AIMS: 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).
METHOD: 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).
RESULTS: 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.
CONCLUSION: 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.
Adolescent substance use disorder treatment programs are often based on the 12-step philosophy of Alcoholics Anonymous and/or link adolescents to these free resources. Despite this, no studies have developed and rigorously tested a twelve-step facilitation (TSF) intervention for young people, leaving a significant evidence gap. This study describes the first systematic development of an outpatient adolescent TSF treatment. An integrated twelve-step facilitation (iTSF) treatment incorporated TSF, motivational enhancement therapy, and cognitive behavioral therapy elements and was developed in an iterative manner with weekly feedback provided by 36 adolescents (M age 17 years [SD = 1.4]; 52.8% white) with DSM-IV substance use disorder recruited from the community. Assessments were conducted at baseline and at three and six months. Participants completed 6 of 10 sessions on average (8 participants completed all 10). Notable treatment developments were the inclusion of "in-services" led by Marijuana Anonymous members, including parents in a portion of individual sessions to provide a rationale for TSF, and use of a Socratic therapeutic interaction style. Acceptability and feasibility of the treatment were excellent (treatment satisfaction was 4.29 [SD = 0.59] out of 5). In keeping with TSF theory, the intervention substantially increased 12-step participation, and greater participation related to greater abstinence. iTSF is a replicable manualized treatment that can be implemented and tested in outpatient settings. Given the widespread compatibility of iTSF with the current adolescent treatment, if found efficacious, iTSF could be relatively easily adopted, implemented, and sustained and could provide an evidence-based option that could undergird current practice.
Background: 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.
Method: 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).
Results: 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.
Conclusions: 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.
Petersen, T. J., Sprich, S., Wilhelm, S., Yeterian, J. D., Labbe, A., & Kelly, J. F. (2015). Substance use disorders. In The Massachusetts General Hospital Handbook of Cognitive Behavioral Therapy (pp. 197-210) . New York: Springer.
Kelly, J. F., & Yeterian, J. D. (2015). Outcomes research on 12-step programs. In M. Galanter, H. Kleber, & K. Brady (Ed.), Textbook of Substance Abuse Treatment (5th ed. pp. 579-593) . Washington (D.C.): American Psychiatric Publishing, Inc.
BACKGROUND: 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.
METHODS: 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, substance use disorder (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.
RESULTS: 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).
CONCLUSIONS: 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.
BACKGROUND: A growing body of research on adults with substance use disorders (SUDs) suggests that higher levels of religiosity and/or spirituality are associated with better treatment outcomes. However, investigation into the role of religiosity and spirituality in adolescent SUD treatment response remains scarce. The present study examines religiosity as a predictor of treatment outcomes in an adolescent sample, with alcohol/other drug problem recognition as a hypothesized moderator of this relationship. Problem recognition was selected as a moderator in an attempt to identify a subset of adolescents who would be more likely to use religious resources when attempting to change their substance use.
METHODS: One hundred twenty-seven outpatient adolescents aged 14 to 19 (Mage=16.7, SD=1.2, 24% female) were followed for 1 year after treatment intake. Growth curve analyses were used to assess the impact of baseline religiosity and problem recognition on subsequent abstinence rates, drug-related consequences, and psychological distress.
RESULTS: On average, abstinence did not change significantly during the follow-up period, whereas drug-related consequences and psychological distress decreased significantly. Religiosity did not predict changes in abstinence or psychological distress over time. Religiosity did predict reductions in drug-related consequences over time (b=-0.20, t=-2.18, P=.03). However, when problem recognition was added to the model, the impact of religiosity on consequences became nonsignificant, and there was no interaction between religiosity and problem recognition on consequences.
CONCLUSIONS: The main hypothesis was largely unsupported. Possible explanations include that the sample was low in religiosity and few participants were actively seeking sobriety at treatment intake. Findings suggest adolescent outpatients with SUD may differ from their adult counterparts in the role that religiosity plays in recovery.
The term “recovery” in the substance use disorder (SUD) field has been used generally and non-technically to describe global improvements in health and functioning typically following successful abstinence. More recently, however, in an attempt to reduce the stigma and negative public and clinical perceptions regarding remission potential for individuals suffering from SUD, “recovery” has been used more strategically to instil hope and to serve as an organizing paradigm that has inspired a growing recovery movement. In addition, with “recovery” gaining momentum internationally within governments' national health care agencies, there is increasing pressure to operationalise this construct as without it, it is difficult to develop, commission, and deliver the tailored packages of recovery support services needed to help individuals suffering from SUD. Initial attempts to define recovery and delineate its constituent parts have agreed on major elements, but differ on important subtleties; generally lacking has been a conceptual grounding of these definitions. The goal of this article is to promote further thought and debate by offering a conceptual basis for, and description of, the recovery construct that we hope enhances clarity and measurability. To accomplish this, we review existing definitions of recovery and offer a simplified bi-axial formulation and definition, reciprocal in nature, and grounded in stress and coping theory, which mirrors conceptually original formulations of the addiction syndrome.
