Pagano, M.E., Krentzman, A.R., Onder, C.C., Baryak, J.L., Murphy, J.L., Zywiak, W.H., & Stout, R.L. (in press). Assessment of service to others in sobriety (SOS). Alcoholism Treatment Quarterly.
Pagano, M. E., Zeltner, B., Post, S., Jaber, J., Zywiak, W. H., & Stout, R. L. (2009). Who should I help to stay sober?: Helping behaviors among alcoholics who maintain long-term sobriety. Alcohol Treatment Quarterly, 27(1), 38-50.
Tonigan, J. S., Connors, G. J., Miller, W.R. (2003). Participation and involvement in Alcoholics Anonymous. In T. F. Babor & F. K. Del Boca (Eds.), Treatment Matching in Alcoholism (pp. 184-204). Cambridge, United Kingdom: Cambridge University Press.
Primary use / Purpose:
Giving, helping, volunteering, being of service, unselfishness, goodwill—whatever the term—human beings worldwide engage in generous, altruistic behavior toward others. Although such acts are, by definition, performed without expectation of external reward or reciprocation (Zemore & Pagano, 2009), they nonetheless provide specific benefits to the helper. A growing body of research shows evidence of the health benefits to helpers across the life span. Youths have been shown to enjoy lower levels of disciplinary problems (Calabrese & Schumer, 1986), better values, and educational improvement as a result of volunteer work (Astin & Sax, 1998; Calabrese & Schumer, 1986; Johnson, Beebe, Mortimer, & Snyder, 1998; Uggen & Janikula, 1999). Adults have been shown to enjoy greater happiness and life satisfaction (Ellison, 1991; Keyes, 1998), better social functioning (Keyes, 1998), decreased depression and anxiety (D. R. Brown, Gary, Greene, & Milburn, 1992; Rietschlin, 1998), and better mental health (Schwartz, Meisenhelder, Ma, & Reed, 2003) as the result of altruistic behavior. Older adults have been shown to enjoy positive affect, self-esteem, and social integration (Midlarsky & Kahana, 1994) as well as increased longevity (S. L. Brown, Nesse, Vinokur, & Smith, 2003; Moen, Dempster-McClain, & Williams, 1989; Post, 2007) as the result of volunteering and providing instrumental and emotional support. Researchers have begun to investigate the sobriety benefit to alcoholic helpers and to consider the helping activities professed to be salient to the recovery process.
Alcoholics Anonymous (AA) was established on a foundation of prosocial behavior (Humphreys & Kaskutas, 1995; Zemore, Kaskutas, & Ammon, 2004). AA’s preamble states its ‘‘primary purpose is to stay sober and help other alcoholics to achieve sobriety,’’ and its Twelfth Step states, ‘‘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’’ (A.A. World Services [AA], 1987, p. 60). In addition to the emphasis on service, AA literature cites the opposite of service—self-centeredness and self-involvement—as the alcoholic’s chief problem: ‘‘Above everything, we alcoholics must be rid of this selfishness. We must, or it kills us!’’ (AA, 2001, p. 62). Several investigations of 12-step programs have linked AA-related helping (AAH) with improved drinking outcomes. Early work identified two forms of AAH, sponsorship and practice of the 12th Step, to be reliable predictors of better drinking outcomes (Emrick, 1987; Emrick, Tonigan, Montgomery, & Little, 1993; Sheeren, 1988). When interviewing alcoholics, Crape, Latkin, Laris, and Knowlton (2002) found that being a sponsor was associated with an almost sevenfold increase in odds of abstinence at the initial interview, and a threefold increase in odds of abstinence at the one-year follow-up interview. When analyzing Project MATCH data, Pagano, Friend, Tonigan, and Stout (2004) found that those who sponsored others and/orworked the 12th step during treatment were twice as likely to remain sober in the 12 months posttreatment. Zemore and Kaskutas (2004) found that sponsorship and step-work were positively associated with longer sobriety, whereas other components of AA involvement were not. Pagano, Zeltner, and colleagues (2009) retrospectively studied the course of AAH among alcoholics with 20 or more years of sobriety. These ‘‘old timers’’ were found to participate in AAH in a pattern that increased linearly over time—not just in the first few months or years of sobriety, but throughout the next 20 years sober. Collectively, this body of work represents significant advances in the empirical study of AAH. However, as highlighted in a recent review by Zemore and Pagano (2009), work to date has been limited by a lack of consensus about how to define helping, among other factors. For instance, some researchers focus on emotional support, such as listening, whereas others focus on instrumental support, such as lending money. Some define helping by the absence of, or the degree to which one avoids, hurting others. Some define helping as actively giving (such as providing advice or information), and others define helping as being receptive (such as being patient with another person). Some define helping as interpersonal and intimate, whereas others define helping to include solitary environmental improvements such as picking up trash (Zemore & Pagano, 2009). Measurement strategies of AAH also vary. Some researchers measure beliefs about the impact of helping (e.g., Magura et al., 2003) whereas others measured specific helping behaviors themselves. Some measured time spent helping (Zemore & Kaskutas, 2004; Zemore et al., 2004), whereas others measured the frequency of specific helping behaviors (Pagano, Philips, Stout, Menard, & Piliavin, 2007). Some measured helping during treatment (e.g., Pagano et al., 2004; Zemore et al., 2004); others have studied the course of AAH over longer periods of time (Pagano, Zeltner, et al., 2009; Pagano, Zemore, Onder, & Stout, 2009). Researchers have used single items, qualitative coding strategies, quantitative scales, categorical items, and self-report measures of varying lengths (Zemore & Pagano, 2009). Some researchers combined several measurement strategies within a single instrument. What these varied AAH measurement strategies all share is a lack of demonstrated psychometric rigor.
