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CORK Bibliography: Self-Help Groups

55 citations. January 2006 to present

Prepared: September 2008

Aromin RA; Galanter M; Solhkhah R; Dermatis H; Bunt G. Preference for spirituality and twelve-step-oriented approaches among adolescents in a residential therapeutic community. Journal of Addictive Diseases 25(2): 89-96, 2006. (43 refs.)

This study sought to determine which adolescents being treated for substance use in a residential Therapeutic Community, (TC) would endorse spirituality and Twelve-Step-oriented approaches as part of their treatment. By identifying individual difference characteristics associated with preference for spirituality and Twelve-Step-oriented approaches, integrated substance abuse treatments can be targeted to appropriate subgroups of adolescents. A total of 181 adolescents completed a survey assessing their substance use and attitudes toward spirituality and Twelve-Step-oriented approaches that was similar to a survey completed by 322 adults in the same residential TC program. In the adolescent sample, three spirituality-related characteristics -- perceived connectedness to others, frequency of prayer, and spiritual orientation to life -- were associated with preference for both spirituality and twelve step oriented approaches being featured more in TC treatment. Adolescents were less likely than adults to express a preference that both approaches be featured more in TC treatment.

Atkins RG; Hawdon JE. Religiosity and participation in mutual-aid support groups for addiction. Journal of Substance Abuse Treatment 33(3): 321-331, 2007. (76 refs.)

Mutual-aid support groups play a vital role in substance abuse treatment in the United States. A national survey of mutual-aid support groups for addiction was conducted to identify key differences between participants in recovery groups. Survey data indicate that active involvement in support groups significantly improves one's chances of remaining clean and sober, regardless of the group in which one participates. Respondents whose individual beliefs better matched those of their primary support groups showed greater levels of group participation, resulting in better outcomes as measured by increased number of days clean and sober. Religious respondents were more likely to participate in 12-step groups and Women for Sobriety. Nonreligious respondents were significantly less likely to participate in 12-step groups. Religiosity had little impact on SMART Recovery participation but actually decreased participation in Secular Organizations for Sobriety. These results have important implications for treatment planning and matching individuals to appropriate support groups.

Banerjee K; Howard M; Mansheim K; Beattie M. Comparison of health realization and 12-step treatment in women's residential substance abuse treatment programs. American Journal of Drug and Alcohol Abuse 33(2): 207-215, 2007. (20 refs.)

The purpose of this study was to compare a relatively new therapeutic option for substance abuse treatment, Health Realization, and 12-Step approaches offered in women's residential programs. The study was sponsored by a large California county's Department of Alcohol and Drug Services, which had offered Health Realization treatment for a number of years. This study constitutes the first systematic evaluation of Health Realization as a substance abuse treatment program for adult women in a residential treatment setting. This was a randomized study with two observations-admission and 9 months post-admission. The results showed that clients in both Health Realization and 12-Step treatment exhibited comparable outcomes on domains such as substance use, criminal justice involvement, employment, housing, adverse effects of substance use and psychological well being. Substance use declined significantly between admission and follow-up in both treatment groups, irrespective of duration of treatment. Similarly, adverse effects of substance use declined between admission and 9-month follow-up. Health Realization and 12-Step treatment offered comparable benefits for women in residential substance abuse treatment programs.

Bogenschutz MP. 12-step approaches for the dually diagnosed: Mechanisms of change. Alcoholism: Clinical and Experimental Research 31(10, Supplement S): 64S-66S, 2007. (30 refs.)

Background: Existing data indicate that 12-step program involvement is associated with improved outcomes in the dually diagnosed, but there are questions concerning the magnitude and mechanisms of this effect in various dually diagnosed populations. Methods: Publications identified in a comprehensive review of the literature pertaining to 12-step programs and patients with addictions and co-occurring psychiatric disorders were reviewed for any content relevant to understanding the process of change involving dually diagnosed patients involved with 12-step programs. Results: Dually diagnosed individuals attend 12-step programs at rates comparable to the nondually diagnosed, although specific diagnoses may have some effect on attendance. The benefits of 12-step attendance do not appear to be markedly different for those with psychiatric disorders. Specialized 12-step programs could have benefits for the dually diagnosed over and above those of traditional 12-step programs. Existing data suggest that nonspecific change mechanisms (self-efficacy, social support) are similar to those found in the general AA literature. Conclusions: Based on existing data, the change mechanisms are broadly similar to those found in the general 12-step literature, but additional factors related to mental illness may also play a significant role. Further work is necessary to test the components of this model and to achieve a firm empirical foundation for understanding the processes of 12-step recovery in the dually diagnosed.

Bogenschutz MP; Geppert CMA; George J. The role of twelve-step approaches in dual diagnosis treatment and recovery. American Journal on Addictions 15(1): 50-60, 2006. (97 refs.)

The authors reviewed the empirical literature concerning the use of twelve-step programs and treatments by patients with co-occurring substance use disorders and other psychiatric disorders. Strong evidence was found that dually diagnosed individuals (DDI), with the possible exception of those with psychotic disorders, attend twelve-step programs at rates comparable to non-DDI. Twelve-step involvement is consistently associated with improved substance use outcomes. Although there have been numerous clinical trials involving twelve step-oriented interventions for DDI, most of the studies suffered from substantial methodological limitations. More work is needed to determine what kinds of twelve-step treatments and programs are effective for various types of patients and elucidate the mechanisms by which these approaches facilitate recovery.

Carrico AW; Gifford EV; Moos RH. Spirituality/religiosity promotes acceptance-based responding and 12-step involvement. Drug and Alcohol Dependence 89(1): 66-73, 2007. (57 refs.)

Background: Previous investigations have observed that spirituality/religiosity (SIR) is associated with enhanced 12-step involvement. However, relatively few studies have attempted to examine the mechanisms for this effect. For the present investigation, we examined whether acceptance-based responding (ABR) - awareness or acknowledgement of internal experiences that allows one to consider and perform potentially adaptive responses - accounted for the effect of S/R on 12-step self-help group involvement 2 years after a treatment episode. Methods: Data were collected as part of a multi-site treatment outcome study with 3698 substance-dependent male veterans recruited at baseline. Assessments were conducted at baseline, discharge, 1-year follow-up, and 2-year follow-up. We utilized structural equation modeling to examine the relationships among latent variables of S/R, ABR, and 12-step involvement over time. Results: In the final model, S/R was not directly related to 12-step involvement at 2-year follow-up. However, S/R predicted enhanced ABR at 1-year follow-up after accounting for discharge levels of ABR. In turn, ABR at 1-year follow-up predicted increased 12-step involvement at 2-year follow-up after accounting for discharge levels of 12-step involvement. Conclusions: S/R promotes the use of post-treatment self-regulation skills that, in turn, directly contribute to ongoing 12-step self-help group involvement.

Center for Substance Abuse Treatment; Forman RF; Nagy PD. Substance Abuse: Clinical Issues in Intensive Outpatient Treatment. Treatment Improvement Protocol (TIP) Series 47. Rockville MD: Center for Substance Abuse Treatment, 2006. (640 refs.)

This Treatment Improvement Protocol was prepared to assist clinicians involved in intensive outpatient treatment programs. It describes the core services such programs should include, the process of assessment and treatment planning, entry and engagement in treatment, common clinical approaches, including family services, as well as the considerations with special groups of clients: women, adolescents, those involved in the criminal justice system, persons with co-occurring psychiatric disorders, racial and ethnic minorities, lesbian, gay and bisexual individuals, the elderly, the homeless, those with HIV/AIDS, and persons with physical or cognitive disabilities. The TIP also outlines 14 principles of intensive outpatient treatment: making treatment readily available, easing treatment entry, building on existing motivation, enhancing the therapeutic alliance, making retention a priority, assess and addressing individual treatment needs, providing ongoing care, monitoring abstinence, using mutual-/self-help and community resources, using medications if indicated, providing education about substance abuse, recovery and relapse, engaging families, employers and significant others, incorporating evidence-based approaches, and improving program administration. There are 11 appendices that provide additional resources such as screening instruments, protocols, sample history forms. There are also 34 "exhibits", e.g. check lists, sample documents, suggested sequence of topics for groups therapy sessions.

Public Domain

Chernus LA. Psychotherapy with alcoholic patients: A self psychological approach. Smith College Studies in Social Work 75(3): 63-92, 2006. (25 refs.)

