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CORK Bibliography: Self-help Groups

48 citations. January 2009 to present

Prepared: September 2012

Bennett T; Jacques S; Wright R. The emergence and evolution of drug user groups in the UK. Addiction Research & Theory 19(6): 556-565, 2011. (22 refs.)

The aim of this article is to describe and explain the development of drug user groups in the UK and elsewhere by drawing on a case study of one of the earliest drug user association formed in England in 1983, known as the Drug Dependents' Association. By way of context, a literature search was conducted to find other examples of original case studies of early drug user groups. The main method of investigating the case study arose out of the recovery of research materials by two of the authors which were used as part of another research project conducted in the early 1980s. The data collected comprised a full transcript of the first meeting of the group, agendas of all of the meetings and notes taken by the authors at the time. The analysis of the search material and the case study data indicates that drug user associations have change markedly since these early forms. The main changes include the integration of drug user groups into mainstream practice through the development of service user groups, a shift away from user-led to service-led organizations, as well as a change in focus from broader political campaigning towards the details of service provision.

Book SW; Thomas SE; Dempsey JP; Randall PK; Randall CL. Social anxiety impacts willingness to participate in addiction treatment. Addictive Behaviors 34(5): 474-476, 2009. (25 refs.)

Individuals with social anxiety have difficulty participating in group settings. Although it makes intuitive sense that social anxiety could present a challenge in addiction treatment settings. which often involve small groups and encouragement to participate in self-help groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). To our knowledge no study has yet assessed the impact of shyness on the treatment experience. Assessment surveys were given to 110 individuals seeking intensive outpatient substance abuse treatment at three community treatment programs. Established cut-offs for presence of clinically-significant social anxiety indicated a prevalence of 37%. Controlling for depression and worry, social anxiety was a unique predictor of endorsement that shyness interfered with willingness to talk to a therapist, speak up in group therapy, attend AA/NA. and ask somebody to be a sponsor. Socially anxious Substance abusers were 4-8 times more likely to endorse that shyness interfered with addiction treatment activities. These findings have clinical and research implications.

Brizer D; Castandea R, eds. Clinical Addiction Psychiatry. New York: Cambridge University Press, 2011. (Chapter refs.)

This book is described as an anthology of essays setting forth the most current and authoritative information on addiction theory, practice and research. Each chapter is authored by a recognized authority in the field. The volume covers diverse material, from the environment, to genetics, culture and spirituality, treatment and pharmacology. The book, with 24 essays, is organized in three parts. Part I sets forth basic constructs of addiction medicine. This includes discussion of the disease concept, abstinence as a treatment goal, medical sequelae of addiction, the relationship of substance use and suicide. psychotherapeutic paradigms, and drug therapies. Part II focuses upon "the real world." It includes twelve step approaches; nicotine addiction and smoking cessation; managing alcoholism in primary care; methadone treatment; prescription drug abuse. Part III considers special topics, such as pain management and addiction treatment; neurofeedback; drug therapies for alcohol dependence; emergency medical presentation; acupuncture; and EEG neurofeedback therapy.

Chi FW; Campbell CI; Sterling S; Weisner C. Twelve-step attendance trajectories over 7 years among adolescents entering substance use treatment in an integrated health plan. Addiction 107(5): 933-942, 2012. (58 refs.)

Aims: This study examines 12-Step attendance trajectories over 7 years, factors associated with the trajectories, and relationships between the trajectories and long-term substance use outcomes among adolescents entering out-patient substance use treatment in a private, non-profit integrated managed-care health plan. Design: Longitudinal observational study. Setting: Four Kaiser Permanente Northern California substance use treatment programs. Participants: A total of 391 adolescents entering treatment between 2000 and 2002 who completed at least one follow-up interview in year 1, and at least one during years 3-7, after treatment entry. Measurements Alcohol and drug use, 12-Step meeting attendance and activity involvement and post-treatment medical service utilization. Findings: Semiparametric group-based modeling identified three distinct 12-Step attendance trajectory groups over 7 years: low/no attendance (60%), early but not continued (26%) and continued (14%). There were lower proportions of males and of adolescents with prior substance use treatment experience in the low/no attendance group (P = 0.019 and P = 0.003, respectively). In addition, those in the low/no attendance group had lower perception on circumstances, motivation and readiness for treatment at baseline (P = 0.023). Multivariate logistic generalized estimating equation analyses found that those in the continued group were more likely to be abstinent from both alcohol and drugs during follow-ups than those in the low/no attendance group [ odds ratio (OR) = 2.40, P = 0.003 and OR = 1.96, P = 0.026, respectively]. However, no differences in long-term outcomes were found between those in the other two groups. Conclusion: Robust connection with 12-Step groups appears to be associated with better long-term outcomes among adolescents with substance use disorders.

Chi FW; Kaskutas LA; Sterling S; Campbell CI; Weisner C. Twelve-Step affiliation and 3-year substance use outcomes among adolescents: Social support and religious service attendance as potential mediators. Addiction 104(6): 927-939, 2009. (78 refs.)

Twelve-Step affiliation among adolescents is little understood. We examined 12-Step affiliation and its association with substance use outcomes 3 years post-treatment intake among adolescents seeking chemical dependency (CD) treatment in a private, managed-care health plan. We also examined the effects of social support and religious service attendance on the relationship. We analyzed data for 357 adolescents, aged 13-18, who entered treatment at four Kaiser Permanente Northern California CD programs between March 2000 and May 2002 and completed both baseline and 3-year follow-up interviews. Measures at follow-up included alcohol and drug use, 12-Step affiliation, social support and frequency of religious service attendance. At 3 years, 68 adolescents (19%) reported attending any 12-Step meetings, and 49 (14%) reported involvement in at least one of seven 12-Step activities, in the previous 6 months. Multivariate logistic regression analyses indicated that after controlling individual and treatment factors, 12-Step attendance at 1 year was marginally significant, while 12-Step attendance at 3 years was associated with both alcohol and drug abstinence at 3 years [odds ratio (OR) 2.58, P < 0.05 and OR 2.53, P < 0.05, respectively]. Similarly, 12-Step activity involvement was associated significantly with 30-day alcohol and drug abstinence. There are possible mediating effects of social support and religious service attendance on the relationship between post-treatment 12-Step affiliation and 3-year outcomes. The findings suggest the importance of 12-Step affiliation in maintaining long-term recovery, and help to understand the mechanism through which it works among adolescents.

Cisler RA; Silverman BL; Gromov I; Gastfriend DR. Impact of treatment with intramuscular, injectable, extended-release naltrexone on counseling and support group participation in patients with alcohol dependence. Journal of Addiction Medicine 4(3): 181-185, 2010. (30 refs.)