Background: Research has shown that participation in Alcoholics Anonymous (AA) confers significant recovery benefit to adults suffering from alcohol use disorder (AUD). Concerns persist, however, that AA may not work as well for younger adults, who tend to have shorter addiction histories, different social circumstances, and less spiritual/religious interest than adults. Methods: Secondary data analysis of Project MATCH, using a prospective, moderated multiple mediation analysis to test and compare six previously identified mechanisms of change in younger adults (n = 266) vs. adults aged 30+ (n = 1460). Nine clinical sites within the United States. Treatment-seeking adults (n = 1726) suffering from AUD who participated in 12 weeks of outpatient treatment and completed follow-ups at 3-, 9- and 15-months. AA attendance during treatment; mediators at 9 months; and outcomes [percentage of days abstinent (PDA) and drinks per drinking day (DDD)] at 15 months. Results: AA attendance was associated with improved drinking outcomes in both younger adults (PDA: F(1, 247) = 8.55, p < 0.01; DDD: F(1, 247) = 15.93, p < 0.01) and adults aged 30+ (PDA: F(1, 1311) = 86.58, p < 0.01; DDD: F(1, 1311) = 11.96, p < 0.01). Only two of the six hypothesized pathways (i.e., decreases in pro-drinking social networks, self-efficacy in social situations) appeared to work in younger adults. Conclusion: Unidentified mechanisms of behavior change that are mobilized by AA participation appear to be at work in young people. Once identified, these mechanisms may shed new light on how exactly AA confers similar benefits for young people and, more broadly, may enhance our understanding of recovery-related change for young adults that could yield novel intervention targets.
The psychological construct of self-efficacy plays a key role in both general, as well as addiction-specific, models of health behavior change and is well supported empirically. As a predictor of treatment outcome it has proven useful; however, to further clarify the nature and role of self-efficacy in predicting the complexities of addiction recovery, it would seem crucial also to consider an individuals' motivation to carry out that future behavior, because the degree to which a measure of self-efficacy predicts behavior may be contingent upon whether that individual is also motivated to enact it. To this end, we tested an interaction model of self-efficacy and motivation on treatment outcome. Young adults (N = 302; M = 20 years; 74% male) undergoing residential substance use disorder treatment were assessed at treatment intake, discharge, and 3, 6, and 12 months postdischarge on self-efficacy (SE), motivation for sobriety (MS), and percent days abstinent (PDA). Hierarchical linear modeling (HLM) results revealed main effects for abstinence SE and MS across time, but a significant interaction was detected, indicating that the influence of SE on PDA depended on MS. Further analysis revealed that for patients high in SE the level of MS made a small, but significant, difference on PDA, whereas for those low in SE, high MS made a substantial difference, such that their outcome was not different than patients with high SE. Findings highlight conceptual nuances in SE theory; and, clinically, convey optimism that, even if a patient reports low confidence in their ability to remain abstinent, it does not necessarily follow that they will have poor outcome, especially if they have a strong recovery motivation.
Conduct disorder (CD) commonly co-occurs among adolescents with substance use disorder (SUD) and complicates the clinical course of SUD. Although research has begun to investigate CD's impact on adolescent response to SUD treatment, comparatively little is known about the effects of outpatient SUD treatment on this population. This study examined how co-occurring CD influences SUD treatment response as well as longer-term outcomes. Adolescent outpatients (N = 126; M age = 16.7, 25% female) with (i.e., SUD-CD; n = 52), and without CD (SUD-only; n = 74), were compared at baseline. Multilevel mixed models tested group effects on percent days abstinent (PDA) and other clinical and continuing care variables during and following treatment at 6 and 12 months. At baseline, SUD-CD participants had significantly greater psychiatric symptoms, substance use consequences, problem severity, and comorbid internalizing disorders. Both groups changed similarly on measured variables during treatment; however, the sample overall showed increases in PDA and drops in psychiatric symptoms. Following treatment, there were no differences in PDA between groups (p = .44). Both groups showed lower rates of psychiatric symptoms and arrests in the year following treatment, though SUD-CD still reported more psychiatric symptoms (p = .01) and higher inpatient (p = .02) and outpatient treatment (p = .04) utilization than SUD-only. SUD-CD patients may require a more psychiatrically integrated treatment approach during outpatient SUD treatment and more assertive and aggressive continuing care to reduce psychiatric distress, decrease the risk of further hospitalizations, and increase quality of life.