This paper demonstrates how use of the empathic mode in outpatient psychotherapy helped an alcoholic patient reduce his denial of the severity of his illness. Both the general psychoanalytic literature and, in particular, the self psychology literature concerning treatment of alcoholics is reviewed and evaluated. This paper also examines in depth how the empathic mode functions to promote self-object transferences, which facilitate internalization processes that may lead to a reduction in the alcoholic patient's need to rigidly maintain his denial of the illness. The complexity of the relationship between alcoholism self-help groups and the professional psychotherapy community is also explored.

Davey-Rothwell MA; Kuramoto SJ; Latkin CA. Social networks, norms, and 12-step group participation. American Journal of Drug and Alcohol Abuse 34(2): 185-193, 2008. (22 refs.)

In a sample of active drug users, we assessed the associations between frequency of attending a 12-step program, perceived social norms, and social network structure. Participants who reported that most or all of their drug partners attended 12-step groups were over ten times more likely to be frequent attenders compared to individuals who did not go to Narcotics Anonymous (NA). While social network structure of number of cocaine and heroin users and number of members in treatment was associated with frequent attendance, there was no association among individuals who infrequently went to a 12-step program. Individuals who are trying to control their drug use should be encouraged to affiliate with others in recovery or attending a 12-step program.

Dawson DA; Grant BF; Stinson FS; Chou PS. Estimating the effect of help-seeking on achieving recovery from alcohol dependence. Addiction 101(6): 824-834, 2006. (38 refs.)

Aims: To investigate the effect of help-seeking on the likelihood of recovery from Diagnostic and Statistical Manual version IV (DSM-IV) alcohol dependence, specifically examining the impact of model selection, factors that moderate the effect of help-seeking and distinctions between the effects of 12-Step participation and formal treatment. Methods This analysis is based on data from the Wave 1 2001-02 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a cross-sectional, retrospective survey of a nationally representative sample of US adults 18 years of age and over. The analytical sample consisted of 4422 individuals with prior-to-past-year (PPY) onset of DSM-IV alcohol dependence. Findings: Logistic regression, proportional hazards and time-dependent proportional hazards models were used to estimate the effects of help-seeking on three outcomes: (1) any recovery from alcohol dependence, which required full remission of all symptoms of alcohol abuse and dependence and excluded asymptomatic drinkers whose alcohol consumption exceeded low-risk drinking guidelines; (2) non-abstinent recovery (NR), representing low-risk asymptomatic drinkers; and (3) abstinent recovery (AR), representing abstainers. Findings Only one-quarter of individuals with PPY-onset alcohol dependence had ever sought help for alcohol problems, including 3.1% who had participated in 12-Step programs only, 5.4% who had received formal treatment only and 17.0% with both 12-Step and formal treatment. Based on the most appropriate model, help-seeking increased the likelihood of any recovery [hazard rate ratio (HRR) = 2.38], NR (HRR = 1.50) and AR (HRR = 4.01). The impact of help-seeking on AR did not show any significant variation across the exposure period but was modified by severity among other factors. Individuals who participated in 12-Step programs in addition to formal treatment had almost twice the chance of recovery and more than twice the chance of AR compared with those who received formal treatment alone. Conclusions: Help-seeking plays a significant role in the achievement of abstinent recovery from alcohol dependence, with 12-Step participation playing a major role. Appropriate model selection is critical to assessing the impact of help-seeking.

Donovan DM; Wells EA. 'Tweaking 12-Step': the potential role of 12-Step self-help group involvement in methamphetamine recovery. Addiction 102(Supplement 1): 121-129, 2007. (71 refs.)

Aims: To determine from a review of the available literature the extent to which involvement in 12-Step mutual support groups could play a role in the recovery process for individuals abusing or dependent on methamphetamine. Method: Review of the literature on outcomes associated with 12-Step meeting attendance and involvement in 12-Step activities among substance abusers, particularly those who abuse stimulants. Results: There are few if any data available on methamphetamine abusers and their use of 12-Step approaches. Evidence derived from work with alcohol-and cocaine-dependent individuals indicates that involvement in 12-Step self-help groups, both attending meetings and engaging in 12-Step activities, is associated with reduced substance use and improved outcomes. Although involvement in 12-Step fellowship improves outcome, many individuals do not engage on their own in 12-Step activities, and there are high rates of dropout from such groups. There are a number of evidence-based therapies available to assist clinicians in facilitating 12-Step involvement; however, these have not been used with methamphetamine abusers. While there are some potential barriers to adopting manualized treatment interventions into clinical practice, the familiarity, in community- based practice, of the 12-Step approach may make this easier. Conclusion More actively integrating 12-Step approaches into the treatment process may provide low- or no-cost options for methamphetamine abusers and increase the capacity for providing treatment. Further research and evaluation are necessary to determine the extent to which methamphetamine abusers do engage in 12-Step self-help programs, whether they prefer more general ( e. g. Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous) or drug-specific ( e. g. Crystal Meth Anonymous) meetings, the rate of dropout and the outcomes associated with their involvement. Further, the efficacy of efforts to facilitate involvement of methamphetamine abusers in such 12-Step groups needs to be determined.

Duffy SQ; Cowell AJ; Council CL; Shi WH. Formal treatment, self-help, or no treatment for alcohol-use disorders? Evidence from the National Household Survey on Drug Abuse. Journal of Studies on Alcohol 67(3): 363-372, 2006. (38 refs.)

Objective: The purpose of this study was to examine further alcohol treatment choice by using data from a nationally representative sample of adults with alcohol-use disorders to test which of three models-sequential, multinomial, or nested-best fit the data. The goals were to provide evidence about how this choice was made and to provide improved coefficient estimates, as well as to inform future analyses of treatment choice. Method: Data from the 2000 National Household Survey of Drug Abuse include respondents ages 18-64 reporting symptoms consistent with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of alcohol abuse or dependence. A nested multinomial framework is used to determine the preferred model and to estimate the effect of respondents' characteristics on the decisions to receive help and what kind of help to receive. Results: A sequential model, in which the choice of whether to receive help is unaffected by the level of satisfaction afforded by the alternatives, best fit the data. Older respondents had higher odds of both receiving help and choosing self-help, and those with a DSM-IV diagnosis of abuse had lower odds of receiving help but higher odds of entering self-help. Conclusions: The decision to receive help for alcohol problems appears unaffected by the perceived differences between these two broad categories of alternatives: self-help or formal treatment. This result may indicate the need to provide more information on the full range of treatment options to those for whom self-help may not be sufficient.

Erbas B; Bui QA; Huggins R; Harper T; White V. Investigating the relation between placement of Quit antismoking advertisements and number of telephone calls to Quitline: a semiparametric modelling approach. Journal of Epidemiology and Community Health 60(2): 180-182, 2006. (13 refs.)

Study objectives: Quitline - an antismoking advertising and a telephone helpline service - is an effective public health intervention strategy for tobacco control. The objective of this short report is to model the relation between placement of antismoking advertisements and calls to Quitline on a given day. Methods/design: Data on daily Quitline antismoking advertisements, television target audience rating points (TARPS), and calls to Quitline Victoria were studied for the period 1 August 2000 and 31 July 2001. The outcome - calls to Quitline - is a count and thus assumed to follow a Poisson distribution. Generalised partial linear models were used to model the logarithm of mean daily calls as a non-parametric function of time and a linear parametric function of the day of week, number of advertisements, and TARPS. Main results: Peak calls to Quitline Victoria occurred during Monday to Wednesday with around three times as many calls compared with Sunday. Both placement of Quitline advertisements (p < 0.001) and an increase in TARPS (p < 0.001) on a given day significantly increased the number of calls made to Quitline Victoria. The model adequately captured fluctuations in call volume and diagnostics showed no model inadequacy. Conclusions: In this short report the emphasis is on modelling the parametric components - day of week, placement of advertisements, and TARPS on call volume. The dynamics of the underlying time trend in call volume is captured in a non-parametric component. Future analysis of hourly data would provide additional information to assess different media buying strategies that might increase call volume.

Forys K; McKellar J; Moos R. Participation in specific treatment components predicts alcohol-specific and general coping skills. Addictive Behaviors 32(8): 1669-1680, 2007. (29 refs.)

