Greene, C. M., & Kelly, J. F. (2014). The prevalence of cannabis withdrawal and its influence on adolescents' treatment response and outcomes: A 12-month prospective investigation. Journal of Addiction Medicine , 8 (5), 359-367 . LWW. Publisher's VersionAbstract


BACKGROUND: Withdrawal, a diagnostic indicator of cannabis use disorder, is often minimized or ignored as a consequence of cannabis use, particularly among adolescents. This study aims to characterize cannabis withdrawal among adolescents in outpatient treatment for substance use disorder and evaluate the clinical significance of withdrawal as a predictor of substance-related outcomes.

METHODS: Adolescent outpatients (N = 127) reporting cannabis as their drug of choice (n = 90) were stratified by the presence of withdrawal and compared on demographic and clinical variables at treatment intake. Hierarchical linear models compared the effect of withdrawal on percentage days abstinent (PDA) and related outcomes over a 1-year follow-up period.

RESULTS: Adolescents reporting withdrawal (40%) were more likely to meet criteria for cannabis dependence, have higher levels of substance use severity, report more substance-related consequences, and have a mood disorder. Withdrawal was not associated with PDA over the follow-up period; however, this relationship was moderated by problem recognition such that adolescents reporting withdrawal and a drug problem improved at a greater rate with respect to PDA than those who did not recognize a problem with drugs and did not report withdrawal.

DISCUSSION: Withdrawal is common among adolescent outpatients and is associated with a more clinically severe profile. In this sample, all adolescents reporting withdrawal met criteria for cannabis dependence, suggesting that withdrawal is a highly specific indicator of cannabis use disorder. Although withdrawal does not seem to be independently associated with substance use outcomes posttreatment, moderating factors such as drug problem recognition should be taken into account when formulating treatment and continuing care plans.


Labbe, A. K., Slaymaker, V., & Kelly, J. F. (2014). Toward enhancing 12-step facilitation among young people: A systematic qualitative investigation of young adults' 12-step experiences. Substance Abuse , 35 (4), 399-407 . Taylor & Francis. Publisher's VersionAbstract


BACKGROUND: 12-Step Facilitation (TSF) interventions designed to enhance rates of engagement with 12-step mutual-help organizations (MHOs) have shown efficacy among adults, but research provides little guidance on how to adapt TSF strategies for young people.

METHODS: To inform TSF strategies for youth, this study used qualitative methods to investigate the self-reported experiences of 12-step participation, and reasons for nonattendance and discontinuation among young adults (18-24 years; N = 302). Responses to open-ended questions following residential treatment were coded into rationally derived domains.

RESULTS: Young adults reported that cohesiveness, belonging, and instillation of hope were the most helpful aspects of attending 12-step groups; meeting structure and having to motivate oneself to attend meetings were the most common aspects young adults liked least; logistical barriers and low recovery motivation and interest were the most common reasons for discontinued attendance; and perceptions that one did not have a problem or needed treatment were cited most often as reasons for never attending.

CONCLUSIONS: Findings may inform and enhance strategies intended to engage young people with community-based recovery-focused 12-step MHOs and ultimately improve recovery outcomes.


Bergman, B. G., Greene, C. M., Slaymaker, V., Hoeppner, B. B., & Kelly, J. F. (2014). Young adults with co-occurring disorders: Substance use disorder treatment response and outcomes. Journal of Substance Abuse Treatment , 46 (4), 420-428 . Elsevier. Publisher's VersionAbstract


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.


Bergman, B. G., Greene, C. M., Hoeppner, B. B., Slaymaker, V., & Kelly, J. F. (2014). Psychiatric comorbidity and 12‐step participation: A longitudinal investigation of treated young adults. Alcoholism: Clinical and Experimental Research , 38 (2), 501-510 . Wiley Online Library. Publisher's VersionAbstract


Background: Evidence indicates 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.

Methods: Young adults (N = 296; 18-24 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 post-treatment 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.

Results: For DD and SUD-only patients, post-treatment attendance and active involvement in 12-step organizations was 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 eight-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 = .436) or active involvement (p = .062). Subsidiary analyses showed, however, that DD patients experienced significantly greater abstinence-related benefit from having a 12-step sponsor.

Conclusion: 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.


Kelly, J. F., Greene, M. C., & Bergman, B. G. (2014). Do drug dependent patients attending Alcoholics Anonymous rather than Narcotics Anonymous do as well? A prospective, lagged, matching analysis. Alcohol and Alcoholism , 49 (6), 645-653. Publisher's VersionAbstract


Aims: 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.

Method: 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).

Results: 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.

Conclusion: 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.


