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WOMEN’S INVOLVEMENT WITH 12-STEP GROUP
SUPPORT PROGRAMS: DOES ALCOHOL DIAGNOSIS
WITH AND WITHOUT COMORBID PSYCHOPATHOLOGY
INFLUENCE PARTICIPATION?

presented by

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WOMEN’S INVOLVMENT WITH lZ-STEP GROUP SUPPORT PROGRAMS:
DOES ALCOHOL DIAGNOSIS WITH AND WITHOUT COMORBID
PSYCHOPATHOLOGY INFLUENCE REPORT OF PARTICIPATION

By

Deborah Jo Smith

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY

Family Studies

2009

ABSTRACT

WOMEN’S INVOLVEMENT WITH 12-STEP GROUP SUPPORT PROGRAMS:
DOES ALCOHOL DIAGNOSIS WITH AND WITHOUT COMORBID
PSYCHOPATHOLOGY INFLUENCE REPORT OF PARTICIPATION

By
Deborah J 0 Smith

This is an exploratory secondary data analysis of women who report having an
alcohol diagnosis and attending 12-step group support from the National Epidemiologic
Survey on Alcohol and Related Conditions (NESARC). Twelve-step research literature
has found that men who are white, over 35 years of age, with at least a high school
education attend 12-step group support. They usually have severe drinking problems and
commonly have comorbid psychopathologies like depression, anxiety and antisocial
personality disorders. Whereas some women specific studies have suggested similar
outcomes, an equally large body of 12-step literature is not available for women problem
drinkers. A study of the women in the NESARC, who report having an alcohol diagnosis
and going to 12-step group support, will add to the literature.

Methods: The research design included 575 women who responded yes or no to
having attended 12-step group support at some time point. A series of binary logistic
regressions were conducted. The first set of relationships explored was alcohol diagnoses
and 12-step group support. Second, the psychopathologies of Major Depressive
Disorder, Generalized Anxiety Disorder, Conduct Disorder and Antisocial Personality
Disorder were added. Third, demographic variables were added.

Results: Women, like men who have more severe alcohol disorders attend 12-step

group support more fiequently than those women with less severe alcohol disorders.

Comorbid psychopathology did not mediate the relationship between alcohol diagnosis
and 12-step group support. Women with antisocial personality disorders and severe
alcohol disorders are more likely to attend 12-step group support than those without
ASPD and less severe alcohol disorders. Race, age, education, income and number of
children in the home did not moderate the relationship between alcohol diagnosis and 12—
step group support. Relationship status did not moderate the relationship between
alcohol diagnosis and 12-step group support, but there was an effect. Those women who
were separated, divorced or widowed were more likely to attend 12-step group support

than those who were married or never married.

DEDICATION

This Dissertation is dedicated to
My sons — Rob, Christian and Noah; the answers rest within you
Gary Christensen (posthumously), Brian Mullin and John Martin; true recovery warriors
Mary Sabaj and my students; your belief in me made this work possible

miigwetch

iv

ACKNOWLEDGEMENTS
The Committee
Francisco A. Villarruel, Committee Chair

You lit a candle to guide me through this process and helped to find the answers
from within.
Hiram E. Fitzgerald, Research Chair

I am deeply indebted to you for being willing to take me on as a student. I have
learned what it means to be both a mentor and a scientist from you.
Ruben Parra Cardona, Anthony Nunez, Esther Onaga, Timothy Tansey, Committee

Over the years each one of you contributed greatly to my development as a
teacher and scientist. Thank you, Dr. Parra Cardona for the independent study that
helped me to operationalize my ideas. Thank you, Dr. Onaga for teaching me how to
connect the structure of my ideas and to make clear the constructs of my design. Thank
you, Dr. Nunez for providing insight into hard science perspectives. Thank you, Dr.
Tansey for pushing me to build the skills I needed to grow as a teacher and mentor,
bringing cutting edge science into the classroom.
The Family
Rob, Christian and Noah

Thank you for your patience with me as a mom over the past several years. You
three sacrificed quite a bit in the name of your mom’s schooling! I am hopeful to repay
the debt now that it is done.
Grace

I am so glad that you picked me as your daughter. I think you worked as hard as I

did through this process.

TABLE OF CONTENTS

List of Tables ......................................................................................... ix

List of Figures ........................................................................................ xv

CHAPTER I

INTRODUCTION TO THE STUDY .............................................................. 1
Statement of the Problem ................................................................... 1
Characteristics of men who attend 12-step group support .............................. 1
Women and 12-step group support ........................................................ 2
Women Problem drinkers .................................................................. 3
Demographic Characteristics of 12-step Group Support ............................... 4
Limitations of Previous Research ......................................................... 4
The Purposes of this study .................................................................. 5
Research Questions .......................................................................... 5

CHAPTER H

BACKGROUND OF THE STUDY .................................................................................. 6
Introduction ................................................................................... 6
Definitions ..................................................................................... 6
12-step Group Support ...................................................................... 6
Alcohol Diagnosis ........................................................................... 8
Comorbidity psychopathology ............................................................ 10
Socioeconomic Status ..................................................................... 12
Review of the Literature .................................................................. 13
Alcohol severity and 12-step group support ............................................ 13
Alcohol treatment modalities and 12-step group support ............................. 13
Comorbid psychopathologies, alcohol disorders and 12-step group support ...... 14
Demographics of 12-step group support ................................................ 15
Limitations of Previous Research ........................................................ 17
The Present Study .......................................................................... 18
Themes that emerged ...................................................................... 18

CHAPTER HI

METHODS .......................................................................................... 19
Introduction ................................................................................. 19
Analysis Plan ............................................................................... 19
Themes, questions and hypotheses ...................................................... 19
NESARC Wave 1 Data .................................................................... 33
Background ................................................................................. 33
Variables for the study ..................................................................... 36
Dependent Variable: 12-step Group Support .......................................... 36
Independent Variables ..................................................................... 36
Imputation of data in the national data set .............................................. 37
Data preparation for this study ............................................................ 38

vi

Alcohol diagnosis ........................................................................... 38

Comorbid psychopathology ............................................................... 40
Demographics .............................................................................. 41
Socioeconomic status ..................................................................... 42
Final dataset ................................................................................. 45

CHAPTER IV

PRESENTATION OF THE RESULTS OF THE ANALYSIS ............................... 48
Introduction ................................................................................. 48
Research Question One .................................................................... 48
Does alcohol diagnosis affect the report of participation by woman in 12-step
group support? ...................................................................................................... 48
Research Question Two ................................................................... 49
Does having a comorbid psychopathology mediate the diagnosed woman’s report
of participation in 12-step group support? ............................................................ 49
Research Question Three .................................................................. 53
Do key demographic variables moderate women’s report of 12-step group support
participation? ............................................................................... 53
Posthoc analyses ........................................................................... 6O
Posthoc comorbid psychopathology analyses .......................................... 6O
Posthoc demographic analyses ........................................................... 62
Relationship Status ......................................................................... 62
Socioeconomic Status ..................................................................... 65
Personal and Household income analyses .............................................. 67

CHAPTER V

DISCUSSION ....................................................................................... 69
Introduction .................................................................................. 69
Research question 1 Does alcohol diagnosis affect women’s participation in 12-
step group support ........................................................................... 69

Research question 2 Does comorbid psychopathology mediate the relationship
between alcohol diagnosis and women’s participation in 12-step group support

programs ..................................................................................... 70
Research question 3 Do key demographic variables moderate alcoholic women’s

participation in 12-step group s‘upport ................................................... 72
Separated women ........................................................................... 74
Widowed women ........................................................................... 74
Demographic characteristics not found significant .................................... 75
Children ....................................................................................... 75
Ethnoracial group ........................................................................... 75
Socioeconomic status ...................................................................... 76
Limitations of the data set chosen ....................................................... 77
Meeting attendance ................................................................. ' ....... 77
Affiliation with 12-step group Support .................................................. 77
Alcoholics Anonymous specific information .......................................... 78
Diagnosis of individuals with DSM-IV disorders ..................................... 78

vii

Lack of Census Occupational Codes ................................................... 79

Policy Implications ......................................................................... 79
Government fimded research ............................................................. 79
Education of Professionals ................................................................ 80
Recap of future study ....................................................................... 81

APPENDIX A

THE TWELVE STEPS OF ALCOHOLICS ANONYMOUS ................................ 83

APPENDIX B

PSYCHOPATHOLOGIES ........................................................................ 84
Major Depressive Disorder ............................................................... 84
Generalized Anxiety Disorder ............................................................ 84
Conduct Disorder ........................................................................... 85
Antisocial Personality Disorder .......................................................... 85

APPENDIX C

GENERAL DEMOGRAPHIC CHARACTERISTICS OF THE NESARC ................ 87
General demographics ..................................................................... 87
Age ........................................................................................... 87
Ethnoracial group ........................................................................... 87
Relationship status ......................................................................... 88
Children ...................................................................................... 88
Education .................................................................................... 89
Drinking Status ............................................................................. 9O
12-step group support meeting attendance by category of drinking status ......... 93
Current alcohol diagnosis ................................................................. 93
Prior to current alcohol diagnosis ........................................................ 93
Comorbid psychopathology ............................................................... 94
Major Depressive Disorder and Generalized Anxiety Disorder ..................... 94
Conduct Disorder and Antisocial Personality Disorder ............................... 96

Appendix D

HOLLINGSHEAD SCALE IMPUTATION .................................................... 97

APPENDIX E

DEMOGRAPHIC CLUSTERS .................................................................... 99

REFERENCES ............................................................................................................... 189

viii

LIST OF TABLES

Table 1 Crosstab of current and prior alcohol diagnoses by level of abuse (abuse)
dependence (depend), abuse and dependence together (Dual) or no alcohol diagnosis

(none) ................................................................................................. 39
Table 2 Crosstab of alcohol diagnosis by 12-step group support ............................. 39
Table 3 Crosstabs of Comorbid Psychopathologies with cell counts ........................ 41
Table 4 NESARC Occupational code converted to Hollingshead categories ............... 42
Table 5 NESARC Education codes converted to Hollingshead Categories ................. 44
Table 6 Hollingshead Socioeconomic coding system with range of scores ................. 45
Table 7 Final dataset for analyses: Sample sizes per category of participation. . . . . . . . ......45
Table 8 Results of the analysis of alcohol diagnosis to 12-step group support ............. 48

Table 9 Results of the analysis alcohol abuse or dependence and abuse and dependence to
12-step group support49

Table 10 Direct effects of alcohol diagnosis and 12-step mediated by Comorbid
Psychopathology .................................................................................... 49

Table 11 Direct effects of alcohol diagnosis and 12-step group support mediated MDD,
MDD/GAD, ASPD, ASPD/MDD and ASPD/GAD/MDD .................................... 50

Table 12 Direct effects of Alcohol Abuse and Dependence and 12-step mediated by
Comorbid Psychopathology ....................................................................... 51

Table 13 Direct effects of alcohol abuse or dependence, alcohol abuse and dependence
and 12-step group support mediated by first MDD, then MDD/GAD, ASPD,
ASPD/MDD and ASPD/GAD/MDD ............................................................. 52

Table 14 Demographic Cluster 1 moderating the relationship between alcohol diagnosis
(Dx) and 12-step group support (12-step) ........................................................ 53

Table 15 Demographic Cluster 2 moderating the relationship between alcohol diagnosis
(Dx) and 12-step group support (12-step) ........................................................ 54

Table 16 Demographic Cluster 1 moderating the relationship between alcohol diagnosis
(Dx) and 12-step group support (lZ-step) ........................................................ 55

ix

Table 17 Demographic Cluster 2 moderating the relationship between more severe

alcohol diagnosis (Dual) and 12-step group support (12-step) ................................ 55
Table 18 Hollingshead Socioeconomic categories (SES categories) with range of

scores ................................................................................................. 56
Table 19 Alcohol diagnosis with Hollingshead SES Categories 1 and 2 .................... 57
Table 20 Alcohol diagnosis with Hollingshead SES Categories 4 and 5 .................... 57
Table 21 Alcohol diagnosis with Hollingshead SES Category 3 ............................. 58

Table 22 Two levels of alcohol diagnosis with Hollingshead SES Categories 1 and 2. . .58
Table 23 Two levels of alcohol diagnosis with Hollingshead SES Categories 4 and 5. . .59
Table 24 Two levels of alcohol diagnosis with Hollingshead SES Category 3 ............ 59

Table 25 Alcohol diagnosis and women with one, two or three children compared
to 12-step group support ........................................................................... 60

Table 26 Posthoc analysis of alcohol diagnosis, antisocial personality and 12-step group
support main effects and interaction effects ..................................................... 61

Table 27 Posthoc analysis of levels of alcohol diagnosis, antisocial personality and 12—
step group support with main effects and interaction effects ................................. 62

Table 28 Posthoc analysis of alcohol diagnosis, previously married and 12-step group
support ................................................................................................ 62

Table 29 Posthoc analysis of alcohol diagnosis, by levels of previously married and 12-
step group support .................................................................................... 63

Table 30 Posthoc analysis of alcohol abuse and dependence, previously married and 12-
step group support ................................................................................... 63

Table 31 Posthoc analysis of alcohol abuse and dependence, by levels of previously
married and 12-step group support ............................................................... 64

Table 32 Posthoc analysis of alcohol abuse or dependence, by levels of previously
married and 12-step group support ............................................................... 64

Table 33 Posthoc analysis of alcohol abuse and dependence, being separated or having
ASPD and 12-step group support .................................................................. 65

Table 34 Interactions between different SES categories and alcohol diagnosis compared

to 12-step group support ........................................................................... 66
Table 35 Interactions between different SES categories and alcohol abuse and

dependence compared to 12-step group support ................................................ 66
Table 36 Personal Income compared to household income .................................... 67

Table 37 Main Effects of Alcohol Diagnosis and household income in relationship to 12-

step group support ................................................................................... 68
Table 38 Main Effects of alcohol abuse and dependence diagnosis and household income
in relationship to 12-step group support .......................................................... 68
Table 39 Comparison of ages between women and men ....................................... 87
Table 40 Comparison of ethnoracial group for women and men ........................... 88
Table 41 Comparison of relationship status for women and men ............................ 88
Table 42 Children in the home for women and men ........................................... 89
Table 43 Highest grade attained for women and men .......................................... 89
Table 44 Percentage of women and men by drinking status .................................. 90
Table 45 Demographic characteristics by drinking status ..................................... 90
Table 46 12-step participation by drinking status for women and men ...................... 93
Table 47 Current diagnosis by drinking status for women and men ......................... 93

Table 48 Prior to current alcohol diagnosis by drinking status for women and men. . .....94

Table 49 Lifetime Major Depressive Disorder for women and men ......................... 95
Table 50 Lifetime Generalized Anxiety Disorder for women and men ........................... 95
Table 51 Conduct disorder for women and men ................................................ 96
Table 52 Antisocial personality disorder for women and men ................................ 96

Table 53 Hollingshead (Code) Irnputed Occupation codes with one imputed education
code .................................................................................................... 97

Table 54 Hollingshead scale ....................................................................... 98

xi

Table 55 Six demographic variables matching .................................................. 99

Table 56 5 Match: Income, Age, Relationship Status, Ethnoracial group,

education ............................................................................................ 110
Table 57 5 Match: Income, Relationship Status, Ethnoracial group, Education and
Children ............................................................................................. 113
Table 58 5 Match: Age, Relationship Status, Ethnoracial group, Education and

Children ............................................................................................. 118
Table 59 5 Match: Income, Age, Relationship Status, Ethnoracial group, Children. . ....122
Table 60 5 Match: Income, age Relationship Status, Education, Children ............... 128
Table 61 Match 5: Income, Age, Ethnoracial group, Education, Children ................ 134
Table 62 4 Match: Income, age, Relationship Status, Ethnoracial group .................. 137
Table 63 4 Match: Income, Relationship Status, Ethnoracial group, Education .......... 139
Table 64 4 Match: Income, Ethnoracial group, Education, Children ....................... 140
Table 65 4 Match: Income, age, Ethnoracial group and Education ......................... 142
Table 66 4 Match: Income, age, Education, Children ........................................ 143
Table 67 4 Match: Income, age, Relationship Status and Education ........................ 145
Table 68 4 Match: Income, age, Relationship Status and Children ......................... 147
Table 69 4 Match: Income, Relationship Status, Ethnoracial group and Children... . . . ...150
Table 70 4 Match: Income, Relationship Status, Education and Children ................. 152
Table 71 Match: Age, Relationship Status, Ethnoracial group, Education ................ 155
Table 72 4 Match: Age, Ethnoracial group, Education and Children ....................... 156
Table 73 4 Match: Age, Relationship Status, Ethnoracial group and Children ............ 158
Table 74 4 Match: Age, Relationship Status, Ethnoracial group and Children. . . . . . . . ....158
Table 75 4 Match: Age, Relationship Status, Education and Children ..................... 160

xii

Table 76 4 Match: Relationship Status, Ethnoracial group, Education and Children. . ..162

Table 77 4 Match: Income, age, Ethnoracial group and Children ........................... 164
Table 78 3 Match: Income, Age, Relationship Status ........................................ 166
Table 79 3 Match: Income, Relationship Status, Ethnoracial group ........................ 166
Table 80 3 Match: Income, Ethnoracial group and Education .............................. 167
Table 81 3 Match: Income, Education and Children .......................................... 168
Table 82 3 Match: Age, Relationship Status and Education ................................. 169
Table 83 3 Match: Income, Age and Ethnoracial group ...................................... 169
Table 84 3 Match: Income, Age and Education ............................................... 170
Table 85 3 Match: Income, Age and Children ................................................. 170
Table 86 3 Match: Income, Relationship Status and Education ............................. 172
Table 87 3 Match: Income, Relationship Status and Children .............................. 172
Table 88 3 Match: Income, Ethnoracial group and Children ................................. 174
Table 89 3 Match: Age, Relationship Status and Ethnoracial group ........................ 175
Table 90 3 Match: Age, Ethnoracial group and Education ................................... 175
Table 91 3 Match: Age, Education and Children ............................................. 176
Table 92 3 Match: Relationship Status, Ethnoracial group and Education ................ 177
Table 93 3 Match: Relationship Status, Education and Children ........................... 177
Table 94 3 Match: Relationship Status, Ethnoracial group and Children .................. 178
Table 95 3 Match: Ethnoracial group, Education and Children ............................. 179
Table 96 3 Match: Age, Relationship Status and Children ................................... 180
Table 97 2 Match: Income and Age ............................................................ 181
Table 98 2 Match: Income and Relationship Status .......................................... 181

xiii

 

Table 99 2 Match: Income and Ethnoracial group ............................................. 182

Table 100 2 Match: Income and Education ..................................................... 182
Table 101 2 Match: Income and Children ...................................................... 182
Table 102 2 Match: Age and Relationship Status ............................................. 183
Table 103 2 Match: Age and Ethnoracial group ............................................ ...183
Table 104 2 Match: Age and Education ........................................................ 184
Table 105 2 Match: Age and Children .......................................................... 184
Table 106 2 Match: Relationship Status, Ethnoracial group ................................. 184
Table 107 2 Match: Relationship Status and Education ...................................... 185
Table 108 2 Match Relationship Status and Children ........................................ 185
Table 109 2 Match: Ethnoracial group and Education ....................................... 185
Table 110 2 Match: Ethnoracial group and Children ......................................... 186
Table 111 2 Match: Education and Children ................................................... 186
Table 112 1 Match: Income ...................................................................... 187
Table 113 1 Match: Age .......................................................................... 187
Table 114 1 Match: Relationship Status ........................................................ 187
Table 115 1 Match: Ethnoracial group ......................................................... 187
Table 116 1 Match: Education ................................................................... 187
Table 117 1 Match: Children ..................................................................... 187

xiv

LIST OF FIGURES
Figure 1 Hla Alcohol diagnosis (Dx) to 12-step group support (12-step). . . . . ...........19

Figure 2 Hlb Abuse or dependence (Single) and Abuse and Dependence (Dual) to 12-
step Group Support (12-step) ............................................................................................ 20

Figure 3 Comorbid psychopathology (CMP) mediating relationship between alcohol
diagnosis (Dx) and 12-step group support (12-step) ............................................ 21