Although pioneering work has made important inroads, our ability to measure AAH is limited. The first limitation pertains to the confusion that respondents may encounter when ascertaining their completion of the 12th Step. The 12th Step is a triple-barreled construct involving (1) having had a spiritual awakening, (2) trying to carry this message to alcoholics, and (3) practicing AA’s principles in ‘‘all our affairs’’ (Pagano et al., 2004). Respondents may not endorse this item if they see themselves as having completed some but not all aspects of the 12th Step. Items that ask about 12th step-work may also inadvertently sew problems into measurement by asking whether respondents have completed the 12th Step. Respondents may not endorse this item if they see the step as one they will never fully complete but will perform on an ongoing basis throughout their lives. Second, limiting AAH to help given by sponsors excludes the helping behaviors of those in early recovery, given the recommendation of one year of sobriety to provide sponsorship. Identifying prescribed acts of support to fellow sufferers was a step in the right direction. Zemore et al. (2004) developed a brief five-item instrument assessing time spent giving prescribed support to other alcoholics/addicts, including moral support, learned experience on how to stay clean and sober, learned experience about other problems, and how to get help inside and outside of the treatment program. However, these venues of help do not capture all the myriad of ways alcoholics routinely help fellow sufferers, assume that the amount of time giving support relates linearly to positive outcomes, and mainly assess support given within treatment settings. It is high time for the development of a validated assessment tool of AAH. Our operationalization of the construct under investigation, service to others within 12-step contexts, was informed in part by AA literature, altruism literature (Monroe, 2002), and pilot focus groups with AA members (Pagano, 2005). The following AA literature guided our careful selection of instrument items: ‘‘Working with Others,’’ a chapter in AA’s central text (AA, 2001); documented conversations with the founders of AA (AA, 1980); formal description of the 12 Steps (AA, 1987); and individual stories of recovering AA members (AA, 2001). Instrument item selection was also based on theoretical knowledge from the social science disciplines of bioethics and positive psychology. Service-oriented behaviors included in the scale reflect kindness toward and consideration of others (Burnstein, Crandall, & Kitayama, 1994) and embody behaviors recognized as altruistic (Monroe, 2002); the help given is voluntary, intentional, without expectation of external reward or reciprocation, and benefits another as its primary goal.
Service to others within 12-Step contexts was assessed with the 12-item SOS. Items are rated on a 5-point Likert-type scale from 1 (rarely) to 5 (always) with reference to the prior month. SOS items reflect acts of good citizenship as a member of a 12-step program (i.e., putting away chairs at meetings, donating money), formal service positions available in 12-step programs of recovery (i.e., donating money, public outreach, etc.), and AAH activities involving the transmission of one’s personal experience to another (i.e., sharing one’s personal story with another alcoholic, sharing progress with step-work). Prior work with SOS items among a small sample of alcoholics has shown adequate internal consistency (alpha D .82) and feasibility (fewer than 10 minutes to complete;Pagano, Zeltner, et al., 2009). Psychometric analyses with the SOS included item analysis, internal consistency, test–retest reliability, convergent validity, and receiver operator curve (ROC) analysis. Internal consistency was determined by calculating Cronbach’s alpha. Test–retest reliability was determined by comparing two administrations of the SOS using the Spearman rank-order correlation, a nonparametric measure of association based on the rank of the data values. For convergent validity and outcome analysis, the SOS was compared to the PSB, HSNS, and length of time sober using nonparametric Kruskal-Wallis chi-square tests. To identify the optimal cutoff score for the SOS, an ROC curve was constructed based on the SOS’s performance compared with the 2-item AAI criterion of AAH. For the purposes of interpretation, Cohen (1988) considers r D 0.10 ‘‘small,’’ r D 0.30 ‘‘medium,’’ and r D 0.50 ‘‘large.’’ All tests were double-sided, and partial-Bonferroni of p < .01 was used to avoid inflating the risk of Type 1 error. With regards to internal consistency, the Cronbach’s alpha for the SOS total score was 0.92, and ranged from 0.74 to 0.77 for individual SOS items. Test–retest item comparisons found large effect size correlations between administrations for all SOS items (rs D .60–.96). The Spearman rank-order correlation was 0.94 (p < .001) between the first and second administration of the SOS total score. The Spearman correlation was 0.62 (p < .001) between the SOS total score and other-oriented empathy PSB subscale. A trend emerged between the SOS total score and helpfulness PSB subscale (r D 0.33, p D 0.07). A cutoff score of 45 or higher was found to provide the highest average of sensitivity and specificity (SN D .78, SP D .64), the highest phi coefficient (phi D .50), and the highest degree of concordance (k D 54).