Objectives: The impact of intramuscular, injectable, extended-release naltrexone (XR-NTX; Vivitrol) on counseling and support group participation was examined in a post hoc analysis of a 24-week, randomized, double-blind study in 624 alcohol-dependent adults, most of whom were nonabstinent at baseline. Methods: Patients were offered 6 monthly injections of XR-NTX 380 mg, XR-NTX 190 mg, or placebo (n = 205, 210, and 209, respectively) and 12 sessions of manualized brief counseling. Voluntary participation in extramural counseling (eg, couples or family therapy) and self-help support groups (eg, Alcoholics Anonymous) was permitted and assessed. Results: The proportion of patients attending all 12 Biopsychosocial, Report, Empathy, Needs, Direct advice, and Assessment sessions was nonsignificantly greater for XR-NTX 380 mg (45%) than for placebo (39%), as was the proportion attending extramural counseling (10% vs 7%) and support groups (13% vs 10%). Attendance rates were intermediate with XR-NTX 190-mg. Attending self-help groups was significantly (P = 0.04) related to reduced heavy drinking across all treatment groups. Conclusions: XR-NTX is compatible with counseling and support group participation in the treatment of alcohol dependence.

Curzio O; Tilli A; Mezzasalma L; Scalese M; Fortunato L; Potente R et al. Characteristics of alcoholics attending 'Clubs of Alcoholics in Treatment' in Italy: A national survey. Alcohol and Alcoholism 47(3): 317-321, 2012. (22 refs.)

Aims: To provide an overview of alcoholics attending a socio-ecological treatment programme [Clubs of Alcoholics in Treatment (CATs)] and to identify factors associated with abstinence and self-perceived improvement in lifestyle. Methods: A national sample of 7522 subjects (76% males and 24% females, mean age 53.2 +/- 11.3 years +/- SD) attending CATs was evaluated using a self-administered questionnaire completed at a weekly meeting in 2006. Results: Of participants, >70% reported no alcohol use in the last year and around 90% indicated no use in the previous month, whereas 4% of them declared no alcohol use before club attendance. Abstinence and lifestyle improvement were related positively to the number of years of club attendance but negatively to the presence of other problems in addition to the alcohol-related one. Moreover, being older or female was associated with more likely achievement of abstinence as well as with the perception of a better lifestyle. Finally, attending the club with one or more family members was associated with achievement of better lifestyle. Conclusion: These data provide an overview of alcoholics attending the CAT programme and are a first step toward developing a surveillance system. In addition, on the basis of this preliminary picture further research (notably longitudinal studies) can be planned considering this method and its effectiveness.

Dadich A. Expanding our understanding of self-help support groups for substance use issues. Journal of Drug Education 40(2): 189-202, 2010. (53 refs.)

Self-Help Support Groups (SHSGs) for substance use issues are recognized in current policies for their role in reducing substance use. However, these policies recognize only their therapeutic value. This article argues that SHSGs can offer more than therapeutic advantage. This contention follows a study involving young people who were involved in a 12 Step fellowship. They valued group involvement for the connectedness, support, and opportunities to learn. These findings have important policy implications, highlighting a need to broaden the scope of current policies so they reflect the array of potential benefit associated with SHSGs. For clinicians and practitioners who are guided by social policy, this would offer an enhanced understanding of these groups, given that they are in prime position to advise clients about available options.

Delucchi KL; Simon AHK; Weisner C. Remission from alcohol and other drug problem use in public and private treatment samples over seven years. Drug and Alcohol Dependence 124(1-2): 57-62, 2012. (42 refs.)

Background: The treatment of alcohol and other drugs is now more commonly framed in terms of a chronic condition which requires ongoing monitoring. A model which includes continuing access to health care may optimize outcomes. Most studies of chronic care models have not included health care and have only examined short term effects. Methods: The sample (n=783) included consecutive admissions in ten public and private alcohol and other drug (ADD) treatment programs followed over seven years. The outcome was remission which was defined as alcohol and drug abstinence or non-problem use. Results: In the private sample, receiving health care services predicted remission across the seven years; however this did not occur in the public sample. More patients in the public treatment sample received AOD treatment readmissions each year, while more of those in the private sector received psychiatric and general health visits. Except for drug problem severity, there were no other clinical differences between the samples. There were no differences in the proportions of patients in the two sectors who received the full spectrum of chronic care services. In the final models, 12-step participation was markedly significant for both samples. Conclusions: Models of chronic care for substance use need to consider differences between private and public treatment and should take into account that individuals may not always have access, or avail themselves of services that may optimize long-term outcomes.

Donovan DM; Daley DC; Brigham GS; Hodgkins CC; Perl HI; Floyd AS. How practice and science are balanced and blended in the National Institute on Drug Abuse Clinical Trials Network: The bidirectional process in the development of the stage-12 protocol as an example. American Journal of Drug and Alcohol Abuse 37(5): 408-416, 2011. (59 refs.)

Background: Bidirectional, collaborative partnerships between academic researchers and practitioners have been a fundamental vehicle to achieve the National Institute on Drug Abuse (National Institute on Drug Abuse) Clinical Trials Network (CTN) goal of improving outcomes of community-based drug treatment. These partnerships blend clinical perspectives of practitioners and methodological expertise of researchers working together to address clinically meaningful issues through randomized clinical trials conducted in community treatment settings. Objectives: Bidirectionality is a guiding principle of the CTN, but its operationlization at the practical level in protocol development and implementation has not been articulated. This descriptive article presents the development of one protocol as an example and model of this bidirectional, collaborative, iterative partnership between researchers and practitioners. Methods: This article illuminates several specific issues encountered while developing STAGE-12, a behavioral intervention to facilitate 12-step mutual support group involvement, as well as the rationale for decisions taken to resolve each. Results: The STAGE-12 protocol was successfully developed through a series of decisions taking into account both design factors and clinical practice needs and realities, thus maintaining a balance between methodological rigor and generalizability. Conclusion: The review demonstrates the process by which research and practice have been blended in protocol development, exemplifying the underlying principle of bidirectionality, a key element in the success of the National Institute on Drug Abuse CTN. Scientific Significance: Bidirectional partnerships as derived in the CTN, employing a hybrid model of efficacy-effectiveness research, are capable of designing and implementing protocols that are both methodologically rigorous and clinically meaningful, thus increasing likelihood of adoption and eventual improvement in public health.

Frank D. The trouble with morality: The effects of 12-step discourse on addicts' decision-making. Journal of Psychoactive Drugs 43(3): 245-256, 2011. (41 refs.)

Since its development in the 1960s, researchers have extensively scrutinized methadone maintenance treatment (MMT) as a medical response to heroin addiction. Studies consistently find that MMT is more successful than other treatment models in the reduction of opiate/opioid misuse, the transmission of diseases like HIV/AIDS and hepatitis C, and criminal arrest and conviction rates. Nonetheless, a significant portion of active and former heroin addicts view MMT negatively and-perhaps as a result-MMT is vastly underused. This study examines the effects of 12-Step discourses on the opinions and treatment decisions of active heroin addicts, addicts in MMT, and addicts in 12-Step treatment programs. The study finds the abstinence/morality based discourse of drug addiction and treatment is pervasive among addicts and their non-drug using relations and peers alike; moreover, addicts have internalized this narrative, oftentimes despite their own knowledge of MMT's success and positive personal experiences. The findings suggest that the dominance of abstinence/morality narratives contributes to MMT's poor reputation among, and low use rate by current and former heroin addicts and that the power of the dominant discourse is such that it produces a desire to buy into its values and tenets even when it is against the individual's interests to do so.

Frydrych LM; Greene BJ; Blondell RD; Purdy CH. Self-help program components and linkage to aftercare following inpatient detoxification. Journal of Addictive Diseases 28(1): 21-27, 2009. (11 refs.)