Figure 4 MDD, MDD/GAD, ASPD, ASPD/MDD and ASPD/MDD/GAD mediating the
relationship between alcohol diagnosis (Dx) and 12-step group support (12-step). . . . . ....22

Figure 5 Comorbid psychopathology (CMP) mediating relationship between alcohol
diagnosis (Dx) and 12-step group support (12-step) ............................................ 22

Figure 6 MDD, MDD/GAD, ASPD, ASPD/MDD and ASPD/MDD/GAD mediating the
relationship between alcohol abuse & dependence (Dual) and 12-step group support (12-
step) ................................................................................................... 23

Figure 7 Demographic Cluster 1 moderating the relationship between alcohol diagnosis
(Dx) and 12-step group support (12-step) ........................................................ 25

Figure 8 Demographic Cluster 2 moderating the relationship between alcohol diagnosis
(Dx) and 12-step group support (12-step) ........................................................ 26

Figure 9 Demographic Cluster 1 moderating the relationship between alcohol abuse and
dependence diagnosis (Dual) and 12-step group support (12-step) ........................... 27

Figure 10 Demographic Cluster 2 moderating the relationship between alcohol abuse and
dependence (Dual) and 12-step group support (12-step) ....................................... 27

Figure 11 Upper socioeconomic classes (Upper socioeconomic) positively moderates the
relationship between alcohol diagnosis (Dx) and 12-step group support (12-step). . . . . ....28

Figure 12 Lower socioeconomic classes (Lower socioeconomic) negatively moderate the
relationship between alcohol diagnosis (Dx) and 12-step group support (12-step). . . . . ....29

Figure 13 Middle socioeconomic class (Middle socioeconomic) moderating the
relationship between alcohol diagnosis (Dx) and 12-step group support (12-step). . . . . ....29

Figure 14 Upper socioeconomic classes (Upper socioeconomic) positively moderates the

relationship between alcohol abuse and dependence (Dual) and 12-step group support
(12-step) .............................................................................................. 3O

XV

Figure 15 Lower socioeconomic classes (Lower socioeconomic) negatively moderate the
relationship between alcohol abuse and dependence (Dual) and 12-step group support
(12-step) .............................................................................................. 30

Figure 16 Middle socioeconomic class (Middle socioeconomic) moderating the
relationship between alcohol abuse and dependence (Dual) and 12-step group support
(12-step) .............................................................................................. 31

Figure 17 Women with children moderating relationship between alcohol diagnosis (Dx)
and 12-step group support (12-step) .............................................................. 31

Figure 18 Women without children moderating relationship between alcohol diagnosis
(Dx) and 12-step group support (12-step) ........................................................ 32

Figure 19 Women with children moderating relationship between alcohol abuse and
dependence (Dual) and 12-step group support (12-step) ....................................... 32

Figure 20 Women without children moderating relationship between alcohol abuse and
dependence (Dual) and 12-step group support (12-step) ....................................... 33

xvi

CHAPTER I
INTRODUCTION TO THE STUDY

Statement of the Problem

Twelve step group support programs have played a significant role in alcohol and
drug treatment in the US since it began with Alcoholics Anonymous (AA) in 1935. Over
the years 12-step group support has been credited with assisting in the development of
long-term sobriety trajectories for individuals who report 12-step affiliation (which
means both attending meetings and engaging in 12-step related activities) (Humphreys et
a1., 2004; Laudet, Stanick, & Sands, 2007; Room, 1993; Tonigan, Connors, & Miller,
2003). There is a large body of research on 12-step group support and treatment
programs that utilize 12-step group support. However, the majority of 12-step treatment
studies conducted to date have used either predominantly or entirely male samples
(Humphreys, 1999; Kaskutas, 2006; Mankowski, Humphreys, & Moos, 2001). The same
holds true for 12-step studies. A meta-analysis of AA specific 12-step studies indicated
that relatively few of the 74 articles had women participants (Tonigan, Toscova, &
Miller, 1996). In 1993 Project Match tested the effectiveness of three treatment methods
one of which was 12-step Facilitation Therapy (TSF). This was the largest alcohol
treatment study to date and women made up less than 25% of the entire sample and made
_ up less than 25% of the 12-step specific portion of the study (Project MATCH Research
Group, 1997).
Characteristics of men who attend 12-step group support

Quite a bit is known about the characteristics of men who participate in 12-step

group support in general and AA in particular (Humphreys, Kaskutas, & Weisner, 1998b;

Kaskutas et al., 2005; Kaskutas, Ye, Greenfield, Witbrodt, & Bond, 2008a; Mankowski,
Humphreys, & Moos, 2001; Tirnko, DeBenedetti, & Billow, 2006; Tonigan, 2001;
Tonigan, Toscova, & Miller, 1996). Male AA attendees have a high incidence of chronic
alcoholism (Humphreys, Kaskutas, & Weisner, 1998b; Kaskutas, Ye, Greenfield,
Witbrodt, & Bond, 2008a; Tonigan, Bogenschutz, & Miller, 2006). They have a high
incidence of comorbid psychopathology (Bogenschutz, Geppert, & George, 2006;
Humphreys, Mavis, & Stoffehnayr, 1991; McKay et al., 1998) and they tend to have a
high incidence of socioeconomic problems (Caetano, 1997; Humphreys, Kaskutas, &
Weisner, 1998b; Mankowski, Humphreys, & Moos, 2001; Tirnko, Billow, &
DeBenedetti, 2006).
Women and 12-step group support

Similar bold statements about women and 12-step group were not supported by a
comparably deep literature. There have been some important findings about women and
AA. Women gain and maintain sobriety by affiliating with AA (Kaskutas et al., 2005;
Laudet, Stanick, & Sands, 2007; Tonigan, 2001). In a small sample recruited partially
from AA meetings, 72% of those with both an alcohol disorder and a comorbid
psychiatric condition were sober at the one year follow up which was higher than the
men in the sample (DisClafani, Finn, & Fein, 2007). Women with depression who
attended AA were more likely than men to experience symptom relief within the first
year of attendance (Moos, Moos, & Tirnko, 2006). Women who attended AA had
greater economic resources than their male counterparts (Moos, Moos, & Timko, 2006)
suggesting that for women a particular socioeconomic population may be attracted more

frequently to meetings.

Women Problem drinkers

Despite the limited representation in the 12-step literature and Project Match,
there have been significant findings regarding problem drinking women in the treatment
and epidemiologic literature. Psychologically, mood and anxiety disorders were the two
most fi'equently co-occurring disorders affecting problem drinking women (American
Psychiatric Association, 1994; Beckman, 1994; Caetano, 2006; Grant et al., 2005;
Kessler, Keller, & Wittchen, 2001; Kessler et al., 1994; Kessler etal., 1996; Moos, Moos,
& Tirnko, 2006; Nolen-Hoeksema, 2002). Women with antisocial personality disorder
(ASPD) are at greater risk than men for developing alcohol related disorders (Grant et al.,
2004)

Knowledge about women problem drinkers has extended beyond the psychological
findings. In one study women facing loneliness, loss of identity and financial hardship
were at heightened risk of developing an alcohol disorder (Brennan, Schutte, & Moos,
1999). Older women were susceptible to stress relief drinking patterns; a phenomenon
occurring after the loss of a relationship or a lifetime spent in unwanted singleness
(Bowman & Gerber, 2006; Brennan, Schutte, & Moos, 1999; Epstein, Fischer-Elber, &
Al-Otaiba, 2007; Gomberg, 1995; Gomberg, 1994). Women particularly those with
children, tended to drink alone, to drink secretly and to avoid seeking help (Beckman,
1994; Gomberg & Nirenberg, 1993; McCrady & Miller, 1993). As important as the
findings are there is no indication whether or not 12-step group support had an impact on

the psychological symptoms or the demographic characteristics of these women.

Demographic Characteristics of 12-step Group Support

Alcoholics Anonymous Membership Survey showed that women and men over
the last ten years have averaged between 33% and 35% for women and 67% to 65% for
men. The survey data readily available to the public was aggregate level data and did
not segregate by gender the characteristics of those who attended. Demographically, the
majority of AA members were between the ages of 41 to 60 years (52.3%). They were
85% white, 16% retired with a full 20% in management, administration, professional or
technology occupations. Most of those reporting membership in AA were married (35%)
with the next largest group being those who reported being single (34%). Only 23% of
the AA members were divorced and 8% made up a variety of ‘other’ relationships. Some
who went to AA reported having comorbid emotional and or psychological problems as

well as drinking problems. But the survey data did not specifically discuss alcohol
diagnoses with or without comorbid psychopathology or how these may or may not have
identified people in general and women in particular who attended AA (Alcoholics
Anonymous World Services, 2008).

Limitations of Previous Research

In summary, there were significant findings about women problem drinkers in
the treatment and epidemiologic literature. But, women are under-represented in the 12-
Step literature and 12-step specific findings about women are under-reported in the
tr eminent and epidemiologic literature. These outcomes suggest that whereas women
Problem drinkers have been brought into the broader conversation about alcohol
treatrnent, they are still quite absent from empirical studies of their involvement in 12-

Step programs with and without comorbid psychopathologies.

The Purposes of this study

This study will contribute to the women specific 12-step literature. Using data

from the National Epidemiologic Survey of Alcohol and Related Conditions, Wave 1
(NESARC), the purposes of this study will be to first determine the strength and
direction of the relationship between alcohol diagnosis and 12-step group support for
women. The second purpose will be to determine if comorbid psychopathologies
mediate the relationship between alcohol diagnosis and 12-step group support for
women. The third purpose will be to determine if there are key demographic
characteristics of women that moderate the relationship between alcohol diagnosis and
12-step group support. These purposes will be organized around the following
questions.

Research Questions

1. Does alcohol diagnosis affect women’s participation in 12-step group support?
2. Does comorbid psychopathology mediate the relationship between alcohol
diagnosis and women’s participation in 12-step group support programs?

3. Do key demographic variables moderate alcoholic women’s participation in 12-

step group support?

 

CHAPTER II
BACKGROUND OF THE STUDY
Introduction

Chapter H is divided into three sections: Definitions, Review of the Literature and
The Present Study which presents the themes brought out by the literature review. The
Definitions section will operationalize the major constructs that need interpretive
clarification and will include 12-step group support, alcohol diagnosis, comorbid
psychopathologies and socioeconomic status. The demographic characteristics of
ethnoracial group, age, children in the home, personal income, education and relationship
status are discussed in the methods section. The use of these terms will be consistent
with the typical definitions used in US. based research. The Review of Literature will
focus on what is known about the population that typically goes to 12-step group support;
i.e. the level of alcohol severity, the presence of comorbid psychopathology and the
demographic characteristics. The chapter will end with the themes brought out by this
review of literature.

Definitions

12-step Group Support

Twelve-step group support is known under different names. The first of the 12-
step group support programs was AA. AA was the consequence of two men, William
Wilson and Dr. Robert Smith, whose fortuitous meeting in 1935 formed the foundation of
the Alcoholics Anonymous support group (Alcoholics Anonymous World Services,
2001). They with other early adherents to this mutual support society drafted 12-steps

that when followed in community with others, was professed to lead an individual to a

life of sobriety and abstinence from alcohol (Appendix A, The 12-steps of Alcoholics
Anonymous). Narcotics Anonymous (NA) and Cocaine Anonymous (CA) followed.
NA began with its first meetings in Los Angeles in the mid-1940’s (Narcotics
Anonymous World Services, 2004). It was patterned after the 12-steps of AA and some
of its earliest members were those who had gone to AA initially but who wished to stay
sober with others in recovery from narcotic addictions (Narcotics Anonymous World
Services, 2004). CA started in Hollywood, California in 1982 and again owed its
foundation to the 12-steps of AA (Cocaine Anonymous World Services, 2008). There
were other 12—step group support programs like Marijuana Anonymous (Marijuana
World Service, 2008) and most recently there has been an initiative to develop a 12-step
support program for methamphetamine users (Donovan & Wells, 2007).

For the purposes of this study the all encompassing term 12-step group support
will be used. The data were not split into separate group support programs but were
lumped together under the heading of 12-step group support. Further, AA is by far “the
most commonly sought form of help” with “a great deal of overlap between the (12-step
support) groups (Miller & McCrady, 1993, p.4).”

Over the years, 12—step research has expanded the definition of 12-step affiliation.
Early literature focused mainly on the number of meetings attended by the individual as a
predictor of affiliation (Ogbome & Glaser, 1981; Tonigan, 2008). More recent research
has found that there were other activities which define a person’s affiliation with 12—step
group support (Galanter & Kaskutas, 2008). The data available for this study did not
allow the investigation of these more subtle conversations regarding people’s specific

investment in 12-step group support. There were no variables that measured adherence to

12-step principles, the acquisition of a sponsor in the program; nor were there any
variables that measured the use of ancillary support materials or even provided the basic
quantity of meetings attended.
Alcohol Diagnosis

The severity of peoples’ drinking is determined by the behaviors manifested by
the drinker over a given period of time. These behaviors are clustered together as
symptoms that define either Alcohol Use Disorders or Alcohol Induced Disorders in a
classification system known as the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) (American Psychiatric Association, 1994). For the purposes of this study only
Alcohol Use Disorders and not the Alcohol Induced Disorders from the DSM-IV will be
used. Alcohol Induced Disorders are reversible substance-specific syndromes which
occur either by the recent ingestion of alcohol (intoxication) or the removal of alcohol
(withdrawal). Alcohol Induced Disorders produce clinically significant maladaptive
behavioral changes due to the effect of the alcohol on the body. AlcoholUse Disorders
form maladaptive patterns of substance use that include and exceed the behaviors caused
by the presence or removal of alcohol from the system. These patterns of behavior are
evidenced over a 12-month period of time. DSM-IV Alcohol Abuse and Alcohol
Dependence are the two levels and combined make up the entirety of Alcohol Use
Disorders (American Psychiatric Association, 1994).

The DSM-IV base definition of alcohol abuse and alcohol dependence begins
with the statement, “A maladaptive pattern of substance use leading to clinically
significant impairment or distress (American Psychiatric Association, 1994, pp. 197,

199).” This maladaptive pattern of substance use must have been persistently present for

the 12 months preceding diagnosis. To be diagnosed with alcohol dependence the person
must endorse at least three of the following behavioral symptoms including increased
tolerance for alcohol, withdrawal symptoms when alcohol is no longer present, drinking
in increasingly larger amounts or over a longer period of time, persistent desire to quit or
cut back without success, spending a lot of time seeking out opportunities to drink, failure
to meet important social, occupational or familial obligations or continued use of the
substance despite knowledge that the use is problematic. To be diagnosed with alcohol
abuse, the individual must endorse one of the following behavioral symptoms including
recurrent use of alcohol resulting in failure to fulfill major role obligations at work,
school, or home; recurrent use of alcohol in situations that could be dangerous; recurrent
substance related legal problems or continued drinking regardless of persistent social or
personal problems that are made worse by the use of alcohol.

Since the DSM-III (American Psychiatric Association, 1980) introduced the
division of alcohol disorders into alcohol abuse and alcohol dependence, there have been
multiple studies seeking to answer the question whether alcohol abuse was merely a
milder form of alcohol dependence. For the most part the answer has been no (Grant &
Dawson, 1997; Hasin, Van Rossem, McCloud, & Endicott, 1997; Hasin, Grant, &’
Endicott, 1990; Mojtabai & Singh, 2007; Schuckit et al., 1994; Schuckit, Smith, & Landi,
2000). While one small study reported that the absence of a lifetime alcohol abuse
disorder was rare in cases of alcohol dependence diagnosed persons (Ridenour, Cottler,
Compton, Spitznagel, & Cunningham-Williams, 2003), other larger population studies
have been consistent in their reports that alcohol abuse and alcohol dependence were

separate diagnoses, that alcohol abuse did not necessarily develop into alcohol

dependence and most importantly that alcohol dependence may exist without any
presentation of alcohol abuse (Hasin & Grant, 2004).

An individual may manifest symptoms consistent with alcohol abuse during one
time period and may also manifest symptoms consistent with alcohol dependence at
another time period. These diagnoses are not lifetime, are not co-dependent, hierarchical
or mutually exclusive. It is possible to be diagnosed alcohol dependent in an earlier time
period and subsequently be diagnosed with alcohol abuse. Thus, the diagnoses are not
hierarchical, i.e. a person does not need to first be diagnosed with alcohol abuse and then
later in time be diagnosed with alcohol dependence (Smith, 2005).

In essence, to be diagnosed alcohol dependent the person must meet physical
dependence, increased quantities to achieve the same effect and or withdrawal symptoms
when the alcohol is removed. Alcohol abuse requires some form of social, occupational
or emotional impairment without the physical addiction required for alcohol dependence
(American Psychiatric Association, 1994). Having both alcohol abuse and dependence
over the life span is more severe because it suggests that the drinker has experienced the
negative physical consequences of alcohol use as well as the social, occupational or
emotional negative consequences of alcohol use.

Comorbidity psychopathology

Comorbidity is the term used in epidemiology to describe the existence of more
than one disorder occurring together. There are three sub-definitions to comorbidity; true
comorbidity, artifactual comorbidity and spurious comorbidity (First, 2005). True
comorbidity is the appearance together of more than one clinically distinct disorder (First,

2005). First defines artifactual comorbidity as a disorder that is split based on a

10

convention that amongst other options, divides a disorder into separate categories that by
definition differ based on some element of the disorder. For example, alcohol abuse and
alcohol dependence are part of the larger grouping of alcohol use disorders under the
category label of Substance-Related disorders (American Psychiatric Association, 1994).
Alcohol abuse and alcohol dependence are artifactually comorbid because, according to
First, they may both appear together but are two separate disorders that are intrinsically
related holding in common many of the same elements but differing in important ways
(First, 2005). Spurious comorbidity is the appearance of a disorder that is actually a
symptom of another disorder. For example, the appearances of symptoms consistent
with Generalized Anxiety Disorder which actually are a byproduct of an alcohol use
disorder and not authentically the symptoms of Generalized Anxiety Disorder. True
comorbidity is also known as Independent Comorbidity (Grant et al., 2004). In this, two
or more authentically different disorders co-occur, each having their own pattern of onset
and course of development. An example of Independent Comorbidity would be the
appearance of ASPD and alcohol dependence.

Psychopathologies are behaviors clustered together as symptoms that define a
variety of disorders that are classified as a Mood Disorder, Anxiety Disorder, Disorders
Diagnosed in Infancy, Childhood or Adolescence or Personality Disorder (American
Psychiatric Association, 1994). Major Depressive Disorder is a Mood Disorder,
Generalized Anxiety Disorder is under Anxiety Disorder, Conduct Disorder is a disorder
diagnosed prior to the age of 18 years and ASPD is a lifelong personality disorder
diagnosed in adulthood. These four disorders are often associated with the early onset of

alcohol use or found co-occurring with alcohol use disorders (American Psychiatric

ll’

Association, 1994). Additional information about the onset and course these disorders
may be found in Appendix B.
Socioeconomic Status

According to the National Center for Educational Statistics (2008),
“Socioeconomic status is a measure of an individual or family’s relative economic and
social ranking.” An individual’s or family’s social ranking is established in sociological
literature through a combination of individual or family income, education, occupation
and gender (American Psychological Association Task Force on Socioeconomic Status,
2007; Bems, 2007; Gilbert, 1998; Hollingshead, 1975; Kahl, 1957).

The most widely used socioeconomic construct is the Hollingshead “Four Factor
Index of Social Status” which was the outgrth of an earlier two factor model
(Hollingshead, 1975). In the four factor model gender, marital status, occupation and
education expanded the original model of paternal occupation and education only. In
making decisions about socioeconomic status, Hollingshead recognized that his earlier
construct was limiting in that it only focused on men as head of household and men’s
income in determining socioeconomic status. The addition of gender and marital status
allowed two income households and single women heads of households to be analyzed
along with men heads of households and one income married households.

