12-step participation among dually-diagnosed individuals: a review of individual and contextual factors.

Abstract

The frequent co-occurrence of substance abuse disorders along with psychiatric disorders creates a number of complexities and needs in terms of long-term treatment for individuals. 12-step groups might provide unique mechanisms by which dually-diagnosed individuals can maintain their abstinence and improve their psychological functioning. This paper reviews the literature on outpatient community 12-step participation among dually-diagnosed individuals, and also focuses on individual factors that may interact with treatment: homelessness, legal status, and ethnicity. A total of 59 articles was included in the review, with an emphasis on these individual factors and findings regarding mechanisms of action. Overall, findings from the studies reviewed suggest a general benefit of 12-step participation across these individual factors and some potential for dual-focus 12-step programs for dually-diagnosed individuals via social support and self-efficacy. However, methodological limitations and lack of research in the area of ethnicity limited some of the conclusions that can be made. Suggestions for further research are discussed.

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12-step participation among dually-diagnosed individuals: A
review of individual and contextual factors
Darrin M. Aasea,*, Leonard A. Jasona, and W. LaVome Robinsonb
aDePaul University, Center for Community Research, 990 W. Fullerton Ave, Suite 3100, Chicago,
IL, 60614, USA
bDePaul University, Department of Psychology, 2219 N. Kenmore Ave., Chicago, IL, 60614, USA
Abstract
The frequent co-occurrence of substance abuse disorders along with psychiatric disorders creates a
number of complexities and needs in terms of long-term treatment for individuals. 12-step groups
might provide unique mechanisms by which dually-diagnosed individuals can maintain their
abstinence and improve their psychological functioning. This paper reviews the literature on
outpatient community 12-step participation among dually-diagnosed individuals, and also focuses
on individual factors that may interact with treatment: homelessness, legal status, and ethnicity. A
total of 59 articles was included in the review, with an emphasis on these individual factors and
findings regarding mechanisms of action. Overall, findings from the studies reviewed suggest a
general benefit of 12-step participation across these individual factors and some potential for dual-
focus 12-step programs for dually-diagnosed individuals via social support and self-efficacy.
However, methodological limitations and lack of research in the area of ethnicity limited some of
the conclusions that can be made. Suggestions for further research are discussed.
Keywords
Dual diagnosis; 12-step; Homeless; Ex-offender; Ethnicity
The co-occurrence of psychiatric disorders with substance abuse is commonly observed in both
research and clinical practice. For example, the prevalence rate for any current mood and/or
anxiety disorder that is not substance-induced among individuals seeking treatment for a
substance use disorder ranges from 33% to 60%, depending on the disorder and substance
abuse typology (Grant et al., 2004). Psychiatric disorders have been found to predict
development of substance abuse problems (Zimmerman et al., 2003). Furthermore, when
improvements in substance use outcomes have been found for dually-diagnosed individuals,
the improvements are less substantial than for those with only substance abuse issues (e.g.
Burns, Teesson, & O’Neill, 2005), and typically comorbid psychiatric disorders are associated
with higher rates of relapse among recovering individuals (Kushner et al., 2005).
Research on individuals who are dually-diagnosed suggests that developing peer networks
supportive of abstinence is an important aspect of recovery (Laudet, Magura, Vogel & Knight,
2004). Given limitations of traditional treatment, and increased vulnerability of dually-
diagnosed individuals to negative outcomes, alternative supportive services are an important
area for research and development (Vogel, Knight, Laudet, & Magura, 1998). For example,
© 2008 Elsevier Ltd. All rights reserved.
*Corresponding author. Tel.: +1 773 325 4962; fax: +1 773 325 4923., daase@depaul.edu (D.M. Aase)..
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Published in final edited form as:
Clin Psychol Rev. 2008 October ; 28(7): 1235–1248. doi:10.1016/j.cpr.2008.05.002.
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mutual-help environments might be beneficial for dually-diagnosed individuals (Magura,
Knight et al., 2003). A key feature of these environments is social support, which might be a
protective factor against negative psychological symptoms (e.g., Laudet, Magura, Vogel, &
Knight, 2000a), and is also associated with maintaining abstinence from substance use (e.g.,
Moos, Brennan, & Moos, 1991). Prior research has also suggested that amount of social support
received from mutual-help settings increases as a function of participation (Humphreys,
Mankowski, Moos, & Finney, 1999; Ouimette, Moos, & Finney, 1998).
Bogenschutz, Geppert, and George (2006) conducted a comprehensive review of the
quantitative literature on 12-step approaches for dually-diagnosed individuals. Their review
found that dually-diagnosed individuals generally attend 12-step programs at a comparable
rate to those with only substance use disorders; there is a consistent, positive association
between 12-step participation and substance use outcomes among dually-diagnosed
individuals; and specialized 12-step programs for dually-diagnosed individuals might be used
differently than traditional 12-step programs by this population. Additionally, their review
called for further research on individual factors that interact with 12-step utilization
(Bogenschutz et al.).
One of the primary findings from Bogenschutz et al. (2006) was a differentiation between 12-
step programs and treatments. While the data in their review suggest that 12-step programs,
both traditional and modified, are utilized by individuals with dual-diagnoses and generally
are associated with beneficial outcomes, there is less evidence from more rigorous efficacy
and effectiveness studies for treatments with a 12-step orientation. As discussed by
Bogenschutz et al., many of these clinical trials have failed to differentiate between effects of
other (variable) intervention components, or lacked in methodological rigor. Furthermore,
absence of experimental designs examining specialized 12-step programs, as well as little focus
on mechanisms of action, have made the potential benefits of participation unclear.