Many patients fail to initiate aftercare for addictive disease rehabilitation following detoxification. This study of 136 inpatients compared characteristics of those who initiated aftercare (behavior therapy or self-help programs) during the week following discharge with those who did not. Among this group of patients, 77% (91/119) linked to aftercare. Self-help treatment related components were associated with increased aftercare treatment attendance rates and included: having a copy of the 12 Steps (81% vs. 46%, P = .002), having read self-help literature (73% vs. 42%, P = .007), and having telephone numbers of self-help program members (50% vs. 18%, P = .008). Those who initiated aftercare treatment were also more likely to have remained abstinent from drugs and alcohol (81% vs. 39%, P .001). Having self-help treatment related components was associated with increased rates of aftercare attendance following hospital inpatient detoxification.

Galanter M. The twelve step approach. (Chapter 11). IN: Brizer D; Castandea R, eds. Clinical Addiction Psychiatry. New York: Cambridge University Press, 2011

This book is described as an anthology of essays setting forth the most current and authoritative information on addiction theory, practice and research. Each chapter is authored by a recognized authority in the field. The volume covers diverse material, from the environment, to genetics, culture and spirituality, treatment and pharmacology. The book, with 24 essays, is organized in three parts. This chapter describes the twelve step approach, its basic elements, and how participation in twelve step program can be combined with formal treatment. This chapter is part of Part II, a section with the title "The Real World." The chapters in this section focus on particular drugs: alcohol; its presentation and treatment in primary care; nicotine addiction and smoking cessation; clinical approaches in working with cocaine and methadone dependence; methadone maintenance for opiate dependence; and prescription drug abuse.

Grella CE; Stein JA; Weisner C; Chi F; Moos R. Predictors of longitudinal substance use and mental health outcomes for patients in two integrated service delivery systems. Drug and Alcohol Dependence 110(1-2): 92-100, 2010. (52 refs.)

Aim: Individuals who have both substance use disorders and mental health problems have poorer treatment outcomes. This study examines the relationship of service utilization and 12-step participation to outcomes at 1 and 5 years for patients treated in one of two integrated service delivery systems: the Department of Veterans Affairs (VA) system and a health maintenance organization (HMO). Methods: Sub-samples from each system were selected using multiple criteria indicating severity of mental health problems at admission to substance use disorder treatment (VA=401: HMO=331). Separate and multiple group structural equation model analyses used baseline characteristics, service use, and 12-step participation as predictors of substance use and mental health outcomes at 1 and 5 years following admission. Results: Substance use and related problems showed stability across time, however, these relationships were stronger among VA patients. More continuing care substance use outpatient visits were associated with reductions in mental health symptoms in both groups, whereas receipt of outpatient mental health services was associated with more severe psychological symptoms. Participation in 12-step groups had a stronger effect on reducing cocaine use among VA patients, whereas it had a stronger effect on reducing alcohol use among HMO patients. More outpatient psychological services had a stronger effect on reducing alcohol use among HMO patients. Conclusion: Common findings across these two systems demonstrate the persistence of substance use and related psychological problems, but also show that continuing care services and participation in 12-step groups are associated with better outcomes in both systems.

Hagarty DE; Clark DJ. Using imagery and storytelling to educate outpatients about 12-Step programs and improve their participation in community-based programs. Journal of Addictions Nursing 20(2): 86-92, 2009. (32 refs.)

The longer a patient remains engaged in recovery activities the greater the success of long-term abstinence. Self-help community programs that use the 12-steps such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are known in the addictions field to contribute to sustained abstinence. Connecting patients to 12-step programs in early stages of recovery increases the chance of prolonged involvement. A nurse working in an outpatient substance abuse clinic developed a unique method to inform and educate patients about the 12-step process. A story and image metaphorically describe this journey. The cleaning of a vessel and subsequent discovery of tools along the way provide an uncomplicated look at the 12-steps. Nurses can use the image and story to develop the necessary tools of honesty, open-mindedness, and willingness for patients to embrace the 12-step journey.

Kaminer Y; Winters KC, eds. Clinical Manual of Adolescent Substance Abuse Treatment. Washington DC: American Psychiatric Association, 2011. (Chapter refs.)

This book in 16 chapters with a total of 45 contributors is a comprehensive work on adolescent substance use problems and treatment. It begins with consideration of adolescent substance use, with data on the prevalence and natural history of substance use and substance use disorders. In respect to etiology and prevention, both protective and risk factors are discussed. Attention then turns to screening, assessment and brief interventions, and includes a chapter on the use of biomarker testing in adolescents. In turning to treatment, there are chapters dealing with treatment planning and placement criteria for different treatment settings, discussion of adolescent behavioral changed, and the use of pharmacotherapy in treatment of substance use disorders. A chapter is directed to club drugs, prescription drugs, and over-the-counter medication, and the diagnosis of treatment and intervention. Individual chapters are directed to specific treatment approaches: brief motivational interventions, cognitive-behavioral therapy, and contingency management; adolescents community reinforcement approach and mutidimensional family therapy, as well as relapse prevention; and twelve-step programs. Several chapters consider co-occurring problems: attention deficit/hyperactivity; internalizing disorders (depression, anxiety disorders, and PTST; assessment and treatment of suicidal behavior; and assessment and treatment of psychotic disorders and bipolar disorder. The final chapter addresses the care of adolescents in the juvenile system with substance use problems.

Kelly JF; Dow SJ; Yeterian JD; Myers M. How safe are adolescents at Alcoholics Anonymous and Narcotics Anonymous meetings? A prospective investigation with outpatient youth. Journal of Substance Abuse Treatment 40(4): 419- 425, 2011. (25 refs.)

Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have proven to be cost-effective recovery resources for adults and also appear helpful for youth. However, anecdotal concerns about adolescents' safety at meetings have dampened enthusiasm regarding youth participation. Unfortunately, little information exists to evaluate such concerns. Outpatients (N = 127; 24% female) were assessed at intake and at 3, 6, and 12 months regarding perceived safety at AA/NA, experience of negative incidents, and reasons for nonattendance/discontinuation. By 12-month follow-up, 57.5% reported some AA/NA attendance with a combined lifetime exposure of 5,340 meetings. Of these, 21.9% reported at least one negative experience, which was more common among NA than AA attendees. Overall, youth reported feeling very safe at meetings, and ratings did not differ by age or gender. Reasons for discontinuation or nonattendance were unrelated to safety or negative incidents. Weighing risks against documented benefits, these preliminary findings suggest that referral to AA/NA should not be discouraged, but, similar to adults, youth experiences at meetings should be monitored.

Kelly JF; Kahler CW; Humphreys K. Assessing why substance use disorder patients drop out from or refuse to attend 12-step mutual-help groups: The "REASONS" questionnaire. Addiction Research & Theory 18(3): 316-325, 2010. (46 refs.)