The four factor index measured education on a scale from 1 to 7 with 1 being
equal to or less than a seventh-grade education and 7 being at least some graduate school
training. Occupation was scored on a scale from 1 to 9 with 1 being equal to menial
service workers and unskilled laborers and 9 being equal to executive or professional

positions. Occupation and education were given factor weights which were calculated

12

according to Hollingshead, “by the use of multiple regression equations (Hollingshead,
1975, p. Reference 2).” Further definitions of the regression analysis process used by
Hollingshead were not available. As a result of his regression analyses, occupation
scores were multiplied by a weight of 5 and education scores were multiplied by a weight
of 3. The resulting scores were added together making a composite score ranging from 8
to 66 points. A person with a high score was said to be in a higher socioeconomic class
than a person with a low score.
Review of the Literature

Alcohol severity and l2-step group support

It was consistently reported in the treatment literature that higher alcohol severity
predicts 12-step group attendance (Humphreys, Kaskutas, & Weisner, 1998b;
Humphreys, Mavis, & Stdffelmayr, 1991; Zemore, Mulia, & Ye, 2008). Humphreys,
Mavis and Stdffelmayr (1991) found that men and women alike who went to 12-step
group support were significantly more likely to have severe alcohol problems.
Humphreys, Kaskutas and Weisner (1998) reported that 82.8% of those entering
treatment, who had a higher prior knowledge of 12-step group support, had more severe
alcohol problems than those who had lower histories of prior 12-step group support.
Zemore, Mulia and Ye (2008) reported that having more severe alcohol disorders was a
strong predictor of 12-step participation. In summary, treatment research found that
people in general and men in particular, who reported histories of 12-step affiliation,
were more severe alcoholics.
Alcohol treatment modalities and 12-step group support

Alcoholics are a heterogeneous group; consequently there is no single form of

13

treatment that consistently works with everyone (Marlatt, 1999; McCrady & Miller,
1993; Project MATCH Research Group, 1996, 1997, 1998a, 1998b, 1998c). However,
most treatment programs in the US (63% to 90% depending on the study) report a high
correlation between alcohol treatment and l2-step group support participation. Patients
come into treatment having some history of 12-step attendance or treatment facilities use
l2-step group support as an aftercare plan (Emrick, Tonigan, Montgomery, & Little,
1993; Humphreys, Kaskutas, & Weisner, 1998b; Kaskutas, Bond, & Ammon, 2008;
Tonigan, Toscova, & Miller, 1996; Weisner, Greenfield, & Room, 1995).
Comorbidpsychopathologies, alcohol disorders and 12-step group support

There were only a few articles in the 12-step literature thoroughly discussing
comorbid psychopathologies combined with alcohol disorders (Bogenschutz, Geppert, &
George, 2006; Humphreys, 1997; Humphreys, Mavis, & Stdffelmayr, 1991; Kelly,
McKellar, & Moos, 2003; McKay et al., 1998). Bogenschutz, Geppert and George
(2006) reported that those who had non-psychotic mental health disorders along with
alcohol disorders had improved days of abstinence if they were affiliated with 12-step
group support. Humphreys, Mavis and Stoffelmayr (1991) found a significant
correlation between psychological problems co-occurring with substance use problems.
And those who attended 12-step group support had significantly more psychological
problems than non-12-step group attendees. McKay, et a1 (1998) in a study of 138
people did not find significant correlations between comorbid psychopathologies and
alcohol disorders in those who reported 12-step group support attendance. This study did
find that Major Depressive Disorder was positively correlated with aftercare

participation, but not specifically 12-step group support as the aftercare modality. Kelly,

14

McKellar and Moos (2003) found in a VA population that despite their exposure to AA
that those with Major Depressive Disorder and an alcohol disorder reported less actual
involvement with 12-step program components. Humphreys (1997) found in a VA
sample that those with psychiatric problems may have been less successful in affiliating
with 12-step group support because of the prejudice of the non-psychiatric 12-step
affiliates. He cited the ‘total abstinence’ philosophy in 12-step groups as a barrier to the
medication-taking psychiatric population’s participation. It is for this reason that referral
to 12-step group support was not included in the substance abuse guidelines for those
with comorbid disorders (American Psychiatric Association, 1995). There were no
studies found of individuals who had more than one comorbid psychopathology co-
occurring with an alcohol use disorder in the treatment of 12-step literature.
Demographics of 12-step group support

Several studies discussed characteristics of people in general and men in
particular who attended 12-step group support with only minimal report of women
specific characteristics (Humphreys, Kaskutas, & Weisner, 1998b; Kaskutas, Ye,
Greenfield, Witbrodt, & Bond, 2008a; Laudet, Stanick, & Sands, 2007; Mankowski,
Humphreys, & Moos, 2001; Moos & Moos, 2006; Ogbome & Glaser, 1981; Tirnko,
DeBenedetti, & Billow, 2006; Tonigan, Toscova, & Miller, 1996). Tonigan, Toscova
and Miller’s (1996) meta-analysis of 74 empirical AA studies found that of the 74
studies, 40 studies reported total sample age means of 42.5 years. Only two studies
reported the age of women AA attendees and in those two reports the mean age was 40.5
years. In 59 studies the mean sample size for men was N=262.53 (SD 467.96), while in

57 studies the mean sample size for women was N=34.67 (SD 63.66). In three-quarters

15

of the studies no report of socioeconomic status was given for men, women or both.
Humphreys, Kaskutas and Weisner (1998) found that 82.8% of the individuals seeking
treatment had prior affiliation with 12-step group support. Further, two-thirds were male,
the average age was 38.7 years, they were divorced or separated and had problems with
stable employment leading to reports of low income. Kaskutas, Ye, Greenfield, Witbrodt
and Bond (2008) reported that the Alcoholics Anonymous Membership Survey from
2004 reported that 90% of the AA membership was 31 years of age or older and was 89%
white. There was a fairly even split of married, never married and previously married
people attending meetings. The sample used in the Tirnko, DeBenedetti and Billow
(1996) study was 98% male, 43% white and only 13% of these sample participants were
married. They did report that the sample was older, averaging above 50 years and having
at least 13 years of formal education. The Mankowski, Humphreys and Moos (2001)
study reported similar demographics, i.e. predominately white, male and higher
educational attainment. Moos and Moos (2006) in a 16 year follow up study reported
that 80% of the sample participants were white and 55.7% were unemployed. This
population entered the study in their mid-305 and had at least 13 years of formal
education at baseline. An older review by Ogbome and Glaser (1981) found that the
socioeconomic status of 12-step group support affiliates was more socially stable and fell
within the middle- and upper socioeconomic classes.

Humphreys, Mavis and Stdffelmayr (1991) found that having predominately
white male samples in 12-step studies is the result of selection bias. They found that
women and blacks were equally likely as men to affiliate with 12-step group support in

certain demographic areas. Having mostly white male study participants was due to

16

participant selection bias. On balance, their report did not say that there were more
women and blacks than white males attending 12-step group support only that it was just
as likely for these two populations to participate in certain geographic areas.

The relationship status of men and women combined who reported attendance in
12-step group support programs varied widely (Alcoholics Anonymous World Services,
2008 ; Groh, Jason, & Keys, 2008; Moos & Moos, 2006). Groh, Jason and Keys (2008)
review of social networks in the AA specific 12-step literature found that in the few
studies where women were the majority of the sample those women were predominately
married. Whereas the studies with predominately male samples, there was an even split
between married, like married or never married/single. Moos and Moos (2006) found
that 76.4% of their sample at the 16 year follow up was unmarried and evenly divided
between female and male respondents.

Limitations of Previous Research

Women were not strongly represented in empirical 12-step studies. Yet treatment
and epidemiologic research has a large body of literature that has focused on the
problems of women who drink. For example, the prevalence rate of alcohol diagnosed
women with a comorbid psychopathology has been well documented. But, the presence
of this topic is minimal in the 12-step literature. When women are discussed in 12-step
literature, they tend to be white, age 35 years or older with at least a high school
education; are in the upper socioeconomic classes and are fairly evenly split between
married and not married. Treatment literature shows a more even balance of ethnoracial
groups, age ranges, educational levels and socioeconomic categories. The makeup of the

family including the children of women problem drinkers was discussed in the treatment

17

literature with emphasis on the barriers to seeking treatment for women with children.
Yet, this important topic was not mentioned in the 12-step literature reviewed.
The Present Study

Themes that emerged

There were three general themes suggested by this literature review that parallel
the research questions presented at the end of Chapter 1. First, studies of problem
drinkers found that 12-step group support programs attract and were successful with
alcohol diagnosed individuals and individuals who go to 12-step group support have
more severe alcohol problems. Second, even though people with comorbid
psychopathologies were not routinely recommended to 12-step programs, those who did
go, especially if they were women benefitted. The third theme that emerged from the
literature was that even though alcohol disorders were heterogeneous by nature, there
may be some homogeneity in the population of individuals who go to 12-step group

support. But, the homogeneity could be the result of sample selection bias. i

18

CHAPTER III
METHODS
Introduction
Chapter III begins with a restatement of the research questions from Chapter 1
and the themes presented after the literature review in Chapter II, followed by the
hypotheses that organize the tests to be conducted. The research design comes next
followed by a thorough discussion of the NESARC data set and the steps used to prepare
the data. The chapter ends with a chart of the prepared data set for the analyses with cell
sizes per category of participation provided.
Analysis Plan
Themes, questions and hypotheses
Question 1: Theme one stated that, studies of problem drinkers found that 12-step
group support programs attracted and were successful with alcohol diagnosed individuals
and individuals who go to 12-step group support have severe alcohol problems. Out of
this, research question one asks, “Does alcohol diagnosis affect women’s participation in
12-step support group programs?” There are two hypotheses that will test this question.
Hlo: Alcohol diagnosis will not be significantly related to 12-step group support.

Hla: Alcohol diagnosis will have a significant and positive relationship to 12-step group

support (Figure 1).

 

DX + 12-step

 

 

Figure 1. Hla Alcohol diagnosis (Dx) to 12-step group support (12-step)

19

Hlb: Women who have a more severe history of both alcohol abuse and dependence will
be significantly more likely to report attending 12-step group support than women

without a severe alcohol disorder (Figure 2).

 

Single

 

 

 

 

l 2-step

 

 

 

Dual

 

 

 

Figure 2 Hlb Abuse or dependence (Single) and Abuse and Dependence (Dual) to 12-
step Group Support (12-step)

Question 2: Theme two states that even though people with a comorbid
psychopathology were not routinely recommended to 12-step programs, those who did
go, especially if they were women benefitted. Out of this, research question two asks,
“Does comorbid psychopathology mediate the relationship between alcoholism diagnosis
and women’s participation in l2-step support group programs?” There are four
hypotheses to be tested related to question two.

H20: Having a comorbid psychopathology does not mediate women’s relationship
between alcohol diagnosis and l2-step group support.
H2a: Having a comorbid psychopathology will mediate women’s relationship between

alcohol diagnosis and 12-step group support and the direction will be negative (Figure 3).

20

 

 

DX 12-step

 

 

ClVIP

 

 

Figure 3 Comorbid psychopathology (CMP) mediating relationship between alcohol
diagnosis (Dx) and 12-step group support (12-step)

H2b1: Having Major Depressive Disorder1 will mediate the relationship between alcohol
diagnosis and 12-step group support and the direction will be negative (Figure 4).
H2b2: Having both Major Depressive Disorder and Generalized Anxiety Disorder2 will
mediate the relationship between alcohol diagnosis and 12-step group support and the
direction will be negative (Figure 4).

H2b3: Having ASPD3 will mediate the relationship between alcohol diagnosis and 12-
step group support and the direction will be negative (Figure 4).

H2b4: Having ASPD and Major Depressive Disorder4 will mediate the relationship
between alcohol diagnosis and l2-step group support and the direction will be negative
(Figure 4).

H2be: Having ASPD with a history of Major Depressive Disorder and Generalized
Anxiety Disorder5 will mediate the relationship between alcohol diagnosis and 12-step

group support and the direction will be negative (Figure 4).

 

’ MDD had sufficient N to make analysis meaningful, see Appendix C, Table C10 for specific cell count
of all psychopathologies

2 Ibid
3 Ibid
4 Ibid
5 Ibid
21

 

 

 

DX + 12-step

MDD

 

 

MDD/ GAD

 

 

ASPD

 

 

ASPD/MDD

 

 

ASPD/MDD/ GAD

Figure 4 MDD, MDD/GAD, ASPD, ASPD/MDD and ASPD/MDD/GAD mediating the
relationship between alcohol diagnosis (Dx) and l2-step group support (12—step)

MDD= Major Depressive Disorder

MDD/GAD= Major Depressive Disorder and Generalized Anxiety Disorder

ASPD= Antisocial Personality Disorder

ASPD/MDD= Antisocial Personality Disorder with Major Depressive Disorder
ASPD/MDD/GAD= Antisocial Personality Disorder with Major Depressive Disorder and
Generalized Anxiety Disorder

 

H2c: Having a comorbid psychopathology will mediate women’s relationship between
alcohol abuse and dependence and 12-step group support and the direction will be

negative (Figure 5).

 

 

Dual + 12-step

V

 

 

 

 

 

 

ClVlP

Figure 5 Comorbid psychopathology (CMP) mediating relationship between alcohol
diagnosis (Dx) and 12-step group support (12-step)

 

H2d1: Having Major Depressive Disorder will mediate the relationship between alcohol
abuse and dependence and 12-step group support and the direction will be negative

(Figure 6).

22

H2d2: Having both Maj or Depressive Disorder and Generalized Anxiety Disorder will
mediate the relationship between alcohol abuse and dependence and 12-step group
support and the direction will be negative (Figure 6).

H2d3: Having ASPD will mediate the relationship between alcohol abuse and
dependence and 12-step group support and the direction will be negative (Figure 6).
H2d4: Having ASPD and Major Depressive Disorder will mediate the relationship
between alcohol abuse and dependence and 12-step group support and the direction will
be negative (Figure 6).

H2d5: Having ASPD with Major Depressive Disorder and Generalized Anxiety Disorder
will mediate the relationship between alcohol abuse and dependence and 12-step group

support and the direction will be negative (Figure 6).

 

 

 

 

 

 

 

 

 

 

ASPD/MDD/GAD

Figure 6 MDD, MDD/GAD, ASPD, ASPD/MDD and ASPD/MDD/GAD mediating the
relationship between alcohol abuse & dependence (Dual) and 12-step group support (12-
step)

MDD= Major Depressive Disorder

MDD/GAD= Major Depressive Disorder and Generalized Anxiety Disorder

ASPD= Antisocial Personality Disorder

ASPD/MDD= Antisocial Personality Disorder with Major Depressive Disorder
ASPD/MDD/GAD= Antisocial Personality Disorder with Major Depressive Disorder and
Generalized Anxiety Disorder

 

23

Question 3 : Theme three states that there may be some homogeneity in the
population of individuals who go to 12-step group support. But, the apparent
homogeneity could be the result of sample selection bias. Out of this, research question 3
asks, “Do key demographic variables moderate alcoholic women’s participation in 12—
step support group programs? ” There are four hypotheses that will test two demographic
clusters; there are six hypotheses that will test socioeconomic status and four hypotheses
that will test the presence or absence of children in the home.

The first demographic cluster to be analyzed will be women who are white, age
35 years of age or older, with at least a high school education who are married. The
ethnoracial group white was chosen based on the results of the literature review which
consistently reported that those who were white were more common 12-step attendees
(Alcoholics Anonymous World Services, 2008; Humphreys, Kaskutas, & Weisner,
19983; Mankowski, Humphreys, & Moos, 2001; Moos & Moos, 2006; Timko, Finney,
Moos, & Moos, 1995) and 65.6% of the NESARC subset was white. The age of 35 years
was set for the study. Most of the literature reviewed found the average age of those
going to 12-step group support to be 40 and above. Timko (1995) was higher with the
average age being 50 years in his study and the Alcoholics Anonymous Membership
Survey had the average age set to 41 years. The NESARC subset had a higher mean age
of 42.7 years. However, the lower number of 35 years was chosen to reflect the lower
age reported by some in the literature. The educational level was set at high school
completion, its equivalent or more schooling based on the literature review that showed
most 12-step attendees have at least a high school education (Alcoholics Anonymous

World Services, 2008; Mankowski, Humphreys, & Moos, 2001; Moos & Moos, 2006;

24

Timko, Finney, Moos, & Moos, 1995). The average education for these data was only
slightly higher than high school completion or the equivalent. The relationship status was
set to married. Groh (2008) reported that women were mostly married in his study. Most
of the other studies have a fairly even split between married, previously married and
never married. Also, women in these data that matched the characteristics of being
white, being age 35 years or older with at least a high school education were mostly
man'ied (Appendix E, Table E1).

H301: Being white, 35 years of age or older, with at least a high school education or
better and married will not moderate the relationship between alcohol diagnosis and 12-
step group support.

H3a1: Demographic Cluster 1 meaning being white, 35 years of age or older, with at least
a high school education or better and married will moderate the relationship between

alcohol diagnosis and 12-step group support in a positive direction (Figure 7).
White, 35+, 12+ed, Married

 

 

 

 

 

DX ' 12-step

V

 

 

 

 

 

 

 

Figure 7 Demographic Cluster 1 moderating the relationship between alcohol diagnosis
(Dx) and 12-step group support (12-step)

White= ethnoracial group white

35+= Age 35 years or older

12+ed= High school completion, equivalent or greater education

The second demographic cluster to be tested included those women who were
other- than-white, under the age of 35 years with less than a high school education who

were previously married. These were the inverse of Demographic Cluster 1 and were

25

tested based on the concern raised by Humphreys (1997) regarding sample selection bias.
The NESARC was a national survey with strict randomization protocols. It was not a
treatment sample. If Humphrey’s idea of sample selection bias prevailed, it would be just
as likely for Demographic Cluster 2 to moderate the relationship between alcohol
diagnosis and 12-step group support as it would be for Demographic Cluster 1 to
moderate this relationship.

H3b1: Demographic Cluster 2 meaning being other-than-white, under the age of 35 years
with less than a high school education and previously married moderated the relationship

between alcohol diagnosis and 12-step group support in a negative direction (Figure 8).

 

Other-than-white, -35, -12ed,
previously married

 

 

 

 

DX V j 12-step

 

 

 

 

 

 

 

Figure 8 Demographic Cluster 2 moderating the relationship between alcohol diagnosis
(Dx) and 12-step group support (12-step)
Other-than-white= ethnoracial group that includes black, Hispanic, Native American
Indian, Alaskan Inuit, Asian, Pacific Islander
-35= Age less than 35 years
-12ed= Less than high school completion or equivalent

A premise of this study is that the more severe alcohol abuse and dependent
women will go to 12-step group support. Because of this, the Demographic Cluster 1 and
2 will be retested using the more severe alcohol abuse and dependence variable.
H3a1: Demographic Cluster 1 meaning being white, 35 years of age or older, with at least

a high school education or better and married will moderate the relationship between

26

alcohol abuse and dependence and 12-step group support in a positive direction (Figure

9).

 

| White, 35+, 12+ed, Married |

 

 

 

DX

V

1 2-step

 

 

 

 

 

 

 

Figure 9 Demographic Cluster 1 moderating the relationship between alcohol abuse and
dependence diagnosis (Dual) and 12-step group support (12-step)
White= ethnoracial group white 35+= Age 35 years or older
12+ed= High school completion, equivalent or greater education

For the same reason given previously, the more severe alcohol abuse and
dependent women will be tested with Demographic Cluster 2 as moderator.
H3b1: Demographic Cluster 2 meaning being other-than-white, under the age of 35 years

with less than a high school education and not married moderated the relationship

between alcohol abuse and dependence and 12-step group support in a negative direction

 

 

 

 

 

(Figure 10).
Other-than-white, -35, -12ed,
previously married
Dual 1 w 12-step

 

 

 

 

 

 

 

Figure 10 Demographic Cluster 2 moderating the relationship between alcohol abuse and
dependence (Dual) and l2-step group support (12-step)

Other-than-white= ethnoracial group that includes black, Hispanic, Native American
Indian, Alaskan Inuit, Asian, Pacific Islander

-35= Age less than 35 years -l2ed= Less than high school completion or equivalent

27

Based on the outcomes of the literature, many of the women who go to 12-step
group support have economic resources (Moos, Moos, & Timko, 2006). It would be
expected that women in the upper socioeconomic categories would be more likely to
attend 12-step group support compared to other socioeconomic classes. By the same
measure, those in the mid and lower socioeconomic ranges would be less likely to go to
12-step group support.