An individual factor that might be highly related to 12-step participation and dual-diagnosis is
homelessness. Rates of comorbid substance use and mental health problems are particularly
high among homeless individuals. For example, the Urban Institute (1999) found that 86% of
homeless individuals from a national sample reported the lifetime occurrence of a substance
use or mental health problem. While that number was lower when asked about substance abuse
or mental health problems within the previous month (66%), 30% of participants reported
having problems with alcohol, drugs, and mental health issues during their lifetime (Urban
Institute). Some earlier estimates find “severe” dual-diagnosis rates to be somewhat lower (e.g.
10–20%) among homeless individuals (Drake, Osher, & Wallach, 1991). Considering the
unique stressors experienced by homeless individuals, identifying barriers to treatment as well
as potentially beneficial interventions continues to be a high priority.
Another factor under current exploration when considering 12-step utilization and dual-
diagnosis is criminal history. Ex-offenders often have mental health and/or substance abuse
problems upon incarceration, which frequently have contributed to their criminal offenses and
recidivism rates. For example, the Bureau of Justice Statistics (BJS) found that over 40% of
offenders on probation or in local U.S. jails were under the influence of alcohol at the time of
their offense (BJS, 1998), and that nearly 70% of inmates met the criteria for a substance use
disorder (BJS, 2005). Estimates for how many incarcerated individuals have a dual-diagnosis
vary, but one such estimate suggests approximately 26% of inmates with substance abuse
problems had a lifetime Axis I disorder (Cote & Hodgins, 1990). While there is variability
among in-prison and community treatment interventions for these individuals (Edens, Peters,
& Hills, 1997), there are unique barriers to intervention among ex-offenders who have a dual-
diagnosis upon community reintegration.
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Finally, ethnicity as a factor in 12-step utilization among dually-diagnosed individuals is an
important area of research with implications for treatment development. While some studies
have examined a specific population, report descriptive demographic information, or make
general comparisons between ethnic groups, ethnic factors are not often the central research
question in the area of dual-diagnosis and 12-step interventions. It is also unclear the extent to
which 12-step groups might or might not be culturally relevant for different ethnic groups.
Jerrell and Wilson (1997) found that participants of color who were dually-diagnosed often
were underserved by outpatient interventions and/or did not receive as many services, which
may have influenced their outcomes. A goal of this review is to assess the degree to which
ethnicity has been explored among dually-diagnosed individuals as a factor related to 12-step
participation.
Comorbidity has become an important issue for both research and clinical practice due to
potentially complex interactions between multiple individual factors and environmental
factors. As a result, dually-diagnosed individuals have unique needs for recovery and often re-
enter treatment in some capacity due to their increased vulnerability to relapse into substance
use and/or psychiatric severity. Community reintegration beyond acute treatment services is
crucial in order to provide effective interventions as well as improve the quality of life among
this population. This article reviews the literature on 12-step participation among individuals
who have been dually-diagnosed, with the goal of assisting in identifying factors associated
with better access and outcomes to inform clinical practice and intervention development, and
ultimately empowering this population through increased quantity and quality of support within
their communities. This review updates Bogenschutz et al.’s (2006) summary of research that
covered articles through 2004, as well as examines in greater detail factors related to
homelessness, criminal history, and ethnicity.
1. Method
1.1. Inclusion criteria and procedure
A comprehensive review of Psychinfo, Social Science Citation Index, and Pubmed was
performed. The search terms included 12-step, dual-diagnosis, mutual help, self help, and
comorbidity, which were used in various combinations. This investigation was limited to peer-
reviewed journal articles, and included only empirical studies using qualitative and/or
quantitative methods. In order to meet the inclusion criteria, each article needed to specify that
it includes research on a dually-diagnosed population, and also assessed 12-step participation
to some extent (or involved a 12-step research sample). This review only focused on outpatient,
mutual-help 12-step groups. Various combinations of the terms homeless and offender were
added to the review in an effort to identify additional articles relevant to these populations.
Inclusion criteria were relaxed slightly with these two keywords in order not to exclude relevant
articles, as the literature is sparse in this area at a high level of specificity. For example, if a
study fulfilled all but one of the criteria, but only reported psychiatric symptoms instead of a
diagnosis, it was included for its relevance to the subpopulation groups.
2. Results
Utilizing the inclusion criteria above, the review produced a total of 42 articles exploring
dually-diagnosed individuals in outpatient 12-step settings. An additional 17 articles were
found when using the keywords “homeless” and “offender” in various combinations with the
other terms yielding a total of 59 articles. Because a large number of these articles were already
summarized in Bogenschutz et al.’s (2006) review, the focus of the results for general findings
regarding 12-step utilization among dually-diagnosed individuals is on the articles that were
not included in the original review, or where qualitative data was not included. However, all
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articles found in the review were examined and population-specific findings for ethnicity,
homelessness, and ex-offenders were recorded.
2.1. Research designs and samples
Demographic information for the studies included in the review is listed in Table 1. Several
studies did not report extensive demographic information. Where ethnicity was reported,
generally the predominant ethnicity in the sample was European-American (41%) or African-
American (36%). In general, participants in the reviewed studies (where reported) were male
(78%) and the majority had 12 or more years of education. Where means were reported, the
average age of the samples in the review was 36.2 years. Finally, when the information was
given, 66.7% of the samples were predominantly unemployed.
Information about research designs for the reviewed studies can be found in Table 2. While
there were no publication date constraints for inclusion in the review, no studies were found
prior to 1991 meeting the inclusion criteria. This is not surprising given the level of specificity
of this review. The sample sizes ranged from 10 to 5060 (Mean N = 566; Median = 146). With
regard to the design of each study, 36% of them were cross-sectional in nature, while the
remaining 64% were longitudinal. Only 15.5% of the studies employed some kind of random
treatment assignment, while the remainder had no treatment assignments but often compared
subgroups of their sample, or employed non-random treatment assignments.