Substance use disorder (SUD) patients who become involved in 12-step mutual-help groups (MHGs), such as Alcoholics Anonymous, experience better outcomes and have reduced healthcare costs. In spite of this, many do not attend at all and other initial attendees drop out. Reasons for non-attendance and dropout have not been systematically studied, yet such knowledge could enhance the efficiency of twelve-step facilitation (TSF) efforts or help clinicians decide which patients might prefer non-12-step MHGs (e.g., SMART Recovery). This study developed and tested a measure of reasons for non-participation and dropout from 12-step MHGs. Items were generated and clustered into eight domains using a rational keying approach. Male veterans (N = 60; M age = 49; 41% African American) undergoing SUD treatment were asked to complete a brief assessment about prior MHG experiences. Psychometric analyses produced a 24-item measure containing seven internally consistent, face-valid, subscales. Co-morbid psychiatric issues and, to a lesser degree, spiritual concerns, were found to be particularly important dimensions relating to this phenomenon. The measure could serve as a useful screening tool for barriers to 12-step participation and subsequently focus TSF efforts or inform referral to non-12 step MHGs.

Kelly JF; Pagano ME; Stout RL; Johnson SM. Influence of religiosity on 12-step participation and treatment response among substance-dependent adolescents. Journal of Studies on Alcohol and Drugs 72(6): 1000-1011, 2011. (95 refs.)

Objective: Religious practices among adults are associated with more 12-step participation which, in turn, is linked to better treatment outcomes. Despite recommendations for adolescents to participate in mutual-help groups, little is known about how religious practices influence youth 12-step engagement and outcomes. This study examined the relationships among lifetime religiosity, during-treatment 12-step participation, and outcomes among adolescents, and tested whether any observed beneficial relation between higher religiosity and outcome could be explained by increased 12-step participation. Method: Adolescents (n = 195; 52% female, ages 14-18) court-referred to a 2-month residential treatment were assessed at intake and discharge. Lifetime religiosity was assessed with the Religious Background and Behaviors Questionnaire; 12-step assessments measured meeting attendance, step work (General Alcoholics Anonymous Tools of Recovery), and Alcoholics Anonymous (AA)/Narcotics Anonymous (NA)-related helping. Substance-related outcomes and psychosocial outcomes were assessed with toxicology screens, the Adolescent Obsessive Compulsive Drinking Scale, the Children's Global Assessment Scale, and the Narcissistic Personality Inventory. Results: Greater lifetime formal religious practices at intake were associated with increased step work and AA/NA-related helping during treatment, which in turn were linked to improved substance outcomes, global functioning, and reduced narcissistic entitlement. Increased step work mediated the effect of religious practices on increased abstinence, whereas AA/NA-related helping mediated the effect of religiosity on reduced craving and entitlement. Conclusions: Findings extend the evidence for the protective effects of lifetime religious behaviors to an improved treatment response among adolescents and provide preliminary support for the 12-step proposition that helping others in recovery may lead to better outcomes. Youth with low or no lifetime religious practices may assimilate less well into 12-step oriented treatment and may need additional 12-step facilitation, or a different approach, to enhance treatment response.

Kelly JF; Urbanoski KA; Hoeppner BB; Slaymaker V. "Ready, willing, and (not) able" to change: Young adults' response to residential treatment. Drug and Alcohol Dependence 121(3): 224-230, 2012. (57 refs.)

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.

Kelly JF; Urbanoski K. Youth recovery contexts: The incremental effects of 12-step attendance and involvement on adolescent outpatient outcomes. Alcoholism: Clinical and Experimental Research 36(7): 1219-1229, 2012. (56 refs.)

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.

Kelly JF; Yeterian JD. The role of mutual-help groups in extending the framework of treatment. Alcohol Research & Health 33(4): 350-355, 2011. (46 refs.)

Alcohol use disorders (AUDs) are highly prevalent in the United States and often are chronic conditions that require ongoing episodes of care over many years to achieve full sustained remission. Despite substantial scientific advances in specialized care, professional resources alone have not been able to cope with the immense burden of disease attributable to alcohol Perhaps in tacit recognition of this, peer-run mutual-help groups (MHGs), such as Alcoholics Anonymous (AA), have emerged and proliferated in the past 75 years and continue to play an important role in recovery from AUDs. This article describes the nature and prevalence of MHGs, particularly AA, and reviews evidence for their effectiveness and cost-effectiveness and the mechanisms through which they may exert their effects. The article also provides details about how health care professionals can facilitate their alcohol-dependent patients' participation in such groups and reviews the evidence for the benefits of doing so.

Kolodziej ME; Muchowski PM; Hamdi NR; Morrissette P; McGowan AJ et al. Adaptation of the Patient Feedback Survey at a community treatment setting. American Journal on Addictions 21(1): 63-71, 2012. (31 refs.)

The Patient Feedback Survey is a performance improvement measure designed to assess the quality of outpatient substance abuse treatment. We modified and administered this measure to 500 individuals at a multisite treatment provider. Although the feedback scores were high in general, analyses of variance showed score variability in relation to type and length of treatment. Moreover, respondents who reported any use of marijuana, cravings for substances, or mutual-support group attendance (ie, Alcoholics Anonymous or Narcotics Anonymous) had lower feedback scores than respondents without these experiences. We highlight the importance of investigating treatment evaluations in the context of other recovery experiences.

Lo Sasso AT; Byro E; Jason LA; Ferrari JR; Olson B. Benefits and costs associated with mutual-help community-based recovery homes: The Oxford House model. Evaluation and Program Planning 35(1): 47-53, 2012. (23 refs.)

We used data from a randomized controlled study of Oxford House (OH), a self-run, self-supporting recovery home, to conduct a cost-benefit analysis of the program. Following substance abuse treatment, individuals that were assigned to an OH condition (n = 68) were compared to individuals assigned to a usual care condition (n = 61). Economic cost measures were derived from length of stay at an Oxford House residence, and derived from self-reported measures of inpatient and outpatient treatment utilization. Economic benefit measures were derived from self-reported information on monthly income, days participating in illegal activities, binary responses of alcohol and drug use, and incarceration. Results suggest that OH compared quite favorably to usual care: the net benefit of an OH stay was estimated to be roughly $29,000 per person on average. Bootstrapped standard errors suggested that the net benefit was statistically significant. Costs were incrementally higher under OH, but the benefits in terms of reduced illegal activity, incarceration and substance use substantially outweighed the costs. The positive net benefit for Oxford House is primarily driven by a large difference in illegal activity between OH and usual care participants. Using sensitivity analyses, under more conservative assumptions we still arrived at a net benefit favorable to OH of $17,830 per person.

Makin-Byrd K; Cronkite RC; Timko C. The influence of abuse victimization on attendance and involvement in mutual-help groups among dually diagnosed male veterans. Journal of Substance Abuse Treatment 41(1): 78-87, 2011. (34 refs.)

Although abuse victimization and dual diagnosis are associated with poor functioning across numerous domains, their impact on attendance and involvement in mutual-help groups (MHGs) is not well understood. This study. examined the impact of physical or sexual abuse victimization on MUG attendance and involvement and the influence of abuse on the association between MHG involvement and outcomes of abstinence and psychiatric health. Participants were 217 dually diagnosed men assessed at intake into mental health treatment and 6 months later. Compared with nonabused patients, sexually abused patients exhibited more substance use, psychiatric, and social problems at baseline and attended and were involved with MHGs more than nonabused patients at follow-up. Moreover, MHG involvement was most predictive of abstinence for sexually abused patients, as compared with nonabused and physically abused patients. Although dually diagnosed patients with abuse histories demonstrate more severe initial problems, they are likely to utilize MHGs, which may benefit efforts to achieve abstinence.

