Although 12-Step is increasingly utilized as a recovery resource and is viewed by many addiction specialists as an integral component of treatment and long-term recovery, quesitons regarding participation and effectiveness of 12-Step programs fro women and ethnic monitories have been raised.

The influence of the 12-Step movement is evident by escalating numbers of attendees, as well as the increasing integration of 12-Step principles in conventional drug treatment programs (Morgenstern, Kahler, Frey, & Laboubie, 1996; Muhleman, 1987; Tournier, 1979). Many addiction specialists now recommend simultaneous involvement in treatment and 12-Step programs as in integral component of treatment and long-term recovery (Freimuth, 1996; Johnson & Chappel, 1994), and continued participation as an "aftercare" activity that is essential for long-term abstinence (Hawkins & Catalano, 1985; Khantzian & Mack, 1994; Troyer, Acampora, O'Connor, & Berry, 1995). A study of virtually all drug treatment programs in Los Angeles County determined that approximately 75% offered treatment that placed some emphasis on 12-Step principles (Polinsky, Hser, Anglin, & Maglione, 1995).

Other studies document the effectiveness of 12-Step programs for those who participate. Findings include, for example, that clients who attend 12-Step programs on a weekly or more frequent basis after treatment report higher levels of abstinence from drug and alcohol use than do those who attend less frequently or not at all (Emrick, 1987; Fiorentine, 1999; McKay, Alterman, McLellan, & Snider, 1994; Montgomery, Miller, & Tonigan, 1995). Simultaneous participation in both treatment and 12-Step programs is associated with higher levels of abstinence than is participation in either traditional treatment or 12-Step alone (Fiorentine & Hillhouse, 2000a; Ouimette, Finney, & Moose, 1997; Ouimette, Moose, & Finney, 1998), and acceptance of some aspects of 12-Step ideology increase one's likelihood of maintaining abstinence (Fiorentine & Hillhouse, 2000b). Although some contend that the voluntary nature of 12-Step programs results in the selection of partic! ipants who are motivated for recovery (Bebbington, 1976; Sobel] & Sobell, 1979; Tournier, 1979), evidence indicates that the elevated rates of abstinence associated with regular 12-Step participation is not the result of higher levels of motivation (Fiorentine, 1999; McKay et al., 1994).

Although popular and effective for at least some participants, the 12-Step program has been criticized as inappropriate or objectionable to some individuals seeking a recovery resource. Criticisms have been made that 12-Step programs may not be appropriate for those who are not European-American males (Denzin, 1987; Galaif & Sussman, 1995; Kaskutas, 1994; Smith, Buxton, Bilal, & Seymour, 1993). Because social-psychological backgrounds and treatment experiences may differ widely as a function of gender (Fiorentine, Gil-Rivas, & Taylor, 1997) and ethnicity (Humphreys & Woods, 1993), it has been suggested that treatment needs to be gender and ethnic specific. Some have speculated that 12Step groups may not address the "unique needs" of women (Kaskutas, 1994) and ethnic minorities (Harper, 1976), and have been criticized as not being gender or culturally congruent. For instance, it has been suggested that 12-Step participation does not appeal to women and some! ethnic groups due to the 12-- Step concept of surrender and powerlessness in recovery. The 12-Step ideology views surrender and powerlessness as an important concept which allows the addict to quit trying to control their drug use and instead direct their activities towards recovery. For those who have traditionally suffered from societal powerlessness, as well as those who are in the process of developing their individuality and associated power, the 12-Step position that acceptance of powerlessness is vital may carry a perceived threat to independence and positive growth, and will thus be rejected (Smith et al., 1993).

Addressing criticisms that 12-Step was developed by and for European-- American men and does not address unique issues and needs of select populations, Humphreys and Woods (1993) report that 12-Step groups reflect the participating community members, and are shaped by the local ecology. Although 12-Step groups may share a general structure, the social environment, membership, and helping techniques vary across local chapters and meetings (Caetano, 1993). An erroneous assumption often made in studies of self-help organizations like 12-Step, is that all 12-Step groups are the same. As Humphreys and Woods (1993, p. 182) explain "...it makes no more sense to think of mutual help organizations as monolithic entities then it does to believe that all Baptist churches, elementary schools, or PTAs are the same across communities." Other investigations have described 12-Step programs addressing diverse ethnic groups including Native American (Jilek-Aall, 1981), African-American (Ca! ldwell, 1983), Hispanic (Hoffman, 1994), and Irish Catholic (Vaillant, 1983) communities. Yoder (1990) reports that membership has changed in the last 20 years and includes men and women of all ages, ethnic backgrounds, religions, professions, and sexual orientations.