Table 2 also contains predominant diagnostic information for each of the study samples in the
review, as well as information regarding homelessness, criminal history, and self-help
outcomes. For studies where diagnostic status was reported, 35.2% had samples with
predominantly schizophrenic individuals in them, followed by 27.8% with Mood Disorders.
However, a number of studies stated that it was a dually-diagnosed sample, but did not give
diagnostic details. Only 17 (28.8%) of the reviewed studies gave information about
homelessness, which also tended to be mostly demographic and not a variable of interest
regarding the outcomes of the studies. Regarding legal issues, 18 (30.5%) of the studies
reported details about legal status, or looked at offenders specifically.
2.2. Outpatient 12-step groups and dual-diagnosis: recent findings
Since the previous review, a few additional studies have focused on mechanisms of action of
specialized 12-step programs. For example, Magura, Cleland, Vogel, Knight, and Laudet
(2007) examined participants of Double Trouble in Recovery (DTR), a specialized 12-step
program for the dually-diagnosed. In a two-year longitudinal, within-subjects design, they
examined self-efficacy for recovery (mental health symptoms), DTR affiliation (via attendance
and types of involvement), psychiatric symptoms, and quality of life among participants in the
program. Their primary finding was evidence for a mediational model, with DTR affiliation’s
relationship with quality of life outcomes being fully or partially mediated by self-efficacy.
However, effect sizes were generally small, explaining around 5% of the variance in quality
of life outcomes.
Two studies using the same sample were conducted to explore abstinence outcomes. First,
Laudet, Magura, Cleland et al. (2004) explored ongoing DTR attendance as a predictor of
abstinence over the two-year course of the study. Their findings revealed that attendance,
independent of demographic and psychiatric factors, predicted higher abstinence rates at the
two-year follow-up. The next study expanded on this finding by examining a mediational model
of participation in DTR, social support, and abstinence outcomes (Laudet, Cleland, Magura,
Vogel, & Knight, 2004). Results indicated that higher social support partially mediated the
significant association between length of participation in DTR and two-year follow-up
outcomes for abstinence. Despite some of the design limitations in these studies, the results
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suggest that increased social support and self-efficacy, as a function of attendance and
participation in DTR, might indirectly improve both mental health and substance use outcomes
(Laudet, Cleland et al., 2004; Laudet, Magura, Cleland et al., 2004; Magura et al., 2007).
A study of the same sample used qualitative methods to explore participant perceptions about
reasons for relapse and methods for quitting (Laudet, Magura, Vogel et al., 2004). More
participants (45%) reported that they used 12-step groups to quit the last time, while 34% stated
that regular treatment helped them to quit. Additionally, 69% of the participants reported that
using made their psychiatric symptoms worse, although 12% reported that they often used to
improve their psychiatric symptoms (Laudet, Magura et al., 2004). An earlier study by the
same research group also asked DTR participants in qualitative interviews about the difference
between traditional 12-step groups and DTR (Laudet, Magura, Vogel, & Knight, 2003). Of the
277 participants, 30% reported that traditional 12-step groups provided more of a “focus on
addiction,” whereas 32% reported that DTR provided more mutual support and identification
than traditional 12-step groups. However, 34% reported that DTR was not any different from
other 12-step programs. These findings suggest that dual-focus 12-step groups might be
perceived as beneficial for some, but not all dually-diagnosed individuals (Laudet, Magura,
Vogel, & Knight, 2003).
A study by Chi, Satre, and Weisner (2006) examined traditional 12-step groups as a predictor
of abstinence among dually-diagnosed individuals. In their subsample of 747 participants
starting an outpatient/day chemical dependency program, 104 were dually-diagnosed. At the
one-year follow-up, Chi et al. found that the participants with comorbid disorders attended
more 12-step meetings compared to those without comorbid disorders. Furthermore, the
number of 12-step meetings that were attended, when controlling for psychiatric services and
baseline characteristics, was correlated with higher rates of abstinence at the one-year follow-
up among dually-diagnosed clients. Their rates of abstinence were comparable to those without
a comorbid psychiatric diagnosis (Chi et al.).
In a randomized study of veterans with both a substance use disorder and major depressive
disorder, Brown et al. (2006) compared a cognitive behavioral intervention with twelve step
facilitation (TSF) therapy over the course of 24 weeks, and then employed at a three and six
months follow-up. While their findings from treatment through all follow-ups did not find any
significant effect of treatment type, the two interventions had different trends for both
depressive symptoms and abstinence rates throughout the study. The cognitive-behavioral
group appeared to have more stable, albeit slight, reductions in depressive symptoms and
relatively stable abstinence percentages, while the TSF group had slightly lower rates of
abstinence, and more variable depressive symptoms throughout the study. However, there was
no significant effect of treatment type on these outcomes. While the results suggest a more
stable treatment trajectory for the cognitive-behavioral intervention, the participants in that
group were still able to utilize 12-step treatments, and 97% of participants in the whole sample
were also receiving pharmacological treatment for depression (Brown et al.).
While Brown et al.’s findings suggest that alternative treatments (i.e., CBT) potentially could
be beneficial in different ways for dually-diagnosed individuals compared to 12-step groups,
Miller, Ninonuevo, Hoffmann, and Astrachan (1999) found that continued participation in self-
help groups was associated with higher abstinence rates one-year later in a sample of
individuals both with and without lifetime depression. Results did not differ between
participants who had lifetime depression or those who did not (Miller et al.).
While there are relatively few new studies examining mechanisms of 12-step programs since
Bogenshutz et al.’s (2006) review, progress has been made in identifying the processes by
which these programs may be helpful for dually-diagnosed clients. In particular, self-efficacy
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(Magura et al., 2007) and social support (Laudet, Cleland et al., 2004) might be mediators of
participation in 12-step groups and both mental health and substance use outcomes for dually-
diagnosed individuals. Additionally, traditional and specialized 12-step programs both appear
to have potentially beneficial impacts on participants who are a part of this population. While
there continues to be a lack of clinical trials for this specific population, the results of the studies
presented above may have more external validity at the expense of more experimentally
rigorous approaches. More research continues to be needed to inform program implementation
and development.
