For more than 150 years, support for the personal resolution of severe and persistent alcohol and other drug problems in the United States has been provided through three mechanisms: family, kinship, and informal social networks; peer-based recovery mutual aid societies; and professionally directed addiction treatment. This article: 1) briefly reviews the history of these traditional recovery supports, 2) describes the recent emergence of new recovery support institutions and a distinctive, all-inclusive culture of recovery, and 3) discusses the implications of these recent developments for the future of addiction treatment and recovery in the United States.
Peer-led mutual-help organizations addressing substance use disorder (SUD) and related problems have had a long history in the United States. The modern epoch of addiction mutual help began in the postprohibition era of the 1930s with the birth of Alcoholics Anonymous (AA). Growing from 2 members to 2 million members, AA's reach and influence has drawn much public health attention as well as increasingly rigorous scientific investigation into its benefits and mechanisms. In turn, AA's growth and success have spurred the development of myriad additional mutual-help organizations. These alternatives may confer similar benefits to those found in studies of AA but have received only peripheral attention. Due to the prodigious economic, social, and medical burden attributable to substance-related problems and the diverse experiences and preferences of those attempting to recover from SUD, there is potentially immense value in societies maintaining and supporting the growth of a diverse array of mutual-help options. This article presents a concise overview of the origins, size, and state of the science on several of the largest of these alternative additional mutual-help organizations in an attempt to raise further awareness and help broaden the base of addiction mutual help.
Over the past 75 years, Alcoholics Anonymous (AA) has grown from 2 members to over 2 million members. AA and similar organizations (e.g., Narcotics Anonymous [NA]) are among the most commonly sought sources of help for substance-related problems in the United States. It is only relatively recently, however, that the scientific community has conducted rigorous studies on the clinical utility and health care cost-offset potential of mutual-help groups and developed and tested professional treatments to facilitate their use. As a result of this research, AA as an organization has experienced an "empirical awakening," evolving from its peripheral status as a "nuisance variable" and perceived obstacle to progress to playing a more central role in a scientifically informed recovery oriented system of care. Also, professionally delivered interventions designed to facilitate the use of AA and NA ("Twelve-Step Facilitation" [TSF]) are now "empirically supported treatments" as defined by US federal agencies and the American Psychological Association. Under the auspices of health care reform, a rational societal response to the prodigious health and social burden posed by alcohol and other drug misuse should encompass the implementation of empirically based strategies (e.g., TSF) in order to maximize the use of ubiquitous mutual-help recovery resources.
BACKGROUND: Participation in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) during and following treatment has been found to confer recovery-related benefit among adults and adolescents, but little is known about emerging adults (18-24 years). This transitional life-stage is distinctive for greater distress, higher density of psychopathology, and poorer treatment and continuing care compliance. Greater knowledge would inform the utility of treatment referrals to 12-step organizations for this age-group.
METHODS: Emerging adults (N=303; 18-24 years; 26% female; 95% White; 51% comorbid [SCID-derived] axis I disorders) enrolled in a naturalistic study of residential treatment effectiveness assessed at intake, 3, 6, and 12 months on 12-step attendance and involvement and treatment outcomes (percent days abstinent [PDA]; percent days heavy drinking [PDHD]). Lagged hierarchical linear models (HLMs) tested whether attendance and involvement conferred recovery benefits, controlling for a variety of confounds.
RESULTS: The percentage attending 12-step meetings prior to treatment (36%) rose sharply at 3 months (89%), was maintained at 6 months (82%), but declined at 12 months (76%). Average attendance peaked at about 3 times per week at 3 months dropping to just over once per week at 12 months. Initially high, but similarly diminishing, levels of active 12-step involvement were also observed. Lagged HLMs found beneficial effects for attendance, but stronger effects, which increased over time, for active involvement. Several active 12-step involvement indices were associated individually with outcome benefits.
CONCLUSIONS: Ubiquitous 12-step organizations may provide a supportive recovery context for this high-risk population at a developmental stage where non-using/sober peers are at a premium.
For more than 150 years, support for the personal resolution of severe and persistent alcohol and other drug problems in the United States has been provided through three mechanisms: family, kinship, and informal social networks; peerbased recovery mutual aid societies; and professionally directed addiction treatment. This article: 1) briefly reviews the history of these traditional recovery supports, 2) describes the recent emergence of new recovery support institutions and a distinctive, all-inclusive culture of recovery, and 3) discusses the implications of these recent developm
Ensuring retention in longitudinal studies of individuals with substance use disorders (SUD) is a continual challenge for researchers. This study made several modifications to a highly intensive follow-up protocol (Scott, 2004), originally designed for adults with SUD, in order to adapt it to a group of adolescents in low-intensity outpatient SUD treatment (N = 127, M age 16.7 yrs) and to accommodate limitations in the financial resources available for study staffing and transportation. In the present sample, adolescent participants generally found it unreasonable for study staff to request to contact people outside their immediate family in order to locate them and to attempt to schedule interviews 3–6 months in advance, as specified in the original protocol. Changes were made to accommodate these concerns and follow-up rates remained high (85–91%). Even though this study is limited by its non-experimental nature, it provides a replicable example of a scaled-down, less costly version of a highly intensive follow-up protocol that can be used to achieve high follow-up rates in studies of adolescents with SUD. We hope this will be encouraging for researchers and program evaluators who have limited resources or who work with participants who express concerns about privacy or study burden.