This study identified which aspects of substance abuse treatment in community residential facilities (CRFs) were correlated with patients' post-treatment coping. A total of 2376 patients supplied demographic information and completed measures at baseline (coping and abstinence self-efficacy) and one year after treatment (coping, level of drug and alcohol use, and substance-related problems). Staff provided information about treatment orientation and patients' participation in treatment (e.g., life skills training, vocational counseling). The data were used to predict coping 1 year after treatment. As expected, higher levels of general approach coping and alcohol-specific coping and lower levels of general avoidance coping were associated with less 1-year alcohol and drug use and fewer drinking problems. Patients' greater level of participation in life skills counseling predicted more approach coping at 1 year. In addition, positive social relationships and participation in 12-step self-help groups predicted less general avoidance coping and more alcohol-specific coping at 1 year post-treatment. Life skills training, 12-step self-help groups, and enhancement of supportive relationships during CRF treatment for substance abuse are related to healthy coping. Future research should examine the effect of these components in less intensive programs and with women.

Galanter M. Spirituality and addiction: A research and clinical perspective. American Journal on Addictions 15(4): 286-292, 2006. (71 refs.)

Spirituality is a construct that has recently gained currency among clinicians because of its close association with twelve-step modalities and its perceived role in the promotion of meaningfulness in recovery from addiction. This article draws on studies from physiology, psychology, and cross-cultural sources to examine its nature and its relationship to substance use disorders. Illustrations of its potential and limitations as a component of treatment in spiritually oriented recovery movements like Alcoholics Anonymous, meditative practices, and treatment systems for the dually diagnosed are given.

Galanter M; Dermatis H; Mansky P; McIntyre J; Perez-Fuentes G. Substance-abusing physicians: Monitoring and twelve-step-based treatment. American Journal on Addictions 16(2): 117-123, 2007. (31 refs.)

This study was designed to provide an independent evaluation of the oversight and rehabilitation of substance-impaired physicians. Records of 104 physicians who had completed their monitoring period by the New York State Committee on Physicians' Health were selected at random from CPH files. They had been followed for an average of 41.3 months. Practice characteristics and substance use before admission, as well as workplace monitoring, twelve-step attendance, urine toxicologies, and relapse incidence after admission are reported. Significant intercorrelations among these variables were ascertained by logistic regression. The utility of twelve-step-based rehabilitation as part of a treatment plan for sustaining abstinence and averting relapse is discussed.

Gossop M; Stewart D; Marsden J. Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and substance use outcomes after residential treatment for drug dependence: a 5-year follow-up study. Addiction 103(1): 119-125, 2008. (44 refs.)

Aims This study investigates the relationship between frequency of attendance at Narcotics Anonymous and Alcoholics Anonymous (NA/AA) meetings and substance use outcomes after residential treatment of drug dependence. It was predicted that post-treatment NA/AA attendance would be related to improved substance use outcomes. Methods Using a longitudinal, prospective cohort design, interviews were conducted with drug-dependent clients (n = 142) at intake to residential treatment, and at 1 year, 2 years and 4-5 years follow-up. Data were collected by structured interviews. All follow-up interviews were carried out by independent professional interviewers. Findings Abstinence from opiates was increased throughout the 5-year follow-up period compared to pre-treatment levels. Clients who attended NA/AA after treatment were more likely to be abstinent from opiates at follow-up. Abstinence from stimulants increased at follow-up but (except at 1-year follow-up) no additional benefit was found for NA/AA attendance. There was no overall change in alcohol abstinence after treatment but clients who attended NA/AA were more likely to be abstinent from alcohol at all follow-up points. More frequent NA/AA attenders were more likely to be abstinent from opiates and alcohol when compared both to non-attenders and to infrequent (less than weekly) attenders. Conclusions: NA/AA can support and supplement residential addiction treatment as an aftercare resource. In view of the generally poor alcohol use outcomes achieved by drug-dependent patients after treatment, the improved alcohol outcomes of NA/AA attenders suggests that the effectiveness of existing treatment services may be improved by initiatives that lead to increased involvement and engagement with such groups.

Gpant J. Rural women's stories of recovery from addiction. Addiction Research & Theory 15(5): 521-541, 2007. (80 refs.)

In general, much has been written on women's patterns of drug use and the varying factors that impel them into addiction and subsequently into recovery. However, there is a paucity of information on rural Appalachian women and how they make meaning of their recovery processes. Drawing on data collected through informal interviews this article explicates dimensions of the various strategies 25 rural women develop and apply as they shift from using alcohol and/or drugs to their nonuse of such substances through a consideration of their self-change processes: the disgusted self, the aware self, the alternative self, and the stable self. Furthermore, with little access to treatment in this region, data show that participants compensated for that within their own cultural contexts: through the use of family, church, friends, work, school, and self-help institutions such as Alcoholics Anonymous and Narcotics Anonymous. I conclude with a discussion of the implications of these strategies for understanding rural women as they manage recovery processes.

Humphreys K; Moos RH. Encouraging posttreatment self-help group involvement to reduce demand for continuing care services: Two-year clinical and utilization outcomes. Alcoholism: Clinical and Experimental Research 31(1): 64-68, 2007. (20 refs.)

Background: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients' health care costs in the first year after treatment, but such initially impressive effects may wane over time. This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up. Methods: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step-based (n = 887 patients) or cognitive-behavioral (CB, n = 887 patients) treatment programs. The 12-step-based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs. The 2-year follow-up assessed patients' substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs. Results: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) versus CB (37.0%) programs. Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs. In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p = 0.01). Conclusions: Promoting self-help group involvement appears to improve posttreatment outcomes while reducing the costs of continuing care. Even cost offsets that somewhat diminish over the long term can yield substantial savings. Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

Jason LA; Groh DR; Durocher M; Alvarez J; Aose DM; Ferrari JR. Counteracting "not in my backyard": The positive effects of greater occupancy within mutual-help recovery homes. Journal of Community Psychology 36(7): 947-958, 2008. (45 refs.)

Group homes sometimes face significant neighborhood opposition, and municipalities frequently use maximum occupancy laws to close down these homes. This study examined how the number of resident in Oxford House recovery homes impacted residents' outcomes. Larger homes (i.e., eight or more residents) may reduce the cost per person and offer more opportunities to exchange positive social support, thus, it was predicted that larger Oxford House would exhibit improved outcomes compared to smaller homes. Regression analyses using data from 643 residents from 154 U.S. Oxford Houses indicated that larger house size predicted less criminal and aggressive behaviour; additionally, length of abstinence was a partial mediator in these relationships. These findings have been used in court cases to argue against closing down larger Oxford Houses.

Jason LA; Olson BD; Ferrari JR; Lo Sasso AT. Communal housing settings enhance substance abuse recovery. American Journal of Public Health 96(10): 1727-1729, 2006. (11 refs.)

Oxford Houses are democratic, mutual help-oriented recovery homes for individuals with substance abuse histories. There are more than 1200 of these houses in the United States, and each home is operated independently by its residents, without help from professional staff. In a recent experiment, 150 individuals in Illinois were randomly assigned to either an Oxford House or usual-care condition (i.e., outpatient treatment or self-help groups) after substance abuse treatment discharge. At the 24-month follow-up, those in the Oxford House condition compared with the usual-care condition had significantly lower substance use, significantly higher monthly income, and significantly lower incarceration rates.

Johnson JE; Finney JW; Moos RH. End-of-treatment outcomes in cognitive-behavioral treatment and 12-step substance use treatment programs: Do they differ and do they predict 1-year outcomes? Journal of Substance Abuse Treatment 31(1): 41-50, 2006. (21 refs.)

This study examined changes in treatment-related proximal outcomes from intake to follow-up, associations between continuing care and maintenance of proximal outcome gains, correlations between specific proximal outcomes and substance use outcomes, and potential mediators of treatment effects for 12-step versus cognitive-behavioral (CB) substance use disorder (SUD) treatment. The participants were 1,873 male veterans seeking SUD treatment at five CB-oriented and five 12-step-oriented VA inpatient/residential SUD programs. Patterns of change in proximal outcomes were similar across the two program types. After discharge, attendance at 12-step groups, but not outpatient treatment, was associated with greater maintenance on most proximal outcomes. Only a few proximal outcomes at discharge were associated with 1-year substance use; most 1-year proximal outcomes were associated with 1-year substance use. Having a sponsor, reading 12-step materials, attending 12-step meetings, and having an abstinence goal appeared to mediate the greater effects of 12-step programs (relative to CB programs) on abstinence.

Kahler CW; Kelly JF; Strong DR; Stuart GL; Brown RA. Development and initial validation of a 12-step participation expectancies questionnaire. Journal of Studies on Alcohol 67(4): 538-542, 2006. (15 refs.)