2.3. Homelessness
Out of the 59 total studies found through the literature searches, only 17 papers reported
information about homelessness. The majority of these articles only reported current or lifetime
homeless prevalence in the demographic section of their studies (Grella, 2003; Laudet et al.,
2000a; Laudet et al., 2000b; Laudet, Magura, Vogel et al., 2003; Laudet, Magura, Cleland et
al., 2004; Laudet, Magura et al., 2004; Laudet et al., 2000a,b; Magura, Laudet et al., 2003;
Magura, Knight et al., 2003; Magura et al., 2007; Timko & Sempel, 2004), without exploring
homelessness as a relevant variable in their analyses. See Table 2 for a summary of
demographic information about homelessness that is provided in the full review. While there
are certainly studies of homelessness in the literature, there are fewer that explore it at this level
of specificity that includes both 12-step participation and dual-diagnosis.
Varying findings have been reported on use of 12-step programs among the homeless. A study
of dually-diagnosed individuals admitted to an inpatient psychiatric unit conducted by Herman,
Galanter, and Lifshutz (1991) compared histories of homeless individuals to those who were
not homeless. Their analyses found no differences between the two groups in terms of recent
substance use, demographic variables, or psychiatric diagnoses. However, homeless
individuals were much more likely to have attended a traditional 12-step program than those
who were not homeless. Herman et al. suggest that mutual-help models of treatment might be
less intrusive for homeless individuals and also more available. However, a contrasting finding
was found in a study of homeless individuals with alcohol use disorders in Germany (Fichter,
Quadflieg, Greifenhagen, Koniarcyzk, & Wolz, 1997). Fichter et al. found that in a sample
with high levels of dual-diagnosis, homeless individuals rarely (15.8%) had attended a self-
help group. Their comparisons to homeless individuals in the United States indicated a large
drop in self-help attendance among the homeless in Germany (Fichter et al.). This suggests
that 12-step attendance may vary internationally among homeless individuals, with higher
utilization by the homeless in the United States.
Availability of substance abuse treatment may impact 12-step participation in the community
in multiple ways. For example, Kilbourne, Herndon, Andersen, Wenzel, and Gelberg (2002)
conducted a study of homeless women and assessed their psychiatric symptoms, substance use,
and HIV risk behaviors. A counter-intuitive finding that they described was that women who
had attended self-help meetings were more likely to have traded sex in the past than those who
had not attended self-help meetings. However, the same analysis found that those who were
unable to access substance abuse treatment were also more likely to have traded sex. Because
women who used substances or had high psychiatric severity were much more likely to engage
in risk behaviors such as trading sex, it is likely that attending 12-step groups was the only
available treatment option when an acute intervention might have been more appropriate. The
authors do not suggest that 12-step programs increase risk behaviors, but that a more intensive
level of care might not have been available to the women in the study (Kilbourne et al.).
Few studies examined outcomes of 12-step programs for homeless individuals with dual-
diagnoses. Kingree (1995) studied a sample of primarily African-American men and women
who were entering residential substance abuse treatment. They examined prior homelessness
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as well as 12-step ideology beliefs as they related to treatment outcomes as potential
moderators, while also exploring gender differences. Their primary finding with regard to prior
homelessness was that it was associated with lower program completion rates, particularly for
males. However, only 25% of the full sample actually completed treatment, and they measured
it based on completing every single day of treatment versus anything less than 120 days.
Interestingly, females in the study who reported higher embracement of 12-step ideology also
reported lower self-esteem. Causal mechanisms of this association cannot be inferred given
the cross-sectional nature of the research design (Kingree), but potential gender differences in
response to 12-step programs warrant further exploration. In fact, Brush and McGee (2000)
found that the spirituality component of 12-step groups was an integral part of treatment for
homeless males in recovery.
Another area of research among dually-diagnosed homeless individuals focuses on social
networks, which are particularly relevant to 12-step groups (Trumbetta, Mueser, Quimby,
Bebout, & Teague, 1999). Trumbetta et al.’s longitudinal study of homeless, dually-diagnosed
individuals indicated that having fewer substance users in your network increased levels of
abstinence 18 months later. Additionally, greater involvement in 12-step groups (frequency of
contact with other members) was a characteristic of participants who reduced their alcohol use
during the study. These findings suggest that even among homeless individuals with psychiatric
disorders, developing peer networks supportive of abstinence is as important as it is for
recovery in non-homeless populations (Laudet, Magura, Cleland et al., 2004; Laudet, Magura,
Vogel et al., 2004). It is possible that 12-step groups in the community play a significant role
in long-term recovery for homeless individuals.
The most comprehensive study of homeless individuals with dual-diagnoses found in this
review was a comparative study of homeless individuals with and without comorbid psychiatric
conditions (Gonzalez & Rosenheck, 2002). This large, one-year longitudinal study found
significantly higher baseline difficulties in psychiatric problems, community adjustment,
homelessness severity, and legal status for dual-diagnosis participants compared to single-
diagnosis participants. Over 12 months, greater use of 12-step groups predicted better outcomes
related to alcohol for the dually-diagnosed participants. However, dually-diagnosed
participants showed less improvement overall than the single-diagnosis participants in the
study over time, although when their use of services was more intensive, they showed similar
levels of improvement to the single-diagnosis participants (Gonazalez & Rosenheck).