McKellar JD; Harris AH; Moos RH. Patients' abstinence status affects the benefits of 12-step self-help group participation on substance use disorder outcomes. Drug and Alcohol Dependence 99(1-3): 115-122, 2009. (37 refs.)

Background: Studies measuring the effectiveness of 12-step self-help group attendance have yielded mixed results but none of the prior studies have accounted for the potential impact of interim abstinence status. Methods: Participants were 1683 patients with substance use disorder, (SUD) from 89 community residential facilities. Self-report data were collected at baseline and 1- and 4-year follow-ups, and included measures of SUD severity, social resources, coping, and 12-step self-help group attendance. We tested the hypothesis that 12-step self-help group attendance is more effective for non-abstinent patients than for abstinent patients. We also controlled for self-selection effects by using propensity score analyses and we cross-validated Our results in a second sample of patients (N=2173). Results: Sample 1. Patients abstinent at 1-year post-treatment who attended 12-step self-help group meetings were no more likely to be abstinent at 4 years than abstinent patients who did not attend. However, for patients not abstinent at 1 year, a significant improvement in abstinence rates at 4 years emerged for those who attended 12-step self-help groups compared to those who did not (42% vs. 28.9%). A similar pattern emerged for SUD problems. There were no benefits from 12-step self-help group attendance for patients abstinent at 1 year, but non-abstinent patients who attended 12-step self-help groups had significantly fewer problems at 4 years. Sample 2. The cross-validation yielded consistent results as 12-step self-help group attendance led to higher abstinence rates and fewer SUD problems only among patients non-abstinent at interim assessment. Conclusions: Individual's abstinence status should be considered when evaluating the potential influence of 12-step self-help group attendance on SUD outcomes. In addition, increased clinical resources should focus on assessing patients after discharge and on improving linkage of non-abstinent patients to self-help groups.

Monica C; Nikkel RE; Drake RE. Dual Diagnosis Anonymous of Oregon. (editorial). Psychiatric Services 61(8): 738-740, 2010. (12 refs.)

Many people with addictions report that support from peer groups fosters recovery. For people with co-occurring mental illnesses, dual-diagnosis peer support groups are considered helpful, but they are often unavailable. Recently, Dual Diagnosis Anonymous peer support groups have spread widely throughout Oregon as a complement to integrated dual diagnosis treatments. This column describes Dual Diagnosis Anonymous and its rapid implementation in Oregon.

Office of Applied Studies, Substance Abuse and Mental Health Administration. The NSDUH Report: Participation in Self-Help Groups for Alcohol and Illicit Drug Use: 2006 and 2007. (November 13, 2008). Rockville MD: Substance Abuse and Mental Health Administration, 2009. (6 refs.)

Participation in self-help groups, such as Alcoholics Anonymous and Narcotics Anonymous, is an important adjunct to formal treatment for substance use problems, and it provides valuable peer support throughout the recovery process. The National Survey on Drug Use and Health (NSDUH) includes a question for persons aged 12 or older about their participation in the past 12 months in a self-help group for substance use (i.e., alcohol use, illicit drug use, or both). NSDUH also asks questions about past year receipt of treatment for substance use problems in a specialty treatment facility. This issue of "The NSDUH Report" examines the characteristics of persons aged 12 or older participating in self-help groups for substance use in the past year. It also reports on past month alcohol and/or illicit drug use among persons who participated in self-help groups in the past year and on past year receipt of specialty treatment. All findings presented in this report are annual averages based on combined 2006 and 2007 NSDUH data. Summary: Combined national data from 2006 and 2007 indicate that an annual average of 5 million persons ages 12 or older (2.0% of the population in that age group) attended a self-help group in the past year because of their use of alcohol or illicit drugs. Among persons aged 12 or older who attended self-help groups in the past year, 45.3% attended a group because of their alcohol use only, and 21.8% attended a group because of their illicit drug use only; 33.0% sought help for both alcohol and illicit drugs. Among past year self-help group participants aged 12 or older, 45.1 percent abstained from substance use in the past month. Almost one third (32.7%) of individuals aged 12 or older who attended a self-help group for their substance use in the past year also received specialty treatment for substance use in the past year. Data is also provided on membership in terms of race/ethnicity, family income, gender, age, and type of community.

Public Domain

Oser CB; Biebel EP; Pullen EL; Harp KLH. The influence of rural and urban substance abuse treatment counselor characteristics on client outcomes. Journal of Social Service Research 37(4): 390-402, 2011. (44 refs.)

Focus group data were collected from 28 substance abuse treatment counselors employed in rural and urban areas to examine their perceptions of factors influencing treatment outcomes. The influence of the counselor characteristics (i.e., education, experience, and recovery status) on client outcomes and geographic differences is explored. Focus group data were analyzed by three raters using line-by-line coding, focused coding, and memoing. This analytic approach revealed geographic differences in the counselors' perceptions of the effect of counselor education, experience, and recovery status on client outcomes. Recommendations for treatment planning and future research are provided.

Oser CB; Harp KLH; O'Connell DJ; Martin SS; Leukefeld CG. Correlates of participation in peer recovery support groups as well as voluntary and mandated substance abuse treatment among rural and urban probationers. Journal of Substance Abuse Treatment 42(1): 95-101, 2012. (41 refs.)

This study explores the correlates of probationers' participation in 12-step programs, voluntary treatment, and mandated treatment, with respect to the geographic location of where the services are being provided as the primary covariate of interest. Data were derived from face-to-face interviews with rural and urban probationers (N=1,464). Results of the three logistic regression models suggested that even when all the covariates are taken into account, urban probationers were significantly more likely to have been involved in 12-step programs, voluntary treatment, and mandated treatment over their lifespan. Despite high levels of self-reported substance use among all participants, treatment services were underused by rural probationers. These data suggest that individuals residing in rural communities may face additional barriers to receiving treatment services and that criminal involvement is associated with participation in peer recovery support groups and treatment. Future studies can investigate criminal involvement as an avenue to enhance recovery and how to overcome treatment barriers in rural areas.

Perron BE; Mowbray OP; Glass JE; DelvaJ; Vaughn MG; Howard MO. Differences in service utilization and barriers among Blacks, Hispanics, and Whites with drug use disorders. Substance Abuse Treatment, Prevention and Policy 5(e-journal 3), 2010. (33 refs.)