Objective: There are no available instruments that assess expectancies for participation in 12-step mutual-help groups despite the impact such expectancies may have on actual participation. The purpose of the present study was to develop a measure of attitudes and expectancies regarding 12-step participation, to conduct preliminary analyses on its psychometric properties, and to explore its concurrent and predictive validity. Method: Alcohol-dependent patients (N = 48) undergoing inpatient detoxification completed a questionnaire that included subscales assessing expected benefits of, concerns about, and barriers to 12-step participation. Participants also completed measures of 12-step group participation and drinking outcomes at 1, 3, and 6 months following discharge. Results: After examining the internal consistency of the items within each subscale and refining the questionnaire accordingly, an exploratory factor analysis showed that the scales could be combined into a higher-order total score. This total score correlated significantly with prior 12-step experience and goals for attending future 12-step meetings. In addition, the Expectancies Total Score at baseline significantly predicted 12-step group participation during follow-up. Conclusions: The measure of attitudes and expectancies regarding 12-step group participation demonstrated good internal consistency, concurrent validity, and predictive validity. The measure may have clinical utility in highlighting patients' expectancies regarding 12-step participation, allowing treatment providers to explore with patients the benefits, concerns, and barriers to involvement that they have endorsed.

Karno MP. A case study of mediators of treatment effectiveness. Alcoholism: Clinical and Experimental Research 31(10, Supplement S): 33S-39S, 2007. (22 refs.)

Background: Recent research has observed that the use of confrontation in psychosocial treatment for alcohol abuse or dependence has a negative effect on posttreatment alcohol use among patients at average or above average levels of trait anger. It is not known what mediates that negative effect. The current study examines the role of session attendance as a mediator of the effect of confrontation on patients' subsequent alcohol use. In doing so, the study demonstrates the process of testing for mediation as well as planning analyses to meet additional conditions that can lend support to a causal mechanism of change. Methods: Multiple regression analyses were used to test for session attendance as a mediator among 107 individuals with alcohol abuse or dependence who received either cognitive behavioral therapy (CBT) (n = 39), motivational enhancement therapy (MET) (n = 34), or twelve-step facilitation therapy (TSF) (n = 34). Emphasis was placed on achieving the desired temporal sequence of the therapy intervention, the mediator, and the outcome variable. Results: The data supported the role of session attendance as a partial mediator of the effect of confrontation on future alcohol use among patients who received CBT, but not among patients who received MET or TSF. In CBT, other potential mediators (e.g., therapeutic alliance and in-session resistance) were not supported and did not change the support for session attendance in the model. Beyond mediation, some but not all criteria for a causal mechanism of change were also met. Conclusion: This study suggests that in CBT the negative impact of confrontation early in treatment is partially explained by a reduction in the number of sessions patients attended. Different processes appear to be occurring in MET and TSF. By carefully constructing analytic models, results can speak both to issues of mediation and to causal mechanisms of change.

Kaskutas LA; Ammon LN; Oberste E; Polcin DL. A brief scale for measuring helping activities in recovery: The Brief Helper Therapy Scale. Substance Use & Misuse 42(11): 1767-1781, 2007. (37 refs.)

Background: Helping others is evident in the philosophy of Alcoholics Anonymous, and is emphasized in formal treatment. However, helping among recovering alcoholics has not been studied, in part because of a lack of helping measures. Methods: This study developed a Brief Helper Therapy Scale to capture helping among individuals with varying lengths of recovery. The 26-item long version of the Helper Therapy Scale was developed from qualitative interviews (n = 21) and item analysis of responses from 200 recovering alcoholics with differing lengths of recovery. Three subscales assessed Recovery, Life, and Community Helping. This brief version was created using an iterative process of item analysis designed to yield good internal consistency and representation of different types of helping. Helping was assessed as a continuous measure of how much time had been spent on each activity in the past week. Results: The resulting 9-item Brief Helper Therapy Scale demonstrated strong internal consistency (alpha = 0.83), but did not correlate well with psychological and spirituality measures used to assess construct validity. The Brief Helper Therapy Scale can be completed in about 5 minutes. Those in early recovery reported move involvement in recovery helping, with service in AA a notable exception. Those with the longest recovery focused more on community helping. Conclusions: Findings suggest that persons more stable in recovery move beyond a singular focus on recovery helping and demonstrate that people in recovery do contribute to society -- potentially dispelling some of the stigma associated with alcoholism.

Kelly JF; Stout R; Zywiak W; Schneider R. A 3-year study of addiction mutual-help group participation following intensive outpatient treatment. Alcoholism: Clinical and Experimental Research 30(8): 1381-1392, 2006. (86 refs.)

Addiction-focused mutual-help group participation is associated with better substance use disorder (SUD) treatment outcomes. However, little has been documented regarding which types of mutual-help organizations patients attend, what levels of participation may be beneficial, and which patients, in particular, are more or less likely to participate. Furthermore, much of the evidence supporting the use of these organizations comes from studies examining participation and outcomes concurrently, raising doubts about cause-effect connections, and little is known about influences that may moderate the degree of any general benefit. Alcohol-dependent outpatients (N=227; 27% female; M age=42) enrolled in a randomized-controlled telephone case monitoring trial were assessed at treatment intake and at 1, 2, and 3 years postdischarge. Lagged-panel, hierarchical linear models tested whether mutual-help group participation in the first and second year following treatment predicted subsequent outcomes and whether these effects were moderated by gender, concurrent axis I diagnosis, religious preference, and prior mutual-help experience. Robust regression curve analysis was used to examine dose-response relationships between mutual-help and outcomes. Mutual-help participation was associated with both greater abstinence and fewer drinks per drinking day and this relationship was not found to be influenced by gender, Axis I diagnosis, religious preference, or prior mutual-help participation. Mutual-help participants attended predominantly Alcoholics Anonymous and tended to be Caucasian, be more educated, have prior mutual-help experience, and have more severe alcohol involvement. Dose-response curve analyses suggested that even small amounts of participation may be helpful in increasing abstinence, whereas higher doses may be needed to reduce relapse intensity. Use of mutual-help groups following intensive outpatient SUD treatment appears to be beneficial for many different types of patients and even modest levels of participation may be helpful. Future emphasis should be placed on ways to engage individuals with these cost-effective resources over time and to gather and disseminate evidence regarding additional mutual-help organizations.

Klaw E; Horst D; Humphreys K. Inquirers, triers, and buyers of an alcohol harm reduction self-help organization. Addiction Research & Theory 14(5): 527-535, 2006. (21 refs.)

Moderation Management (MM) is the only self-help organization designed to help problem drinkers who wish to moderate their alcohol consumption rather than abstain. Experienced MM members tend to be highly educated and employed and have minimal signs of physical dependence on alcohol or co-occurring drug use. As a result, MM is sometimes dismissed as an organization that attracts only "the worried well'', or, is initially accessed by a wide range of problem drinkers but ultimately retains only "easy cases'' as enduring members (e. g., alcoholic individuals are tempted to join MM but relapse and drop out immediately). Both of these possibilities were evaluated by comparing 445 nonmembers who were called MM's helpline ("inquirers'' or "callers''), 41 early stage MM members ("triers''), and 124 experienced MM members ("buyers''). In general, experienced MM members reported the most severe drinking histories, followed by early stage members and then by callers, whose reported problems were quite modest. Measures of social stability and resources did not tend to differentiate the groups. Thus, it appears that contrary to what some have speculated, even though MM does attract a relatively privileged population in demographic terms, those with more serious alcohol problems are the most likely, rather than the least likely to become long-term MM members.

Kosok A. The Moderation Management programme in 2004: What type of drinker seeks controlled drinking? International Journal of Drug Policy 17(4, Special Issue): 295-303, 2006. (39 refs.)

