of 12-step group members were rated higher on friendship re-sources (M = 16.1, SD = 5.0) than were non-12-step friendship networks(M = 14.4, SD = 5.3). This is a difference of about one third of a standarddeviation (a small to medium effect size, Cohen, 1992). Table III presentscontrasts on categorical variables between primarily 12-step and primarilynon-12-step close friendship networks. In terms of size, 12-step close friend-ship networks are less likely to be small (16.8% were composed of onlyone close friend vs. 23.1% of non-12-step member friendship networks)and more likely to be large (34.9% were composed of four or more closefriends vs. 27.3% of non-12-step member networks). Close friendship net-works composed primarily of 12-step group members are also characterizedby more frequent contact than are networks composed primarily of non-members.

There are dramatic differences (large effect sizes) in substance usebetween the two types of networks. Twelve-step close friendship networksare much more likely to be composed primarily of people who abstain fromalcohol (67.9 vs. 39.6% for non-12-step friendship networks), and do notuse other drugs (29.3 vs. 19.3% for non-12-step friendship networks). Sur-prisingly, this does not translate into differences in hindrance of efforts toabstain. Both types of networks had virtually identical scores on this vari-able (M = 3.9, SD = 3.3 for 12-step friendship networks, M = 3.7, SD =3.3 for non-12-step friendship networks).


DISCUSSION

Although AA, NA, and CA obviously focus attention on substanceabuse problems, they also influence other areas of members' lives, particu-larly friendship networks. Even after controlling for baseline friendship net-work characteristics, posttreatment 12-step group involvement predictedhaving friendship networks with more close friends, more frequent contact,higher overall quality, and lower support for substance use. These findingsare probably not due to selection effects (e.g., only friendly and sociallyskilled people go to 12-step groups) because baseline friendship charac-teristics were poor predictors of subsequent 12-step group involvement.Hence, collectively, the results of this study both highlight the social bene-fits of membership in 12-step groups and validate the conceptualization of12-step organizations as a social world (i.e., not just a treatment) with itsown norms for interaction and personal behavior.

Changes in size and quality of friendship networks may result fromthe atmosphere fostered by mutual help groups. Although each mutual helpgroup has a unique character, most groups offer a supportive context inwhich members have the opportunity to share their experiences of main-taining, or failing to maintain, sobriety. Denzin (1987) argued that becauseindividuals with substance abuse problems sometimes feel that no outsidercan understand their situation, they gain a powerful sense of emotional


Table III. Comparison of 12-Step and Non-12-Step Close FriendshipNetworks on Categorical Variables

No. of close friends (%)1234 or more

Frequency of contact with friends (%)NeverLess than once a monthOnce or twice a monthOnce a weekSeveral times a week

Substance use of most of friendsUse of alcohol (% yes)Use drugs (% yes)

12-step(n = 968)

16.830.018.234.9

0.09.4

18.225.246.8

39.619.3

Non-12-step(n = 964)

23.130.019.627.3

2.014.722.023.138.1

67.929.3

aAll differences significant at p < .0001 for chi-square test.

understanding and intimacy when they join a 12-step group and expressthemselves to others who have similar experiences. This sense of under-standing provides a basis for members to form bonds with each other bothduring and outside of meetings.

In addition to the social climate of 12-step group meetings, 12-steporganizations have codified procedures (e.g., the 12 steps) that promoteimproved relationships with others. For example, one of the steps asksmembers to make a clean breast of personal defects and shameful experi-ences with another trusted 12-step member. Further, the institution of spon-sorship, in which an experienced member serves newcomers as a coach androle model, may help less socially skilled members learn how to interactconstructively. To some extent, such friendship-building experiences mayalso occur in treatment settings, but the extent to which individuals withsubstance abuse problems can learn how to have and build friendships withprofessionals will always be constrained by brevity of contact and the pro-fessional role (e.g., power differentials, ethics regarding dual relationships).Hence, professionals who believe their patients would benefit from en-hanced friendship networks may wish to develop collaborations with localself-help groups, particularly because professional substance abuse treat-ment services are currently contracting in length and intensity under theinfluence of managed health care (Humphreys, Hamilton, Moos, & Suchin-sky, in press).

Earlier studies had suggested that 12-step involvement can counteractthe problem of erosion in friendship size after substance-abuse treatment.In the current sample, we found a variant of this effect. Although therewas no friendship network size erosion to counter, only 12-step membersexperienced an increase in their number of close friends over the courseof the study. Thus, instead of merely "eliminating a negative," 12-stepgroup involvement "added a positive" in this study. We believe our studyis the first to illuminate how this process occurs, namely, through the re-placement of non-12-step friends with friends who also belong to 12-stepgroups. This may because some non-12-step friends are active drug or al-cohol users with whom the member no longer wishes to associate. On theother hand, some members may become less close to non-12-step friendsbecause these friends are not comfortable with the language, culture, andworld view of 12-step groups. 12-step lore maintains that for the first fewmonths of involvement, some members become so immersed in 12-step cul-ture that they lose interest in nonrecovering friends (and vice versa).

