Substance use and substance-related disorders are among the most prodigious public health problems in the United States. Emerging adults (ages 18–25) appear to carry a disproportionately large share of this societal burden, as they are more than twice as likely as adolescents and older adults to be diagnosed with substance use disorders (SUDs), and comprise more than 20% of SUD treatment seekers. Described as the "age of feeling in-between," emerging adulthood is associated with a biopsychosocial profile distinct from both adolescence and older adulthood, making members of this age group unique and challenging clinical cases. Data suggest that although emerging adults can benefit from cognitive-behavioral (CB) and other psychosocial treatments for SUD, they are likely to have poorer treatment response than their younger and older counterparts. Therefore, we propose several theoretically and empirically-grounded treatment modifications for this vulnerable group, such as parent counseling (or "coaching") to facilitate better treatment engagement and benefit via contingency management. A case example is used to illustrate challenges typical in SUD treatment for emerging adults and how a CB practitioner might choose to modify his/her approach based on the proposed modifications. We also offer several recommendations for practitioners who wish to address their patients' SUD or harmful substance use when it is not the primary focus of treatment.
While a growing body of literature supports the role of mutual help organizations in helping members achieve abstinence, fellowships other than Alcoholics Anonymous and outcomes beyond abstinence have been studied far less often. The current study examined recovery-related correlates of psychological well-being in a sample of Narcotics Anonymous (NA) members. Participants (N = 128) were self-identified NA members from across the United States who completed an online survey assessing an array of psychosocial outcomes. Hierarchical regression models assessed whether abstinence duration and other recovery-related variables accounted for significant incremental variance in psychological well-being, over and above several covariates. As a block, abstinence duration and the recovery predictors accounted for significant incremental variance in three of four psychological well-being domains. As a complement to studies on short-term benefits of mutual help organizations, these data suggest ongoing recovery involvement may be positively associated with subjective psychological well-being in NA members.
Smartphone technology is ideally suited to provide tailored smoking cessation support, yet it is unclear to what extent currently existing smartphone "apps" use tailoring, and if tailoring is related to app popularity and user-rated quality.
We conducted a content analysis of Android smoking cessation apps (n = 225), downloaded between October 1, 2013 to May 31, 2014. We recorded app popularity (>10,000 downloads) and user-rated quality (number of stars) from Google Play, and coded the existence of tailoring features in the apps within the context of using the 5As ("ask," "advise," "assess," "assist," and "arrange follow-up"), as recommended by national clinical practice guidelines.
Apps largely provided simplistic tools (eg, calculators, trackers), and used tailoring sparingly: on average, apps addressed 2.1 ± 0.9 of the 5As and used tailoring for 0.7 ± 0.9 of the 5As. Tailoring was positively related to app popularity and user-rated quality: apps that used two-way interactions (odds ratio [OR] = 5.56 [2.45-12.62]), proactive alerts (OR = 3.80 [1.54-9.38]), responsiveness to quit status (OR = 5.28 [2.18-12.79]), addressed more of the 5As (OR = 1.53 [1.10-2.14]), used tailoring for more As (OR = 1.67 [1.21-2.30]), and/or used more ways of tailoring 5As content (OR = 1.35 [1.13-1.62]) were more likely to be frequently downloaded. Higher star ratings were associated with a higher number of 5As addressed (b = 0.16 [0.03-0.30]), a higher number of 5As with any level of tailoring (b = 0.14 [0.01-0.27]), and a higher number of ways of tailoring 5As content (b = 0.08 [0.002-0.15]).
Publically available smartphone smoking cessation apps are not particularly "smart": they commonly fall short of providing tailored feedback, despite users' preference for these features.
J. F. Kelly, C. O'Connor, and B.G. Bergman. 2016. “ Narcotics Anonymous.” In Sage encyclopedia of abnormal and clinical psychology, edited by A. E. Wenzel, Pp. 2188-2190. Thousand Oaks, CA: Sage Publications.
The "therapeutic alliance" between clinicians and patients has been associated with treatment response and outcomes in professionally-delivered psychotherapies. Although 12-step mutual help organizations (MHOs), such as Alcoholics Anonymous, are the most commonly sought source of support for individuals with substance use disorder (SUD), little is known about whether a stronger alliance in comparable MHO relationships between 12-step sponsors and those they help ("sponsees") confers benefits similar to those observed in professional contexts. Greater knowledge could inform clinical recommendations and enhance models that explain how individuals benefit from 12-step MHOs.
Young adults (N=302) enrolled in a prospective, clinical effectiveness study of residential SUD treatment were assessed at treatment entry, and 3, 6, and 12 months after discharge on whether they had a sponsor, contact with a sponsor, and degree of sponsor alliance. Hierarchical linear models (HLM) tested their effects on 12-step MHO attendance, involvement, and percent days abstinent (PDA).