BACKGROUND: 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.
METHODS: 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.
RESULTS: 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.
CONCLUSIONS: 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.
BACKGROUND: Social factors play a key role in addiction recovery. Research with adults indicates individuals with substance use disorder (SUD) benefit from mutual-help organizations (MHOs), such as Alcoholics Anonymous, via their ability to facilitate adaptive network changes. Given the lower prevalence of sobriety-conducive, and sobriety-supportive, social contexts in the general population during the life-stage of young adulthood, however, 12-step MHOs may play an even more crucial recovery-supportive social role for young adults, but have not been investigated. Greater knowledge could enhance understanding of recovery-related change and inform young adults' continuing care recommendations.
METHODS: Emerging adults (N = 302; 18-24 yrs; 26% female; 95% White) enrolled in a study of residential treatment effectiveness were assessed at intake, 1, 3, 6, and 12 months on 12-step attendance, peer network variables ("high [relapse] risk" and "low [relapse] risk" friends), and treatment outcomes (Percent Days Abstinent; Percent Days Heavy Drinking). Hierarchical linear models tested for change in social risk over time and lagged mediational analyses tested whether 12-step attendance conferred recovery benefits via change in social risk.
RESULTS: High-risk friends were common at treatment entry, but decreased during follow-up; low-risk friends increased. Contrary to predictions, while substantial recovery-supportive friend network changes were observed, this was unrelated to 12-step participation and, thus, not found to mediate its positive influence on outcome.
CONCLUSIONS: Young adult 12-step participation confers recovery benefit; yet, while encouraging social network change, 12-step MHOs may be less able to provide social network change directly for young adults, perhaps because similar-aged peers are less common in MHOs. Findings highlight the importance of both social networks and 12-step MHOs and raise further questions as to how young adults benefit from 12-step MHOs.
Alcoholics Anonymous (AA) is based on a spiritual program of action. In keeping with AA's spiritually based recovery theory, rigorous studies have revealed that spirituality may be one of the mechanisms through which AA aids recovery. A question that has lingered, however, is how exactly does an increase in spiritual beliefs and practices translate into more abstinence and remission? To help answer this question, this article reviews theory and research related to AA and spirituality as a mechanism of behavior change and offers five possible psychological pathways that may help explain how increases in spirituality may translate into enhanced abstinence and remission rates.
From an addiction treatment and recovery standpoint maladaptive motivational hierarchies lie at the core of the challenge in mobilizing salutary behavior change. Motivation has been conceptualized as dynamic, interactive and modifiable, as well as multidimensional. Measures of recovery motivation have been developed and validated, but are generally only modest and variable predictors of future behavior. A related, but potentially more potent, construct, is that of commitment to sobriety as it denotes a clearer re-ranking of motivational hierarchies such that the recovery task is now given a top priority potentially less susceptible to the risks associated with undulating future circumstance. This study investigated the psychometric properties of a novel commitment to sobriety scale (CSS). Results revealed a coherent, psychometrically valid, and reliable tool that outperformed an existing commitment to abstinence scale (ATAQ; J. Morgenstern, R.M. Frey, B.S. McCrady, E. Labouvie, & C.J. Neighbors, 1996) and a gold standard measure of motivation (SOCRATES; W.R. Miller & J.S. Tonigan, 1996). This study highlights commitment to sobriety as an important addiction construct. Researchers and theoreticians may find the CSS useful in helping to explain how individuals achieve recovery, and practitioners may find clinical utility in the CSS in helping identify patients in need of more intensive or alternative intervention.
Objective: College students embrace mobile cell phones (MCPs) as a primary communication and entertainment device. The aim of this study was to investigate college students’ perceptions toward using mHealth technology to deliver interventions to prevent high-risk drinking and associated consequences.
Design/setting: Four focus group interviews were conducted during the spring and fall of 2011 at a large public university in the southeastern United States of America (USA) to collect data on the applicability of mHealth technology to alcohol-prevention programmes. The participants were students currently enrolled in a face-to-face alcohol-prevention programme.
Method: Thematic analysis of the content in the transcriptions was used to analyse the focus group responses using a codebook.
Results: Four major themes emerged which were: (1) education and usability; (2) Skype capabilities; (3) enhanced social networking; and (4) use for tracking and feedback. All of the participants said they would join an alcohol-intervention programme that incorporated mHealth mobile technology as a primary mode of communication.
Conclusions: The positive responses to the use of mobile applications indicate that use of interactive, real-time technology would be valuable to college students. Given the cost of face-to-face delivery of interventions, the findings are encouraging and support further exploration of the application of mHealth technology. Mobile technologies (mHealth) could provide a more effective delivery of alcohol-intervention programmes and increase the accessibility, relevance, and value of alcohol-intervention programmes.