These social dynamics may produce the split found between the twoworlds of friendship at follow-up. Half of the sample drew almost all oftheir close friends from 12-step groups, whereas the other half drew almostno friends from 12-step groups. The two types of friendship networks were


different in size, frequency of contact, and quality (12-step being higher inall three respects), but the most striking finding was the difference in sub-stance use. 12-step friendship networks include much smaller proportionsof alcohol and drug users than do non-12-step friendship networks.

Being personally involved in 12-step groups seems a necessary butnot sufficient condition for having a network of 12-step friends. Almost allindividuals with 12-step friendship networks were involved in groups, yeta third of those without such a network were also involved. These findingsecho those of Lieberman and Videka-Sherman (1986), who studied self-help groups for individuals who spouse had died. Only a subset of widowedpeople who attend self-help groups form strong social linkages with othermembers that extend outside of group meetings. Importantly, these mem-bers also derive the greatest benefit from involvement (Lieberman &Videka-Sherman, 1986).

In future research, we plan to investigate whether high quality, "dryand clean" friendship networks fully or partially mediate the relationshipbetween 12-step group involvement and members' substance abuse behav-ior. Individuals who have just been treated for substance dependence areprobably less likely to relapse if they are surrounded by supportive peoplewho do not use alcohol and other drugs. Yet, even if such an effect cannotbe identified, the friendship network improvements produced by 12-stepinvolvement are important in and of themselves: High quality, close friend-ships make life more worth living.

The strengths and limitations of the sample deserve comment. Onthe positive side, the large size of the sample inspires confidence in theprecision of parameter estimates. Second, because this was a low-incomesample composed predominantly of members of racial and ethnic minoritygroups, and because positive social network effects were shown to holdacross racial groups, the study provides more evidence that 12-step groupsappeal to and benefit a broad spectrum of society (see also Humphreys,Mavis, & Stoffelmayr, 1994; McKay et al, 1994).

In terms of weaknesses, there are two potential limits to the gener-alizability of the results. First the sample included no women. However,positive effects of 12-step involvement on friendship networks have beenfound in samples that included large proportions of women (Humphreys,Finney, & Moos, 1994; Humphreys, Mavis, & Stoffelmayr, 1994), so theresults would probably have been similar if women had been included inthe study. Second, individuals who had extensive self-help involvement priorto initial data collection were excluded in order to strengthen the basis forcausal inference. The results presented here may not generalize to indi-viduals who have extensive self-help group involvement and subsequently


come to professional treatment, especially because self-help groups appar-ently were not sufficient intervention for the problems of these individuals.

An additional methodologic concern is that participants may have ex-aggerated their self-help involvement and the quality and quantity of theirfriendships at follow-up in order to present themselves positively. Two factsweigh against the hypothesis. First, another study of this sample found highconcordance rates between participants' self-reports of abstinence fromsubstances and the results of biological assays at: follow-up (e.g., Breatha-lyzer, urine screen, see Ouimette, Finney, & Moos, 1997). Second, at in-take, participants self-reported unflattering information about themselveson the same variables assessed at follow-up (e.g., little or no self-help in-volvement, weak friendship networks).

In this paper, we decided to evaluate 12-step organizations as socialworlds rather than only as treatments for substance abuse, and found someinteresting results on the interplay of friendship networks and 12-step mu-tual help involvement. When considered along with those of other similarstudies, our results show that a full accounting of the effects of 12-stepgroups requires attention to changes in the quality and quantity of mem-bers' friendship networks.

REFERENCES

Alcoholics Anonymous. (1953). Twelve steps and twelve traditions. New York: AA WorldServices.

Beattie, M. C., & Longabough, R. (1996). Social relationships and drinking outcome.Manuscript submitted for publication.

Booth, B. M., Russell, D. W., Soucek, S., & Laughlin, P. R. (1992). Social support andoutcome of alcoholism treatment: An exploratory analysis. American Journal of Drug andAlcohol Abuse, 18, 87-101.

Browne, M. W. (1984). Asymptotically distribution-free methods for the analysis of covariancestructures. British Journal of Mathematical and Statistical Psychology, 37, 62-83.

Cohen, J. (1992). A primer on power. Psychological Bulletin, 112, 155-159.Collins, R. L., Emont, S. L., & Zywiak, W. H. (1990). Social influence processes in smoking

cessation: Postulating predictors of long-term outcome. Journal of Substance Abuse, 2,389-403.

Denzin N. K. (1987). The recovering alcoholic. Beverly Hills, CA: Sage.Edwards, G. (1989). As the years go rolling by: Drinking problems in the time dimension.