Approximately two-thirds of the sample (n=208, 68.87%) reported having a sponsor at one or more follow-up time points. Both having sponsor contact and stronger sponsor alliance were significantly associated with greater 12-step participation and abstinence, on average, during follow-up. Interaction results revealed that more sponsor contact was associated with increasingly higher 12-step participation whereas stronger sponsor alliance was associated with increasingly greater abstinence.
Similar to the professional-clinical realm, the "therapeutic alliance" among sponsees and their sponsors predicts better substance use outcomes and may help augment explanatory models estimating effects of MHOs in SUD recovery.
Within 12-step mutual-help organizations (MHOs), a sponsor plays a key recovery-specific role analogous to a ‘lay therapist’, serving as a role model, support and mentor. Research shows that attendees who have a sponsor have higher rates of abstinence and remission from substance use disorder (SUD), yet, while myriad formal psychotherapy studies demonstrate the therapeutic significance of the alliance between patients and professional clinicians on treatment outcomes, very little is known about the influence of the ‘therapeutic alliance’ between 12-step members and their sponsor. Greater knowledge about this key 12-step relationship could help explain greater degrees of 12-step effects. To bridge this gap, this study sought to develop and test a measure assessing the 12-step sponsee–sponsor therapeutic alliance—the Sponsor Alliance Inventory (SAI).
Young adults (N = 302) enrolled in a prospective effectiveness study who reported having a 12-step sponsor during the study (N = 157) were assessed at treatment entry, and 3, 6 and 12 months later on the SAI, their 12-step MHO attendance, involvement and percent days abstinent (PDA).
Principal axis extraction revealed a single, 10-item, internally consistent (α's ≥ 0.95) scale that explained the majority of variance and was largely invariant to primary substance, gender and time. Criterion validity was also supported with higher SAI scores predicting greater proximal 12-step attendance, involvement and PDA.
The SAI may serve as a brief, valid measure to assess the degree of sponsee–sponsor ‘therapeutic alliance’ within 12-step communities and may help augment explanatory models estimating the effects of MHOs on recovery outcomes.
Professional continuing care services enhance recovery rates among adults and adolescents, though less is known about emerging adults (18-25 years old). Despite benefit shown from emerging adults’ participation in 12-step mutual-help organizations (MHOs), it is unclear whether participation offers benefit independent of professional continuing care services. Greater knowledge in this area would inform clinical referral and linkage efforts.
Emerging adults (N = 284; 74% male; 95% Caucasian) were assessed during the year after residential treatment on outpatient sessions per week, percent days in residential treatment and residing in a sober living environment, SUD medication use, active 12-step MHO involvement (e.g., having a sponsor, completing step work, contact with members outside meetings), and continuous abstinence (dichotomized yes/no). One generalized estimating equation (GEE) model tested the unique effect of each professional service on abstinence, and, in a separate GEE model, the unique effect of 12-step MHO involvement on abstinence over and above professional services, independent of individual covariates.
Apart from SUD medication, all professional continuing care services were significantly associated with abstinence over and above individual factors. In the more comprehensive model, relative to zero 12-step MHO activities, odds of abstinence were 1.3 times greater if patients were involved in one activity, and 3.2 times greater if involved in five activities (lowest mean number of activities in the sample across all follow-ups).
Both active involvement in 12-step MHOs and recovery-supportive, professional services that link patients with these community-based resources may enhance outcomes for emerging adults after residential treatment.
Narcotics Anonymous (NA) is a community-based, 12-step organization that holds nearly 62,000 meetings weekly in 129 countries. Relatively little is known about NA members’ recovery experiences. This study presents results of focus groups conducted with long-term NA members to identify key ingredients of recovery, recovery-related processes, and quality-of-life outcomes beyond abstinence. Participants identified personal and program characteristics that were critical to recovery (e.g., responsibility), illuminated several recovery-related processes (e.g., using the 12 steps to obtain a deeper self-understanding), and described personal and interpersonal quality-of-life enhancements (e.g., improved relationships). In addition, fellowship was described as a pervasive and essential element of recovery.
Generalist mental health practitioners are likely to encounter patients with substance use disorders, indicating community-based, 12-Step mutual-help organizations (MHOs) can be a valuable referral source for these clinicians. Little is known, however, about how generalist practitioners and trainees understand these organizations. Results of a survey among 316 clinical trainees showed that knowledge levels were below a competency benchmark. While views were positive overall, empirically-inconsistent beliefs were also common. Beliefs and attitudes accounted for approximately one half of the variance in professional intentions (e.g., appropriate referral). The study highlighted knowledge gaps, though trainees appeared open to learning more about 12-Step MHOs. Thus systematic development and evaluation of clinical training in the area may be warranted.