In summary, there is a lack of research looking specifically at dually-diagnosed, homeless
individuals. However, the research suggests that this population uses 12-step programming
(Herman et al., 1991), and benefits from improving social networks over time with more
participation (Gonzalez & Rosenheck, 2002; Trumbetta et al., 1999). Some potential gender
differences in reaction to 12-step participation and ideology has been suggested (e.g., Brush
& McGee, 2000; Kingree, 1995), although more research is needed to support any specific
hypotheses about differential benefits or detriments that 12-step groups have for homeless
males and females. Overall, existing research seems to support the use of 12-step groups among
this population, although there are a number of other service needs as well. In many cases, 12-
step organizations in the community that are freely available may be the only available
treatment for homeless individuals.
2.4. Ex-offenders and legal issues
Out of the 59 total studies found in the review, only 18 reported information about previous
incarceration. The majority of these articles only reported general legal status in the
demographic section of their studies without following up or exploring prior incarceration as
a central research question (Gonzalez & Rosenheck, 2002; Laudet et al., 2000a,b; Laudet,
Magura, Cleland et al., 2003; Laudet, Magura et al., 2003; Magura, Knight et al., 2003; Magura,
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Laudet et al., 2003; Ouimette, Moos, & Finney, 2003; Penn & Brooks, 2000). See Table 2 for
a summary of basic information about legal status that is provided for the full review.
A descriptive study of individuals in a suburb within the United Kingdom also compared
retrospective criminal histories of those who had a dual-diagnosis versus those who only had
a psychiatric condition (Wright, Gournay, Glorney, & Thornicroft, 2002). About half of all
participants in the study reported a lifetime offending history. Among the dually-diagnosed
participants, 77% reported offending behavior compared to only 22% of the group with only
psychiatric problems. While their analyses are limited by a small sample size (n = 40), they
suggest that there may be differences in dually-diagnosed individuals’ offending behavior that
might be attributable to substance use over time (Wright et al.), although how substance use
and criminal behavior interact might be reciprocal in nature. A similar study by Friedman et
al. (2005) examined offending rates among men and women with Bipolar Disorder. Many men
(79%) and women (53%) had been previously charged with a crime in their sample, and the
criminal history rates were higher than those of the general population (particularly for women
with Bipolar Disorder; Friedman et al.).
Despite not examining 12-step characteristics, a study by Hoff, Rosenheck, Baranosky,
Buchanan, and Zonana (1999) is worth mentioning. They evaluated both dually-diagnosed and
non-dually diagnosed individuals who were involved in the criminal justice system and
considered for a jail diversion program. Interestingly, they found that dually-diagnosed
individuals were more likely to spend time in jail in the subsequent year, regardless of whether
they received jail diversion or not. However, there was also a main-effect of jail diversion,
such that those who were diverted spent fewer days incarcerated in the subsequent year than
those not diverted, and this did not vary by diagnostic status. While Hoff et al. did not examine
re-arrest rates, these findings suggest that dually-diagnosed individuals have more difficulty
when placed into incarceration and that jail diversion might be appropriate when
comprehensive treatment is the alternative.
With regard to 12-step program usage among ex-offenders, a qualitative study of female
offenders indicated that there are a number of stressors anticipated by those who are nearing
community reintegration (Severance, 2004). Aside from employment, family, and housing
concerns, a number of participants expressed plans to engage in 12-step programming upon
release for addictions. Interestingly, plans to seek other forms of treatment that might be more
comprehensive were rarely mentioned, though the majority of inmates likely lack the resources
to have other treatments readily available to them upon release (Severance). Additionally,
Severance’s qualitative analysis also indicated that spirituality (a component of 12-step
programs) was also mentioned by inmates as a strategy for success upon community
reintegration. Future research should explore why this component of an intervention might be
particularly appealing to ex-offenders.
DiNitto, Webb, and Rubin (2002) conducted a study of dually-diagnosed individuals that
included baseline and up to 90 days following discharge from inpatient treatment. In this
sample, men tended to have more legal problems and more incarceration history at baseline
than women, although both groups had similarly low rates of legal problems after 90 days.
Additionally, men and women did not differ in rates of self-help group utilization (DiNitto et
al.). DiNitto, Webb, Rubin, Morrison-Orton, and Wambach (2001) studied dually-diagnosed
individuals following inpatient substance abuse treatment, of whom the majority were on
probation or parole. They found that more 12-step group attendance in their sample was
associated with fewer legal problems at the 90 day follow-up. While the findings reported in
this section so far are very basic and do not include a long-term follow-up, they suggest that
12-step interventions might be useful for those with criminal backgrounds, at least in the short
term.
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A growing research trend related to legal issues among the dually-diagnosed has involved
comparative studies that examine 12-step interventions versus other intervention types. For
example, Ouimette, Gima, Moos, and Finney (1999) studied dually-diagnosed individuals in
comparison to those with only substance use disorders. They compared cognitive-behavioral
and 12-step approaches to treatment, and found that overall patients in 12-step programs had
better substance use outcomes than the cognitive behavioral intervention. However, dual-
diagnosis patients did not differ across intervention type. Additionally, among this population,
attending more 12-step groups was associated with lower arrest rates at a one-year follow-up
(Ouimette et al.). Moos, Finney, Ouimette, & Suchinsky (1999), however, found that self-help
group attendance did not predict lower arrest rates, though it did predict reduced psychiatric
symptoms when participants attended more meetings.
Brooks and Penn (2003) conducted a study of an intensive outpatient 12-step program versus
a cognitive behavioral intervention for dually-diagnosed individuals. While half of the sample
had been previously incarcerated, most of the sample experienced decreases in legal problems
over time. There was no difference between treatment conditions for legal problems, indicating
that both 12-step and cognitive behavioral interventions helped participants similarly in this
domain (Brooks & Penn). Easton et al. (2007) conducted a different clinical trial comparing a
12-step facilitation treatment to an integrated treatment for substance use and violence for
domestic violence offenders. While prevalence rates of comorbid diagnoses were relatively
low (ranging from 5–14% of participants per disorder), not all diagnostic information was
reported. Participants in both interventions had similarly lower levels of legal problems at the
12 week follow-up. Some evidence suggested that individuals in the integrated treatment had
better outcomes for alcohol use over 12-weeks than the 12-step group, but otherwise there were
few differences between the two groups (Easton et al.).