H3 02: The socioeconomic status of women will not moderate the relationship between
alcohol diagnosis and 12-step group support.

H3a2: Women in the upper socioeconomic classes will moderate in a positive direction
the relationship between alcohol diagnosis and 12-step group support and the direction

will be positive (Figure 11).

 

Upper Socioeconomic

 

 

 

DX 12-step

V

 

 

 

 

 

 

 

Figure 11 Upper socioeconomic classes (Upper socioeconomic) positively moderates the
relationship between alcohol diagnosis (Dx) and 12-step group support (12-step)

H3b2; Women in the lower socioeconomic classes will moderate the relationship
between alcohol diagnosis and 12-step group support and the direction will be negative

(Figure 12).

28

 

Lower Socioeconomic

 

 

 

V

 

DX 1 2-step

 

 

 

 

 

 

Figure 12 Lower socioeconomic classes (Lower socioeconomic) negatively moderate the
relationship between alcohol diagnosis (Dx) and 12-step group support (12-step)

H3cz; Women in the middle socioeconomic class will moderate the relationship between
alcohol diagnosis and 12-step group support and the direction will be negative (Figure

13).

 

Middle Socioeconomic ll

 

 

 

 

DX ' p 12-step

 

 

 

 

 

 

 

Figure 13 Middle socioeconomic class (Middle socioeconomic) moderating the
relationship between alcohol diagnosis (Dx) and 12-step group support (12-step)

Women with the more severe alcohol abuse and dependence disorder may have
more socioeconomic problems. But, the literature reports that those with more severe
alcohol problems go to 12-step group support and have more economic resources. The
next three hypotheses will retest the moderating effect of socioeconomic status with the
more severe alcohol abuse and dependence disorder.

H3d2: Women in the upper socioeconomic classes will moderate in a positive direction
the relationship between alcohol abuse and dependence diagnosis and l2-step group

support and the direction will be positive (Figure 14).

29

 

Upper Socioeconomic

 

 

 

V

 

Dual 12*step

 

 

 

 

 

 

Figure 14 Upper socioeconomic classes (Upper socioeconomic) positively moderates the
relationship between alcohol abuse and dependence (Dual) and 12-step group support
(12-step)

H3e2; Women in the lower socioeconomic classes will moderate the relationship between

alcohol abuse and dependence and 12-step group support and the direction will be

negative (Figure 15).

 

Lower Socioeconomic

 

 

 

 

Dual a 12-step

 

 

 

 

 

 

Figure 15 Lower socioeconomic classes (Lower socioeconomic) negatively moderate the
relationship between alcohol abuse and dependence (Dual) and 12-step group support
(12-step)

H3f2; Women in the middle socioeconomic class will moderate the relationship between
alcohol diagnosis and 12-step group support and the direction will be negative (Figure

16).

30

 

Middle Socioeconomic

 

 

 

 

Dual 12-step

V

 

 

 

 

 

 

Figure 16 Middle socioeconomic class (Middle socioeconomic) moderating the
relationship between alcohol abuse and dependence (Dual) and l2-step group support
(12-step)

There was no information found regarding women with children who go to 12-
step group support. For this reason, the last demographic characteristic to be tested will
deal with women drinkers who have children in the home. Through a series of four tests,
women with children absent who have an alcohol diagnosis, women with children present
who have an alcohol diagnosis, women who have children absent who have the more
severe alcohol abuse and dependence and women who have children present in the home
who have the more severe alcohol abuse and dependence will be analyzed.

H303: Having children will not moderate the relationship between alcohol diagnosis and
12-step group support.

H3a3: Having children will moderate the relationship between alcohol diagnosis and 12-

step group support and the direction will be negative (Figure 17).

 

Women with Children

 

 

 

 

DX l q 12-step

 

 

 

 

 

 

Figure 17 Women with children moderating relationship between alcohol diagnosis (Dx)
and 12-step group support (12-step)

31

H3 b3: Women without children will moderate the relationship between alcohol diagnosis

(Dx) and 12-step group support (12-step) and the direction will be positive (Figure 18).

 

I Women without Children

 

 

 

 

DX

 

'

1 2-step

 

 

 

 

 

Figure 18 Women without children moderating relationship between alcohol diagnosis
(Dx) and l2-step group support (12-step)

H3 C3: Having children will moderate the relationship between alcohol abuse and
dependence (Dual) and 12-step group support (12-step) in a negative direction (Figure

19).

 

Women with Children I

 

 

 

Dual p 12-step

 

 

 

 

 

 

 

Figure 19 Women with children moderating relationship between alcohol abuse and
dependence (Dual) and 12-step group support (12-step)

H3d3: Women without children will moderate the relationship in a positive direction the

relationship between alcohol diagnosis and 12-step group support (Figure 20).

32

 

Women without Children

 

 

 

Dual : 12-Step

 

 

 

 

 

 

 

Figure 20 Women without children moderating relationship between alcohol abuse and
dependence (Dual) and l2-step group support (l2-step)

Research design

This is an exploratory secondary data analysis of a subset of women taken from
the NESARC. Through a series of binary logistic regressions the analyses will
investigate the research questions: 1. Does alcohol diagnosis affect women’s participation
in 12-step support group programs? 2. Does comorbid psychopathology mediate the
relationship between alcoholism diagnosis and women’s participation in 12-step support
group programs? 3. Do key demographic variables moderate alcoholic women’s
participation in l2-step support group programs? Because this is an exploratory study
the P value will be set to p_<_.10. Each analysis will include a report of the ratios with
confidence intervals to determine if the results of the binary logistic regressions have
meaning.

NESARC Wave 1 Data

Background

The subjects for this study are a subset of the larger NESARC Wave 1. The
NESARC was designed as a nationally representative longitudinal survey with its first
wave of interviews occurring between 2001 and 2002. The NESARC Wave 1 is the first
data set in a series of which two waves are currently available. Wave I collected

33

responses using computer assisted personal interviewing (CAPI) in the US. on questions
about alcohol use, alcohol experiences, demographic characteristics, treatment utilization,
other drug use and comorbid psychiatric conditions. Sponsored by the US. Department
of Health and Human Services, National Institute of Health, National Institute of Alcohol
. Abuse and Alcoholism, the survey was designed to measure the “magnitude of alcohol
use disorders and their associated disabilities in the general population and in subgroups
of the population (Grant, Kaplan, Shepherd, & Moore, 2003, p. 1).”

Persons with at least five years of interviewing experience with the US. Census
Bureau were recruited to conduct all interviews with participants. Each interviewer
further completed a minimum required five days of training on the NESARC
questionnaire, data collection and consenting protocols (Grant et al., 2004a).

The sampling frame consisted of Census 2000/2001 Supplementary Survey
(CZSS) data collected from approximately 78,300 households per month in 2000 and
2001. The subjects were collected during the CZSS from the non-institutionalized
population of 18 years and older adults who resided in the United States (including
Hawaii and Alaska) and the District of Columbia. Individuals could have been living in
single family homes (which included apartments and mobile homes), boarding houses,
rooming houses, non-transient hotels and motels, shelters, facilities for housing workers,
college quarters and group homes. The frame was adjusted using a variety of accepted
procedures until the final individual was identified within the households of the defined
C2SS population. The data set was a representative sample of the heterogeneous

population in the US. and thus was consistent with what we know to be true about the

34

heterogeneity of the alcohol using population (Dawson, Grant, Stinson, & Chou, 2006;
Grant et al., 2005; Grant et al., 2004a; Stinson et al., 2005).

Wave 1 of the NESARC oversampled non-Hispanic Afiican Americans,
Hispanics, and individuals younger than 25 years of age. Oversampling of non-Hispanic
African Americans increased the number of households surveyed fiom 12.3% to 19.1%
(equaling an additional 8,245 cases). Oversampling of Hispanics increased the number of
households surveyed from 12.5% to 19.3% (equaling an additional 8,308 cases). More
women than men were sampled reflecting data collection methods that attempt to limit
gender bias and shows an underlying acknowledgement that women may exhibit drinking
behaviors that need to be studied. Oversampling increased power in these groups and
allowed for specific study of traditionally under represented populations in key interest
areas including treatment related service programs and 12-step group support attendance
(Grant, Kaplan, Shepard, & Moore, 2003).

The diagnostic variables in the NESARC were not based on respondent report.
The data collectors did not ask, “Do you now or have you ever been diagnosed with
alcohol dependence?” Instead, these diagnoses were based on respondent endorsement of
operationalized symptom profiles from the DSM-IV (American Psychiatric Association,
1994) collected during the interview. Afterwards the responses were sorted into various
diagnoses based on the symptom criteria (Grant et al., 2004a; National Institute for
Alcoholism and Alcohol Abuse, 2004; Pulay et al., 2008).

Tables depicting the diagnosis, comorbid psychopathology and demographic
distribution of the entire NESARC dataset (N=43,093) of women and men may be found

in Appendix C.

35

Variables for the study

Dependent Variable: 12-step Group Support. The variable for 12-step group
support attendance asked, “Have you ever went to Alcoholics/Narcotics/Cocaine
Anonymous, or 12-step meeting (National Institute on Alcohol Abuse and Alcoholism,
2004, p. 67)?” It was dichotomized as attended 12-step or not (1, 0). There were nine
missing data points that were coded as not (0) based on the prior work by Kaskutas
(Kaskutas, Ye, Greenfield, Witbrodt, & Bond, 2008b). She determined that there were
432 women who validly reported attending a 12-step group at least once. This produced
a variable with 575 women (432, yes; 143, no) answering the question regarding 12-step
group attendance.

Independent Variables. There are three major categories of independent variables
that will be used for this study. The first set of independent variables will be for alcohol
diagnoses. During data collection individuals were asked a series of questions regarding
their experiences with alcohol. There were three time points; during the current twelve
months, prior to the current twelve months or in both time periods. After the interview
the respondents experiences were cataloged by time period into DSM-IV alcohol abuse,
alcohol dependence, both alcohol abuse and dependence or neither alcohol abuse nor
dependence.

The second set of independent variables to be used will be comorbid
psychopathologies and will include Major Depressive Disorder and Generalized Anxiety

Disorder. These have three time points which are current twelve months, prior to current

36

twelve months or both. Recalling the discussion by First about True Comorbidity those
individuals who experienced Major Depressive Disorder or Generalized Anxiety
Disorder as a result of a substance abuse disorder will be removed from the disorder
leaving only truly comorbid depression and anxiety. Whereas this will also remove those
individuals whose drug of choice was not alcohol; by keeping substance disorders in with
psychopathologies a confound in the data would be created. This study will also test
Conduct Disorder and ASPD.

The third set of independent variables to be used will be a collection of key
demographic characteristics including the age of the respondent, their relationship status,
the number of children in the home, the ethnoracial group, the educational level and their
personal income. Using the NESARC-defmed variables for education and occupation a
socioeconomic (SES) variable will be calculated. Discussion on the procedures used to
calculate the SES variable follows later in the chapter.

Imputation of data in the national data set

The NESARC had two imputation methods used for the data by the original
research team. The first was the allocation method and the second was the assignment
method. The allocation method of imputation refers to imputation of missing data using
characteristics of households believed to be similar to the household containing-the
missing data (Schafer, 1999). Although the use of allocation imputation saves data that
would have otherwise been deleted, it does increase the chance of error. The assignment
method used the respondent’s own information to assign the level (i.e. first name to

indicate sex of respondent) and was much more reliable (Grant, Kaplan, Shepard, &

37

Moore, 2003). The assignment method was preferred because of the reduction in error
and the assumption that the data was missing at random.

There was a trivially low allocation rate in the missing data for most variables
chosen which helped reduce potential for error. The allocation imputation method was
used to impute gender (.14%), age (1.12%) and marital status (.59%). These numbers
excluded those data points imputed using the assignment method. The variables Personal
Income (11.11% imputed data) and Family Income (10.11% imputed data) had allocation
rates higher than the other items. However, even with these higher percentages, the data
were still almost 90% non-imputed (Grant, Kaplan, Shepard, & Moore, 2003).

Data preparation for this study

All data was prepared using SPSS 14 grad pack (SPSS Inc., 2005).

Alcohol diagnosis. The aggregate variable for alcohol diagnosis (Dx) was
computed by combining current 12 months and prior to current 12 months alcohol
diagnoses into a dichotomous variable with a diagnosis or without (1, O).

Dichotomous variables for different levels of alcohol diagnoses were then
constructed using the variables for current and prior alcohol diagnoses. These variables
were dummy coded into a total of six dichotomous variables; current alcohol abuse,
current alcohol dependence, both current alcohol abuse and dependence, prior to current
alcohol abuse, prior alcohol dependence and both prior alcohol abuse and dependence. A
crosstab revealed problems with using both the prior to current alcohol diagnoses with
the current alcohol diagnoses. First, the sample sizes in the cells for alcohol dependence
at both time points were low or empty. Second, there were disproportionate cell sizes

across the matrix.

38

Table 1 Crosstab of current and prior alcohol diagnoses by level of abuse (abuse)
dependence (depend), abuse and dependence together (Dual) or no alcohol diagnosis

 

(none)
Prior Dx Current Dx
None Abuse Depend Dual Total

None 27 5 1 l 34
Abuse 140 16 0 4 160
Depend 14 0 1 1 16
Dual 245 25 22 73 365
Total 426 46 24 79 575

None= no alcohol diagnosis, Abuse = Alcohol abuse, Depend= Alcohol dependence,
Dua1= Alcohol abuse and dependence diagnosis

Given these concerns, it was more meaningful to collapse the data into one time
point. The resulting variable was a lifetime diagnosis with four levels: Women without
an alcohol diagnosis (none) with an N=27, women diagnosed with alcohol abuse (abuse)
with an N=161, women diagnosed with alcohol dependence (Depend) with an N=16 or
women diagnosed with both alcohol abuse and alcohol dependence (Dual) with an N=
371 at some time in their life.

One additional step was taken. The level for alcohol dependence had a small cell
count (N=16) and the decision was made to collapse this cell into alcohol abuse and
rename that level ‘Single’ with an N=177 and the cell for both alcohol abuse and
dependence (Dual) maintained N=371 and the cell for no alcohol diagnosis (None)
maintained N=27. A crosstab with 12-step group support and alcohol diagnosis is
represented in the following matrix (Table 2).

Table 2 Crosstab of alcohol diagnosis by 12-step group support

Attendance
Yes No Total

 

None 15 12 27

Single 123 54 177

Dual 294 77 371

None = No alcohol diagnosis

Single = Alcohol abuse or alcohol dependence
Dual= Both alcohol abuse and alcohol dependence

39

Comorbid psychopathology. Comorbid psychopathology was the second category
of independent variables to be prepared for this study. The disorders used for this study
were Major Depressive Disorder, Generalized Anxiety Disorder in two time points,
Conduct Disorder and ASPD.

Note that like alcohol disorders, Maj or Depressive Disorder and Generalized
Anxiety Disorder had two time points; current and prior to current. Conduct Disorder has
only one time point because it is only diagnosed in adolescence and ASPD is a lifetime
diagnosis thus no time period qualifier is needed. By definition this is the most severe
form of disorder being studied because once diagnosed with ASPD the individual will
have no periods of remission. The disorder persists and typically worsens with age
(Hesselbrock & Hesselbrock, 1994).

The first procedure was too collapse the two time points for Major Depressive
Disorder and Generalized Anxiety Disorder into two dichotomized lifetime variables of
Lifetime Major Depressive Disorder and Lifetime Generalized Anxiety Disorder. Using
the same procedure used to collapse the two time points of alcohol diagnoses earlier, the
four variables, Lifetime Major Depressive Disorder, Lifetime Generalized Anxiety
Disorder, Conduct Disorder and ASPD were placed in a single matrix. The result was a
set of dichotomous variables either matching a diagnosis or not (1, 0). The matrix
showed overlaps and empty/low cell counts (Table 3). Only the cells with sufficient N to
make analysis meaningful were used. Those psychopathologies selected for use in the

analyses were underlined in the New Variable column of Table 3.

40

Table 3 Crosstabs of Comorbid Psychopathologies with cell counts

 

 

 

ASPD CD GAD MDD Total New Variable
0 0 0 0 230 No CMP
1 1 80 M
1 0 11 GAD
1 51 GAD/MDD
1 0 0 5 CD
1 3 CD/MDD
l 0 0 0 23 ASPD
1 45 ASPD/MDD
1 0 3 ASPD/GAD
1 24 ASPD/GAD/MDD
575

ASPD = Antisocial Personality Disorder

CD = Conduct Disorder

GAD = Lifetime Generalized Anxiety Disorder

MDD = Lifetime Major Depressive Disorder
No CMP = No Comorbid Psychopathology

0=No
1=Yes

In the second procedure the four variables Lifetime Major Depressive Disorder,

Lifetime Generalized Anxiety Disorder, Conduct Disorder and ASPD were collapsed into

one variable. The result was 345 women who had at least one psychopathology and 230

women who did not have any psychopathologies.

Demographics. There were three categorical demographic variables and two

scale demographic variables. The categorical variables were ethnoracial group, education

and relationship status. Age, personal income and number of children in the home were

scale variables.

The categorical variables comprising the ethnoracial variable was dichotomized

as white or not (1, 0), education was dichotomized as plus or minus high school (1, 0) and

relationship status became three separate dichotomized variables; married or not (1, 0),

41

previously married (meaning divorced, widowed or separated) or not (1 , 0) and never
married or not (1, 0).

The scale variable age was dichotomized as plus or minus 35 years (1, 0) and the
scale variable women with children present in the home or absent from the home was
dichotomized (1, 0).

Socioeconomic status. Socioeconomic status was constructed following the
Hollingshead (1975) formulation. In order to apply the Hollingshead “Four Factor Index
for Social Status” all persons in the dataset needed to have an education and occupation
code. First, the variable for occupation was recoded following the weighting system of
Hollingshead using the occupation table found in the NESARC Technical Documents
(10) (National Institute for Alcoholism and Alcohol Abuse, 2004). The definitions used
in the NESARC for each occupation were carefully matched to the definitions given by

Hollingshead even though the categories may not appear to match (Hollingshead, 1975)

 

(Table 4).
Table 4 NESARC Occupational code converted to Hollingshead categories
NES ARC Hollingshead
Code Heading code Heading
Administrators, Lesser
professionals,
Executive, Administrative, & Proprietors of med-size
1 Managerial 8 business

Higher executives,
Proprietors of large
business, Major

2 Professional Specialty 9 Professionals
Technicians,
Semiprofessionals,

3 Technical & related support 6 Small business owners

42

Table 4 (cont’d).

10

11

12

13

14

Sales

Administrative support,
including clerical

Private household

Protective services
Other services

Farming, Forestry, Fishing
Precision production, craft and
repair

Operators, fabricators, Laborers
Transportation, material moving

Handlers, Equipment cleaners,
laborers

Military

4

Technicians,
Semiprofessionals,
Small business owners
Clerical and sales
workers, small farm and
business owners
Smaller business
owners, skilled manual
workers, craftsmen, and
Tenant farmers

Smaller business
owners, skilled manual
workers, craftsmen, and
Tenant farmers

Unskilled workers
Machine operators and
Semiskilled workers
Smaller business
owners, skilled manual
workers, craftsmen, and
Tenant farmers
Machine operators and
Semiskilled workers
Machine operators and
Semiskilled workers

Unskilled workers
Smaller business
owners, skilled manual
workers, craftsmen, and
Tenant farmers

Next, the occupational codes were compared to personal income and matched to the

government report fi'om 2001 comparing occupations with expected incomes (Pearson

Education Inc., 2007). Last, the variable for education was recoded following the coding

system of Hollingshead using the education table in the NESARC Technical Documents

(Hollingshead, 1975, p.10) (Table 5).