British Journal of Psychiatry, 154, 18-26.Emrick, C. D., Tonigan, J. S., Montgomery, H., & Little, L. (1993). Alcoholics Anonymous:

What is currently known? In B. S. McCrady & W. R. Miller (Eds.), Research AlcoholicsAnonymous: Opportunities and Alternatives (pp. 41-76). New Brunswick, NJ: Center ofAlcohol Studies.

Finney, J. W., Moos, R. H., & Chan, D. (1981). Length of stay and program componenteffects in the treatment of alcoholism: A comparison of two techniques for processanalysis. Journal of Consulting and Clinical Psychology, 49, 120-131.

Humphreys, K., Finney, J. W., & Moos, R. H. (1994). Applying a stress and coping frameworkto research on mutual help organizations. Journal of Community Psychology, 22, 312-327.


Humphreys, K,, Hamilton, E. G., Moos, R. H., & Suchinsky, R. T. (in press). Policy-relevantprogram evaluation in a national substance abuse treatment system. Journal of MentalHealth Administration.

Humphreys, K., Mavis, B. E., & Stoffelmayr, B. E. (1994). Are twelve step programsappropriate for disenfranchised groups?: Evidence from a study of posttreatment mutualhelp involvement. Prevention in Human Services, 11, 165-179.

Humphreys, K., Moos, R. H., & Cohen, C. (1997). Social and community resources andlong-term recovery from treated and untreated alcoholism. Journal of Studies on Alcohol,58, 231-238.

Humphreys, K., Moos, R. H., & Finney, J. W. (1996). Life domains, Alcoholics Anonymous,and role incumbency in the 3-Year course of problem drinking. Journal of Nervous andMental Disease, 184, 475-481.

Joreskog, K. G., & Sorbom, D. (1989). Lisrel 7: A guide to the program and applications (2nded.). Chicago: SPSS.

Kraemer, H. C., & Thiemann, S. (1987). How many subjects?: Statistical power analysis inresearch. Newbury Park, CA: Sage.

Kurtz, L. F. (1990). The self-help movement: Review of the past decade of research. SocialWork with Groups, 13, 101-115.

Kurtz, L. F., & Powell, T. J. (1987). Three approaches to understanding self-help groups.Social Work with Groups, 10, 69-80.

Kus, R. J. (1991). Sobriety, friends, and gay men. Archives of Psychiatric Nursing, 3, 171-177.Lieberman, M. A., & Videka-Sherman, L. (1986). The impact of self-help groups on the

mental health of widows and widowers. American Journal of Orthopsychiatry, 56, 435-449Makela, K., Arminen, I., Bloomfield, K., Eisenbach-Stangl, I., Helmersson Bergmark, K.,

Kurube, N., Mariolini, N., Olafsdottir, H., Peterson, J. H., Phillips, M., Rehm, J., Room,R., Rosenqvist, P., Rosovsky, H., Stenius, K., Swiatkiewitz, G., Woronowicz, B., &Zielinski, A. (1996). Alcoholics Anonymous as a mutual help movement: A study in eightsocieties. Madison: University of Wisconsin Press.

McKay, J. R., Alterman, A. I., McLellan, A. T., & Snider, E. (1994). Treatment goals,continuity of care, and outcome in a day hospital substance abuse rehabilitation program.American Journal of Psychiatry, 151, 254-259.

Meehl, P. E. (1967). Theory testing in psychology and physics: A methodological paradox.Philosophy of Science, 34, 103-115.

Moos, R. H., Finney, J. W., & Cronkite, R. C. (1990). Alcoholism treatment: Context, processand outcome. New York: Oxford University Press.

Moos, R. H., & Moos, B. S. (1994). Life stressors and social resources inventory. Odessa, FL:Psychological Assessment Resources.

Narcotics Anonymous. (1992). An introductory guide to Narcotics Anonymous (Rev. ed.). VanNuys, CA: Author.

Ouimette, P. C, Finney, J. W., & Moos, R. H. (1997). Twelve step and cognitive-behavioraltreatment for substance abuse: A comparison of treatment effectiveness. Journal ofConsulting and Clinical Psychology, 65, 230-240.

Ribisl, K. M. (1997, April). The role of social networks in predicting substance abuse treatmentoutcome in a dual diagnosis sample. Paper presented at the annual meeting of the Societyfor Behavioral Medicine, San Francisco.

Room, R., & Greenfield, T. (1993). Alcoholics Anonymous, other 12-step movements andpsychotherapy in the U.S. population, 1990. Addiction, 88, 555-562.

Rosenberg, H. (1983) Relapsed versus non-relapsed alcohol abusers: Coping skills, life events,and social support. Addictive Behaviors, 8, 183-186.

Tonigan, J. S., Connors, G. J., & Miller, W. R. (1996). Alcoholics Anonymous Involvement(AAI) Scale: Reliability and Norms. Psychology of Addictive Behaviors, 10, 75-80.

Vaillant, G. (1983). The natural history of alcoholism. Cambridge, MA: Harvard UniversityPress.


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