Objective: Moderation Management (MM) is a mutual aid support group that helps problem drinkers reduce drinking to non-harmful levels. This study describes member characteristics as part of an organisational evaluation. The results are compared to those of an earlier survey. Methods: An anonymous survey was distributed to all members in the online and face-to-face MM groups. Respondents (N=272) reported demographic characteristics, drinking history, frequency/amount of drinking, alcohol dependence, life problems six months prior to MM, drinking goals upon programme entry, and pre-MM help sought. Data were analysed for the entire group and by programme delivery format: online-only (OL), face-to-face only (F2F), and both (Both). Results: Members had a mean age of 44 years, and were 66% female, 98% White, 90% US residents, 80% employed, 54% married, 94% college educated; 77% had an annual income over $50,000; 54% had not sought prior help. The pre-MM mean number of drinks per week was 34 (S.D. 20, range 0-105), dependence score was I I of a possible 39 (S.D. 5, range 0-24), and number of life problems was 1.9 (S.D. 1.4, range 0-6) of a possible 6. The OL group was younger than the other two groups. The F2F group had sought more prior help than the OL group and drank less than the Both group. Those using Both formats sought to move from abstinence to moderation more frequently than the OL group. Conclusions: People participating in MM are largely White and upper middle class. Participation by women has increased since 1999; MM may be attracting members with a higher level of dependence than previously. As over 50% have not previously sought help, MM is an important addition to other treatment choices. It is an option problem drinkers want.

Laudet A; Stanick V; Sands B. An exploration of the effect of on-site 12-step meetings on post-treatment outcomes among polysubstance-dependent outpatient clients. Evaluation Review 31(6): 613-646, 2007. (92 refs.)

Rates of return to active substance use after addiction treatment tend to be high; participation in 12-step fellowships (e.g., Alcoholics Anonymous) reduces relapse rates but many clients do not attend or attend for a short period only. This quasi-experimental study uses repeated measurement to explore the role of presence/absence of on-site 12-step meetings during treatment on posttreatment outcomes. Polysubstance-dependent clients (N = 219) recruited at a program with and one without 12-step on-site, were followed for one year post-treatment. On-site 12-step enhanced 12-step attendance, especially during treatment, and predicted continuous abstinence for the post-treatment year. Holding 12-step meetings on-site is a low-cost strategy that programs should consider to foster post-treatment remission maintenance.

Laudet AB; White WL. Recovery capital as prospective predictor of sustained recovery, life satisfaction, and stress among former poly-substance users. Substance Use & Misuse 43(1): 27-54, 2008. (85 refs.)

Many recovering persons report quitting their drug use because they are "sick and tired" of the drug life. Recovery is the path to a better life, but that path is often challenging and stressful. There has been little research on the millions of recovering persons in the United States, and most research has focused on substance use outcomes rather than on broader functioning domains. This study builds on our previous cross-sectional findings that recovery capital (social supports, spirituality, religiousness, life meaning, and 12-step affiliation) enhances the ability to cope with stress and enhances life satisfaction. This study (a) tests the hypothesis that higher levels of recovery capital prospectively predict sustained recovery, higher quality of life, and lower stress one year later, and (b) examines the differential effects of recovery capital on outcomes across the stages of recovery. Recovering persons (N = 312), mostly inner-city ethnic minority members whose primary substance had been crack or heroin, were interviewed twice at a one-year interval in New York City between April 2003 and April 2005. Participants were classified into one of four baseline recovery stages: under 6 months, 6-18 months, 18-36 months, and over 3 years. Multiple regression findings generally supported the central hypothesis and suggested that different domains of recovery capital were salient at different recovery stages. The study's limitations are noted and implications of findings for clinical practice and for future research are discussed, including the need for a theoretical framework to elucidate the recovery process.

Lessenger JE; Feinberg SD. Abuse of prescription and over-the-counter medications. (review). Journal of the American Board of Family Medicine 21(1): 45-54, 2008. (46 refs.)

The nonmedical use of prescription or over-the-counter (OTC) medications implies that the user is using them for reasons other than those indicated in the prescribing literature or on the box label. The abuse of these medications is a national issue. Intentional drug abuse of prescribed and OTC medicines has climbed steadily. Data from the 2005 National Survey on Drug Use and Health demonstrated that 6.4 million (2.6%) people aged 12 or older had used prescription drugs for nonmedical reasons during the past month. Of these, 4.7 million used pain relievers, 1.8 million used tranquilizers, and 1.1 million used stimulants. The nonmedical use of prescription drugs in the past month among young adults aged 18 to 25 increased from 5.4% in 2002 to 6.3% in 2005, primarily because of an increase in the abusive use of pain relievers. Physicians need to watch for prescription and OTC medication abuse. Treatment strategies include (1) inquiring about prescription, OTC, and herbal drug use at the initial examination (even though many individuals are drug-abuse savvy, some are naive and do not realize that OTC medications can be problematic); (2) inquiring about drug use during office visits; (3) providing disposal containers that patients can use to dispose of their unused or unneeded prescription or OTC medications; (4) treating pain aggressively and appropriately; (5) practicing careful record keeping of prescription refills and controls over prescription blanks; (6) referring patients who are addicted to medications to 12-step programs such as Alcoholic Anonymous, Narcotics Anonymous, and Pills Anonymous; and (7) considering detoxification.

Magura S. The relationship between substance user treatment and 12-step fellowships: Current knowledge and research questions. Substance Use & Misuse 42(2-3): 343-360, 2007. (59 refs.)

This article reviews and synthesizes information about the relationship between two distinct approaches to helping substance users, formal "addiction treatment" and 12-step mutual aid. The following issues are addressed: Extent of formal treatment and 12-step fellowship participation for persons with substance use-related problems; overlap between treatment and 12-step participation; early attempts to "integrate" treatment and 12-step mutual aid; differences and similarities between the 12-step program and treatment; issues ofspirituality in the 12-step program; effectiveness of 12-step participation as treatment aftercare; and whether help-seekers can be "matched" to 12-step. The article poses pertinent questions that could answered by additional research, including life cycle patterns of usage of treatment and 12-step, outcomes of such episodes, reasons for using different interventions at different times, feasibility of 12-step participation as a primary intervention, the relative contributions of striving for spiritual values vs. social support factors to the effectiveness of 12-step, and the comparative effectiveness of secular vs. 12-step, mutual aid. The article concludes with a proposed reconceptualization of the relationship between formal treatment and 12-step mutual aid that may help in structuring future research.

Magura S; Rosenblum A; Villano CL; Vogel HS; Fong C; Betzler T. Dual-focus mutual aid for co-occurring disorders: A quasi-experimental outcome evaluation study. American Journal of Drug and Alcohol Abuse 34(1): 61-74, 2008. (49 refs.)

Previous observational research has indicated the effectiveness of a 12-step, dual-focus mutual aid group, Double Trouble in Recovery (DTR), for assisting individuals to recover from co-occurring substance use and psychiatric disorders. The current study extends this line of research by evaluating DTR with a quasi-experimental design; controlled designs are rare in studies of mutual aid. Patient outcomes in the same psychiatric day treatment program were compared for two consecutive admission cohorts characterized by high rates of co-occurring disorders. The first cohort did not have DTR available while the second cohort was exposed to DTR after it was established at the program. Both cohorts were assessed at program admission and at a six-month follow-up. Using intent to treat analysis, the Post-DTR cohort as compared with the Pre-DTR cohort had significantly fewer days of alcohol and drug use, more frequent traditional 12-step groups outside of the program and higher psychiatric medication adherence. There were no differences in psychiatric symptoms or program retention, however. This study helps demonstrate the benefits of introducing 12-step, dual-focus mutual aid into psychiatric treatment programs that serve patients with co-occurring disorders.

Majer JM; Jason LA; North CS; Ferrari JR; Porter NS; Olson B et al. A longitudinal analysis of psychiatric severity upon outcomes among substance abusers residing in self-help settings. American Journal of Community Psychology 42(1/2): 145-153, 2008. (50 refs.)

A longitudinal analysis of psychiatric severity was conducted with a national sample of recovering substance abusers living in Oxford Houses, which are self-run, self-help settings. Outcomes related to residents' psychiatric severity were examined at three follow-up intervals over one year. Over time, Oxford House residents with high versus low baseline psychiatric severity reported significantly more days using psychiatric medication, decreased outpatient psychiatric treatment, yet no significant differences for number of days abstinent and time living in an Oxford House. These findings suggest that a high level of psychiatric severity is not an impediment to residing in self-run, self-help settings such as Oxford House among persons with psychiatric comorbid substance use disorders.

Matheson JL; Mccollum EE. Using metaphors to explore the experiences of powerlessness among women in 12-step recovery. Substance Use & Misuse 43(8-9): 1027-1044, 2008. (22 refs.)