43

Table 5 NESARC Education codes converted to Hollingshead Categories

 

NES ARC Hollingshead
Code Heading Code Heading
1 No formal schooling 0 No formal education
2 Completed K, 1, 2 1 Less than 7th grade
3 Completed 3,4 1 Less than 7th grade
4 Completed 5, 6 1 L635 than 7th grade
5 Completed 7 2 Junior high school (9th grade)
6 Completed 8 2 Junior high school (9th grade)
7 Completed 9-11 3 Partial high school (10"‘/11"‘)
8 Completed 12 4 High 5011001 graduate
High school High school graduate
9 equivalence 4
10 Partial College 5 Partial college or special training
Associates/ Tech Partial college or special training
11 degree 5
Standard college or University
12 College graduation 6 graduation
13 Graduate 7 Graduate professional training
14 Completed graduate 7 Graduate professional training

There was one case (IDNUM 854) that did not have an education level or an
occupation indicated. For this data point, education level was assigned based on the
income of $19,000 which was the only income reported by the respondent. Her income
was compared to the government report from 2001 which indicated that the income
expectation for people who completed some high school was about $19,000 annually
(Pearson Education Inc., 2007). Further, she was assigned a service related occupational
code based on her imputed level of education. The fact that she was a 38 year old mother
with a history of alcohol abuse and dependence who had three children between the ages
of 12 and 15 years added support to the decisions made. She was fitted into Hollingshead
Code 2, Unskilled workers occupation category (Hollingshead, 1975) (Table 4).

There were 55 respondents who did not have an occupation listed in the

NESARC. Personal or household incomes (for those women without personal income)

44

and education were used to determine the occupational code. Personal incomes and
educational levels were compared to a 2001 government report of education and income
expectations for various occupations and the corresponding Hollingshead occupational
code was assigned (Appendix D) (Pearson Education Inc., 2007).

The final step was to calculate the socioeconomic status by multiplying the
occupation by a weight of 5 and the education level by a weight of 3 then summing the
result (See Chapter 2, p. 13 to review discussion on factor weighting) (Hollingshead,
1975, p.15). This score then was compared to the Hollingshead chart of socioeconomic
status (Table 6). Each person was assigned a 1, 2, 3, 4, or 5 with 1 being the highest
socioeconomic status and 5 being the lowest socioeconomic status.

Table 6 Hollingshead Socioeconomic coding system with range of scores

 

Social Strata Code Key Range of computed scores
1. Major Business and professional 66-55
2. Medium business, minor professional, technical 54-40
3. Skilled craftsmen, clerical, sales workers 39-30
4. Machine operators, semiskilled workers 29-20
5. Unskilled laborers, menial service workers 19- 8
Final dataset

Table 7 is the final dataset with sample sizes per category of participation used for
the analyses.

Table 7 Final dataset for analyses: Sample sizes per category of participation
Participation in 12-step

 

group support
Demographics Yes No Total
Sample 432 143 575
Age
-35 (18-34) 124 50 174
+35 (35-49) 308 93 401
Ethnoracial
White 283 94 377
Other than white 149 49 198

45

Table 7 (cont’d).
Non Hispanic Black
Hispanic
Native American Indian/Alaskan
Inuit
Asian/Pacific Islander
Relationship
Married/LTP
Previously marriage
Divorced
Widowed
Separated
Never
Children
Children Absent
Children Present
Education
Less high school
High school or equiv
Some college
2 yr degree
4 yr degree
Graduate school
Personal Income
No personal income
$1 -$24,999
$25,000-$54,999
Social strata

Maj or business/Prof
Medium business, Minor
professional, technical

Skilled crafts, clerical, sales worker
Machine operators, semi-skilled

workers
Unskilled, laborer, menial service
workers
Alcohol
Diagnosis
None
Yes

Abuse or Dependence

(67)
(50)

(25)
(7)

142
183
(114)
(36)
(33)
107

255
177

69
120
124

47

34

38

19
286
127

122

87
33

74
116
17

415
(121)

46

(16)
(25)

(6)
(2)

59
43
(35)
(5)
(3)
41

82
61

20
44
43
10
14
12

76
62

39

35
13

20
36
11

132
(55)

(83)
(75)

(31)
(9)

201
226
(149)
(41)
(36)
148

337
238

89
164
167

57

48

50

24
362
189

161

122
46

94
152
28

547
(176)

Table 7 (cont’d).

Abuse/Dependence (294) (77) (371)
Comorbid Psychopathology
None 174 56 230
Major Depressive Disorder 126 54 180
Generalized Anxiety Disorder 9 2 11
Major Depressive Disorder &
Generalized Anxiety Disorder 39 12 51
Conduct Disorder 3 2 5
Conduct Disorder with Major
Depressive Disorder 1 2 3
Antisocial Personality Disorder 80 15 95
Antisocial Personality Disorder (16) (7) (23)
Antisocial Personality Disorder with
Major Depressive Disorder (40) (5) (45)
Antisocial Personality Disorder with
Generalized Anxiety Disorder (3) (0) (3)

Antisocial Personality Disorder with
Major Depressive Disorder and
Generalized Anxiety Disorder (21) (3) (24)
Numbers in parentheses ( ) are related to the preceding aggregate level of that variable

47

CHAPTER IV
PRESENTATION OF THE RESULTS OF THE ANALYSIS
Introduction

Chapter IV presents the outcomes of the analyses. These outcomes are presented

in the same order as the research questions.
Research Question One

Does alcohol diagnosis affect women ’s participation in 12-step support group programs?

Women with an alcohol diagnosis when compared to those women without a
diagnosis are 2.6 (CI 1.163, 5.578) times more likely to attend a 12-step group support
when compared to those women without a diagnosis. The Wald x2 of 5.460 is significant
(p=.019) meaning that having an alcohol diagnosis is an important factor in women’s
participation in l2-step group support (Table 8).

Table 8 Results of the analysis of alcohol diagnosis to 12-step group support
12-step 13 SE Wald x2 P = Exp (B) CI

Dx .935 .400 5.460 .019 2.547 1.163, 5.578
N=575 -2Log likelihood=639.878 Model x2 =5.154 P =.023
Dx= alcohol diagnosis
12-step= 12-step group support

 

Women with a history of the more severe alcohol abuse and dependence
diagnoses are 3.8 (C12.971, 4.907) times as likely to go to 12-step group meetings when
compared to women without the more severe alcohol diagnosis. The Wald x2 of 109.539
is significant (p=.000) meaning that having the more severe alcohol abuse and
dependence diagnosis in an important factor in women’s participation in 12-step group

support (Table 9).

48

Table 9 Results of the analysis alcohol abuse or dependence and abuse and dependence to
12-step group support
12-step group support

 

Relationship to Exp

12 -step 13 SE Wald x2 P= ([3) CI
Single .788 .163 23.507 .000 2.200 1.600, 3.026
Dual 1.340 .128 109.529 0.000 3.818 2.971, 4.907

-2 Log Likelihood 636.370 Model )6 =160.750 P= 0.000
Single= Alcohol abuse or dependence Dual= Abuse and dependence

Research Question Two
Does comorbid psychopathology mediate the relationship between alcoholism diagnosis
and women ’s participation in 12—step support group programs?

In these data, the presence of a comorbid psychopathology did not mediate the
relationship between having an alcohol disorder and going to 12-step group support. In
fact it had no impact at all. Without the comorbid psychopathology in the model,
women are 2.6 times (CI 1.163, 5.578) more likely to attend ’12-step group support when
compared to those women without a diagnosis (Table 8, p. 48). With comorbid
psychopathology in the model, women are still 2.6 times (CI 1.179, 5.708) more likely to
attend 12-step group support when compared to those women without a diagnosis.
Further, adding comorbid psychopathology did not change the model. The -2log
likelihood went from 639.878 (Model )8 5.154) without comorbid psychopathology to
639.674 (Model 38 5.358) with comorbid psychopathology (Table 10).

Table 10 Direct effects of alcohol diagnosis and 12-step mediated by Comorbid

 

Psychopathology
Relationship to Wald Exp
12-step 13 SE 11’ P (p) or
Dx 0.953 .402 5.614 0.018 2.594 1.179, 5.708
CMP -0.09 .200 0.203 0.652 0.914 .618, 1.352
-2 Log Likelihood 639.674 Model x2 5.358 P= 0.069
Dx= Alcohol diagnosis CMP= Comorbid psychopathology

49

The next step analyzed the mediating relationships between each
psychopathology of interest as it related to alcohol diagnosis and 12-step group support.
None of the psychopathologies mediated the relationship between alcohol diagnosis and
12-step group support. Women with an alcohol diagnosis when considering comorbid
psychopathologies in the model are 2.7 times (CI 2.028, 3.488) more likely to attend 12-
step group support (Table 11). Women with an alcohol diagnosis when not considering
comorbid psychopathology in the model are 2.6 times (CI 1.163, 5.578) more likely to go
to 12-step group support (Table 8, p.48). Women diagnosed with Major Depressive
Disorder were 1.5 times more likely to attend 12—step group support when considering
alcohol diagnosis and other comorbid psychopathologies (Table 11). No other
psychopathologies in this model were significant. The moderating impact of Major
Depressive Disorder was non-existent. Women with an alcohol diagnosis with or without
comorbid psychopathology considered were 2.6 times more likely to go to 12-step group
support.

Table 11 Direct effects of alcohol diagnosis and 12-step group support mediated MDD,
MDD/GAD, ASPD, ASPD/MDD and ASPD/GAD/MDD

 

Relationship Wald Exp

to 12-step [3 SE x2 P (I3) CI

Dx .978 .138 49.961 .000 2.659 2.028,3.488
MDD .381 .222 2.958 .085 1.464 .948. 2.260
MDD/GAD .384 .365 1.106 .293 1.469 .718, 3.005
ASPD . .636 .568 1.254 .263 1.888 .621,5.742
ASPD/MDD .463 .396 1.367 .242 1.589 .731,2.455
ASPD/GAD/MDD -.424 .444 .914 .339 .654 .274,1.561

—2 Log Likelihood 633.366 Modelx2163.753 P= 0.000

Dx= Alcohol Diagnosis 12-step=12-step Group Support

MDD = Major Depressive Disorder

MDD/GAD = Major Depressive Disorder and Generalized Anxiety Disorder

ASPD= Antisocial Personality Disorder

ASPD/MDD= Antisocial Personality Disorder with Major Depressive Disorder
ASPD/MDD/GAD= Antisocial Personality Disorder with Major Depressive Disorder and
Generalized Anxiety Disorder

50

The mediating relationship between each psychopathology of interest as it related
to a diagnosis of both alcohol abuse and dependence and 12-step group support was
analyzed. In these data, the presence of a comorbid psychopathology did not mediate the
relationship between having the more severe alcohol abuse and dependence and going to
12-step group support. As with the aggregate alcohol diagnosis, comorbid
psychopathology had no impact at all. Without the comorbid psychopathology in the
model, women with the more severe alcohol abuse and dependence are 3.8 times (CI
2.971, 4.907) more likely to attend 12-step group support when compared to those
women without the more severe diagnosis. The Wald x2 of 109.529 was significant
(P=.000) making this relationship important to the model (Table 9, p.49). With comorbid
psychopathology in the model, women are 4.3 times (CI 2.925, 6.207) more likely to
attend 12-step group support when compared to those women without the more severe
alcohol diagnosis. Adding comorbid psychopathology did not change the relationship
between the more severe alcohol diagnosis and 12-step group support. The Wald x2 of
57.024 was significant (P=.000) but was not appreciably changed fi'om the model without
comorbid psychopathology (Table 12).

Table 12 Direct effects of Alcohol Abuse and Dependence and 12-step mediated by
Comorbid Psychopathology

 

Relationship to Wald Exp

12-step [3 SE 12 P (B) CI

Single .847 .186 21.287 .000 2.256 1.637, 3.391

Dual 1.449 .192 57.024 .000 4.261 2.925, 6.207

CMP -.156 .201 .605 .437 .855 .577, 1.268
-2 Log Likelihood 635.761 Model )8 161.358 P= 0.000

Single= Alcohol abuse or dependence
Table 12 (cont’d).

Dual= Alcohol abuse and dependence
CMP= Comorbid psychopathology

51

None of the psychopathologies mediated the relationship between the more severe
alcohol abuse and dependence and 12-step group support. However, women with Major
Depressive Disorder were 1.5 times (CI .993, 2.356) more likely to participate in 12-step
group support when considering alcohol diagnoses and comorbid psychopathologies
(Table 13). Women with the more severe alcohol abuse and alcohol dependence were
3.4 times (CI 2.498, 4.669) more likely to attend 12-step group support when considering
comorbid psychopathologies. The outcome of comorbid psychopathology does not
mediate the relationship between alcohol disorders and 12-step group support. The
change in the relationship between the two levels of diagnosis and 12-step group support
has more to do with the disaggregation of the disorder and not the impact of the
psychopathologies.

Table 13 Direct effects of alcohol abuse or dependence, alcohol abuse and dependence

and 12-step group support mediated by first MDD, then MDD/GAD, ASPD,
ASPD/MDD and ASPD/GAD/MDD

 

Relationship Wald Exp

to l2-step 0 SE 91’ P (13) CI

Single .628 .193 10.631 .001 1.875 1.285, 2.735
Dual 1.228 .159 59.308 .000 3.415 2.498, 4.669
MDD .425 .220 3.716 .054 1.530 .993, 2.356
MDD/GAD .396 .366 1.169 .280 1.486 .725, 3.045
ASPD -.282 .289 .947 .331 .755 .428,1.331
ASPD/MDD .444 .399 1.238 .266 1.558 .713, 3.404
ASPD/GAD/MDD -.483 .447 1.168 .280 .617 .257,1.481

—2 Log Likelihood 628.618 Modelx2168.502 P= 0.000

Single= Alcohol abuse or dependence

Dual= Both alcohol abuse and alcohol dependence

12-step= 12-step Group Support MDD = Major Depressive Disorder
MDD/GAD = Major Depressive Disorder and Generalized Anxiety Disorder

ASPD= Antisocial Personality Disorder

ASPD/MDD= Antisocial Personality Disorder with Maj or Depressive Disorder,
ASPD/MDD/GAD= Antisocial Personality Disorder with Major Depressive Disorder and
Generalized Anxiety Disorder '

52

Research Question Three
Do key demographic variables moderate alcoholic women’s participation in 12—step
support group programs?

The first hypothesis tested under question three stated that women who were
manied, age 35 years or older, who were white with at least a high school or better
education would moderate the relationship between alcohol diagnosis and 12-step group
support.

This cluster of demographic variables did not moderate the relationship between
alcohol diagnosis and 12-step group support. Without the demographic variables in the
model, women are 2.6 times (CI 1.163, 5.578) more likely to go to 12-step group support
than those without a diagnosis (Table 8, p. 48). With this demographic cluster women
are 2.7 times (CI 1.386, 5.241) more likely to go to 12-step group support than those
without a diagnosis (Table 12). Further, only women who were married were 40% less
likely to report attending 12-step group support (Table 14).

Table 14 Demographic Cluster 1 moderating the relationship between alcohol diagnosis
(Dx) and 12-step group support (12-step)

 

Relationship to Wald Exp

12-step 13 SE 71’ P (13) c1

Dx .991 .404 6.009 .014 2.695 1.386. 5.241

White .055 .210 .070 7.92 1.057 .749,1.492

Age 35+ .303 .208 2.121 .145 1.353 .962,1.905

HS orbetter -.141 .282 .248 .618 .869 .546,1.382

Married -.361 .201 3.225 .073 .697 .501, .970
-2 Log Likelihood 634.036 Model 71’ 10.996 P= 0.051

White= Ethnoracial group white, Age35+= at least age 35 years or older, HS or higher =
High school education, its equivalent or more education, Married: the relationship status
is married or like married

The second hypothesis tested under question three stated that being other-than-

white, under the age of 35 years with less than a high school education and being

53

previously married would moderate the relationship between alcohol diagnosis and 12-
step group support. The only characteristic in Demographic Cluster 2 that significantly
moderated the relationship between alcohol diagnosis and 12-step group support are
those women who are previously married who are 1.7 times (CI 1.195, 2.464) more likely
to go to 12-step group support than women not previously married (Table 15).

Table 15 Demographic Cluster 2 moderating the relationship between alcohol diagnosis
(Dx) and 12-step group support (12-step)

 

Relationship to Wald Exp
12-step 13 SE 71’ P ([3) CI
Dx 1.056 .408 6.714 .010 2.876 1.471,5.623
Previouslymarried .540 .220 6.015 .014 1.716 1.195, 2.464
UnderAge 35 .146 .218 .449 .503 1.157 .808,1.657
Other-than-white .008 .210 .001 .969 1.008 .714,1.424
Lessthan HS -.158 .283 .311 .577 .854 .536,1.361
-2 Log Likelihood 631.031 Modelx214.001 P= 0.016

Previously married= could be separated, widowed or divorced,

Under age 35 years: could be ages 18 to 34 years of age, _
Other-than-white= Black, Hispanic, Native American Indian, Alaskan Inuit, Pacific
Islander, Asian

Less than HS= Did not complete high school or high school equivalent

The third hypothesis tested under question three stated that women who are
married, age 35 years or older, who are white with at least a high school or better
education will moderate the relationship between the more severe alcohol abuse and
dependence diagnosis and 12-step group support. Women who were 35 years of age of
older are 1.5 times (CI 1.012, 2.196) more likely to go to 12-step group support than
younger women. Women who are married were 40% less likely to go to 12-step group
support when compared to those women who are not married. In this demographic
cluster, women with severe alcohol abuse and dependence are 3.4 times (C12.014, 5.631)
more likely to go to 12-step group support than those without the more severe alcohol

disorder (Table 16).

54

Table 16 Demographic Cluster 1 moderating the relationship between alcohol diagnosis
(Dx) and 12-step group support (12-step)

 

Relationship to Wald Exp
12-step 13 SE 712 P (B) CI
Single .616 .284 4.695 .030 1.852 1.061, 3.234
Dual 1.214 .262 21.431 .000 3.368 2.014, 5.631
White .071 .205 .121 .728 1.074 .719, 1.603
Age 35+ .399 .198 4.083 .043 1.491 1.012, 2.196
HS or better -.047 .252 .034 .854 .955 .582, 1.565
Married -.361 .202 3.193 .074 .697 .469, 1.036
-2 Log Likelihood 629.065 Model x2 168.054 P= 0.000

Single= Having one alcohol diagnosis, either abuse or dependence

Dual = Having both alcohol abuse and alcohol dependence over the life span
White= Ethnoracial group white

Age35+= at least age 35 years or older

HS or higher = High school education, its equivalent or more education
Married: the relationship status is married or like married

The fourth hypothesis tested under question three stated that being other-than-
white, under the age of 35 years with less than a high school education and being
previously married will moderate the relationship between the more severe alcohol abuse
and dependence diagnosis and 12-step group support. Women who are previously
married are 1.7 times (CI 1.203, 2.497) more likely to go 12-step group support and
women with the more severe alcohol abuse and dependence disorder are 3.5 times (CI
1.773, 6.982) more likely to attend 12-step group support than those with lesser alcohol
problems (Table 17).

Table 17 Demographic Cluster 2 moderating the relationship between more severe
alcohol diagnosis (Dual) and 12-step group support (12-step)

 

Relationship to 12- Wald Exp

step 13 SE 12 P ([3) CI
Single .580 .211 7.565 .006 1.787 1.182. 2.702
Dual 1.175 .185 40.230 .000 3.238 2.252, 4.655
Other-than-white .028 .208 .018 .893 1.028 .684, 1.546
Under Age 35 -.162 .215 .570 .450 .850 .558, 1.296
Less than HS .162 .284 .327 .568 1.176 .674, 2.051

Previously married .567 .210 7.295 .007 1.762 1.168, 2.658
-2 Log Likelihood 625.938 Model 12 171.182 P= 0.000
Single= Having one alcohol diagnosis, either abuse or dependence

55

Table 17 (cont’d).