Aside from some of these more basic studies, few studies have explored mechanisms of action
for 12-step programs among populations with criminal backgrounds. Chen (2006) conducted
an in-prison study of incarcerated individuals who were enrolled in either Narcotics
Anonymous only or Narcotics Anonymous with a 12-step spirituality component. Although
there was no diagnostic information for psychiatric disorders in the sample, symptoms of
negative emotions such as depression and anxiety were measured over time. The findings
indicated that there were better and more stable decreases in all negative emotions (i.e.,
depression, anxiety, hostility) in the group that received the 12-step component compared to
those in the Narcotics Anonymous only condition. Additionally, there was in increase in sense
of coherence among those in the 12-step condition. These findings suggest that the spirituality
component of 12-step programs might be a critical factor in reducing negative emotions and
promoting positive emotions (Chen). While information about diagnoses was not available for
this sample, it is possible that 12-step programs might provide a beneficial environment for
psychiatric symptoms that are separate from substance use.
In summary, few studies have examined ex-offenders and 12-step use at the level of specificity
to include dual-diagnosis status. In contrast, more studies gathered descriptive legal history
from those who have been dually-diagnosed and were participating in interventions, or
examined arrests or legal problems prospectively. While there are a number of in-prison studies
of offenders, there are fewer specific studies that examined ex-offenders upon community
reintegration, particularly with dual-diagnosis status as a variable. Considering the prevalence
of dual-diagnosis among this population, and the additional barriers to reintegration that are
faced, more research in this area is warranted, and in particular, more investigations are needed
concerning program components that might account for potential change.
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2.5. Ethnicity
Out of the 59 total studies found in the review, almost all of them reported basic demographic
information that included ethnicity. However, the majority of these articles only reported
ethnicity in the demographic section of their studies without assessing the influence of ethnicity
on outcome. As indicated in Table 1, most samples were predominantly European-American
(41%) or African-American (36%). The samples tended to be ethnically diverse, and in some
cases there were population-specific studies based on ethnicity (e.g., Native American). Only
13 studies explore ethnicity beyond reporting it descriptively.
Most of these studies did basic comparative analyses between ethnic groups, often on outcome
variables pertinent to each study. For example, Bogenschutz and Akin (2000) found no
differences in lifetime 12-step attendance between Hispanic and non-Hispanic whites.
Similarly, DiNitto et al. (2001) found no association between ethnic minority status and
frequency of traditional self-help group attendance. Similarly, ethnicity was not correlated with
attendance at a specialized 12-step program for dual-diagnosis over the course of a year
(Laudet, Magura, Cleland et al., 2003) or with abstinence over the course of 2 years (Laudet,
Magura et al., 2004). The only comparison that yielded a difference in 12-step participation
was found by Jordan, Davidson, Herman, and Bootsmiller (2002), who reported that African-
Americans with dual-diagnoses were more likely to attend traditional NA or AA meetings than
European-American individuals with dual-diagnoses.
While this type of analysis is extremely limited, some findings are interesting given the dual-
diagnosis status involved for each ethnic group. For example, in Hoff et al.’s (1999) study of
jail diversion for dually-diagnosed individuals, there were no differences in arrest rates at
follow-up between different ethnic groups, which is in contrast to disparities in arrest rates in
the general population. Additionally, Kilbourne et al. (2002) found that among homeless
women, African-American women were less likely to have injected drugs but more likely to
have had unprotected sex or traded sex than white women. However, both of these studies
failed to examine ethnicity in relation to 12-step participation.
Aside from basic comparisons, there were 5 studies that looked at one ethnic population
primarily, or where the focus of the study was on a specific ethnic comparison. Beals, Novins,
Spicer, Whitesell, Mitchell, and Manson (2006) explored service usage among American
Indians that included assessments of mental health problems and substance use disorders. A
considerable portion of the sample had current or lifetime depressive or anxiety disorders
(22.6%). Participants tended to seek help through treatment more often when they were men
and when they had co-occurring problems (such as mental health issues). Use of 12-step
programming was common among individuals with substance use disorders who identified
more with white culture and who felt that spirituality was more important in their lives (Beals
et al.).
With regard to a different ethnic group, the previously mentioned study of Israeli offenders
(Chen, 2006) also found 12-step groups to be more beneficial than a mutual-support group
without a spirituality component. Similar findings were reported for African-Americans
homeless individuals (Trumbetta et al., 1999). With greater contact with 12-step groups, and
a larger social network, there were more reductions in alcohol use over time in a sample that
was 90% African-American and 92% female (Trumbetta et al.). However, while these basic
studies suggest that 12-step groups are beneficial for ethnic minorities and that spirituality is
an important component, the mechanisms of action have rarely been explored.
In terms of psychiatric outcomes, Westermeyer and Chitasombat (1996) compared opiate-
dependent Hmong immigrants (refugees from Laos) to native-born Americans in a cross-
cultural study of treatment utilization and history of addiction. Hmong individuals also
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experienced more symptoms of depression and phobic anxiety than native-born American
users, which may be related to acculturation and refugee status. Hmong individuals also tended
to smoke opium as opposed to use heroin by injections, which was more common among
native-born Americans. Americans were much more likely to use 12-step programming
compared to Hmong participants (Westermeyer and Chitasombat). Fichter et al.’s (1997) study
of a German sample of homeless men also found low 12-step utilization and high rates of
lifetime psychiatric comorbidity (64%) with alcohol dependence. These two studies suggest
that 12-step groups may not be as culturally relevant given the low level of usage for some
ethnic groups.