The therapeutic alliance is deemed to be integral to psychotherapeutic interventions, yet little is known about the nature of its role in treatment for substance use disorders (SUD), especially among young people. We investigated baseline predictors of the therapeutic alliance measured midtreatment and tested whether the alliance influenced during-treatment changes in key process variables (psychological distress, motivation, self-efficacy, coping skills, and commitment to Alcoholics Anonymous/Narcotics Anonymous [AA/NA]) independent of these baseline influences. Young adults in residential treatment (N = 303; age 18-24 years) were assessed at intake, midtreatment, and discharge. Older age and higher baseline levels of motivation, self-efficacy, coping skills, and commitment to AA/NA predicted a stronger alliance. Independent of these influences, participants who developed a stronger alliance achieved greater reductions in distress during treatment. Findings clarify a role for alliance in promoting during-treatment changes through reducing distress.
There is considerable enthusiasm for the potential of genetics research for prevention and treatment of addiction and other mental disorders. As a result, clinicians are increasingly exposed to issues of genetics that are fairly complex, and for which they may not have been adequately prepared by their training. Studies suggest that the heritability of substance use disorders is approximately 0.5. Others report that family members of affected individuals experience a 4- to 8-fold increased risk of disorder themselves. Statements that addiction is "50% genetic" in origin may be taken by some to imply one's chances of developing the disorder, or that a lack of a positive family history confers immunity. In fact, such conclusions are inaccurate, their implications unwarranted given the true meaning of heritability. Through a review of basic concepts in genetic epidemiology, we attempt to demystify these estimates of risk and situate them within the broader context of addiction. Methods of inferring population genetic variance and individual familial risk are examined, with a focus on their practical application and limitations. An accurate conceptualization of addiction necessitates an approach that transcends specific disciplines, making a basic awareness of the perspectives of disparate specialties key to furthering progress in the field.
OBJECTIVE: Multiple studies have shown social network variables to mediate and predict drinking outcome, but, because of self-selection biases, these studies cannot reliably determine whether the influence is causal or correlational. The goal of this study was to evaluate evidence for a causal role for social network characteristics in determining long-term outcomes using state-of-the-art statistical methods.
METHOD: Outpatient and aftercare clients enrolled in Project MATCH (N = 1,726) were assessed at intake and at 3, 6, 9, 12, and 15 months; the outpatient sample was also followed to 39 months. Generalized linear modeling with propensity stratification tested whether changes in social network ties (i.e., number of pro-abstainers and pro-drinkers) at Month 9 predicted percentage of days abstinent and drinks per drinking day at 15 and 39 months, covarying for Alcoholics Anonymous (AA) attendance at Month 9.
RESULTS: An increase in the number of pro-drinkers predicted worse drinking outcomes, measured by percentage of days abstinent and drinks per drinking day, at Months 15 and 39 (p < .0001). An increase in the number of pro-abstainers predicted more percentage of days abstinent for both time periods (p < .01). The social network variables uniquely predicted 5%-12% of the outcome variance; AA attendance predicted an additional 1%-6%.
CONCLUSIONS: Network composition following treatment is an important and plausibly causal predictor of alcohol outcome across 3 years, adjusting for multiple confounders. The effects are consistent across patients exhibiting a broad range of alcohol-related impairment. Results support the further development of treatments that promote positive social changes and highlight the need for additional research on the determinants of social network changes.
BACKGROUND: Young adulthood represents a key developmental period for the onset of substance use disorder (SUD). While the number of young adults entering treatment has increased, little is known about the mechanisms of change and early recovery processes in this important clinical population. This study investigated during-treatment change in key therapeutic processes (psychological distress, motivation, self-efficacy, coping skills, and commitment to AA/NA), and tested their relation to outcome at 3 months post-treatment.
METHODS: Young adults undergoing residential treatment (N=303; age 18-24; 26% female; 95% Caucasian) were enrolled in a naturalistic prospective study and assessed at intake, mid-treatment, discharge, and 3 months following discharge. Repeated-measures and regression analyses modeled during-treatment change in process variables and impact on outcome.
RESULTS: Statistically significant medium to large effect sizes were observed for changes in most processes during treatment, with the exception of motivation, which was high at treatment intake and underwent smaller, but still significant, change. In turn, these during-treatment changes all individually predicted 3-month abstinence to varying degrees, with self-efficacy emerging as the sole predictor in a simultaneous regression.