Dual = Having both alcohol abuse and alcohol dependence over the life span
Previously married= could be separated, widowed or divorced

Under age 35 years= could be ages 18 to 34 years of age

Other-than-white= Black, Hispanic, Native American Indian, Alaskan Inuit, Pacific
Islander, Asian

Less than HS= Did not complete high school or high school equivalent

The fifth set of hypotheses tested under question three focus on the
socioeconomic status of the women in the data. Table 18 recalls the socioeconomic
coding system used based on the Hollingshead scale discussed in Chapter III. In the data
there are 161 women in the 1. Major Business or Professional category. There are 122
women in the 2. Medium Business, Minor Professional and Technical category. There
are 46 women in the 3. Skilled Craftsmen, Clerical, Sales Workers category and 94
women in the 4. Machine Operators, Semiskilled Workers category. There are 152
women in the 5. Unskilled Laborers, Menial Service Workers category.

Table 18 Hollingshead Socioeconomic categories (SES categories) with range of scores

 

Social Strata Category Range of computed scores
1. Major Business and professional 66-55
2. Medium business, minor professional, technical 54-40
3. Skilled craftsmen, clerical, sales workers 39-30
4. Machine operators, semiskilled workers 29-20
5. Unskilled laborers, menial service workers 19- 8

Women in the upper socioeconomic categories, (1) Major Business and
Professional and (2) Medium Business, Minor Professional, Technical Workers did not
moderate the relationship between alcohol diagnosis and 12-step group support. Further,
being in the upper two socioeconomic categories did not influence whether or not women
went to 12-step group support at all (Table 19). Women with an alcohol diagnosis, when
not considering socioeconomic status are 2.6 times (CI 1.163, 5.578) more likely to go to

12-step group support (Table 8, p.48). This is the same results when socioeconomic

56

status is added to the model; i.e. women are 2.6 times (CI 1.330, 4.971) more likely to go
to l2-step group support.

Table 19 Alcohol diagnosis with Hollingshead SES Categories 1 and 2

 

Relationship Wald Exp

to 12-step B SE 712 P (13) CI

Dx .945 .401 5.556 .018 2.572 1.330, 4.971
SES Category 1 -.031 .231 .018 .893 .969 .663, 1.418
SES Category 2 -.273 .244 1.248 .264 .761 .509, 1.138

-2 Log Likelihood 638.587 Model )8 6.445 P= 0.092
Dx=Alcohol Diagnosis
SES Categoryl= Major Business and Professional
SES Category2= Medium Business, Minor Professional, Technical Workers

Women in the lower socioeconomic categories, (4) Machine operators,
semiskilled workers and (5) Unskilled laborers, menial service workers did not moderate
the relationship between alcohol diagnosis and 12-step group support. Further, being in
the lower socioeconomic categories did not influence whether or not women went to 12-
step group support (Table 20).

Table 20 Alcohol diagnosis with Hollingshead SES Categories 4 and 5

 

Relationship Wald Exp

to 12-step 13 SE x" P (B) CI

Dx .945 .401 5.551 .018 2.572 1.330, 4.975
SES Category 1 .288 .283 1.038 .308 1.334 .838, 2.123
SES Category 2 .167 .230 .531 .466 1.182 .810, 1.725

-2 Log Likelihood 638.574 Model 712 6.458 P= 0.091
Dx=Alcohol Diagnosis
SES Category4= Machine operators, semiskilled workers
SES Category5= Unskilled laborers, menial service workers
Women in the middle socioeconomic category, (3) Skilled craftsmen, clerical,
sales workers did not moderate the relationship between alcohol diagnosis and 12-step

group support. Further, being in the middle socioeconomic category did not influence

whether or not women went to 12-step group support (Table 21).

57

Table 21 Alcohol diagnosis with Hollingshead SES Category 3

 

Relationship Wald Exp

to 12-step [3 SE 11’ P (13) CI

Dx .946 .401 5.574 .018 2.574 1.332, 4.975
SES Category 3 -.222 .344 .416 .519 1.334 .455, 1.411

-2 Log Likelihood 639.473 Model 71’ 5.559 P= 0.062

Dx=Alcohol Diagnosis
SES Category3= Skilled craftsmen, clerical, sales workers

Now, looking at the more severe alcohol abuse and dependence disorder, women
in the upper socioeconomic categories did not moderate the relationship between the
more severe alcohol abuse and dependence and 12-step group support. Further, being in
the upper two socioeconomic categories did not influence whether or not women went to
12-step group support (Table 22). Women with alcohol abuse and dependence, when
considering the two upper socioeconomic categories, are 3.8 times (CI 2.971, 4.907)
more likely to go to 12-step group support. However, when not considering the upper

two socioeconomic categories, women with severe alcohol abuse and dependence

disorders are still 3.1 times (CI 1.562, 5.975) more likely to go to 12-step group support

 

(Table 9, p.49).

Table 22 Two levels of alcohol diagnosis with Hollingshead SES Categories 1 and 2
Relationship Wald Exp
to 12-step 13 SE x2 P ((3) CI
Single .614 .421 2.130 .144 1.849 .925, 3.695
Dual 1.123 .408 7.558 .006 3.074 1.570, 6.018
SES Category 1 —.011 .232 .002 .963 .989 .675, 1.450
SES Category 2 -.246 .246 .998 .318 .782 .522, 1.172

-2 Log Likelihood 632.701 Model 71’ 12.332 P= .015
Single=Alcohol abuse or dependence
Dual=Alcohol abuse and dependence
SES Category1= Major Business and Professional
SES Category2= Medium Business, Minor Professional, Technical Workers

Women in the lower socioeconomic categories did not moderate the relationship

between alcohol abuse and dependence and 12-step group support. Further, being in the

58

lower socioeconomic categories did not influence whether or not women went to 12-step
group support. Women with both an alcohol abuse and dependence disorder were 3.1 (CI
1.569, 6.020) times more likely to go to 12-step group support when considering the two
lowest socioeconomic categories (Table 23), but this is no different than the outcome
when not considering socioeconomic status.

Table 23 Two levels of alcohol diagnosis with Hollingshead SES Categories 4 and 5

 

Relationship Wald Exp

to 12-step 13 SE 212 P (13) CI

Single .608 .422 2.077 .140 1.837 .918, 3.676

Dual 1.123 .409 7.551 .006 3.074 1.569, 6.020

SES Category 4 .297 .284 1.096 .295 1.346 .844, 2.148

SES Category 5 .127 .231 .300 .584 1.135 .776, 1.661
-2 Log Likelihood 632.561 Model 11’ 12.471 P= .014

Single= Alcohol abuse or dependence
Dual= Alcohol abuse and dependence
SES Category4= Machine operators, semiskilled workers
SES Category5= Unskilled laborers, menial service workers

Women in the middle socioeconomic category, (3) Skilled craftsmen, clerical,
sales workers did not moderate the relationship between alcohol diagnosis and 12-step
group support. Further, being in the middle socioeconomic category did not influence

whether or not women went to 12-step group support (Table 24).

Table 24 Two levels of alcohol diagnosis with Hollingshead SES Category 3

 

Relationship Wald Exp

to 12-step [3 SE 12 P ([3) CI

Single .610 .421 2.105 .147 1.841 .922, 3.678
Dual 1.129 .408 7.633 .006 3.091 1.579, 6.052
SES Category 3 -.231 .346 .446 .504 .794 .449, 1.402

-2 Log Likelihood 633.342 Model 212 11.690 P= 0.009
Single=Alcohol abuse or dependence
Dual= Alcohol abuse and dependence
SES Category3= Skilled craftsmen, clerical, sales workers

The sixth set of hypotheses tested under question three focus on women with

children 17 years or under present or absent in the home. Women with children under 17

59

years in the home did not moderate the relationship between alcohol diagnosis and 12-
step group support (Table 25). The inverse was also true. Women with children absent

from the home are were not significantly more likely to attend 12-step group support

 

(Table 25).
Table 25 Alcohol diagnosis and women with one, two or three children compared to 12-
step group support
Relationship Wald Exp
to 12-step 13 SE 212 P (B) CI
Dx .939 .400 5.500 .019 2.557 1.324, 4.938
Women w/children -.079 .196 .163 .686 .924 .669, 1.276
-2 Log Likelihood 638.929 Model 71’ 6.103 P= 0.192
Dx .939 .400 5.500 .019 2.557 1.324, 4.938
Women w/o child -.079 .196 .163 .686 .924 .669, 1.276

Dx=Alcohol Diagnosis
Women w/children= women with one or more 17 or under children in the home
Women w/child= women without any children 17 or under in the home
Posthoc analyses

There were additional analyses that were conducted as a result of the outcomes of
the analyses corresponding to research questions two and three that were not anticipated
by the original design.
Posthoc comorbid psychopathology analyses

The original hypotheses expected that comorbid psychopathologies would
mediate the relationship between alcohol diagnosis and 12-step group support. However,
the outcome of the analyses found that at the aggregate level, comorbid psychopathology
had no mediating influence on the relationship between alcohol diagnosis and 12-step
group support. When comorbid psychopathology was disaggregated the main effects of
having a Major Depressive Disorder moderated the relationship between alcohol
diagnosis and 12-step group support was the only disorder that was significant (Table 11,
p. 50).

60

In retrospect, the decision to disaggregate ASPD into ASPD with one of the other
mood or anxiety disorders or both was not reasonable. ASPD is a lifetime diagnosis and
by definition the most severe of the disorders studied. Looking at ASPD by itself
regardless of the co-occurrence of other pathologies was more appropriate. Women with
ASPD were 1.8 times (CI 1.118, 3.013) more likely to attend 12-step group support when
considering alcohol diagnosis (Table 26). Further, there is a significant interaction
between alcohol diagnosis and ASPD in women. The result is that women with both an
alcohol diagnosis and ASPD are 1.9 times (CI 1.185, 3.175) more likely to report going
to 12-step group support than those without an alcohol diagnosis or ASPD together
(Table 26).

Table 26 Posthoc analysis of alcohol diagnosis, antisocial personality and 12-step group
support main effects and interaction effects

 

Relationship Wald Exp

to lZ-step [3 SE 712 P (13) c1

Dx .843 .402 4.896 .036 2.324 1.200, 4.502
ASPD .607 .301 4.066 .044 1.836 1.118, 3.013

-2 Log Likelihood 635.396 Model )8 9.636 P= 0.008
Dx*ASPD .662 .300 4.885 .027 1.939 1.185, 3.175

-2 Log Likelihood 639.589 Model x2 5.443 P= 0.020
Dx= Alcohol Diagnosis ASPD= Antisocial Personality Disorder
Dx*ASPD = interaction between alcohol diagnosis and Antisocial Personality Disorder

In a model with the more severe alcohol abuse and dependence disorders, women

with ASPD are 2.065 times (CI 1.138, 3.745) more likely to report going to 12-step group
support than those without this disorder. There is also a significant interaction between
alcohol abuse and dependence diagnosis and ASPD in women. They are 6.273 times (CI

3.320, 11.852) more likely to report going to 12-step group support than those without an

alcohol diagnosis or ASPD together (Table 27).

61

Table 27 Posthoc analysis of levels of alcohol diagnosis, antisocial personality and 12-
step group support with main effects and interaction effects

 

Relationship Wald Exp

to 12-step (3 SE )6 P ([3) CI

Dual 1.209 .136 78.810 .000 3.350 2.565,4.375

ASPD .725 .304 5.694 .017 2.065 1.138,3.745
-2 Log Likelihood 655.421 Model 12141698 P= 0.000

Dual*ASPD 1.836 .325 31.989 .000 6.273 332011852

-2 Log Likelihood 750.280 Model )8 446.840 P= 0.000
Dual= Alcohol abuse and dependence, ASPD= Antisocial Personality Disorder,
Dual*ASPD = interaction between alcohol diagnosis and Antisocial Personality Disorder

Posthoc demographic analyses

Relationship Status. The original hypothesis expected that a collection of
demographic variables (Ethnoracial group, Age, Education and Relationship status)
would moderate the relationship between alcohol diagnosis and 12-step group support.
The results of the main of effects of Demographic Cluster 2 showed that only one that the
variable for previously married is significant which included widowed, divorced and
separated (Table 14, P. 54).

Women who are previously married and who had an alcohol diagnosis are 4.7
times (CI 3.298, 6.706) more likely to go to 12-step group support than those who are not
previously married and who do not have an alcohol diagnosis (Table 28).

Table 28 Posthoc analysis of alcohol diagnosis, previously married and 12-step group

 

support
Relationship Wald Exp
to 12-step 13 SE 912 P (B) or
Dx*Previously
Married 1.548 .181 73.129 .000 4.703 3.298. 6.706

-2 Log Likelihood 700.536 Model 712 96.583 P= 0.000
Dx*Previously = interaction between alcohol diagnosis and previously married

Previously married could mean that the women are divorced, separated or
widowed. Women with an alcohol diagnosis and who are separated are 11 times (CI
3.374, 35.866) more likely to go to 12-step group support than those who are not

62

previously married. Women who are widowed are 8 times (CI 2.829, 22.621) more likely
to go to 12—step group support and women who are divorced are 3.6 times (CI 2.426,
5.443) more likely to go to 12-step group support. By far, women who are separated who
have an alcohol diagnosis are more likely to go to 12-step group support (Table 29).

Table 29 Posthoc analysis of alcohol diagnosis, by levels of previously married and 12-

 

step group support
Relationship Exp
to 12-step 13 SE Wald )8 P ([3) CI
Dx*Div 1.290 .206 39.157 .000 3.633 2.426, 5.443
Dx*Sep 2.398 .603 15.812 .000 11.000 3.374, 35.866
Dx*Wid 2.079 .530 15.374 .000 8.00 2.829, 22.621

-2 Log Likelihood 700.536 Model 71’ 96.583 P= 0.000

Dx*Div = interaction between alcohol diagnosis and divorced
Dx*Sep = interaction between alcohol diagnosis and separated
Dx*Wid =interaction between alcohol diagnosis and widowed

Women who have the more severe alcohol abuse and dependence disorder who
are previously married are 6.7 times (CI 4.097, 11.029) more likely than those without a
diagnosis or who have only a single diagnosis to go to 12-step group support (Table 30).
Further, women who have both an alcohol abuse and dependence diagnosis who are
separated are 25 times (CI 3.388, 1.84.501) more likely to go to 12-step group support
than any other relationship group with or without a diagnosis (Table 31). However,

women who have only a single diagnosis of either abuse or dependence and who are

divorced, separated or widowed still have a high probability of going to a 12-step group

 

(Table 32).
Table 30 Posthoc analysis of alcohol abuse and dependence, previously married and 12-
step group support

Relationship Wald Exp

to 12-step 13 SE 12 P ([3) CI

Dual*Previously

Married 1.905 .2.53 56.888 .000 6.722 4.097, 11.029

-2 Log Likelihood 711.573 Model )6 85.546 P= 0.000

63

Table 30 (cont’d).
Dual*Previously = interaction between alcohol abuse and dependence and previously

married

Table 31 Posthoc analysis of alcohol abuse and dependence, by levels of previously
married and l2-step group support

 

Relationship Wald Exp

to l2-step [3 SE x2 P (13) CI

Dual*Div 1.484 .269 30.532 .000 4.412 2.606, 7.469
Dual*Sep 3.219 1.020 9.963 .002 25.000 3.388, 184.501
Dual*Wid 21.203 8770.825 .00 .998 .00 .00

-2 Log Likelihood 700.958 Model )8 96.161 P= 0.000
Dual*Div = interaction between alcohol abuse and dependence and divorced
Dual*Sep = interaction between alcohol abuse and dependence and separated
Dual*Wid =interaction between alcohol abuse and dependence and widowed

Table 32 Posthoc analysis of alcohol abuse or dependence, by levels of previously
married and 12-step group support

 

Relationship Wald Exp

to 12-step 1) SE x2 P ([3) CI

Single*Div .961 .326 8.692 .003 3.615 1.380, 4.956
Single*Sep 1.386 .791 3.075 .080 4.000 .849, 18.836
Single*Wid 1.012 .584 3.002 .083 2.750 .876. 8.636

-2 Log Likelihood 780.144 Model 3816.975 P= 0.001

Single*Div = interaction between alcohol abuse or dependence and divorced
Single*Sep = interaction between alcohol abuse or dependence and separated
Single*Wid =interaction between alcohol abuse or dependence and widowed

Because of the impact of ASPD on the relationship between alcohol diagnosis and
12-step group support and the impact of being separated on this same relationship, ASPD
and being separated were included in the same model with more severe alcohol disorders.
Women with both alcohol abuse and dependence who have ASPD were 5.7 times (2.990,
10.770) more likely to go to 12-step group support in comparison to women with the
more severe diagnosis who do not have ASPD when considering the interaction between

being separated and having a severe alcohol disorder (Table 33). When considering the

interaction between severe alcohol disorder and ASPD, women who have an alcohol

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disorder and are separated are 19.3 times (€12.590, 143.632) more likely to go to 12-step

group support.

Table 33 Posthoc analysis of alcohol abuse and dependence, being separated or having
ASPD and 12-step group support

 

Relationship Wald Exp

to 12-step 13 SE 12 P (I3) CI
Dual*ASPD 1.736 .327 28.200 .000 5.675 2.990, 10.770
Dual*Sep 2.959 1.024 8.345 .004 19.286 2.590, 43.632

2 Log Likelihood 729.732 Model {67.387 P= 0.000
Dual*ASPD = interaction between alcohol abuse and dependence and Antisocial
Personality Disorder
Dual*Sep = interaction between alcohol abuse and dependence and separated

Socioeconomic Status. A posthoc analysis of the interaction between alcohol

diagnosis and socioeconomic status was conducted. Women with an alcohol diagnosis in
every socioeconomic category with the exception of those women who were in category
3) Skilled craftsmen, clerical and sales workers were significantly more likely to attend
12-step group support than those without a diagnosis. However, Category 3 has a very
small cell count of 46 women which contributed to its low Wald )6. Category 4)
Machine operators, semiskilled workers are the second smallest cell with 94 women. The
women in Category 4 who have an alcohol disorder are 3.2 times (CI 1.481, 6.915) more
likely to attend a 12-step group in a model with all levels or socioeconomic status (Table

34). This is higher than women with an alcohol diagnosis when not considering

socioeconomic status (Table 8, p.48).

65

Table 34 Interactions between different SES categories and alcohol diagnosis compared
to 12-step group support

 

Relationship Wald Exp

to 12-step 13 SE 71’ P (13) CI

Dx“ SES Category 1 .920 .431 4.555 .033 2.508 1.235, 5.095
Dx* SES Category 2 .797 .440 3.278 .070 2.219 1.076, 4.579
Dx“ SES Category 3 .788 .513 2.358 .125 2.200 .945, 5.119
Dx“ SES Category 4 1.163 .468 6.165 .013 3.200 1.481, 6.915
Dx“ SES Category 5 .981 .435 5.079 .024 2.667 1.303, 5.456

-2 Log Likelihood 638.426 Model x2 6.606 P= 0.252

Dx=Alcohol Diagnosis
SES Category1= Major Business and Professional
SES Category2= Medium Business, Minor Professional, Technical Workers
SES Category3= Skilled craftsmen, clerical, sales workers
SES Category4= Machine operators, semiskilled workers
SES Category5= Unskilled laborers, menial service workers

The interaction between having the more severe alcohol abuse and dependence
with socioeconomic status was conducted. Women with both alcohol abuse and
dependence are significantly more likely to go to 12-step group support in every
socioeconomic category again with the exception of those women who were in category
3) Skilled craftsmen, clerical and sales workers were significantly more likely to attend
12-step group support than those without a diagnosis (Table 35). In Category 4 the
women with more severe alcohol abuse and dependence are 3 times (CI 1.525, 5.859)
more likely to attend a 12-step group support when considering socioeconomic status.
This outcome is slightly less than women with the more serious diagnosis only (Table 9,

p. 49).