Contradictory evidence exists that questions the assumption that 12-Step membership is confined to European-American males (Mathew, Mathew, Wilson, & Georgi, 1994; McCrady, Epstein, & Hirsch, 1996; Room & Greenfield, 1993; Smith et al., 1993; Walsh et al., 1991), and documents that women and ethnic minorities do participate in 12-Step groups (Beckman, 1993; Caetano, 1993; Humphreys, Mavis, & Stoffelmayr, 1991, 1992, 1994). For example, in a study assessing both whether disenfranchised groups attend and then drop out of 12-Step programs, and whether African-Americans benefit from 12-Step, Humpreys et al. (1994) found no difference between those who participated and did not participate in mutual help groups by race, gender, education, employment status, or marital status. Additionally, African-American men who participated in 12-Step had better outcomes than those who did not participate.

Conflicting evidence regarding the benefits of 12-Step for women and ethnic minorities may have caused addiction specialists, treatment providers, and others to question whether women and ethnic minorities should be encouraged to participate concurrently in treatment and 12-Step groups, as well as to participate in 12-Step meetings after treatment. Although investigations separately addressing 12-Step, gender, and ethnicity have increased, we are aware of only one empirical study comparing 12-Step participation and recovery rates across gender and ethnic groups (Humphreys et al., 1994). To date, there appears to be little research regarding the use of 12-Step by women and ethnic populations, or about the effectiveness of 12-Step as a treatment for women (Beckman, 1993) and minorities "...vis-a-vis the majority population" (Caetano, 1993, p.209). The current investigation was designed to examine whether 12-Step programs best reflect the interests of European-American men, ! and overlook the needs and interests of women and ethnic minorities. Two questions are addressed: (1) Do women and ethnic minorities participate in 12-Step less often than European-American males? (2) Are women and ethnic minorities equally likely as European-American males to maintain abstinence in conjunction with 12-Step participation?

METHOD

This inquiry utilizes a prospective, longitudinal treatment outcomes evaluation associated with the Los Angeles site of the Target Cities Treatment Enhancement Project, Years 1-3. Interviews were scheduled within the first eight weeks of treatment entry (study intake), and at approximately 6 and 24 months after the first interview. Funded by the Center for Substance Abuse Treatment, the general goal of the Target Cities Project was to improve the accessibility and effectiveness of drug treatment in cities with severe drug problems.

PARTICIPANTS

Eligible participants were identified by treatment providers in April 1993, and recruited from all clients participating in 26 outpatient drug treatment programs in the Los Angeles metropolitan area for at least eight weeks. Including only clients who had been in treatment for eight weeks was implemented for practical reasons in order to reduce the time needed to collect data and to complete the evaluation within the scheduled time constraints.

Including only those remaining in treatment for 8 weeks or longer does not appear to have influenced the gender and ethnic composition of the sample. Data from the California Department of Alcohol and Drug Programs monitoring system indicates that the gender and ethnic composition of the sample closely mirrors the population utilizing Los Angeles County publicly-funded drug and alcohol outpatient programs during this time period (California Department of Alcohol and Drug Programs, 1994). Further, the gender and ethnic composition of this sample duplicates the gender and ethnic composition of a study conducted 2 years after this one which sampled all outpatient participants in the Los Angeles area who completed a treatment intake assessment, typically during the first week of treatment (Fiorentine, Gil-Rivas, & Hillhouse, 1998). Including only those in treatment for 8 weeks, however, may have resulted in the inclusion of clients with higher levels of motivation for rec! overy than those generally presenting for treatment, and may reflect participants who were more satisfied with treatment than those who had dropped out within the first eight weeks of treatment. Although this sample may reflect a higher level of motivation, there is no reason to expect that higher levels of motivation would be differentially distributed as a function of gender and/or ethnicity, and as such is not a confound in this study.