CONCLUSIONS: Findings help to clarify the mechanisms through which treatment confers recovery-related benefit among young adults. At treatment intake, high levels of abstinence motivation but lower coping, self-efficacy, and commitment to AA/NA, suggests many entering treatment may be "ready and willing" to change, but "unable" to do so without help. Treatment appears to work, in part, by helping to maintain motivation while conferring greater ability and confidence to enact such change.
BACKGROUND: A major barrier to youth recovery is finding suitable sobriety-supportive social contexts. National studies reveal most adolescent addiction treatment programs link youths to community 12-step fellowships to help meet this challenge, but little is known empirically regarding the extent to which adolescents attend and benefit from 12-step meetings or whether they derive additional gains from active involvement in prescribed 12-step activities (e.g., contact with a sponsor and other fellowship members). Greater knowledge in this area would enhance the efficiency of clinical continuing care recommendations.
METHODS: Adolescent outpatients (N = 127; M age 16.7; 75% male; 87% white) enrolled in a naturalistic study of treatment effectiveness were assessed at intake and 3, 6, and 12 months later using standardized assessments. Mixed-effects models, controlling for static and time-varying confounds, examined the concurrent and lagged effects of 12-step attendance and active involvement on abstinence over time.
RESULTS: The proportion attending 12-step meetings was relatively low across follow-up (24 to 29%), but more frequent attendance was independently associated with greater abstinence in concurrent and, to a lesser extent, lagged models. An 8-item composite measure of 12-step involvement did not enhance outcomes over and above attendance, but separate components did; specifically, greater contact with a 12-step sponsor outside of meetings and more verbal participation during meetings.
CONCLUSIONS: The benefits of 12-step participation observed among adult samples extend to adolescent outpatients. Community 12-step fellowships appear to provide a useful sobriety-supportive social context for youths seeking recovery, but evidence-based youth-specific 12-step facilitation strategies are needed to enhance outpatient attendance rates.
AIMS: Evidence indicates that Alcoholics Anonymous (AA) participation reduces relapse risk but less is known about the mechanisms through which AA confers this benefit. Initial studies indicate self-efficacy, negative affect, adaptive social networks and spiritual practices are mediators of this effect, but because these have been tested in isolation, their relative importance remains elusive. This study tested multiple mediators simultaneously to help determine the most influential pathways.
DESIGN: Prospective, statistically controlled, naturalistic investigation examined the extent to which these previously identified mechanisms mediated AA attendance effects on alcohol outcomes controlling for baseline outcome values, mediators, treatment, and other confounders.
SETTING: Nine clinical sites within the United States.
PARTICIPANTS: Adults (n = 1726) suffering from alcohol use disorder (AUD) initially enrolled in a randomized study with two arms: aftercare (n = 774); and out-patient (n = 952) comparing three out-patient treatments (Project MATCH).
MEASUREMENTS: AA attendance during treatment; mediators at 9 months; and outcomes [percentage of days abstinent (PDA) and drinks per drinking day (DDD)] at 15 months.
FINDINGS: Among out-patients the effect of AA attendance on alcohol outcomes was explained primarily by adaptive social network changes and increases in social abstinence self-efficacy. Among more impaired aftercare patients, in addition to mediation through adaptive network changes and increases in social self-efficacy, AA lead to better outcomes through increasing spirituality/religiosity and by reducing negative affect. The degree to which mediators explained the relationship between AA and outcomes ranged from 43% to 67%.
CONCLUSION: While Alcoholics Anonymous facilitates recovery by mobilizing several processes simultaneously, it is changes in social factors which appear to be of primary importance.
A large proportion of emerging adults treated for substance use disorder (SUD) present with symptoms of negative affect and major depressive disorder (MDD). However, little is known regarding how these comorbidities influence important mechanisms of treatment response, such as increases in abstinence self-efficacy (ASE). This study tested the degree to which MDD and/or depressive symptoms interacted with during-treatment changes in ASE and examined these variables' relation to outcome at 3 months' posttreatment. Participants (N = 302; 74% male) completed measures at intake, midtreatment, end-of-treatment, and at 3-month follow-up. ASE was measured with the Alcohol and Drug Use Self-Efficacy (ADUSE) scale; depressive symptoms were assessed with the Brief Symptom Inventory 18 (BSI 18) Depression scale; and current MDD diagnoses were deduced from the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Random coefficient regression analyses focused on during-treatment changes in ASE, with BSI 18 scores and MDD diagnosis included as moderators. At intake, individuals with MDD or high levels of depressive symptoms had significantly lower ASE, particularly in negative affect situations. No evidence for moderation was found: ASE significantly increased during treatment regardless of MDD status. There was a main effect of BSI 18 Depression scores: those with lower BSI 18 scores had lower ASE scores at each time point. MDD and BSI 18 Depression did not predict 3-month outcome, but similar to previous findings ASE did predict abstinence status at 3 months. Treatment-seeking emerging adults with MDD merit particular clinical attention because of their lower reported self-efficacy throughout treatment. (PsycINFO Database Record (c) 2012 APA, all rights reserved).