Finally, Jerrell and Wilson (1997) compared white and non-white (predominantly Hispanic)
dual-diagnosis patients receiving 12-step and cognitive-behavioral interventions upon
discharge from inpatient treatment. Non-white participants often did not receive as many
services as white participants despite being assigned equally to treatment conditions, and often
were underserved by the interventions that they received. Non-white participants began the
study with lower psychological functioning levels and poorer community support systems than
white participants. Additionally, clinicians reported that non-white participants often faced
more stigmatization that was particularly devastating given their dual-diagnosis status (Jerrell
& Wilson).
In summary, few basic ethnic comparisons have been made among dually-diagnosed samples.
Furthermore, studies of 12-step participation that have focused on specific ethnic groups are
variable, suggesting that some ethnic groups might benefit from 12-step programs while others
may not find them as culturally relevant. However, due to the general lack of focus at this level
of specificity in research on ethnicity, and a paucity of in-depth research examining cultural
mechanisms within 12-step participation, few conclusions about ethnic factors can be made
based on the findings of this review.
2.6. Overall findings
Table 2 includes outcomes that are summarized for self-help involvement based on the primary
findings from each study. Based on the summary in Table 2 of the findings, the majority (19)
of the studies reported positive outcomes or associations for self-help involvement with
abstinence (out of 24 reporting). The findings for psychological outcomes were more varied,
although the article predominantly (9 articles out of 21) reported positive outcomes or
associations of self-help with psychological functioning variables. In most cases (10 out of
15), group membership was not associated with participation in self-help activities. However,
in a few cases (e.g., homelessness or diagnostic group), group membership did predict level
of involvement.
3. Discussion
In summary, this review examined 59 studies that contained qualitative and/or quantitative
data regarding dual-diagnosis and 12-step participation. Additionally, information specific to
ethnicity, homelessness, and ex-offender issues was a primary focus. First, the most note-
worthy findings will be discussed, followed by the limitations of the studies and this review,
as well as conclusions and suggestions for future research in this area.
3.1. Primary findings
Findings from this review suggest that 12-step participation generally leads to beneficial
outcomes for individuals who are dually-diagnosed. As an extension of the findings from
Bogenschutz et al.’s (2006) review, several potential mechanisms of action by which
individuals improve in their sobriety and psychological functioning have been identified. First,
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increased social support via more involvement in dual-focus 12-step groups appears to lead to
beneficial outcomes for both mental health (Laudet et al., 2000a) and substance use outcomes
(Laudet, Magura, Cleland et al., 2004; Laudet, Cleland et al., 2004). This mediational role of
social support has been reported in the general 12-step literature frequently (Groh, Jason, &
Keys, 2008), but this is the first time that similar findings have been reported for a dually-
diagnosed sample.
Additionally, increased self-efficacy also plays a mediational role between participation and
outcomes for dually-diagnosed individuals with respect to dual-focus 12-step groups (Magura
et al., 2007). This finding, as it relates to specialized programs, is interesting because dually-
diagnosed individuals face more barriers to sobriety due to psychological and socioeconomic
burdens (Laudet et al., 2000b), so enhancement of self-efficacy in these programs is a strong
finding. Exactly who benefits from specialized 12-step programs such as DTR is unclear,
especially given qualitative findings that had somewhat mixed results for perceptions of how
different DTR is from traditional 12-step groups. However, a substantial portion of DTR
members felt increased peer identification and support surrounding mental health problems
was attributable to the program (Laudet, Magura, Vogel et al., 2003), suggesting that some
participants might gain more from this type of a group compared to a regular 12-step program.
While traditional 12-step participation appears to be generally well-attended and beneficial for
dually-diagnosed clients (e.g.,Pristach & Smith, 1999), evidence from studies other than dual-
focus 12-step groups seem to suggest that more comprehensive service models that address
the multiple co-occurring problem domains are the most appropriate. For example, Easton et
al.’s (2007) comparison of 12-step versus integrated treatment for substance use and domestic
violence yielded somewhat similar results, although a few outcomes suggested that the
integrated treatment might have been more effective overall. Hence, traditional 12-step
programs can have beneficial functions and build support, but might not be able to assist with
all types of problems given that the focus is generally limited to sobriety. For a dually-
diagnosed population, it is critical to gain support at all levels of co-occurring problems.
A primary finding from studies that examined homeless populations was that 12-step
participation tends to be higher among homeless individuals than others in the United States
(Herman et al., 1991), and this may be a function of what treatments are available to homeless
individuals with few resources. Interestingly, Kilbourne et al.’s (2002) findings that homeless
women who had previously attended 12-step groups had more sexual risk behaviors than those
who had not, illustrate this lack of availability. It is unlikely that 12-step programming promotes
sexual risk behaviors, and much more likely that there were barriers to other forms of treatment
or access to resources for these individuals.
Generally, outcome studies suggested positive results of 12-step participation on abstinence
outcomes (e.g., Gonzalez & Rosenheck, 2002) among dually-diagnosed homeless individuals.
Trumbetta et al.’s (1999) social network analysis suggests that generating more support (via
increased network size) is critical for this population, and 12-step participation appears to
contribute to this. However, some findings suggested potential gender differences in response
to 12-step participation (Kingree, 1995), which warrants further exploration. Overall, 12-step
participation appears to be a good resource for these individuals, although previous research
suggests that other types of community-level support (particularly with housing and more
immediate needs) are needed in addition to this component (Drake et al., 1991).
With regard to ex-offenders, studies frequently reported only criminal histories of a dual-
diagnosis sample and legal outcomes for the entire sample. In general, there were high rates
of previous criminal history in the samples reviewed. Overall, 12-step participation appeared
to have a positive association with desirable legal outcomes such as lower arrest rates (Brooks
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& Penn, 2003; Ouimette et al., 1999). Given the higher re-arrest rate of dually-diagnosed ex-
offenders (e.g., Hoff et al., 1999) and the generally high availability of 12-step programs;
participation should continue to be encouraged.