12-Step programs of substance abuse recovery are the most utilized mutual-help models in the United States. A pivotal aspect of 12-Step is the often-controversial idea of powerlessness. There is debate about the usefulness of the concept of powerlessness, especially for women in recovery. This study used a metaphor-elicitation interviewing technique to examine the experiences of powerlessness among 13 women of varied racial, ethnic, and socioeconomic backgrounds, ages 21 to 60, who had an average of 9.5 years of recovery. Interviews were conducted during a 6-month span between 2004 and 2005 in the Washington, DC metropolitan area. Open and axial coding was used to determine emergent themes. Concepts of powerlessness were found to be process oriented and developmental. Some metaphors indicated positive emotions around powerlessness such as relief, whereas others indicated negative emotions such as fear. Implications for future research and study strengths and limitations are included.

Moos RH. Active ingredients of substance use-focused self-help groups. (review). Addiction 103(3): 387-396, 2008. (74 refs.)

Aims and methods: This paper provides an overview of some of the probable active ingredients of self-help groups in light of four related theories that identify common social processes that appear to underlie effective psychosocial treatments for and continuing remission from these disorders. Results Social control theory specifies active ingredients such as bonding, goal direction and structure; social learning theory specifies the importance of norms and role models, behavioral economics and behavioral choice theory emphasizes involvement in rewarding activities other than substance use, and stress and coping theory highlights building self-efficacy and effective coping skills. A review of existing studies suggests that the emphasis on these active ingredients probably underlies some aspects of the effectiveness of self-help groups. Conclusions: Several issues that need to be addressed to enhance understanding of the active ingredients of action of self-help groups are discussed, including consideration of indices of Alcoholics Anonymous (AA) affiliation as active ingredients, identification of personal characteristics that may moderate the influence of active ingredients on substance use outcomes, examination of whether active ingredients of self-help groups can amplify or compensate for treatment, identification of potential detrimental effects of involvement in self-help groups and focusing on the link between active ingredients of self-help groups and other aspects of the overall recovery milieu, such as the family and social networks.

Morgenstern J; McKay JR. Rethinking the paradigms that inform behavioral treatment research for substance use disorders. (review). Addiction 102(9): 1377-1389, 2007. (99 refs.)

Aim: Over the last three decades, the randomized controlled trial or 'psychotherapy technology' approach has been the dominant model of inquiry in research on addiction treatment. This period has yielded impressive discoveries, but recent failures to confirm core research hypotheses such as occurred in Project MATCH and the Cocaine Collaborative Treatment Study have raised questions about future research directions. The paper identifies several testable assumptions of the psychotherapy technology model. A review is conducted on four substance use disorder behavioral interventions-motivational interviewing, cognitive-behavioral treatment, behavioral couples treatment and 12-Step-oriented treatment-to determine whether these assumptions are supported by research findings. Results: Overall, the review suggests weak support for the technology model of psychotherapy research. Lack of support is interpreted as indicating flaws in several model assumptions about how to conceptualize and measure patient responsivity and the interaction of non-specific and specific therapeutic factors. The paper offers alternative strategies for addressing these issues drawn from the general psychotherapy process literature and provides illustrative examples of how these could be used to spur innovation in addiction treatment research. The addiction treatment research field is coming up against the limitations of the psychotherapy technology model as the dominant paradigm guiding treatment research. It is important for addiction treatment researchers to explore alternative conceptualizations and methodologies in order to understand more clearly how treatment works.

Naughton F; Prevost AT; Sutton S. Self-help smoking cessation interventions in pregnancy: A systematic review and meta-analysis. Addiction 103(4): 566-579, 2008. (52 refs.)

Aims: Self-help smoking cessation interventions for pregnant smokers are of importance due to their potential to be wide-reaching, low-cost and their appeal to pregnant smokers who are interested in quitting smoking. To date, however, there has been no systematic assessment of their efficacy. This systematic review aimed to assess the efficacy of self-help interventions for pregnant smokers and to investigate whether self-help material intensity, type or delivery are associated with cessation. Methods The literature was searched for randomized and quasi-randomized controlled trials of self-help smoking cessation interventions for pregnant smokers without significant cessation counselling. Fifteen trials met the inclusion criteria and relevant data were extracted independently. Results: The primary meta-analysis pooled 12 trials comparing usual care (median quit rate 4.9%) with self-help (median quit rate 13.2%) and yielded a pooled odds ratio (OR) of 1.83 [95% confidence interval (CI) 1.23-2.73], indicating that self-help interventions on average nearly double the odds of quitting compared with standard care. However, a further meta-analysis failed to find evidence that intervention materials of greater intensity increase quitting significantly over materials of lesser intensity (pooled OR = 1.25, 95% CI 0.81-1.94). There was insufficient evidence to determine whether the tailoring of materials or levels of one-to-one contact were related to intervention efficacy. Conclusions: Self-help interventions appear to be more effective than standard care although, due mainly to a lack of trials, it is unclear whether more sophisticated and intensive approaches increase intervention effectiveness.

Norcross JC. Integrating self-help into psychotherapy: 16 practical suggestions. Professional Psychology: Research and Practice 37(6): 683-693, 2006. (92 refs.)

Psychologists routinely recommend self-help to their patients but desire guidance on the optimal methods and resources for doing so. This article provides 16 suggestions, culled from both the research literature and clinical experience, for integrating self-help into psychotherapy. Among the clinical recommendations are broadening the definition of self-help, assessing clients' self-help histories, offering tangible support in linking clients with self-help, tailoring the self-help resource to the person (not only the disorder), assisting clients with the administration of difficult self-help programs, using self-help during waiting and maintenance stages, and addressing clients' reservations about its use. Psychologists' top-rated self-help books, autobiographies, and films are presented. By their behavior, psychologists can enhance the effectiveness of self-help within the context of psychotherapy.

O'Connell D; Bevvino D. Managing Your Recovery from Addiction: A Guide for Executives, Senior Managers, and Other Professionals. Binghamton NY: Haworth/Routledge, 2007

This book is described as applying business approaches to the process of planning, implementing, and becoming engaged in the first year of recovery. It draws upon the language of business to present the basic premises of substance abuse treatment to impaired executives and professionals. Rather than 'chapters', the book is organized into seven 'lessons.' Lesson 1, "Creating and Implementing a Strategic Recovery Plan", includes analyzing the environment and personal circumstances, developing action steps, and implementing a strategic plan. Lesson 2, "Relapse Prevention and Recovery Maintenance", covers high-relapse situations, dysfunctional beliefs, coping with lapses and relapses. Lesson 3, "Dealing with Conflict in Recovery," addresses the nature of conflict, determining the individual style for handling conflict. Lesson 4, "Managing Feelings and Moods", examines the need to recognize feelings and moods, disclosing feeling, and examining and modifying mistaken beliefs. Lesson 5, "Managing Spirituality", explores the nature of spirituality, the twelve Steps and spirituality, and scientific research into spirituality and meditation. Lesson 6, "The Twelve Steps and the Business of Recovery," is directed working the Twelve Steps. Lesson 7, "A Refresher Course in Addictions Treatment," reviews working Steps One, Two, and Three, the role of psychological defenses, the impact on the family, addressing the process of relapse, and important notes in alcohol education.

Orford J; Templeton L; Patel A; Velleman R; Copello A. The 5-step family intervention in primary care: II. The views of primary healthcare professionals. Drugs: Education, Prevention and Policy 14(2): 117-135, 2007. (29 refs.)

Background: This is the second of two papers using qualitative methods from a study of an intervention for family members affected by close relatives' substance misuse problems. Participants: 168 primary healthcare professionals (PHCPs: GPs, practice nurses and health visitors) working in general practices in two areas of England, and who took part in the study. Data sources: Recruitment and post-session forms completed by PHCPs; telephone interviews with each PHCP 12 weeks after recruitment of a family member; interviews with PHCPs at the end of the study. Results: At the end of the project PHCPs were overwhelmingly positive about the family member intervention and about primary care as the appropriate site. Difficulties were encountered, however, in identifying and engaging affected family members, who were often excluded on grounds of the complexity of their problems or the level of their distress. Shortage of PHCP time and other practice-related factors added to the difficulty. Active work by a PHCP was often necessary in order to make the link between presenting symptoms of physical or mental ill-health and the existence of a family substance misuse problem. When family members were identified and recruited, PHCPs were usually positive about what was achieved. Nearly all were in favour of an approach that combined giving a self-help manual with some follow-up contact with a family member as needed. Conclusions: Taken in conjunction with statistical outcome findings of significant reductions in symptoms and changes in ways of coping, plus qualitative analysis of the views of family members, the present results encourage the view that a flexible form of this intervention should be developed for use in primary healthcare, and that further work should build on existing strengths and attempt to overcome weaknesses identified.