Kelly, J. F., & Yeterian, J. D. (2013). Mutual-help groups for alcohol and other substance use disorders. In B. S. McCrady & E. E. Epstein (Ed.), Addictions: A comprehensive guidebook (2nd ed. pp. 500-525) . New York: Oxford University Press.
Kelly, J. F., Humphreys, K. N., & Yeterian, J. D. (2013). Mutual-help groups. In M. Herie & W. Skinner (Ed.), Fundamentals of addiction: A practical guide for counselors (4th ed. pp. 321-347) . Toronto: Centre for Addiction and Mental Health.
Roth, J., White, W. L., & Kelly, J. F. (Ed.). (2013). Broadening the base of addiction mutual support groups: Bringing theory and science to contemporary trends (1st ed. pp. 272) . New York: Taylor and Francis.
Yeterian, J. D., Greene, C. M., Bergman, B. G., & Kelly, J. F. (2013). Does mandated treatment benefit youth? A prospective investigation of adolescent justice-system involvement, treatment motivation, and substance use outcomes. Alcoholism Treatment Quarterly , 31 (4), 431-449 . Taylor & Francis. Publisher's VersionAbstract


Background: 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.

Method: 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.

Results: 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.

Conclusions: 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.


Pagano, M. E., Kelly, J. F., Scur, M. D., Ionescu, R. A., Stout, R. L., & Post, S. G. (2013). Assessing youth participation in AA-related helping: Validity of the Service to Others in Sobriety (SOS) questionnaire in an adolescent sample. American Journal on Addictions , 22 (1), 60-66. Publisher's VersionAbstract


Background and Objectives: The positive outcomes derived from participation in Alcoholics Anonymous-related helping (AAH) found among adults has spurred study of AAH among minors with addiction. AAH includes acts of good citizenship in AA, formal service positions, public outreach, and transmitting personal experience to another fellow sufferer. Addiction research with adolescents is hindered by few validated assessments of 12-step activity among minors. This study provides psychometric findings of the “Service to Others in Sobriety (SOS)” questionnaire as completed by youths.

Methods: Multi-informant data was collected prospectively from youth self-reports, clinician-rated assessments, biomarkers, and medical chart records for youths (N = 195) after residential treatment.

Results: Few youths (7%) did not participate in any AAH during treatment. Results indicated the SOS as a unidimensional scale with adequate psychometric properties, including inter-informant reliability (r = .5), internal consistency (alpha = .90), and convergent validity (rs = −.3 to .3). Programmatic AAH activities distinguished abstinent youths in a random half-sample, and replicated on the other half-sample. The SOS cut-point of 40 indicated high AAH participation.

Conclusions and Significance: The SOS appears to be a valid measure of AAH, suggesting clinical utility for enhancing treatment and identifying service opportunities salient to sobriety.


Pagano, M. E., White, W. L., Kelly, J. F., Stout, R. L., & Tonigan, S. J. (2013). The 10-year course of Alcoholics Anonymous participation and long-term outcomes: A follow-up study of outpatient subjects in Project MATCH. Substance Abuse , 34 (1), 51-59 . Taylor & Francis. Publisher's VersionAbstract


This study investigates the 10-year course and impact of Alcoholics Anonymous (AA)-related helping (AAH), step-work, and meeting attendance on long-term outcomes. Data were derived from 226 treatment-seeking alcoholics recruited from an outpatient site in Project MATCH and followed for 10 years post treatment. Alcohol consumption, AA participation, and other-oriented behavior were assessed at baseline, end of the 3-month treatment period, and 1, 3, and 10 years post treatment. Controlling for explanatory baseline and time-varying variables, results showed significant direct effects of AAH and meeting attendance on reduced alcohol outcomes and a direct effect of AAH on improved other-oriented interest.


Kelly, J. F., & Hoeppner, B. B. (2013). Does Alcoholics Anonymous work differently for men and women? A moderated multiple-mediation analysis in a large clinical sample. Drug and Alcohol Dependence , 130 (1-3), 186-193 . Elsevier. Publisher's VersionAbstract


BACKGROUND: Alcoholics Anonymous (AA) began as a male organization, but about one third is now female. Studies have found that women participate at least as much as men and benefit equally from AA, but it is unclear whether women benefit from AA in the same or different ways as men. This study tested whether gender moderated the mechanisms through which AA aids recovery.

METHODS: A cohort study of alcohol dependent adults (N=1726; 24% female; Project MATCH) was assessed on AA attendance during treatment; with mediators at 9 months; outcomes (Percent Days Abstinent [PDA] and Drinks per Drinking Day [DDD]) at 15 months. Multiple mediator models tested whether purported mechanisms (i.e., self-efficacy, depression, social networks, spirituality/religiosity) explained AA's effects differently for men and women controlling for baseline values, mediators, treatment, and other confounders.

RESULTS: For PDA, the proportion of AA's effect accounted for by the mediators was similar for men (53%) and women (49%). Both men and women were found to benefit from changes in social factors but these mechanisms were more important among men. For DDD, the mediators accounted for 70% of the effect of AA for men and 41% for women. Again, men benefitted mostly from social changes. Independent of AA's effects, negative affect self-efficacy was shown to have a strong relationship to outcome for women but not men.

CONCLUSIONS: The recovery benefits derived from AA differ in nature and magnitude between men and women and may reflect differing needs based on recovery challenges related to gender-based social roles and drinking contexts.