Table 35 Interactions between different SES categories and alcohol abuse and
dependence compared to 12-step group support

 

Relationship [3 SE Wald P Exp

to 12-step x2 ([3) CI

Dual* SES Category 1 .600 .287 4.361 .037 1.822 1.136, 2.922
Dual“ SES Category 2 .490 .314 2.435 .119 1.632 .974, 2.734
Dual“ SES Category 3 .318 .437 .531 .466 1.375 .670, 2.821
Dua1* SES Category 4 1.095 .409 7.162 .007 2.989 1.525, 5.859
Dual* SES Category 5 .546 .279 3.822 .051 1.726 1.090, 2.732

66

Table 35 (cont’d).
-2 Log Likelihood 638.426 Model 71’ 6.606
Dual=Alcohol abuse and dependence diagnosis
SES Category]= Major Business and Professional
SES Category2= Medium Business, Minor Professional, Technical Workers
SES Category3= Skilled craftsmen, clerical, sales workers
SES Category4= Machine operators, semiskilled workers
SES Category5= Unskilled laborers, menial service workers

P= 0.252

Personal and household income analyses

The personal incomes reported in the sample were compared to the report of
household income. There were N=255 women who reported a household income
between $1 and $24,999. There were N=192 women who reported having a total
household income of $25,000 to $54,999. There were N=74 women who reported having
total household income of $55,000 to $84,999 and N=54 with household income $85,000
or above (Table 36).

Table 36 Personal Income compared to household income

 

N Personal Income Household Income

245 $1-$24,999 $1-$24,999
10 $0 $1-$24,999

70 $1-$24,999 $25,000-$54,999

7 $0 $25,000-$54,999

1 15 $25,000-$54,999 $25,000-$54,999

30 $ 1 -$24,999 $55,000-$84,999

2 $0 $55,000-$84,999

25 $25,000-$54,999 $55,000-$84,999

l4 $55,000-$ 84,999 $0
3 $55,000-$ 84,999 $0
17 $1-$24,999 $85,000+
5 $0 $85,000+
22 $25,000-$54,999 $85,000+
10 $85,000+ $0

Women with an alcohol diagnosis were unaffected in a model including the
household income. Women without considering household income were 2.6 times (CI

1.163, 5.578) more likely to participate in 12—step group support than those without a

67

diagnosis (Table 8, p 48). In this model, women were 2.6 times (CI 1.171, 5.692) (Table
37). There were no other significant relationships.

Table 37 Main Effects of Alcohol Diagnosis and household income in relationship to 12-
step group support

 

Relationship Exp

to 12-step [3 SE Wald x2 P ([3) CI

Dx .949 .403 5.533 .019 2.582 1.171, 5.692
HS] .445 .406 1.199 .273 1.561 .704, 3.461
HS2 .169 .416 .166 .684 1.184 .524, 2.2676
HS3 -.296 .459 .416 .519 .744 .303, 1.828
HS4 .069 .473 .021 .884 1.072 .424, 2.707

-2 Log Likelihood 633.325 Model 71’ 163.794 P= 0.000

Dx= Alcohol Diagnosis
HSl=Household income equal to $l-$24,999
HS2=Household income equal to $25,000-$54,999
HS3=Household income equal to $55,000-$84,999
HS4=Household income equal to $85,0000+

When considering only those women with the more severe alcohol abuse and
dependence diagnosis, they are 1.8 times (CI .998, 3.057) more likely to go to 12-step
group support when considering their household income. Those women in the lower
economic brackets (HSl and HS2) who have more severe alcohol disorders are 2.2 to 2.8

times (CI 1.180, 4.189 and 1.504, 5.115) more likely to go to 12-step group support.

Table 38 Main Effects of alcohol abuse and dependence diagnosis and household income
in relationship to 12-step group support

 

Relationship Exp

to l2-step [3 SE Wald x2 P (B) CI

Single -.078 .284 .076 .783 .925 .530, 1.615
Dual .557 .286 3.808 .051 1.746 .998, 3.057
HSl 1.020 .312 10.673 .001 2.774 1.504, 5.115
H32 .799 .323 6.112 .013 2.223 1.180, 4.189
HS3 .274 .375 .534 .465 1.315 .631, 2.742
HS4 .600 .394 2.322 .128 1.822 .842, 3.843

-2 Log Likelihood 633.325 Model 71’ 163.794 P= 0.000
Dx= Alcohol Diagnosis
HSl=Household income equal to $1-$24,999
HS2=Household income equal to $25,000-$54,999
HS3=Household income equal to $55,000-$84,999
HS4=Household income equal to $85,0000+

68

CHAPTER V
DISCUSSION
Introduction

There were three primary questions examined in this study.

1. Does alcohol diagnosis affect women’s participation in 12-step support group
programs?
2. Does comorbid psychopathology mediate the relationship between alcoholism

diagnosis and women’s participation in 12—step support group programs?
3. Do key demographic variables moderate alcoholic women’s participation in 12-
step support group programs?

In this chapter, an overview of the findings related to each of the key questions is
provided, consider reasonable interpretations of the findings, discuss several limitations
of the data, and consider policy implications. The key take home answer to the questions
raised is that women with more severe alcoholism are more likely to attend 12-step
programs. Moreover, evidence for mediating effects of co-morbid psychopathology was
not obtained and evidence for moderating effects was mixed.

Research question 1 Does alcohol diagnosis aflect women ’s participation in 12-step
group support?

The central question raised in this study was whether women with more severe
alcohol disorders would go to 12-step group support. They do! Women with more
severe alcoholism went to 12-step group support on average 3.8 times more often than
those without a more severe disorder. In these data those with any type of alcohol

disorder were 2.6 times more likely to go to 12-step group than those without any

69

diagnosis. This outcome is consistent with the broader alcohol treatment and 12-step
literatures (Humphreys, Kaskutas, & Weisner, 1998b; Kaskutas, Ye, Greenfield,
Witbrodt, & Bond, 2008a; Tonigan, Bogenschutz, & Miller, 2006).

Research question 2 Does comorbid psychopathology mediate the relationship between
alcohol diagnosis and women ’s participation in 12-step group support programs?

Comorbid psychopathologies were not significant mediators of the relationship
between alcohol diagnosis and 12-step group support. Major Depressive Disorder was
the only psychopathology that was significant in the model. This finding was surprising
given the extensive literature indicting the high degree of comorbid psychopathology
among samples of predominately males with alcohol disorders who are in treatment
(Bogenschutz, Geppert, & George, 2006; Humphreys, 1997; Humphreys, Mavis, &
Stdffehnayr, 1991; Kelly, McKellar, & Moos, 2003; McKay et al., 1998). This finding
did not hold for women. The presence of psychopathologies did increase the strength of
the alcohol diagnosis coefficient, but it did not differentiate between women with and
without comorbidity apropos of their likelihood of attending 12-step programs.

ASPD was a strong predictor of 12-step group support attendance. Women who
have ASPD go to 12-step group support and its presence in the model did increase the
strength of the alcohol diagnosis coefficient. But, it did not mediate or moderate the
relationship between alcohol disorders and l2-step group support. There was a
significant interaction between severe alcoholic and ASPD diagnosed women. This
outcome was not expected. Group support is fundamentally a social support group. One
would expect antisocial personality disordered individuals to be less likely to seek out

such groups. The literature on ASPD and alcoholism provided little insight into the

70

phenomenon in these data. There is literature on the co—occurrence of severe alcohol
disorders with ASPD (Hesselbrock, 1991; Hesselbrock & Hesselbrock, 1994); however,
this literature provides little information about ASPD and treatment effects for women.
In lieu of any explanation of this outcome in the 12-step or treatment literatures a
logical argument was found in court mandated treatment literature. As with men, women
with ASPD tend to come in frequent contact with the law. For example, the first criteria
stated for DSM-IV 301.7 ASPD is, “failure to conform to social norms with respect to
lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
(American Psychiatric Association, 1994).” Women express ASPD differently than men,
with more antisociality focused inward than in outward expressions (Cadoret, O’Gorman,
Troughton & Heywood, 1985; Cloninger, Christiansen, Reich & Gottesman, 1978;
Kendler, Prescott, Myers & Neale, 2003; Lex, Goldberg, Mendelson, Lawler & Bower,
1994; Windle, 1990). Women do have more internalizing symptoms in contrast to men,
and men are more likely to have more externalizing symptoms than women (Kendler,
Prescott, Myers & Neale, 2003; Windle, 1990). For women this could mean engagement
in prostitution, retail fraud or drug dealing behaviors which would bring them in front of
the court. Prostitution, retail fraud and similar behaviors are not the violent, externalizing
behaviors of men, but none-the-less, they are illegal behaviors that can get one arrested.
Continuing to follow this logic, severe alcoholic women with ASPD who are prosecuted
for their behaviors would typically be referred to some type of remediation through
treatment (Daughters, Stipelman, Sargent, Schuster, Bomovalova & Lejuez, 2008;
Young, 2002). In one study, women with ASPD and severe alcohol disorders were court

mandated to treatment with significant benefit in regards to treatment completion and

71

maintenance of abstinence from alcohol (Daughters, Stipelman, Sargent, Schuster,
Bomovalova & Lejuez, 2008). In another study, while not a specifically ASPD study, the
one and five year outcomes relative to abstinence rates for those arrested showed that
court ordered treatment worked for those with substance abuse with and without co-
occurring disorders (Kelly, 2005). Research shows the practice of mandating people with
ASPD and severe alcoholism is successful reducing the use of alcohol and deve10ping
better coping mechanisms. Further, outcomes reinforcing court mandated treatment for
substance abusers would naturally increase the likelihood that other courts would
mandate to treatment. Thus, even though no specific reference to 12-step group support
participation was found for women with comorbid severe alcoholism and ASPD in the
literature, a case could be made that a) these women went to treatment because it was
court mandated rather than voluntary and b) 12-step group support was a common
treatment component. This is a plausible speculation that is not proved by this study, but
provides the foundation for future research.

Research question 3 Do key demographic variables moderate alcoholic women ’s
participation in IZ-step group support?

Demographic Clusters. The first demographic cluster of women who were white,
married, age 35 years or older, with at least a high school education was themost
common demographic cluster in the NESARC. The presence of these characteristics in
the 12-step literature is well documented. However, the presence of these variables in a
model with alcoholic women did not moderate the relationship between alcohol diagnosis

and 12-step group support.

72

Women who were married were less likely to go to 12-step group support than
other relationship groups. This outcome was not expected. Manied alcoholic women are
not specifically represented in the 12-step literature. One possible explanation for this
outcome was found in intimate partner violence (IPV) literature. The presence of alcohol
in family settings where violence occurs is well documented (Steinglass & Moyer, 1977;
Straus, 1974; Straus, 1990). Alcoholic women seeking to prevent future abuse go to
treatment to improve her behaviors but do not stay (Hattery, 2009; Shannon, Logan, Cole
& Medley, 2006). Women who seek outside responses to home abuse may have
husbands or partners who become jealous and increase the risk of being hurt again
(Hattery, 2009). Further, fear of losing access to her children creates a barrier to help
seeking (Beckman, 1994). Women were more likely to seek help through doctors or
mental health professionals and were less likely to seek traditional substance abuse
treatment (Beckman, 1975 Schober & Annis, 1996). All of these possibilities do not
speak directly to the low numbers of married alcoholic women attending 12-step group
support. But, it does provide a plausible reason for not attending that could form the
basis for future study.

Demographic Cluster 2 included those women who were other-than—white, were
under the age of 35 years with less than a high school education who were previously
manied. These characteristics were the inverse of Demographic Cluster 1 and were
tested based on the concern raised by Humphreys (1997) about sample selection bias.
This cluster did not moderate the relationship between alcohol diagnosis and 12-step
group support. The 12-step literature did not specifically discuss why alcoholic women

who were separated went to 12-step group support. A possible explanation is found in the

73

treatment literature. Alcoholic women who were separated entered treatment when they
had experienced the more adverse consequences of their drinking like relationship
disruption and financial instability (F inney & Moos, 1995; Lipsky, Caetano, Field &
Larkin, 2006).

Separated women. Women who were previously married; meaning separated,
widowed or divorced were significant in the model. It was expected that women who
were divorced would go to 12-step group support based on the literature. This was
supported by the outcomes. That women who were separated or widowed would go to
12-step group support in significant numbers was a surprise. The 12-step literature did
not specifically discuss why alcoholic women who were separated went to 12-step group
support. A possible explanation is found in the treatment literature. Alcoholic women
who were separated entered treatment when they had experienced the more adverse
consequences of their drinking like relationship disruption and financial instability
(F inney & Moos, 1995; Lipsky, Caetano, Field & Larkin, 2006). This makes sense then
that since 12-step participation is a very common element of treatment, if separated
women went to treatment, they would most probably go to 12-step group support.

Widowed women. Even though it was not expected, widowed women with severe
alcohol problems were significantly more likely to go to 12-step group support. One
study reported that self-help support groups in general were successful in helping widows
cope with identity loss and aloneness (Epstein, F ischer-Elber, K. & Al-Otaiba, 2007).
Widowed women were at increased risk of problem drinking due to limited social
supports brought about by the loss of relationship after the death of a partner (Gomberg

& Nirenberg, 1993; Stewart, Craig, MacPherson & Alexander, 2001). Therefore, it

74

makes sense that drinking women would seek out the social support of a 12-step support
group that could help with the alcohol problems.
Demographic characteristics not found significant.

Children. The influence of children being present or absent in the home played no
significant role in a woman’s decision to go to l2-step group support. From the onset
there was no research found in the 12-step literature that spoke of women in 12-step with
or without children. In the epidemiologic literature there were significant findings
regarding treatment baniers and one of those barriers was the presence of children in the
home (Gomberg & Nirenberg, 1993). In the family studies literature the presence of
children in the home added a layer of severity to the problems within the system which
included problem drinking (Steinglass & Robertson, 1993). Future research could help to
determine if children pose the same barriers to seeking group support as it has posed to
seeking treatment.

Ehnoracial Group Ethnoracial group played no significant role in these data. The
minority ethnoracial makeup of women in treatment has been studied (Kaskutas &
Weisner, 1996; Rouse, Carter & Rodriguez-Andrew, 1995; Zemore, 2008, #17499).
However, the majority of treatment data, the NESARC data and the 12-step data
available all were consistently made up of white participants. Ethnoracial studies of
women who attend l2-step group support are an important topic for future research. The
prevalence of meetings, the person to person model of helping and the low cost
associated with self-help make 12-step group support are an attractive program for a wide

range of recovering communities.

75

Socioeconomic Status. The presence or absence of socioeconomic status did not
moderate the relationship between alcohol disorders and 12-step group support. Women
in the upper socioeconomic brackets were expected to be more likely to attend l2-step
group support and they were. Alcoholic women who worked as skilled craftsmen,
clerical and sales workers (Category 3 workers) were not significantly more likely to
attend 12-step group support. All other categories of workers were significantly more
likely to go to 12-step group support. But, the literature was only consistent in that
women with more economic resources go to 12-step group support (Moos, Moos, &
Tirnko, 2006; Ogbome & Glaser, 1981).

Women in lower socioeconomic groups went to 12-step group support and this
was not expected. But, searching for the cause of this phenomenon may need to begin
with the process of analysis first. The way that the socioeconomic variable was
constructed in this study may have skewed the results. It was discovered after the
analysis had been completed that the 1975 unpublished work of Hollingshead was not the
actual rubric known in the socioeconomic literature as the Hollingshead scale of
Socioeconomic Status. After the original unpublished work, the construct was expanded.
Second, there were two factors (occupation and education) with weights used to calculate
what was thought to be the Hollingshead scale of Socioeconomic Status. The more
accurate Census Occupation Codes were not used in the NESARC and even though
education was a stable variable in these data, given the instability of the occupation
variable the outcomes of the calculations were suspect. The fault then in these findings
must be traced back to the writer and not the absence of literature on the subject. In the

end, there needs to be research done on the socioeconomic status of women who go to

76

12-step group support. It must be grounded in better methodology than the one
incorporated here.
Limitations of the Data set chosen

These data represent the largest randomly sampled, non-treatment data set to date.
It is a well prepared collection of responses that have brought significant findings to the
field of alcohol research. However, there were some limitations to its use as secondary
data in a 12-step study.
Meeting attendance

These data only asked if a person had ever participated in a 12-step group and
then only asked if their participation was within the current 12 months, prior to the
current 12 months or in both time periods. A person who had gone to one 12-step
meeting would be weighted the same as a person who had gone to 100 12-step meetings.
Meeting attendance is not the most important factor in determining the potential for
abstinence from alcohol. However, the number of meetings attended is one factor that
does impact abstinence from alcohol (Gossop, Stewart & Marsden, 2008; Kaskutas,
Ammon, Delucchi, Room, Bond & Weisner, 2009; McKeller, Harris & Moos, 2009;
Witbrodt & Kaskutas, 2005).
Afiiliation with IZ—step group support

Elements of 12-step affiliation are important predictors of abstinence patterns
(Humphreys, Kaskutas & Weisner, 1998; Laudet, White & Storey, 2006). This dataset
did not ask questions about the types of activities in which a person engaged who was

going to 12-step group support (ie did they read 12-step literature, did they do service

77

work, were they sponsored and do they have a sponsor). The lack of depth in questioning
12-step affiliation limits the conclusions that may be drawn from this subset.
Alcoholics Anonymous specific information

These data limit the AA specific conclusions that may be drawn. There were no
AA-specific variables. Even though alcohol is still the most fi‘equently reported primary
drug at treatment admission and even though 63% of all persons going into treatment
have a history of AA involvement this national alcohol data set did not explore AA
specific information.
Diagnosis of individuals with DSM—I V disorders

The designers of the NESARC operationalized the symptom criteria for a number
of DSM-IV pathologies into a series of questions. After the survey data were collected, a
posthoc analysis of the responses to the operationalized criteria was completed. The
result was that individuals were given a diagnosis or not based on their responses to the
symptoms and not based on their self report (Grant et al., 2004a; National Institute for
Alcoholism and Alcohol Abuse, 2004; Pulay et al., 2008).

There was a shifting of the time frames established for diagnosis by the DSM-IV
in the NESARC. Major Depressive Disorder and Generalized Anxiety Disorder have a
much shorter window than the 12 months required to make a diagnosis of alcohol abuse
or dependence. However, these two disorders were assigned posthoc based on this 12-
month time frame. These procedures create potential for ‘false positive’ and ‘false
negative’ endorsements of the psychopathologies in that women may have had symptoms
of depression over the course of 12-months that would never have met the two week

requirement for symptoms to occur.

78

Lack of Census Occupational Codes

The NESARC did not use the census occupational codes when assigning
occupations to the participants in their study. Instead they used a more descriptive
approach to assign an occupation. Unfortunately, this made it impossible to have
portability between their occupational coding system and other systems. The
Hollingshead Scale which was reliant on the Census Occupational Codes which did not
smoothly relate to the NESARC codes.

Policy Implications

There has been a growing body of literature since the 1970’s focusing research on
women specific health consequences and treatment options for alcoholic women. There
have been several treatment studies and epidemiologic studies sited that have either been
gender specific or gender balanced. The 12-step literature is still limited because of the
small amount of women-specific research outcomes available.

Two policy directions were implied by this; 1) Government funded research on
women specific 12-step group support needs to expand and 2) More education needs to
be done to build capacity for women to go to and continue to be successful in 12-step
group support.

Government funded research

Study has to be done relative to women alcoholics and AA specific 12-step group
support. Recent research has shown that 12-step group support in general and AA in
particular transcends the criticism so frequently levied that 12-step group support is only
for white, middle aged men (White, 2008). Women in certain conditions benefit from

AA (Kelly, Stout, Zywiak & Schneider, 2006). People of color benefit from participation

79

in AA (Humphreys, Mavis & Stoffelmayr, 1994; Kaskutas, 1996). People with co-
occuning mental health problems benefit from AA (Chi, Satre & Weisner, 2006; Laudet,
Magura, Vogel & Knight, 2000). Yet, these studies are few. And despite the outcomes,
even the NESARC, the largest population study of alcohol to date did not differentiate
between AA and other 12-step programs. Conclusions had to be couched in the more
universal 12-step group support language. Further, given the current economic crisis, the
increased use of alcohol by women and the shrinking resources to address this problem, it
seems that government funded research of AA specific group support could be a
beneficial priority. Group support is free and it works. It is a people-centered movement
that does not rely on expert opinion to function, but rather on a set of supportive
relationships built on one person helping another person to stay sober one day at a time.
The 12-steps when followed provide a mechanism whereby a person once segregated
from society by alcoholism is now reunited with their community as a productive and
contributing member. This makes economic sense to expand the body of government
funded research to incorporate female specific study of alcoholism and Alcoholics
Anonymous.
Education of Professionals

A second policy concern rests in the education of society regarding the hope that
AA provides to women with this debilitating disease. Women who go to AA get sober
and stay sober. By following the 12-steps women like men are restored to community.
The misperceptions, through education, need to be dispelled that AA is only for middle
aged, white men. Women seek help for alcoholism at their private physicians’ and

therapists’ office and family support centers including government and non-profit

80

agencies. These locations could be better equipped to provide referrals to AA for their
female clients. Professionals need to avail themselves of the opportunity to attend open
meetings of AA and to learn about 12-step facilitation programming that builds a
foundation for AA for newcomers to the program. Increasing knowledge capacity
regarding the benefits of group support furthers the goals of alcohol treatment research
which promotes recovery oriented systems of care.