Passetti LL; Godley SH. Adolescent substance abuse treatment, clinicians' self-help meeting referral practices and adolescent attendance rates. Journal of Psychoactive Drugs 40(1): 29-40, 2008. (37 refs.)

Clinicians in adolescent substance abuse treatment programs often recommend attendance at 12-Step meetings; however, there has been no systematic study of their referral practices or possible influence on attendance rates. Quantitative and qualitative data were used to examine: (a) the self-help referral practices of clinicians employed in adolescent substance abuse treatment programs; and (b) the potential relationship between practices and self-help attendance. Data were analyzed from open-ended interviews with 28 clinicians at eight CSAT-funded SCY sites and from follow-up inter-views with over 1,600 adolescents. Results indicated that clinicians referred adolescents almost exclusively to 12-Step groups. Various factors were considered when recommending attendance, including substance use severity and ability to grasp 12-Step concepts. Meeting age composition and availability were common influences when suggesting specific meetings. Clinicians who described their treatment programs as "12-Step based" and actively linked adolescents to groups tended to be employed at sites that had the highest overall rates of self-help attendance. Findings suggest that if clinicians want to facilitate self-help attendance, they might assess the "fit" between individual adolescents and particular meetings. Additionally, programs may want to develop and train staff in standardized referral procedures. Further research is needed to empirically test referral strategies with adolescents.

Pull CB. Self-help Internet interventions for mental disorders. (editorial). Current Opinion in Psychiatry 19(1): 50-53, 2006. (13 refs.)

Purpose of review: In recent years a considerable number of publications has appeared on various aspects of Internet interventions for mental health care. The purpose of the present article is to review the current scientific status of Internet interventions for the treatment of mental disorders. Recent findings: Randomized controlled studies on the use Internet interventions for the treatment of mental disorders are still scarce. Most studies in the field have been on Internet interventions for the treatment of depressive disorders and anxiety disorders, using cognitive behavioural therapy. In addition, a few studies have been published on the use of Internet interventions in the treatment of substance use disorders (smoking, problem drinking), insomnia and tinnitus. Summary: Recent studies provide provisional evidence that Internet interventions may be a promising tool for the treatment of some mental disorders.

Rassool GH; Rassool GH. The self-help movement in the addiction field: Revisited. Journal of Addictions Nursing 17(1): 47-52, 2006. (26 refs.)

The self-help principle has witnessed a recent upsurge in popularity in response to popular movements towards self-care and individual responsibility. It was power-to-the-people social movements in the 1960s that provided avenues for the development of the self-help group movement. Self-help groups in the treatment of addiction provide a non-judgmental caring and supportive focus, are based in the community, and are freely available to anyone who wishes to attend. Self-help groups in the addiction field are not explicitly used by the recovering drug-user or problem-drinker. Family self-help groups also have emerged and are good examples of sources of empowerment for those people who have become victims of circumstances. The aims of this paper are to examine the nature, ideologies, beliefs, benefits, and limitations of self-help groups and their role in advocacy and in complementing professional help in the addiction field.

Riper H; Kramer J; Smit F; Conijn B; Schippers G; Cuijpers P. Web-based self-help for problem drinkers: A pragmatic randomized trial. Addiction 103(2): 218-227, 2008. (72 refs.)

Aims Self-help interventions for adult problem drinkers in the general population have proved effective. The question is whether this also holds for self-help interventions delivered over the internet. Design We conducted a pragmatic randomized trial with two parallel groups, using block randomization stratified for gender and with follow-up at 6 months. Setting The intervention and trial were conducted online in the Netherlands in 2003-2004. Participants We selected 261 adult problem drinkers from the general population with a weekly alcohol consumption above 210 g of ethanol for men or 140 g for women, or consuming at least 60 g (men) or 40 g (women) at least 1 day a week over the past 3 months. Participants were randomized to either the experimental drinking less (DL) condition or to the control condition (PBA). Intervention DL is a web-based, multi-component, interactive self-help intervention for problem drinkers without therapist guidance. The recommended treatment period is 6 weeks. The intervention is based on cognitive-behavioural and self-control principles. The control group received access to an online psychoeducational brochure on alcohol use (PBA). Outcome measures We assessed the following outcome measures at 6-month follow-up: (i) the percentage of participants who had reduced their drinking levels to within the normative limits of the Dutch guideline for low-risk drinking; and (ii) the reduction in mean weekly alcohol consumption. Findings At follow-up, 17.2% of the intervention group participants had reduced their drinking successfully to within the guideline norms; in the control group this was 5.4% [odds ratio (OR) = 3.66; 95% confidence interval (CI) 1.3-10.8; P = 0.006; number needed to treat (NNT) = 8.5]. The intervention subjects decreased their mean weekly alcohol consumption significantly more than control subjects, with a difference of 12.0 standardized units (95% CI 5.9-18.1; P < 0.001; standardized mean difference 0.40). Conclusions To our knowledge this is one of the first randomized controlled trials on a web-based self-help intervention without therapist guidance for self-referred problem drinkers among the adult general population. The intervention showed itself to be effective in reducing problem drinking in the community.

Severson HH; Andrews JA; Lichtenstein E; Danaher BG; Akers L. Self-help cessation programs for smokeless tobacco users: Long-term follow-up of a randomized trial. Nicotine & Tobacco Research 9(2): 281-289, 2007. (28 refs.)

This paper presents long-term outcomes of the largest clinical trial of smokeless tobacco (SLT) cessation reported to date. SLT users in five northwestern states were recruited to call a toll-free number, and 1,069 users were randomized to one of two self-help conditions: either a manual-only condition or an assisted self-help condition, which included the manual, a targeted video, and two support phone calls. Significant between-group differences were not found for either the 12- or 18-month point-prevalence measure of abstinence from either SLT only or all tobacco products using outcomes based on either the responder or intention-to-treat outcomes. However, using a repeated point-prevalence measure across all three assessment points, we found that significantly more assisted self-help participants reported abstinence, compared with manual-only participants. Compared with manual-only participants, those in the assisted self- help condition were significantly more likely to use recommended cessation techniques. Results demonstrate that low-cost, minimal interventions delivered by mail and phone can help a sizable proportion of individuals quit using SLT.

Spada M. Overcoming Problem Drinking a Self-help Guide Using Cognitive Behavioural Techniques. London: Constable and Robinson, 2007

This self-help book is intended for individual use as well as "homework" assignments for those entering treatment, whether for alcohol dependence or alcohol abuse. The volume is organized into four parts. Part I introduces the idea of problem drinking and explores how problem drinking can develop. Part II focuses upon developing/enhancing motivation to change. Part III is a guide to implementing change. Part IV sets out a variety of strategies to maintain the change. Explanations of various techniques and skills are augmented by exercises to serve as an action guide. There are a series of appendices that address things such as tips on relaxation, improving sleep, tackling worry and dealing with anger.

Timko C; Billow R; DeBenedetti A. Determinants of 12-step group affiliation and moderators of the affiliation-abstinence relationship. Drug and Alcohol Dependence 83(2): 111-121, 2006. (80 refs.)

This study examined characteristics of substance use disorder (SUD) outpatients at intake to treatment (N=345) that were associated with more 12-step group attendance and involvement, Steps worked, and acceptance of 12-step philosophy at a 6-month follow-up (N=281, 81.4%). Patient characteristics covered the domains of sociodemographics, SUD severity, personal functioning, and previous help received. Distinguishing baseline characteristics of patients who attended more 12-step group meetings during follow-up were being less-educated, more engaged in religious practices, and more extroverted and interpersonally competent, and having had more previous 12-step group exposure. These patient characteristics were generally similar to those associated with more 12-step meeting involvement and philosophy acceptance. More 12-step meeting attendance and involvement were related to abstinence at 6 months. Associations of attendance with abstinence were stronger among patients who were younger, white, less-educated, unstably employed, less religious, and less interpersonally skilled. These patients may have had fewer available social resources and so benefitted more from the fellowship and support for abstinence that 12-step group members often provide. We suggest methods by which treatment providers may encourage 12-step group affiliation among patients likely to benefit from it on substance use outcomes.