Background: Treatment for drug use disorders (DUD) can be effective, but only a small proportion of people with DUD seek or receive treatment. Research on racial and ethnic treatment differences and disparities remains unclear. Understanding racial and ethnic differences and disparities in drug treatment is necessary in order to develop a more effective referral system and to improve the accessibility of treatment. The purpose of the current study was to explore the role of race and ethnicity in service utilization. Methods: Using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), this study examined racial and ethnic differences in use of 14 types of treatment services for DUD and 27 different treatment barriers among persons who met lifetime criteria for a DUD. Multivariate logistic regression analyses were used to examine service utilization and barriers among the racial and ethnic groups, while adjusting for other sociodemographic and clinical variables. Results and discussion: Among Blacks, Hispanics and Whites in the overall NESARC sample, approximately 10.5% met criteria for at least one lifetime drug use disorder. Approximately 16.2% of persons with a lifetime DUD received at least one type of service. Overall, this study indicated that Whites were less likely to report receiving help for drug-related problems than Blacks, Blacks used a greater number of different types of services, and no racial and ethnic differences were observed with respect to perceived barriers to drug treatment. However, by examining types of services separately, a complex picture of racial and ethnic differences emerges. Most notably, Whites were most likely to use professional services, whereas Blacks were most likely to use 12-step and clergy. The service use pattern of Hispanics most resembled that of Whites. Conclusion: While structural barriers to accessing treatment were observed, broad-based educational programs and interventions that are appropriately targeted to racial and ethnic groups remains an important area for prevention and treatment.

Polcin DL; Korcha R; Bond J; Galloway G. What did we learn from our study on sober living houses and where do we go from here? Journal of Psychoactive Drugs 42(4): 425-433, 2010. (25 refs.)

Lack of a stable, alcohol- and drug-free living environment can be a serious obstacle to sustained abstinence. Destructive living environments can derail recovery for even highly motivated individuals. Sober living houses (SLHs) are alcohol- and drug-free living environments for individuals attempting to abstain from alcohol and other drugs. They are not licensed or funded by state or local governments and the residents themselves pay for costs. The philosophy of recovery emphasizes 12-Step group attendance and peer support. We studied 300 individuals entering two different types of SLHs over an 18-month period. This article summarizes our published findings documenting resident improvement on measures of alcohol and drug use, employment, arrests, and psychiatric symptoms. Involvement in 12-Step groups and characteristics of the social network were strong predictors of outcome, reaffirming the importance of social and environmental factors in recovery. This article adds to our previous reports by providing a discussion of implications for treatment and criminal justice systems. We also describe the next steps in our research on SLHs, which will include: (1) an attempt to improve outcomes for residents referred from the criminal justice system and (2) a depiction of how attitudes of stakeholder groups create a community context that can facilitate and hinder the legitimacy of SLHs as a recovery modality.

Powell T; Perron BE. Self-help groups and mental health/substance use agencies: The benefits of organizational exchange. Substance Use & Misuse 45(3): 315-329, 2010. (83 refs.)

Self-help groups benefit clients by linking them to people who have "been there" and are successfully coping with their situations. Mental health/substance use agencies can increase access to evidence-based benefits of self-help groups by engaging them in organizational exchanges. Organizational theories are used to frame beneficial exchanges with self-help groups. Adaptational theory is used to frame exchanges with self-help groups and various service agency subunits, e.g., board, practitioner, and client units. Institutional theory is used to frame joint agency/self-help initiatives to promote community acceptance of self-help groups, which in turn may enhance the credibility of the professional agency.

Raftopoulos A; Flora K. Substance use related behavior of the members of Narcotics Anonymous and Alcoholics Anonymous in Greece. Journal of Psychoactive Drugs 43(3): 238-244, 2011. (17 refs.)

The aim of this research project is to provide basic information regarding the use of substances and its behavioral consequences such as health problems and criminal offences. It is the first survey in Greece in the field of self-help groups. The main research instrument was a 55-item questionnaire that was administered to members of NA and AA in the Greek cities of Athens, Thessaloniki, Series, Nafplio, Iraklio, and Katerini. This article presents an analysis of the answers given by the respondents to 12 of the 55 items of the questionnaire. It also includes a comparison of the relevant findings with data provided by the central organizations of AA and NA as well as by official therapeutic programs in Greece and by other researchers who have studied the same subject. More specifically, this article presents, examines and analyzes data which focuses on: (a) the age at which a substance was first used, (b) the time it took the individual respondents to acknowledge such use as a problem, (c) the main substance abused at the onset, (d) the main substance in use when the individuals approached the self-help group, (e) the existence or not of another individual with a substance abuse disorder in the immediate family, (f) possible health problems and (g) the entanglement or not with the penal justice system.

Ronel N; Gueta K; Abramsohn Y; Caspi N; Adelson M. Can a 12-Step program work in methadone maintenance treatment? International Journal of Offender Therapy and Comparative Criminology 55(7): 1135-1153, 2011. (72 refs.)

Three consecutive, professionally led (as opposed to self-help) groups following the 12-step program (TSP) were integrated into a methadone maintenance treatment (MMT) program that included 32 heroin-addicted individuals in recovery. This report describes our experience in meeting the challenges that arose and our conclusions regarding the therapeutic potential of this integration. A professional therapeutic staff guided the groups. In-depth interviews of 10 participants and the reflections of the group leaders provided data for learning about the groups' experience. Initially the participants rejected the concepts of Step 1, powerlessness and unmanageability of life. The assimilation of Step 4 (defining character defect) also aroused some resistance. The participants eventually adopted the pragmatic aspects of TSP, including its terminology. The establishment of a common language of recovery helped to create group coherence and a sense of belonging, and helped to meet the needs of those who felt stigmatized by both the nonaddicted and addicted population undergoing nonmethadone recovery. TSP could be adapted to various aspects of daily life, produced a sense of self-efficacy, and stimulated motivation for change. Therapeutic implications are discussed.

Russell-Mayhew S; von Ranson KM; Masson PC. How does Overeaters Anonymous help its members? A qualitative analysis. European Eating Disorders Review 18(1): 33-42, 2010. (34 refs.)

Overeaters Anonymous (OA) is a 12-step, self-help group for individuals who perceive themselves to have problems with compulsive overeating. Despite the popularity of OA and the frequent use of addictions-based treatments for eating disorders, little is known about how OA is helpful. The purpose of this qualitative study was to explore members' experiences with and perceptions of OA. We conducted three focus groups with self-selected members of OA (N = 20). We present three primary themes that emerged from the analysis of the focus groups' discussions, which emphasize why individuals entered OA, OA's 'tools', and how individuals perceived OA to 'work'. Overall, although participants agreed OA was helpful to them, there was no consensus regarding how OA 'works'.

Schenker M. A Clinician's Guide to Twelve Step Recovery. New York: W. W. Norton, 2009

Those in treatment for substance use problems may be wary of clinicians who have no personal experience of addiction and recovery. The question posed "Are you in recovery yourself?" can create discomfort. This book endeavors to explicate the addiction experience and particularly the experience of involvement in Twelve Step programs. It is intended as a guide to experiences commonly encountered by those in these programs, from what might be encountered in attending a meeting to encountering views that are dismissive of professional help, or the use of medications.

Sered S; Norton-Hawk M. Whose higher power? Criminalized women confront the "Twelve Steps". Feminist Criminology 6(4): 308-332, 2011. (58 refs.)

Drawing on 3 years of fieldwork with a community of criminalized women in eastern Massachusetts, this article explores their ambivalent, often negative, relationship with and feelings about Alcoholics Anonymous/Narcotics Anonymous (AA/NA). We suggest that coerced participation in AA/NA undermines any potential value that these programs may have for other types of participants and that the Twelve Step ideology of personal responsibility and turning oneself over to a Higher Power fails to resonate for women who are homeless, poor, incarcerated, abused, and have had their children taken from them.