Group support is a program of attraction, not promotion. Because of this court
jurisdictions need to be more thoroughly trained to work with committees within the AA
community to provide appropriate linkages to local meetings in general and to women
friendly meetings in particular. The misconceptions that all meetings are the same must
be dispelled. It is not appropriate to mandate anyone to a closed meeting of AA. Court
mandated women should only be steered to open meetings and leave it to the women
being referred to decide when and if they are ready for closed meetings. Court
professionals who will make it mandatory for women to attend AA need to know what
meetings will be the most effective given the level or readiness to change expressed by
the client (White, 1998). Further, sending women to appropriate meetings for her level
of readiness increases the likelihood that women will stay in the program.

Recap of future study

The outcomes of this study point towards three general areas for firture study.

First, more needs to be known about the relationship between alcohol severity and ASPD

in relationship to 12-step group support.

81

Second, the impact of family relations on women’s participation in l2-step group
support needs to be studied in greater depth. This dataset offers more information
regarding family histories of alcohol use.

Third, these data offer extensive information about treatment participation.
Future study should compare women who go to 12-step group support to the kinds of
treatment they are attending. It is of interest to know if a particular type or types of
treatment mediate or moderate the relationship between alcohol diagnosis and l2-step
group support.

In conclusion the outcomes of this study confirmed the fundamental premise that
women with severe alcohol problems with and without comorbid psychopathologies

attend 12-step group support. Future studies will be assisted by these findings.

82

10.

ll.

12.

APPENDIX A
THE TWELVE STEPS OF ALCOHOLICS ANONYMOUS

We admitted we were powerless over alcohol, that our lives had become
unmanageable.

Came to believe that a Power greater than ourselves could restore us to sanity.

Made a decision to turn our will and our lives over to the care of God as we
understood Him.

Made a searching and fearless moral inventory of ourselves.

Admitted to God, to ourselves, and to another human being the exact nature of our
wrongs.

Were entirely ready to have God remove all these defects of character.
Humbly asked Him to remove our shortcomings.

Made a list of all persons we had banned, and became willing to make amends to
them all.

Made direct amends to such people wherever possible, except when to do so
would injure them or others.

Continued to take personal inventory and when we were wrong promptly admitted
it.

Sought through prayer and meditation to improve our conscious contact with God,
as we understood Him, praying only for knowledge of His will for us and the
power to carry that out.

Having had a spiritual awakening as the result of these Steps, we tried to carry this
message to alcoholics, and to practice these principles in all our affairs.

(Alcoholics Anonymous World Services, 1991)

83

APPENDIX B
PSYCHOPATHOLOGIES

Major Depressive Disorder

Major Depressive Disorder is a Mood Disorder. It is an episodic disorder
characterized by having one or more time periods where at least five behaviors are
present for the same two week period". These behaviors include persistent depressed
mood, markedly diminished interest or loss of pleasure in activities, significant weight
loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue,
feelings of worthlessness or inappropriate guilt, diminished ability to concentrate or
recurrent thoughts of death. These symptoms must not be combined with any periods of
manic behaviors, must cause clinically significant distress or impairment in functioning
and may or may not be due to physical illness or from the effects of psychoactive
substances (an important point to consider during the analysis of the data) (American
Psychiatric Association, 1994).
Generalized Anxiety Disorder

Generalized Anxiety Disorder is characterized by having excessive anxiety or
worry occurring more days than not for a period of six months.7 The person must

possess at least three behaviors which include feelings of restlessness, fatigue, difficulty

 

6 Note the two week time period required for determination of this disorder. For an
alcohol use disorder the time period is broader. The person has up to a year to manifest
symptoms. Major Depressive Disorder must manifest in a concentrated two week
period. Refer to page 35 of Chapter III, Methods for a complete discussion of how
these diagnoses were determined in the NESARC.

7 Compare now Generalized Anxiety Disorder to Maj or Depressive Disorder and
alcohol use disorders. Generalized Anxiety Disorder needs a period of six months of
symptom presentation for diagnosis.

84

concentrating, irritability, muscle tension and sleep disturbance. The focus of the anxiety
or worry is not fixated on an event but is generally present in all areas of life. The
symptoms cause clinically significant distress or impairment in functioning and the
disturbance may or may not be due to a physical illness or brought on by the use of
psychoactive substances (American Psychiatric Association, 1994).
Conduct Disorder

The defining characteristic of Conduct Disorder is an ongoing pattern of behavior
that disregards the rights of others or fails to comply with social norms and rules. This
disorder is age dependent and must be diagnosed before the age of 18 years. Three or
more behaviors must be met for this disorder to be diagnosed including bullying,
instigating physical fights, use of weapons or objects as weapons, physical cruelty to
people or animals, forcing sexual contact with others, fire starting, theft or robbery,
repetitive curfew violations, truancy from school or work. The behaviors must occur
within a consistent 12 month period and with at least one of these behaviors present
within the most recent six month period (American Psychiatric Association, 1994).
Antisocial Personality Disorder

ASPD is a lifetime diagnosis. The symptoms of this disorder do not abate, but
may be managed through therapy. There must be a consistent disregard for the rights of
others. These behaviors often appear during middle adolescence as Conduct Disorder
and persist throughout the person’s lifetime. However, there is support for adult onset of
ASPD without Conduct Disorder (Goldstein et al., 2007). Three or more of the following

criteria must be present including complete failure to conform to social norms, lying,

85

impulsivity, aggressiveness, and reckless disregard for others safety, irresponsibility and

total lack of remorse for anything done to harm others.

86

APPENDIX C
GENERAL DEMOGRAPHIC CHARACTERISTICS OF THE NESARC
General demographics. There were a total of 43,093 participants in the survey;
N=24,575 Women and N=18,5 18 Men.
Age. Women were slightly older than men. The average age was about 47 years
for women and 45.5 years for men. There were more people over the age of 35 years.
There were 70.3% of women over the age 35 years and 69.5% of men (Table 39).

Table 39 Comparison of ages between women and men

 

Females
(mean 47.12, sd Males
Age 18.64) (mean 45.45, sd 17.51) Total
18-24 2,789 6.47% 2,410 5.59% 5,199 12.06%
25-29 2,060 4.78% 1,407 3.27% 3,467 8.05%
30-34 2,458 5.70% 1,834 4.26% 4,292 9.96%
35-39 2,661 6.18% 1,989 4.62% 4,650 10.79%
40-44 2,406 5.58% 2,034 4.72% 4,440 10.30%
45—49 2,142 4.97% 1,876 4.35% 4,018 9.32%
50-54 2,004 4.65% 1,603 3.72% 3,607 8.37%
55-59 1,611 3.74% 1,236 2.87% 2,847 6.61%
60-64 1,343 3.12% 1,025 2.38% 2,368 5.50%
65+ 5,101 11.84% 3,104 7.20% 8,205 19.04%

Ethnoracial group. White females and males represented the largest group in the
data (Table 40). The order of the distribution was the same between females and males
(i.e. the order of most to least was white, black, Hispanic, Asian/Pacific Islander and
Native American Indian/Alaskan Inuitg). The percent in each category was weighted to

females which is consistent with the oversampling of females reported by the researchers.

 

8 The writer acknowledges that there are more appropriate terms used in the literature
to describe individuals’ ethnoracial group. The terminology used by the authors of the
study was the terminology adopted for this study.

87

Table 40 Comparison of ethnoracial group for women and men

 

Ethnorace Females (n=24,575) Males (N=18,518) Total (N=43,093)
White 13,662 55.6% 10,845 31.7% 24,507 56.9%
Black 5,204 21.2% 3,041 12.1% 8,245 19.1%
Hispanic 4,586 18.7% 3,722 10.6% 8,308 19.3%
As‘a‘” Pac‘fi" 736 3.0% 596 1.7% 1,332 3.1%
Islander

Native American

Indian/ Alaskan 387 1.6% 314 0.9% 701 1.6%
Inuit

Relationship status. In these data 48.2% of the respondents were married. Those
who were living together as married (LTP’s) are separated in this chart and make up
3.04% of the population. In the dataset used for analysis, LTP’s were included with those
who were married. Note, also in this sample, there were several more women who
reported being widowed in comparison to widowers which is consistent with national
trends (Table 41).

Table 41 Comparison of relationship status for women and men
Relationship Females (n=24,575) Males (N=18,518) Total (N=43,093)

 

Married 10,969 25.45% 9,800 22.74% 20,769 48.20%
LTP 714 1.66% 598 1.39% 1,312 3.04%
Widowed 3,488 8.09% 783 1.82% 4,271 9.91%
Divorced 3,306 7.67% 2,095 4.86% 5,401 12.53%
Separated 960 2.23% 485 1.13% 1,445 3.35%

Never Married 5,138 11.92% 4,757 11.04% 9,895 22.96%
Children. The percentage of women without children in these data was greater
than the percentage of men without children and together, about 62.5% of the entire
dataset did not have children. Those who had one to two children made up 29% of the
dataset and only a little less than 8.5% of these data had three or more children (Table

42).

88

Table 42 Children in the home for women and men

 

# of Children Females
under 17 (N=24,575) Males (N=18,518) Total (N=43,093)
33.97
0 14,638 % 12,302 28.55% 26,940 62.52%
1 4,061 9.42% 2,498 5.80% 6,559 15.22%
2 3,557 8.25% 2,382 5.53% 5,939 13.78%
3 1,581 3.67% 935 2.17% 2,516 5.84%
4 520 1.21% 266 0.62% 786 1.82%
5 150 0.35% 87 0.20% 237 0.55%
6 48 0.11% 32 0.07% 80 0.19%
7 or more 20 0.05% 16 0.04% 36 0.08%

Education. Slightly less than 82% of the entire dataset completed at least high
school or its equivalent. There were 32% of these data that completed a two-year
associates or more post-secondary education (Table 43).

Table 43 Highest grade attained for women and men

 

Females Males Total

# of Children under 17 (N=24,575) (N=18,518) (N=43,093)
No formal schooling 127 0.29% 91 0.21% 218 0.51%
completed grad K, 1 or 2 74 0.17% 63 0.15% 137 0.32%
completed grade 3 or 4 236 0.55% 185 0.43% 421 0.98%
Completed grade 5 or 6 516 1.20% 415 0.96% 931 2.16%
Completed grade 7 247 0.57% 167 0.39% 414 0.96%
Completed grade 8 690 1.60% 520 1.21% 1210 2.81%
Some high school 9-11 2590 6.01% 1928 4.47% 4518 10.48%
Completed high school 6394 14.84% 4541 10.54% 10935 25.38%
Graduate equivalency 889 2.06% 723 1.68% 1612 3.74%
Some college no degree 5170 12.00% 3721 8.63% 8891 720.63%
Completed associate 2243 5.21% 1529 3.55% 3772 8.75%
Completed college
bachelor's degree 2810 6.52% 2441 5.66% 5251 12.19%
Some graduate or
professional 897 2.08% 629 1.46% 1526 3.54%
Completed graduate/
professional degree 1692 3.93% 1565 3.63% 3257 7.56%

89

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12-step group support meeting attendance by category of drinking status. Both women
and men were more likely to be current drinkers (Table 46).

Table 46 12-step participation by drinking status for women and men

 

Women Men
1 2-step Current Former Total Current Former Total
Yes 256 176 432 619 393 1012
No 110 33 143 256 67 323
Total 366 209 575 875 460 1335

Current alcohol diagnosis. More women (N =12,766) than men (N=10,853)
reported being current drinkers with no current _12-month alcohol diagnosis (Table 47).
Fewer currently drinking women (N=594) than men (N=1,249) reported having a
diagnosis of alcohol abuse in the past 12 months and the same was true for having an
alcohol dependence diagnosis in the past 12 months. Overall, women were less likely to
have a current alcohol diagnosis than men.

Table 47 Current diagnosis by drinking status for women and men

 

Women Men
Alcohol Former Lifetime Former Lifetime
Diagnosis Current Drinker Abstainer Current Drinker Abstainer
None 12,766 4,674 6,022 10,853 3,207 2,244
Abuse 594 1,249
Dependence 243 310
Both 276 655
Total 13,879 13,067

Prior to current alcohol diagnosis. The same held true for individuals receiving a
diagnosis prior to the last 12 months with the exception of current drinking women who
were diagnosed with past alcohol dependence. There were slightly more women than
men who had a prior alcohol dependence diagnosis than were currently drinking women.
In the group of former drinking women, slightly more had a past alcohol dependence

diagnosis than former drinking males (Table 48).

93

Table 48 Prior to current alcohol diagnosis by drinking status for women and men

Women Men
Prior Former Lifetime Former Lifetime
Diagnosis Current Drinker Abstainer Current Drinker Abstainer

 

None 10,477 3,894 6,022 7,289 1,751 2,244

Abuse 2,061 481 0 3,552 900 0
Dependence 273 39 0 227 24 0
Both 1068 260 0 1,999 532 0

Total 13,879 4,674 6,022 13,067 3,207 2,244

Comorbid psychopathology. Using the criteria established in the DSM-IV as the
basis for interview questions, the survey questionnaire operationalized amongst other
disorders the symptoms for Major Depressive Disorder, Generalized Anxiety, Conduct
Disorder and ASPD. Individuals meeting the appropriate criteria for a disorder based on
their responses to the survey questions were assigned to the named disorder. In other
words, the respondent was not asked to endorse the disorder per se but instead was asked
to endorse behaviors that were consistent with the operationalized definitions of the
disorders (Grant et al., 2004a; National Institute for Alcoholism and Alcohol Abuse,
2004; Pulay et al., 2008). The time period when the symptoms were manifested was
only reported for Major Depressive and Generalized Anxiety Disorders. For both of
these disorders the current 12 months and the time period prior to the current 12 months
was used. Conduct Personality Disorder is diagnosed in adolescence and ASPD is a
lifetime diagnosis.

Major Depressive Disorder and Generalized Anxiety Disorder. More women
were diagnosed with lifetime Major Depressive Disorder than men (Table 49). A higher
percentage of women than men were diagnosed with Generalized Anxiety Disorder and

about 4% of the dataset was diagnosed with lifetime Generalized Anxiety Disorder

94

(Table 50). Major Depressive Disorder and Generalized Anxiety Disorder had an
aggregate variable (Table 49 and Table 50). They both had a variable where substance
abuse was ruled out of the diagnosis. The substance abuse ruled out variable was chosen
over the aggregate level data to avoid confounding the alcohol diagnosis with Major
Depressive Disorder and Generalized Anxiety Disorder (Table 46 and Table 47).

Table 49 Lifetime Major Depressive Disorder for women and men

 

 

Major Females Males
Depressive Substance Substance
Disorder Abuse Ruled Abuse
Lifetime Frequency out Frequency Ruled out
No 19,161 19,216 16,093 16,135
Yes 5,414 5,359 2,425 2,383
Table 50 Lifetime Generalized Anxiety Disorder for women and men
Females Males
Generalized Substance Substance
Anxiety Disorder Abuse Abuse
Lifetime Frequency Ruled out Frequency Ruled out
No 23,203 23,207 17,952 17,959
Yes 1,372 1,368 566 559

According to the DSM-IV, the period of time needed to sustain a diagnosis of
Major Depressive Disorder or Generalized Anxiety Disorder vary from the time period
needed for a diagnosis of alcohol abuse or alcohol dependence and vary in time between
one another. For a diagnosis of a major depressive episode the symptoms must only be
present for a two week period of time. Further, Major Depressive Disorder may be
diagnosed for either a single episode or as recurrent when multiple major depressive
episodes are present. For Generalized Anxiety Disorder to be diagnosed, symptoms must
be present for duration of six months (pp.356, 375-376, and 472-473) (American

Psychiatric Association, 1994).

95

In the NESARC dataset, these time frames are not observed. A standard 12-
month time fi'ame for the appearance of behavioral symptoms is used which allows for
comparison between alcohol abuse, alcohol dependence, Major Depressive Disorder and
Generalized Anxiety Disorder.

Conduct Disorder and Antisocial Personality Disorder. Fewer females reported
histories of Conduct Disorder than males (Table 51). Generally, about 3% of the US.
population and 3.3% of the NESARC sample are diagnosed with ASPD and fewer
women are diagnosed with ASPD than men (Table 52).

Table 51 Conduct disorder for women and men

 

 

Conduct
Disorder Females Males
No 24,418 18,260
Yes 157 258
Table 52 Antisocial personality disorder for women and men
Antisocial Females Males
Personalrty
Disorder Frequency Frequency
No 24,102 17,569
Yes 473 949

96

Appendix D

Table 53 Hollingshead (Code) Imputed Occupation codes with one imputed education
code

 

 

IDNum Difference Personal Education Occupation Code

854 0 19000 39 service 2
20883 30,000 500 1 sales office 6
6646 0 10,800 1 forestry, farm 3
6008 125,714 286 1 professional 9
6131 23,000 10,000 1 sales office 6
1551 37,000 18,000 1 service 2
28103 38,000 12,000 1 service 2
42985 1 9,400 2,500 2 forestry, farm 3
23409 49,000 16,000 2 professional 9
16655 62,000 22,000 2 professional 9
23812 46,000 39,000 2 professional 9
6959 15,000 0 3 service 2
12490 15,000 17,500 3 service 2
5662 7,000 49,000 3 professional 9
30255 98,000 32,500 3 professional 9
21857 0 24,000 3 sales office 6
2900 27,197 8,803 3 service 2
2399 27,500 17,500 3 service 2
7036 23,184 5,040 3 far 3
16256 28,000 12,000 3 service 2
45 9,000 16,00010 3 service 2
5576 8,200 6,800 4 forestry, farm 3
29272 0 35,000 4 professional 9
41354 45,000 25,000 4 professional 9
19649 55,000 30,000 4 professional 9
35808 21,000 13,000 4 production 3
3901 7 3 1,000 24,000 4 production 3
32401 23,000 22,000 4 forestry, farm 3
33874 33,500 38,500 4 sales office 6
10776 10,500 8,500 4 service 2
18600 0 140,000 4 professional 9

9 (Pearson Education Inc., 2007).

10 The household and family income were different a and the household was higher

97

Table 53 (cont’d).

28058
11015
12999
24363
26479
11445
14722
20207
20840
21863

1213
40981
27317

2668
14620
20915
40326
32371

5811
25043
39842
21997
41448
31534

1595

45,000
43,000
1,200
9,5 14
10,000
0
20,000
0

0
50,000
9,900

1 13,000
75,000
46,000
7,000
18,500

1 19,000
98,000
0
17,500
0
125,000
6,000
95,000
32,000

10,000
27,000
1,200
22,486
27,000
9,000
15,000
4,750
52,000
25,000
2,600
37,000

9,000
30,000
9,000
6,000
22,000
2,500
5,000
25,000
5,000
39,000

Table 54 Hollingshead scale

Social Strata

9'5"pr

\l\1QQMMMMMMMMMMMMhhhAhAhhg

Major Business and professional
Medium business, minor professional, technical
Skilled crafismen, clerical, sales workers
Machine operators, semiskilled workers
Unskilled laborers, menial service workers

professional
professional
other service
sales office
construction
other service
production
other service
professional
professional
other service
professional
professional
professional
construction
service
professional
professional

forestry, farm

service

construction
professional
professional
professional
construction

Range of computed scores

N\O\O\ONNWODNNOOONOONWNNQNOO

66-55 0
54-40
39-30
29-20
19- 8

 

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mm 5.22 53

+5220 m
5220 N
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+8680 N
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