Evidence indicates that 12-step mutual-help organizations (MHOs), such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), can play an important role in extending and potentiating the recovery benefits of professionally delivered addiction treatment among young adults with substance use disorders (SUD). However, concerns have lingered regarding the suitability of 12-step organizations for certain clinical subgroups, such as those with dual diagnosis (DD). This study examined the influence of diagnostic status (DD vs. SUD-only) on both attendance and active involvement (e.g., having a sponsor, verbal participation during meetings) in, and derived benefits from, 12-step MHOs following residential treatment.
Young adults (N = 296; 18 to 24 years old; 26% female; 95% Caucasian; 47% DD [based on structured diagnostic interview]), enrolled in a prospective naturalistic study of SUD treatment effectiveness, were assessed at intake and 3, 6, and 12 months posttreatment on 12-step attendance/active involvement and percent days abstinent (PDA). t-Tests and lagged, hierarchical linear models (HLM) examined the extent to which diagnostic status influenced 12-step participation and any derived benefits, respectively.
For DD and SUD-only patients, posttreatment attendance and active involvement in 12-step organizations were similarly high. Overall, DD patients had significantly lower PDA relative to SUD-only patients. All patients appeared to benefit significantly from attendance and active involvement on a combined 8-item index. Regarding the primary effects of interest, significant differences did not emerge in derived benefit between DD and SUD-only patients for either attendance (p = 0.436) or active involvement (p = 0.062). Subsidiary analyses showed, however, that DD patients experienced significantly greater abstinence-related benefit from having a 12-step sponsor.
Despite concerns regarding the clinical utility of 12-step MHOs for DD patients, findings indicate that DD young adults participate and benefit as much as SUD-only patients, and may benefit more from high levels of active involvement, particularly having a 12-step sponsor. Future work is needed to clarify how active 12-step involvement might offset the additional recovery burden of a comorbid mental illness on substance use outcomes.
Opioid misuse and dependence rates among emerging adults have increased substantially. While office-based opioid treatments (e.g., buprenorphine/naloxone) have shown overall efficacy, discontinuation rates among emerging adults are high. Abstinence-based residential treatment may serve as a viable alternative, but has seldom been investigated in this age group.
Emerging adults attending 12-step-oriented residential treatment (N=292; 18-24 years, 74% male, 95% White) were classified into opioid dependent (OD; 25%), opioid misuse (OM; 20%), and no opiate use (NO; 55%) groups. Paired t-tests and ANOVAs tested baseline differences and whether groups differed in their during-treatment response. Longitudinal multilevel models tested whether groups differed on substance use outcomes and treatment utilization during the year following the index treatment episode.
Despite a more severe clinical profile at baseline among OD, all groups experienced similar during-treatment increases on therapeutic targets (e.g., abstinence self-efficacy), while OD showed a greater decline in psychiatric symptoms. During follow-up relative to OM, both NO and OD had significantly greater Percent Days Abstinent, and significantly less cannabis use. OD attended significantly more outpatient treatment sessions than OM or NO; 29% of OD was completely abstinent at 12-month follow-up.
Findings here suggest that residential treatment may be helpful for emerging adults with opioid dependence. This benefit may be less prominent, though, among non-dependent opioid misusers. Randomized trials are needed to compare more directly the relative benefits of outpatient agonist-based treatment to abstinence-based, residential care in this vulnerable age-group, and to examine the feasibility of an integrated model.
Compared to other life stages, young adulthood (ages 18-24) is characterized by qualitative differences including the highest rates of co-occurring substance use and psychiatric disorders (COD). Little is known, however, regarding young adults' response to substance use disorder (SUD) treatment, especially those with COD. Greater knowledge in this area could inform and enhance the effectiveness and efficiency of SUD care for this patient population. The current study investigated differences between 141 COD and 159 SUD-only young adults attending psychiatrically-integrated residential SUD treatment on intake characteristics, during-treatment changes on clinical targets (e.g., coping skills; abstinence self-efficacy), and outcomes during the year post-discharge. Contrary to expectations, despite more severe clinical profiles at intake, COD patients showed similar during-treatment improvements on clinical target variables, and comparable post-treatment abstinence rates and psychiatric symptoms. Clinicians referring young adults with COD to specialized care may wish to consider residential SUD treatment programs that integrate evidence-based psychiatric services.
Alcoholics Anonymous (AA) is the most prevalent 12-step mutual-help organization (MHO), yet debate has persisted clinically regarding whether patients whose primary substance is not alcohol should be referred to AA. Narcotics Anonymous (NA) was created as a more specific fit to enhance recovery from drug addiction; however, compared with AA, NA meetings are not as ubiquitous. Little is known about the effects of a mismatch between individuals' primary substance and MHOs, and whether any incongruence might result in a lower likelihood of continuation and benefit. More research would inform clinical recommendations.