Timko C; DeBenedetti A; Billow R. Intensive referral to 12-Step self-help groups and 6-month substance use disorder outcomes. Addiction 101(5): 678-688, 2006. (60 refs.)

Aims: This study implemented and evaluated procedures to help clinicians make effective referrals to 12-Step self-help groups. Design Randomized controlled trial. Setting: Out-patient substance use disorder treatment. Participants Individuals with substance use disorders (SUDs) entering a new treatment episode (n = 345) who were assigned randomly to a standard referral- or an intensive referral-to-self-help condition. Measurements: Self-reports of 12-Step group attendance and involvement and substance use at baseline and a 6-month follow-up. Intervention: The intensive referral intervention focused on encouraging patients to attend 12-Step meetings by connecting them to 12-Step volunteers. Findings: Among patients with relatively less previous 12-Step meeting attendance, intensive referral was associated with more meeting attendance during follow-up than was standard referral. Among all patients, compared with those who received standard referral, those who received intensive referral were more likely to be involved with 12-Step groups during the 6-month follow-up (i.e. had provided service, had a spiritual awakening and currently had a sponsor). Intensive referral patients also had better alcohol and drug use outcomes at 6 months. Twelve-Step involvement mediated part of the association between referral condition and alcohol outcomes. Conclusions: The brief intensive referral intervention was associated with improved 12-Step group involvement and substance use outcomes even among patients with considerable previous 12-Step group exposure and formal treatment. Future 12-Step intensive referral procedures should focus on encouraging 12-Step group involvement in addition to attendance to benefit patients most effectively.

Timko C; DeBenedetti A. A randomized controlled trial of intensive referral to 12-step self-help groups: One-year outcomes. Drug and Alcohol Dependence 90(2/3): 270-279, 2007. (50 refs.)

Objective: This study implemented and evaluated procedures to help clinicians make effective referrals to 12-step self-help groups (SHGs). Methods: In this randomized controlled trial, individuals with substance use disorders (SUDs) entering a new outpatient treatment episode (N=345; 96% had previous SUD treatment) were randomly assigned to a standard referral or an intensive referral-to-self-help condition and provided self-reports of 12-step group attendance and involvement and substance use at baseline and at six-month and one-year follow-ups (93%). In standard referral, patients received a schedule for local 12-step SHG meetings and were encouraged to attend. Intensive referral had the key elements of counselors linking patients to 12-step volunteers and using 12-step journals to check on meeting attendance. Results: Compared with patients who received standard referral, patients who received intensive referral were more likely to attend and be involved with 12-step groups during both the first and second six-month follow-up periods, and improved more on alcohol and drug use outcomes over the year. Specifically, during both follow-up periods, patients in intensive referral were more likely to attend at least one meeting per week (70% versus 61%, p = .049) and had higher SHG involvement (mean = 4.9 versus 3.7, p = .021) and abstinence rates (51% versus 41 %, p = .048). Twelve-step involvement mediated the association between referral condition and alcohol and drug outcomes, and was associated with better outcomes above and beyond group attendance. Conclusions: The intensive referral intervention was associated with improved 12-step group attendance and involvement and substance use outcomes. To most benefit patients, SUD treatment providers should focus 12-step referral procedures on encouraging broad 12-step group involvement, such as reading 12-step literature, doing service at meetings, and gaining self-identity as a SHG member.

Tuten M; Jones HE; Lertch EW; Stitzer ML. Aftercare plans of inpatients undergoing detoxification. American Journal of Drug and Alcohol Abuse 33(4): 547-555, 2007. (17 refs.)

Drug use relapse rates are high following residential detoxification. This study examined the aftercare plans and desired services of participants currently enrolled in residential detoxification programs. Participants completed a survey regarding their aftercare plans and services that they desired from an aftercare program. Participants (98%) reported some form of aftercare plans following detoxification. Among the services that participants endorsed wanting were individual counseling, help with finding a job, and Narcotics Anonymous (NA) meetings. With low rates of enrollment in aftercare programs, the findings of this study may be of help in determining what services will best assist individuals recovering from addiction.

Wilton R; DeVerteuil G. Spaces of sobriety/sites of power: Examining social model alcohol recovery programs as therapeutic landscapes. Social Science & Medicine 63(3): 649-661, 2006. (42 refs.)

While there has been interest in geographical variations in alcohol use and their implications for health, similar attention has not been given to geographies of alcohol treatment and recovery. This paper is concerned with exploring these geographies of alcohol recovery and treatment. Specifically. the paper uses the therapeutic landscape concept coupled with Foucault's concept of governmentality to frame a qualitative Case Study of a 'social model' recovery community in San Pedro, California. Analysis of the programs operating in San Pedro consisting of observation and interviews, demonstrates the complexity and contradictory character of such recovery landscapes. In particular. the governmentality perspective suggests that spaces created for alcohol recovery and support call be simultaneously understood as sites designed to govern the health-related conduct of individuals. Within programs. clients were provided with support and encouragement from staff and peers, but these same relations also made possible surveillance and the governing of daily routines. In the neighbourhood, program staff intervened to create 'healthy' spaces but these interventions also shaped the conduct of local residents and contributed to the spatial regulation of problem groups. While a focus on governmentality does not preclude recognition of the positive effects associated with therapeutic landscapes. it does provide an opportunity for further consideration of the complexities underlying such environments

Winters KC; Stinchfield R; Latimer WW; Lee S. Long-term outcome of substance-dependent youth following 12-step treatment. Journal of Substance Abuse Treatment 33(1): 61-69, 2007. (29 refs.)

The adolescent drug treatment outcome research literature primarily focuses on short-term follow-up periods (e.g., 1 year). This study extends the said literature by describing the pattern of drug use at 1, 4, and 5.5 years in three groups of adolescents: a Treatment group, which underwent a 12-step-based drug treatment program (n = 159); a Waiting List group (n = 62); and a Community Control group (n = 94). The Treatment group consistently showed significantly lower levels of drug involvement than the Waiting List group. However, at all points, both the Treatment and Waiting List groups showed higher levels of drug use than the Community Controls. Within the Treatment group, completing treatment and involvement in aftercare were positively associated with improved outcomes. The treatment implications of the study are discussed.

Yu JW; Buka SL; Fitzmaurice GM; McCormick MC. Treatment outcomes for substance abuse among adolescents with learning disorders. Journal of Behavioral Health Services & Research 33(3): 275-286, 2006. (34 refs.)

This paper assesses whether chemically dependent adolescents with comorbid learning disorders (LDs) derived less effective treatment results when compared to chemically dependent adolescents without LD and examines the moderating effects of prior treatments, treatment length, and treatment completion. Two hundred one adolescents were recruited between 1992 and 1993 from Massachusetts residential treatment centers and subsequently followed up 6 months after enrollment. Compared to chemically dependent teenagers without LD, those with LD were twice as likely to re-use substances at least once by follow-up. LD teenagers were more likely to attend Alcoholics/Narcotics Anonymous if they had prior admissions to treatment programs and longer treatment length. LD teenagers who completed treatment also experienced a greater decrease in current depression compared to LD teenagers not completing the treatment. This study is the first to consider outcomes of substance abuse treatment for adolescents with LD and contributes to the growing literature on comorbidity and substance abuse treatment.

Zemore SE. A role for spiritual change in the benefits of 12-step involvement. Alcoholism: Clinical and Experimental Research 31(10, Supplement S): 76S-79S, 2007. (26 refs.)

Background: Emerging evidence implies a role for spirituality in recovery from substance abuse. The current study examines the hypothesis that spiritual change helps mediate (or explain) effects for involvement in 12-step groups on recovery outcomes among substance-abusing populations. Methods: Participants (baseline N = 733) received treatment at 1 of 5 day hospital and 7 residential substance abuse treatment programs in California. Assessments included a baseline interview and 1-year follow-up; analyses incorporated regressions informed by Baron and Kenny (1986) and Sobel's (1982) test. To assess spirituality, measures included (1) the Religious Background and Behaviors scale and (2) an item assessing whether or not participants had had a spiritual awakening through their involvement with 12-step groups. Results: Results confirmed the hypothesis. Increases in 12-step involvement from baseline to follow-up predicted higher odds of total abstinence at follow-up, and this relationship was partially explained by increases in spirituality. Results held in multivariate analyses and regardless of which spirituality measure was analyzed. Conclusions: The present study provides further evidence that spiritual change contributes to recovery, at least within the context of 12-step involvement. The study also deepens our understanding of how 12-step involvement works.