Stahler GJ; Mennis J; Cotlar R; Baron DA. The influence of neighborhood environment on treatment continuity and rehospitalization in dually diagnosed patients discharged from acute inpatient care. American Journal of Psychiatry 166(11): 1258-1268, 2009. (38 refs.)

Objective: Environmental contingencies inherent in neighborhoods and communities have been shown to affect individual behavior. The authors analyzed neighborhood and individual factors predicting initial outpatient treatment attendance and rehospitalization within 1 year among patients who were dually diagnosed with at least one mental disorder and a substance use disorder and discharged from an acute psychiatric inpatient care unit. Method: Stepwise-forward logistic regression modeling and a geographic information system were utilized to assess data extracted from the medical records of 380 patients who, upon hospital admission, had one or more mental health disorders and a positive urine drug screen for prototypical illicit drugs. Geographic data on patients' neighborhood environment were obtained from public sources. Outcome variables were whether a patient attended the first outpatient treatment appointment within 30 days of hospital discharge and whether a patient was readmitted to the inpatient unit within 1 year of discharge. Predictor variables were features relating to individual-level patient characteristics and features associated with neighborhood environment. Results: Factors that decreased the likelihood of attending the initial outpatient treatment were returning home following hospitalization (versus returning to an institutional setting), residing in an area with a high vacant housing rate, residing in an area far from an Alcoholics Anonymous meeting location, having the chief complaint of bizarre behavior (i.e., grossly inappropriate behavior), and having a urine drug screen positive for heroin. The likelihood of being rehospitalized within 1 year was greater for Hispanic patients, patients who had at least one prior hospital admission, and patients who lived in close proximity to a Narcotics Anonymous meeting location. Patients living in areas with higher educational attainment had a reduced likelihood of rehospitalization. Conclusions: A more explicit focus on the neighborhood and community context represents an important area in psychiatry, in terms of both research and clinical practice, which can potentially enhance long-term care and treatment planning for psychiatric patients. Future research is needed to better understand the influence of the neighborhood environment to help predict important clinical outcomes.

Thatcher MS. Negotiating the tension between the discourses of Christianity and spiritual pluralism in Alcoholics Anonymous. Journal of Applied Communication Research 39(4, special issue): 389-405, 2011. (35 refs.)

This study employs dialogism theory and relational dialectics theory as sensitizing concepts to understand how meaning emerges as members of Alcoholics Anonymous (AA) negotiate the tension between two religious discourses: Christianity and spiritual pluralism. Focus groups consisting of 32 AA members revealed instances of emergent meaning as the participants negotiated the dialectical tension between these discourses by employing four strategies: (a) centering and muting; (b) eliding tension through ambiguity; (c) inverting discourses; and (d) hybridity. Close analysis of the enactment of these strategies reveals how participants construct meaning while engaging the interplay of these discourses. The usefulness of this study for alcoholism treatment, public-health agencies, and individuals seeking treatment for alcohol abuse is discussed.

Timko C; Sutkowi A; Moos R. Patients with dual diagnoses or substance use disorders only: 12-step group participation and 1-year outcomes. Substance Use & Misuse 45(4): 613-627, 2010. (43 refs.)

We compared outpatients (regional facility) with substance use and psychiatric (N = 199) or only substance use (N = 146) disorders on baseline and one-year symptoms (93% follow-up), and treatment and 12-step group participation over the year (2005). We examined whether diagnostic status moderated associations between participation and outcomes (Addiction Severity Index) with regressions. At follow-up, dual diagnosis patients had more severe symptoms, despite comparable treatment. The groups were comparable on 12-step participation, which was associated with better outcomes. However, associations of participation with better outcomes were weaker for dual diagnosis patients. Study (VA HSR&D-funded) implications and limitations are

Tonigan JS; Beatty GK. Twelve-Step program attendance and polysubstance use: Interplay of alcohol and illicit drug use. Journal of Studies on Alcohol and Drugs 72(5): 864-871, 2011. (38 refs.)

Objective: The primary aim of this study was to advance understanding of the efficacy of 12-step programs by determining the temporal relationships between alcohol and illicit drug use among 12-step program affiliates. Method: A total of 253 early 12-step affiliates without extensive histories of Alcoholics Anonymous (AA) attendance were recruited from substance use treatment and community-based AA. A majority of the sample met criteria for a diagnosis of alcohol dependence, reported lifetime use of illicit drugs, and reported illicit drug use in the 90-day period before recruitment. After informed consent, participants were interviewed at intake and in 3-month increments for I year. Results: Preliminary analyses indicated that 12-step attendance was predictive of reductions in substance use and that such reductions were not moderated by illicit substance use disorder diagnosis or alcohol problem severity. Lagged hierarchical linear models indicated that illicit drug use was a robust predictor of later use of alcohol, although the frequency and intensity of drinking were contingent on whether participants sustained 12-step program affiliation. Alcohol use did not predict later illicit drug use among participants who sustained 12-step program participation. Conclusions: Findings suggest that 12-step participation may serve as a protective factor after substance use occurs. Although our results suggest that the initiation of illicit drug use may undermine efforts to achieve and sustain abstinence from alcohol, our findings do not suggest that alcohol use necessarily mobilizes relapse across different substances among 12-step program affiliates.

Travis T. The Language of the Heart: A Cultural History of the Recovery Movement from Alcoholics Anonymous to Oprah Winfrey.. Chapel Hill, NC: The University of North Carolina Press, 2010. (Chapter refs.)

This book, authored by a cultural historian, traces the history of recovery movements in the United States, from the earliest days of Alcoholics Anonymous to the present day, and examines their connections to broader historical and cultural currents. It is based on the extensive examination of archival documents. The author discusses the relationship of the recovery movement to the broad American tradition of self-help, highlighting the roles that gender, mysticism, and print culture have played in that development. Organized into three parts, Part I examines the origins of the recovery movement in the experiences of Alcoholics Anonymous, its philosophy, its postulating alcoholism as a disease, but different than the usual definitions of disease, as it is not limited to the physical body. The debt to earlier Protestant Evangelical fellowships is recognized, but the differences are significant. Shorn from specific religious content, it embraces spirituality. The goal was not only embrace sobriety, but also to renounce toxic self-centeredness in favor of humility and service. Part II focus upon the importance of print media in the history of the recovery movement. This too represents a legacy from the evangelical Protestantism and from "new thought Christianity" which William James discussed. While formed in 1935, by 1951, AA had begun publishing conference approved literature. For a group with little formal organization, this was in effect its "glue". In 1971, Hazelden a leading treatment program also established a publishing arm. The expansion of the recovery movement beyond AA is also discussed. There were other twelve-step programs modeled after AA, but also growing attention to behavioral addiction. Of note was the attention to co-dependency, a word that has become part of the culture. Part III considers the nature of the recovery movement in the past decade. A component is seen as attention to empowerment, and efforts to escape/confront the psychological consequences of social conditions and social hierarchies. The thread which ties these to earlier efforts is the appeal to spiritual solutions to problems of gender and power.

Witbrodt J; Romelsjo A. Gender differences in mutual-help attendance one year after treatment: Swedish and US samples. Journal of Studies on Alcohol and Drugs 71(1): 125-135, 2010. (71 refs.)