Of the 381 eligible clients, 356 (93%) agreed to participate in the first interview (TI). The 6 month follow-up (T2) included 330 (92%) of the original participants. For the 24 month follow-up (T3), 83% of the baseline sample were located, however 13 clients refused to be interviewed and 3 clients had died, resulting in a 74% overall follow-up rate (n = 262).

Table I describes the gender and ethnic composition of the sample at all interview points. The sample is representative of the population entering treatment at the time of the study, however, this included more women than in previous time periods. The participating Target Cities programs, as well as most ofthe comparison outpatient programs, had specifically targeted women for treatment by enhancing existing services and implementing new services for women over the three year period of the evaluation. This table shows, however, that the gender and ethnic composition of the sample remains stable over the data collection episodes, indicating that no population is proportionally underrepresented in follow-up interviews.

MEASURES

The UCLA Client-Needs-Services-Outcomes Questionnaire (CNSOQ) was developed to obtain information from participants presenting for treatment on a wide range of topics from several domains. The measurement domains of the CNSOQ- Part I include: psychosocial background information, barriers to treatment and treatment utilization, treatment needs, drug and alcohol use, criminal activity, family and social functioning, ancillary health and human service needs, and attitudes and values. The measurement domains of the follow-up instruments, CNSOQ- Part 2 and Part 3, include: treatment needs, services received, drug and alcohol use, criminal activity, employment/vocational training/education, psychosocial functioning, family functioning, health status, and pertinent psychological attitudes and constructs.

The assessment of 12-Step participation was operationalized as the frequency of meeting attendance in the 6 months prior to the first and second follow-ups. Four patterns of participation in 12-Step programs over the two time periods were discerned (Florentine 1999). Persistors were those who maintained weekly or more frequent attendance at 12-Step meetings in the six months prior to the first and second follow-ups. Initiates were defined as those who did not attend 12-Step meetings on a weekly or more frequent basis during the six months prior to the first follow-up, but did so in the six months prior to the second follow-up. Dropouts were those who maintained weekly or more frequent 12-Step participation in the six months prior to the first follow-up, but stopped attending meetings on a weekly basis during the six months prior to the second follow-up. Nonattenders were those who did not maintain weekly or more frequent participation at 12-Step meetings during either six! month period. 12-Step Effectiveness was measured as abstinence from alcohol and other drug use in the 6 months prior to the last follow-up.

PROCEDURE

Part I of the CNSOQ was administered to each eligible participant at their treatment facility and each respondent was paid $10. Participants in the first posttreatment interview (T2), conducted approximately 6 months after the in-treatment interview, and the second post-treatment interview (T-3), approximating a 24-month follow-up. were each paid $25 for their participation. When clients were located, his or her identity was verified from information privy only to the client and the interviewer. Once verified, the client was administered a telephone interview for the first post-treatment follow-up, and a face-to-face or telephone interview for the second post-treatment follow-up, usually by the same interviewer who administered the baseline interview. Urine testing was conducted at the second post-treatment follow-up, on all accessible participants (82% of those completing all three interviews), with no refusals. Non-accessible participants were those living outside of So! uthern California at the time of the interview.

A NOTE ON SELF REPORT

A number of studies have examined the validity and reliability of self-report concerning alcohol and drug use behavior, and in general, self-report has been consistently found to be reasonably accurate (Ball, 1967; Davidson & Stein, 1983; Hser, Anglin, & Chou, 1992; Hubbard, Eckerman, & Rachal, 1976; O'Malley, Bachman, & Johnson, 1983; Stacy, Widaman, Hays, & DiMatteo, 1985). Empirical evidence documents fairly high to near perfect rates of agreement between self-- reports and objective measures of alcohol and drug use such as urinalysis (Magura, Goldsmith, Casriel, Goldstein, & Lipton, 1987; Sherman & Bigelow, 1992). Additionally, the accuracy of self-report has been improved when strict confidentiality was guaranteed (Babor, Stephens, & Marlatt, 1987; Harrison & Hoffman, 1988; Hser et al. 1992; Hser, Maglione, & Boyle, 1999; O'Farrell, Cutter, Bayog, Dentch, & Forgang, 1984; O'Malley et al., 1983; Smith & Hoffmann, 1992) a! s was the case in this study.