Kelly, J. F., & Greene, C. M. (2013). The Twelve Promises of Alcoholics Anonymous: Psychometric measure validation and mediational testing as a 12-step specific mechanism of behavior change. Drug and Alcohol Dependence , 133 (2), 633-640 . Elsevier. Publisher's VersionAbstract


BACKGROUND: Empirical support for the recovery utility of 12-step mutual-help organizations (MHOs) has led to increased investigation of how such organizations confer benefit. The Twelve Promises of Alcoholics Anonymous (AA) feature prominently in 12-step philosophy and culture and are one of the few documented explications of the cognitive, affective, and behavioral benefits that members might accrue. This study investigated the psychometric properties of a measure of AA's Twelve Promises and examined whether it mediated the effect of 12-step participation on abstinence.

METHOD: Young adults (N=302, M age 20.4 [1.6], range 18-25; 27% female; 95% White) enrolled in an addiction treatment effectiveness study completed assessments at intake and 3-, 6-, and 12-months post treatment including a 26-item, Twelve Promises Scale (TPS). Factor analyses examined the TPS' psychometrics and lagged mediational analyses tested the TPS as a mechanism of behavior change.

RESULTS: Robust principal axis factoring extraction with Varimax rotation revealed a 2-factor solution explaining 45-58% of the variance across three administrations ("Psychological Wellbeing"=26-39%; "Freedom from Craving=17-21%); internal consistency was high (alpha=.83-.93). Both factors were found to increase in relation to greater 12-step participation, but significant mediation was found only for the Freedom from Craving factor explaining 21-34% of the effect of 12-step participation in increasing abstinence.

CONCLUSIONS: The TPS shows potential as a conceptually relevant, and psychometrically sound measure and may be useful in helping elucidate the extent to which the Twelve Promises emerge as an independent benefit of 12-step participation and/or explain SUD remission and recovery.


Dow, S. J., & Kelly, J. F. (2013). Listening to youth: Adolescents’ reasons for substance use as a unique predictor of treatment response and outcome. Psychology of Addictive Behaviors , 27 (4), 1122-1131 . American Psychological Association. Publisher's VersionAbstract


National efforts have focused on improving adolescent substance use disorder (SUD) treatment outcomes, yet improvements remain modest. Because adolescents are noteworthy for heterogeneity in their clinical profiles, treatment might be enhanced by the identification of clinical subgroups for which interventions could be more effectively tailored. Some of these subgroups, such as those based on abstinence motivation, substance involvement, and psychiatric status are promising candidates. This study examined the unique predictive utility of adolescents' primary reason for alcohol and other drug use. Adolescent outpatients (N = 109; 27% female, aged 14-19) were assessed at treatment intake on their reason for substance use, as well as demographic, substance use, and clinical variables, and reassessed at 3, 6, and 12 months. Reason for use fell into two broad domains: using to enhance a positive state (positive reinforcement [PR]; 47% of youth) and using to cope with a negative state (negative reinforcement [NR]; 53% of youth). Compared with PR patients, NR patients were significantly more substance involved, reported more psychological distress, and had a more extensive treatment history. It is important to note that NR patients showed a significant treatment response, whereas PR patients showed no improvement. PR-NR status also uniquely predicted treatment response and outcome independent of a variety of other predictors, including abstinence motivation, self-efficacy, coping, and prior treatment. Adolescents' primary reason for substance use may provide unique clinical information that could inform treatment planning and patient-treatment matching.


Kelly, J. F., Stout, R. L., & Slaymaker, V. (2013). Emerging adults’ treatment outcomes in relation to 12-step mutual-help attendance and active involvement. Drug and Alcohol Dependence , 129 (1), 151-157 . Elsevier. Publisher's VersionAbstract


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.


Labbe, A. K., Greene, C., Bergman, B. G., Hoeppner, B., & Kelly, J. F. (2013). The importance of age composition of 12-step meetings as a moderating factor in the relation between young adults’ 12-step participation and abstinence. Drug and Alcohol Dependence , 133 (2), 541-547. Publisher's VersionAbstract


BACKGROUND: 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.

METHOD: Young adults (n=302; 18-24 years; 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.

RESULTS: 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.

CONCLUSIONS: 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.


Urbanoski, K. A., & Kelly, J. F. (2012). Demystifying the genetics of addiction. Counselor: the magazine for addiction professionals , 6 23-30.
Hoeppner, B. B., Kelly, J. F., Urbanoski, K. A., & Slaymaker, V. (2012). Can the answer to just one simple question predict later relapse? . Counselor: The magazine for addiction professionals , 13 (2), 20-27.
White, W. L., Kelly, J. F., & Roth, J. D. (2012). New recovery support institutions: Mobilizing support beyond professional addiction treatment and recovery mutual aid. Journal of Groups in Addiction & Recovery , 7 (2-4), 297-317.Abstract


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.


Kelly, J. F., & White, W. L. (2012). Broadening the base of addiction mutual help organizations. Journal of Groups in Addiction & Recovery , 7 (2-4), 82-101. Publisher's VersionAbstract


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.