The primary finding related to mechanisms of action in 12-step groups for ex-offenders was
that spirituality was a salient component of recovery. The in-prison studies from this review
that examined spirituality qualitatively (Severance, 2004) and quantitatively (Chen, 2006)
suggested that offenders discuss 12-step and spirituality as planned strategies for success in
reintegration. Chen’s well-designed study clearly highlighted that the 12-step spirituality
component plays a critical role in mutual-help groups, given the more stable and beneficial
outcomes for mental health and group cohesion compared to mutual-help groups without this
component.
However, the benefits of spirituality as a component of mutual-help groups may vary by
individual beliefs and ethnicity. For example, Native Americans tended to only attend 12-step
programming when they identified more with white culture and valued spirituality (Beals et
al., 2006). Because of cultural and ethnic differences related to these values, 12-step
participation may not always be an appropriate approach compared to mutual-help groups
without a spirituality component. The current review found almost no differences in 12-step
participation among ethnicities, although in one case African-Americans were reportedly more
frequent users (Jordan et al., 2002). However, the vast majority of the studies reviewed included
samples that were predominantly European-American or African-American, and few looked
at specific ethnicities.
Overall, this review found few studies involving ethnic factors related to 12-step participation
and dual-diagnosis. The main finding from Jerrell and Wilson (1997) was that dually-diagnosed
non-white individuals experience considerably more barriers to treatment, and are often
underserved by programs that are offered. There appears to be some ethnic and cultural
variation in the types of psychological problems that certain cultures may have. For example,
non-native U.S. cultures might experience more depression and phobic anxiety in certain
contexts (Westermeyer & Chitasombat, 1996) due to acculturation factors. In addition, 12-step
programming might not be culturally relevant for some groups, given low rates of utilization
observed in some studies (e.g., Fichter et al., 1997).
3.2. Limitations and research suggestions
There were a number of issues in this review that make interpretation of the findings tentative.
The literature is somewhat limited at the level of specificity for the three individual factors
reviewed (i.e., homelessness, ex-offenders, ethnicity) in conjunction with 12-step participation
among dually-diagnosed individuals. Because of this, some of the articles reviewed for those
particular areas were admitted with relaxed inclusion criteria, but did not meet all specified
criteria. However, these articles were included given prevalence of dual-diagnosis and these
co-occurring problems. Furthermore, the majority of studies did not go beyond exploring basic
diagnostic information as demographics in their analysis sections and simply used a
comprehensive “dual-diagnosis” group. This is problematic because there are likely differences
between people who exhibit severe psychopathology and those who have conditions where
their functioning is not as severely impaired. Future research in the dual-diagnosis area should
include these types of comparisons to more adequately address treatment options and
mechanisms of 12-step programming that are beneficial (or detrimental) for particular
diagnostic groups.
Additionally, methodological limitations were frequently present in the reviewed studies.
Although the majority of the studies were longitudinal in nature (64%), almost all studies relied
on convenience samples and a very small percentage (15.5%) employed some kind of
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assignment protocol. Typically, studies were designed to make comparisons between a dually-
diagnosed group and a substance abuse only group, which is informative yet limited. Moreover,
several of these studies were drawn from a few research groups using the same data, which
makes the size even smaller.
Furthermore, several of these studies are outcome-based effectiveness studies that employed
a number of treatment variables. Typically studies were not able to tease apart the effect of
other treatment and support systems on participants in the studies. Additionally, most of the
reviewed studies explored associative effectiveness, without investigating mechanisms and
processes involved within 12-step groups that may vary across ethnic groups, diagnostic status,
and other relevant variables. Beyond the need for more research in the area of ethnicity and
culture, there is a need to determine what about these interventions might make them beneficial,
and for what groups these processes tend to work for (and not work for) while considering
individual factors. Although there were a few qualitative studies in this review, more research
using this methodology is the next step in exploring 12-step group participation, and how
individual factors interact with the group processes. Finally, there is a need for more studies
exploring the influence of varying community-level variables such as legal system practices,
housing policies and reintegration support. Particularly with the individual factors explored in
this review, community and societal-level issues create systemic barriers to recovery and
maintenance, and these factors are rarely explored.
Additionally, it is possible that these group processes might have unique relevance for dually-
diagnosed individuals. For example, Longabaugh, Beattie, Noel, Stout, and Malloy (1993)
proposed a model of social support that has two basic components. Abstinence-specific social
support is believed to promote abstinence, while general social support is posited to promote
general psychological functioning. Perhaps for dually-diagnosed individuals, the types of
social support that they receive via participation in 12-step groups is differently received or
given than for individuals with substance use issues only. Moreover, it is possible that dual-
focus groups might enhance the general social support that is received compared to traditional
12-step groups. However, further exploration of this area is needed in research in order to build
accurate models for interventions while taking into account individual factors beyond an
associative level.
4. Conclusions
Overall, it appears that 12-step programming remains a useful tool for individuals who are
dual-diagnosed. While most 12-step groups are focused solely on abstinence, the processes
involved also can have positive psychological benefits. The advent of specialized 12-step
groups such as DTR has begun to demonstrate advantages of more comprehensive efforts to
provide dually-diagnosed individuals with support and mutual understanding. However, it
remains unclear what individual factors might interact with these group processes, although
the evidence suggests that some members might get more benefit from the groups than others.
An examination of ethnicity, homelessness, and criminal history as factors in this review
suggested many important areas for future research. The potential benefits of both traditional
and specialized 12-step group involvement seem to be relatively consistent in research findings,
although these types of programs might not be culturally relevant for some groups of people.
Future research would benefit from more in-depth understanding of the processes involved in
group participation, and who these processes are most likely to benefit.
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