RESULTS

12-STEP PARTICIPATION

Table 2 shows 12-Step participation patterns by gender and ethnicity. No significant differences in patterns of 12-Step participation was found between males and females (x^sup 2^ = 2.47, p = .481). Approximately 35% of females and 30% of males maintained weekly or more frequent participation in 12-Step programs (Persistors) over the 24-month study period. Females were also no more likely than males to drop out or never attend 12-Step programs.

Similarly, there are no statistically significant ethnic differences in patterns of 12-Step participation. African-Americans and Latinos are no less likely than European-Americans to maintain weekly participation in 12-Step programs (Persistors) over the 24-month period, and they are no more likely to drop out or never attend 12-Step programs.

12-STEP EFFECTIVENESS

Table 3 provides a general summary of alcohol and drug abstinence assessed at the 24-month follow-up by pattern of 12-Step participation. About 80% of all those who report weekly participation in 12-Step programs (Persistors) are alcohol and drug abstinent during the six months prior to the second follow-up. By contrast, of those who never attend 12-Step programs (Nonattenders), only about 39% maintain alcohol abstinence and 46% maintain drug abstinence.

Addressing the question of whether 12-Step programs are less effective for women and ethnic minorities, the findings reported in Table 4 provide evidence that participation in 12-Step programs is as effective for women and ethnic minorities as for European-American males. Of those identified as 12-Step Persistors (n =86), females are no less likely than males to maintain abstinence from alcohol and drug use. Additionally, when comparing each ethnic group individually with a combined other ethnic group, African-Americans, and Latinos are no less likely than European-Americans to maintain alcohol and drug abstinence.

DISCUSSION

Results from this study document the similarities in 12-Step participation and effectiveness for diverse gender and ethnic groups. Contrary to previous suppositions, women and ethnic minorities are equally as likely as European-- American males to attend 12-Step programs and to recover in conjunction with that participation. Although empirically documented differences in recovery and treatment issues as a function of gender (Grella, Perry, & Anglin, 1996) and ethnicity (Humphreys & Woods, 1993) have been reported, 12-Step Programs appear to be a recovery resource as useful to females and ethnic minorities as for European-American males. These are important findings that contradict others who have outlined why 12-Step may not be appropriate for some groups (Galaif & Sussman, 1995; Kaskutas, 1994). Although 12-Step may not be for everyone, these results indicate that gender and ethnic minorities are not systematically overlooked or excluded. Research to determin! e whether there are client characteristics that do predict successful 12-Step affiliation, however, should continue.

An important aspect of 12-Step programs is the open-door policy which allows entry to anyone wishing to recover from addiction. It may be that, in conjunction with this open-door policy, that the similarities of the addiction experience rather than demographic differences may be one reason why 12-Step seems to be equally utilized and effective for all gender and ethnic populations. Alternately, although 12-Step groups may share a general structure, philosophy, and techniques (Caetano, 1993), they also may be sufficiently flexible to reflect the local ecology and different needs and interests of participating community members (Humphries & Woods, 1993). The 12-Step program may be equally utilized and effective because it attends to the needs and interests of the gender and ethnic populations it serves.

The findings from this study have important clinical implications for individuals seeking a recovery resource, traditional treatment programs, and addiction specialists. Accepting the general effectiveness of 12-Step membership for those who regularly participate, the practice of recommending 12-Step participation or implementing 12-Step components into traditional treatment as a recovery resource may have been limited to groups such as women and ethnic minorities. Treatment providers may have questioned whether such recommendations were in the client's best interests, and may have avoided referrals or made referrals to 12-Step for women and/or ethnic minority clients with trepidation. These findings provide evidence that such apprehension is unwarranted. Although many with alcohol and drug problems choose not to participate in 12-Step, the current findings demonstrate that participation in 12-Step programs and the effectiveness of 12-Step programs are similar for recover! ing individuals from all gender and ethnic groups.

ACKNOWLEDGMENTS

This research was supported by the National Institute of Drug Abuse (NIDA) grants DA00301, DA 11047 and DA 11195. Please direct correspondence to: Maureen P. Hillhouse, UCLA Drug Abuse Research Center, 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA 90025, hillhous@ucla.edu.