Young adults (N = 279, M age 20.4, SD 1.6, 27% female; 95% White) in a treatment effectiveness study completed assessments at intake, and 3, 6, and 12 months post-treatment. A matching variable was created for 'primary drug' patients (i.e. those reporting cannabis, opiates or stimulants as primary substance; n = 198/279), reflecting the proportion of total 12-step meetings attended that were AA. Hierarchical linear models (HLMs) tested this variable's effects on future 12-step participation and percent days abstinent (PDA).
The majority of meetings attended by both alcohol and drug patients was AA. Drug patients attending proportionately more AA than NA meetings (i.e. mismatched) were no different than those who were better matched to NA with respect to future 12-step participation or PDA.
Drug patients may be at no greater risk of discontinuation or diminished recovery benefit from participation in AA relative to NA. Findings may boost clinical confidence in making AA referrals for drug patients when NA is less available.
The majority of adolescents treated for substance use disorder (SUD) in the United States are now referred by the criminal justice system. Little is known, however, regarding how justice-system involvement relates to adolescent community treatment outcomes. Controversy exists, also, over the extent to which justice system involvement reflects a lack of intrinsic motivation for treatment. This study examined the relation between justice system referral and reported reason for treatment entry and tested the extent to which each predicted treatment response and outcome.
Adolescent outpatients (N = 127; M age = 16.7, 24% female) with varying levels of justice-system involvement (i.e., no justice system involvement [No-JSI; n = 63], justice-system involved [JSI; n = 40], justice system involved-mandated [JSI-M; n = 24]) and motivation levels (i.e., self-motivated [n = 40], externally-motivated [n = 87]) were compared at treatment intake. Multilevel mixed models tested these groups' effects on percent days abstinent (PDA) and odds of heavy drinking (HD) over 12 months.
JSI-M were less likely to be self-motivated compared to No-JSI or JSI (p = 0.009). JSI-M had higher PDA overall, but with significant declines over time, relative to no-JSI. Self-motivated patients did not differ from externally-motivated patients on PDA or HD.
Mandated adolescent outpatients were substantially less likely to report self-motivated treatment entry. Despite the notion that self-motivated treatment entry would be likely to produce better outcomes, a judicial mandate appears to predict an initially stronger treatment response, although this diminishes over time. Ongoing monitoring and/or treatment may be necessary to help maintain treatment gains for justice system-involved adolescents.
Participation in 12-step mutual help organizations (MHO) is a common continuing care recommendation for adults; however, little is known about the effects of MHO participation among young adults (i.e., ages 18-25 years) for whom the typically older age composition at meetings may serve as a barrier to engagement and benefits. This study examined whether the age composition of 12-step meetings moderated the recovery benefits derived from attending MHOs.
Young adults (N=302; 18-24 yrs; 26% female; 94% White) enrolled in a naturalistic study of residential treatment effectiveness were assessed at intake, and 3, 6, and 12 months later on 12-step attendance, age composition of attended 12-step groups, and treatment outcome (Percent Days Abstinent [PDA]). Hierarchical linear models (HLM) tested the moderating effect of age composition on PDA concurrently and in lagged models controlling for confounds.
A significant three-way interaction between attendance, age composition, and time was detected in the concurrent (p=0.002), but not lagged, model (b=0.38, p=0.46). Specifically, a similar age composition was helpful early post-treatment among low 12-step attendees, but became detrimental over time.
Treatment and other referral agencies might enhance the likelihood of successful remission and recovery among young adults by locating and initially linking such individuals to age appropriate groups. Once engaged, however, it may be prudent to encourage gradual integration into the broader mixed-age range of 12-step meetings, wherein it is possible that older members may provide the depth and length of sober experience needed to carry young adults forward into long-term recovery.
C. DeLucia and B.G. Bergman. 2010. “Interaction.” In Encyclopedia of research design, edited by N. J. Salkind, Pp. 610-615. Thousand Oaks, CA: Sage Publications. Publisher's Version
Despite the multitude of published accounts that focus on “aggressive athletes,” scientific investigation into aggression and violence within an athletic population has been surprisingly absent. Publications have often been more editorial in nature, with scientific rigor, sound methodology, and empirical exploration appearing to be secondary concerns. The present review seeks to summarize what is currently known about aggression and violence in sports through actual empirical investigation. The information presented herein was synthesized from the inclusion of studies that met strict scientific and methodological inclusion criteria, representing less than one-third of published studies on the subject over the past 30 years.