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Factor structure and internal consistency measures were examined across time points to assess factorial invariance. Factors were extracted using principal axis factoring and orthogonally rotated using a Varimax rotation. Considering the slight variation between factors at each administration 3-, 6- and month , we assembled the final factors by including items that loaded most highly on the respective factor s at 2 or more administrations. We then computed Spearman rank order correlations to examine the bivariate relationships among the incipient TPS factors and the other variables of interest e.
Prior to conducting the mediation analyses, given significant skewness, we transformed the dependent variable, PDA, using a negative log transformation. To avoid temporal confounding among the independent variables step attendance and step involvement , the mediator TPS , and the outcome variable PDA , we employed a lagged and a partially lagged mediational design Figure 1. The fully lagged model examined step attendance and involvement from 1—3 months post-treatment, the TPS mediator 4—6 months post-treatment, and PDA 6—12 months post-treatment.
The partially lagged model examined step attendance and involvement from 4—6 months post-treatment, mediators 6—12 months post-treatment and PDA 6—12 months post-treatment. This partially lagged model was investigated because we wanted to assess for any potential differential effects among variables later in the course of recovery given that the Twelve Promises are deemed to take a while to accrue typically following substantial participation in step MHOs Alcoholics Anonymous, , p. It would have been more ideal had there been a subsequent follow-up for PDA i. To help rule out causes of change in the mediators and outcomes beyond the effects of step attendance and involvement, we controlled for other independent predictors of PDA age, self-efficacy and commitment to sobriety , predictors of attrition education , treatment related variables associated with PDA, and baseline levels of the outcome and mediator variables.
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To statistically assess mediation, the Sobel statistic was calculated to quantify the mediational effect of the TPS subscale on the predictor-outcome relationship. In addition, we calculated the percent of the total effect that was mediated by the TPS subscale and the ratio of the indirect to the direct effect. All analyses were generated using SAS Version 9.
At 6-months, attendance dropped to approximately The number of participants receiving additional SUD treatment dropped to Further details on step participation in this sample may be found elsewhere Kelly et al, a , The principal axis factoring extraction yielded two interpretable factors that were consistent across three administrations accounting for Factor labels were determined based on the item content and consequently were denoted as Psychological Wellbeing factor 1 and Freedom from Craving factor 2.
Psychological Wellbeing consisted of thirteen items derived from eight of the Twelve Promises see Table 1. Freedom from Craving consisted of three items derived from one of the step promises. The internal consistency did not appreciably change when any one item was removed for either factor.
Spearman rank order correlations revealed significant bivariate associations between step attendance, step involvement, psychological wellbeing, freedom from craving and PDA Table 2. Increased attendance and involvement at any time point appeared to be most strongly associated with greater Psychological Wellbeing and Freedom from Craving at months, with one exception: Greater levels of Psychological Wellbeing and Freedom from Craving were most strongly associated with higher PDA concurrently at each administration respectively.
Conversely, levels of attendance and involvement 1—3 months post-treatment were not significantly associated with PDA at 12 months. Mediation model Paths for the effects of step meeting attendance and involvement on mediators and PDA. All models controlling for predictors of attrition education , baseline levels of PDA, baseline levels of the mediator, and predictors of PDA age, commitment to sobriety and self-efficacy at baseline.
When considered together, the parameter estimates produced by these models provide some evidence of mediation when tested formally using the mediational approach and the Sobel product of coefficients test. Results from the partially lagged mediation model demonstrated that Freedom from Craving explained There was some additional evidence for mediation with respect to Freedom from Craving in the fully lagged models, which explained Psychological Wellbeing, in contrast, was not found to mediate either attendance or involvement on PDA in either the fully or partially lagged models Table 4.
The two sub-scales showed stability across follow-up assessments and possessed high internal consistency. Mediational testing, however, found that only Freedom from Craving, and not Psychological Wellbeing, helped explain the effect of step attendance on later abstinence. Findings add important new information to the limited body of evidence in mechanisms research examining step mediators of behavior change Kelly et al, ; consequently, findings have implications for AA theory and in understanding how AA and similar step organizations may confer benefit and aid addiction recovery.
The TPS Psychological Wellbeing subscale was found to increase significantly in relation to greater step attendance in the partially, but not fully, lagged model. The partially lagged model measured the Promises at month follow-up as opposed to the 6-month follow-up in the fully lagged model. As alluded to earlier, the emergence of the significant relationship at the later follow-up may be because it takes a longer duration of participation in step MHOs before members begin to accrue more of these positive psychological and emotional benefits.
Concretely, in the AA main text Alcoholics Anonymous, , the Twelve Promises are surmised to emerge only after completing the first nine of the steps, implying a considerable duration of involvement. In future research we plan to examine the TPS at later follow-up points to help determine whether these begin to accrue following longer step tenure. Contrary to predictions, attendance was related to greater Psychological Wellbeing but greater step involvement was not. This was surprising since more active participation in terms of having and using a sponsor, working the steps, reading step literature, and verbally participating during meetings, in theory, might be expected to accelerate accrual of these benefits.
It may be the case, however, that the Promises are more a function of extensity rather than intensity of participation or, at least, need some time to emerge. Again, however, we think it prudent to examine these relationships over longer periods of time to help support or refute this notion.
Similarly, the Freedom from Craving subscale was found to increase significantly in relation to greater step attendance in the partially lagged, but not the fully lagged model, and again, involvement was not related to greater Freedom from Craving. In terms of successfully meeting all significant paths that are necessary for the support of a mediational effect, this was found only for the Freedom from Craving subscale.
Noteworthy, too, was the amount of the direct effect that was explained by this factor; this ranged from Generalizations from the current study should be made with caution in light of certain limitations. Now, as my own long term recovery endures, I finally have the opportunity to share my ideas and experiences with others.
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In my books, The Bipolar Challenge and Memoirs of a Bipolar Soul, I have written about my life in some detail and given some suggestions about symptom management. During these presentations I continue to share my story and exchange ideas with others. These presentations have included: hospitals, middle schools and high schools, colleges and universities, a medical school, nursing schools, support groups, senior centers, and police trainings. Not surprisingly, during these presentations, certain topics continue to surface that deeply interest individuals with bipolar disorder, mental health professionals, and their families.
These discussions have challenged my own perceptions and deepened my understanding of the illness and its effect on everyone who encounter it. After giving a number of these talks, I soon realized that these recurring themes could be expanded upon, far beyond the limits of my other books. So, in my new book, The Promise of Long Term Recovery, I have decided to share some of my ideas that reflect a more in depth look at some relevant challenges many of us face.
This includes some pressing and persistent problems associated with long term recovery and some useful ideas for inner stability and growth. In addition, I also point out some of the differences in viewpoints among mental health professionals, families and individuals in regard to the treatment of bipolar disorder. The purpose of The Promise of Long Term Recovery is to examine the symptoms of bipolar disorder with a fresh perspective. While underscoring the essential need for medications, counseling, and coping skills, this interpretation is also presented as an opportunity for creative expression and spiritual evolution.
In this effort to expand on some traditional beliefs about bipolar disorder, delusional states are described as having underlying significance for individuals even though these states of mind are largely ignored by mental health professionals. Yet, if these symptoms do, in fact, provide some sense of purpose for those of us with a mental illness, then, I believe, these symptoms may continue to manifest until these needs are addressed not only medically and psychologically, but also, creatively and spiritually.
However, this book is not meant to be considered as a debate over whether bipolar disorder is a major illness or not. Nor does this book suggest that will power and creativity alone can take the place of medication and counseling.
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