Objective: In the United States, many people turn to Alcoholics Anonymous (AA) and other mutual-help groups as a first source of help for an alcohol or drug problem, whereas others are introduced to AA while in treatment. Because AA and similar groups in the United States add to the treatment system and function without governmental funds, they represent an important element in ongoing care for individuals with substance-use disorders in the health care system. In countries with free (or more affordable) and more comprehensive systems of care, their role is less clearly defined. Method: In this study, we compared men and women from representative treatment samples from studies with parallel designs, one Swedish (n = 1,525) and the other American (n = 926), to explore whether rates and correlates of attendance at 1-year follow-up (63% and 78% followed) differ by gender. We explore individual characteristics (demographic, severity, motivational) and formal and informal influences (treatment, mutual help, coercive, social) as possible help-seeking correlates of attendance. Results: In both countries, similar proportions of men and women attended mutual-help groups. However, twice as many U.S. clients reported attendance. Moreover, twice as many U.S. clients set abstinence as a treatment goal. In multivariate models, having an abstinence goal, a perceived need for treatment, suggestions from one's employment environment, and prior mutual-help attendance predicted posttreatment attendance for men and women in both countries. Gender differences were also found. Conclusions: Given the stages in which individuals seek care and the cyclical nature of relapse and recovery, mutual-help groups are an efficient resource in the continuum of services.

Wright S; Nebelkopf E; King J; Maas M; Patel C; Samuel S. Holistic system of care: Evidence of effectiveness. Substance Use & Misuse 46(11): 1420-1430, 2011. (30 refs.)

The Native American Health Center provides substance use and mental health services for urban American Indians and Alaska Natives (AIs/ANs) utilizing a culturally based holistic system of care (HSOC). Substance use prevention, treatment, and recovery services emphasize traditional AI/AN healing practices alongside evidence-based practices. This article describes the HSOC approach and provides preliminary findings from an outcome evaluation. Participants in outpatient and residential treatment were interviewed at baseline and 6-month follow-up with a standardized assessment tool (n = 490). The sample we composed of 86% AI/AN, 70% females, 30% males, and was entirely urban. Decreases in substance use and its related consequences were evident in both modalities but were most pronounced in residential treatment. Study's limitations and implications are included.

Ye Y; Kaskutas LA. Using propensity scores to adjust for selection bias when assessing the effectiveness of Alcoholics Anonymous in observational studies. Drug and Alcohol Dependence 104(1-2): 56-64, 2009. (60 refs.)

Background: The effectiveness of Alcoholics Anonymous (AA) is difficult to establish. Observational studies consistently find strong dose-response relationships between AA meeting attendance and abstinence, and the only experimental studies favoring AA have been of 12-step facilitation treatment rather than of AA per se. Pending future randomized trials, this paper uses propensity score (PS) method to address the selection bias that potentially confounds the effect of AA in observational studies. Method: The study followed a treatment sample for 1 year to assess post-treatment AA attendance and abstinence (n = 569). Propensity scores were constructed based on known confounders including motivation, problem severity, and prior help-seeking. AA attendance during the 12-month follow-up period was studied as a predictor of alcohol abstinence for 30 days prior to the follow-up interview. PS stratification and PS matching techniques were used to adjust for the self-select bias associated with respondents' propensity to attend AA. Results: The overall advantage in abstinence initially observed narrowed when adjusted. The odds ratio associated with AA attendance reduced from 3.6 to 3.0 after PS stratification and 2.6 after PS matching to AA-attenders. Support for AA effectiveness was strengthened in the quintile with lower propensity scores and when AA-nonattenders were matched as the target group, but was weakened among those in the higher PS quintiles and when matching to AA-attenders. Discussion: These results confirm the robustness of AA effectiveness overall, because the results for higher abstinence associated with AA attendance following propensity score adjustment remained significant, and the reduction in the magnitude of AA's effect was moderate. However, the effect modification by propensity scores in both PS stratification and PS matching approaches seems to suggest that AA may be most helpful, or matter more, for those with a lower propensity to attend AA. Conversely, for those with a high propensity to go to AA (operationalized as higher motivation, greater problem severity, more prior AA and treatment exposure, etc.), attending AA may not make as much of a difference. It will be important that future studies replicate our results, as this is the first paper to use propensity score adjustment in this context.

Zafiridis P; Lainas S. Alcoholics and Narcotics Anonymous: A radical movement under threat. Addiction Research & Theory 20(2): 93-104, 2012. (118 refs.)

In recent decades, the considerable proliferation of the self-help groups (especially those of the Alcoholics Anonymous (AA) and Narcotics Anonymous (NA)) has attracted the interest of those engaged in the social sciences as well as of those responsible for mapping out health policies. This article is based on the 10-year involvement of the authors in a participatory action research project for the promotion of self-help groups in Greece as well as to an extensive literature review of the AA and NA movements. Based on this methodology, the objective of this article is twofold. First, it identifies the radical perspective of self-help groups, as the main source for their effectiveness, while it attempts an assessment of their effect on traditional professional attitudes. Second, it raises concerns over the radical perspective of these initiatives in the framework of their transition from an alternative stance towards their integration in formal Health Systems. This transition process is manifested in the following developments: the constantly increasing number of old members who quit the role of the volunteer sponsor and undertake the financially beneficial role of (para-) professional addiction counselor; the instrumentalization of 12 steps; the increasing number of members who adopt the nosological perspective of addiction. The various adverse effects of dominant culture on the internal working of the groups are studied. Moreover, this article attempts a comparative assessment of the produced experience with the AA and NA movements in Greece and abroad.

Zemore SE; Kaskutas LA. Development and validation of the Alcoholics Anonymous Intention Measure (AAIM). Drug and Alcohol Dependence 104(3): 204-211, 2009. (56 refs.)

Background: Drop-out from 12-step groups is notoriously high, yet the field lacks strong models and scales for addressing this problem. We aim to determine whether the theory of planned behavior (TPB) can be applied to 12-step involvement, and to develop and validate a scale of 12-step readiness based on that theory: the Alcoholics Anonymous Intention Measure (AAIM). Method: Data were from a longitudinal trial of a manual-guided 12-step facilitation intervention called Making AA Easier (MAAEZ) involving two treatment programs in California (N = 508). Participants completed surveys at baseline, 7 weeks, 6 months, and 12 months. Surveys included the preliminary AAIM, a 12-step involvement measure, other readiness measures, and substance use outcomes. Results: The final, 17-item AAIM measured Attitude (5-item alpha's=.75-.83), Subjective Norm (4-item alpha's=.56-81), Perceived Control (5-item alpha's=.78-.85), and Intention (3-item alpha's=.80-95) regarding attendance at 12-step groups. Components were correlated with each other and other readiness measures as expected, supporting the AAIM's validity. Scale components predicted 31% of the variance in Intention to attend 12-step groups at 6 months and 41% of the variance in 12-step involvement at 12 months. Social factors were among the strongest predictors of 12-step involvement. Results did not support the expectancy-value formulation of the TPB, as unweighted (vs. weighted) belief items performed optimally. Conclusions: Results generally support the TPB as a model of 12-step involvement and suggest specific targets for 12-step facilitation interventions within attitude, norm, and control components. Findings also support the AAIM as a tool for identifying drop-out risks and tailoring individual interventions.