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Alcoholics Anonymous Science Update: Introduction to the Special Issue

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Substance Abuse
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Alcoholics Anonymous Science Update: Introduction to
the Special Issue
John F. Kelly PhD a
a Center for Addiction Medicine, Massachusetts General Hospital and Harvard Medical
School, Boston, Massachusetts, USA
Accepted author version posted online: 22 May 2012.Version of record first published: 17 Jan
2013.
To cite this article: John F. Kelly PhD (2013): Alcoholics Anonymous Science Update: Introduction to the Special Issue,
Substance Abuse, 34:1, 1-3
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SUBSTANCE ABUSE, 34: 1–3, 2013
Copyright C
Taylor & Francis Group, LLC
ISSN: 0889-7077 print / 1547-0164 online
DOI: 10.1080/08897077.2012.691447
INTRODUCTION
Alcoholics Anonymous Science Update:
Introduction to the Special Issue
John F. Kelly, PhD
Center for Addiction Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
In most developed nations, alarming increases in the prodi-
gious economic, social, and medical burden attributable to
alcohol and other drug misuse has opened the door for greater
coordination among formal and informal intervention and
support services to help reduce harm, curb health care costs,
and enhance long-term recovery (1–5). Significant increases
in the quantity and quality of professional addiction treat-
ment options has been welcome. In addition, there have been
parallel increases in the emergence and spread of addic-
tion mutual-help organizations (6–8). The most ubiquitous
of these is Alcoholics Anonymous (AA).
In the United States, AA is the most commonly sought
source of help for alcohol-related problems (9–11). In 1990,
AA’s increasing reach and influence led to a call from the
Institute of Medicine of the National Academy of Sciences
for more research on AA and its mechanisms (12). Legit-
imizing serious scientific investigation into the public health
significance of AA and how it works, and underwritten by ap-
propriations through the National Institutes of Health and the
Department of Veterans Affairs, the ensuing 20-year period
witnessed an explosion of investigations on the effectiveness,
efficacy, health care cost offset potential, and mechanisms of
behavior change within AA that attracted some of the addic-
tion fields’ top research teams.
In terms of its verifiable impact, hundreds of published
studies have supported the beneficial effects of AA in help-
ing alleviate alcohol and other drug problems. This body of
scientific literature has been summarized in narrative reviews
as well as quantitatively, through rigorous meta-analyses (6,
13–19). AA has been shown to be associated with producing
and maintaining salutary changes in alcohol and other drug
use that are on par with professional interventions while si-
Correspondence should be addressed to John F. Kelly, PhD, Cen-
ter for Addiction Medicine, Massachusetts General Hospital and Harvard
Medical School, 60 Staniford Street, Boston, MA 02114, USA. E-mail:
jkelly11@partners.org
multaneously reducing reliance on professional services and
thus lowering related health care costs (6, 20–22).
The most recent areas of investigation have been in exam-
ining AA’s mechanisms of behavior change as well as poten-
tial moderators. That is to say, research has been conducted
into determining how exactly AA aids addiction recovery
and whether particular subgroups benefit more or less from
AA (23, 24). It is striking to note that one of the most prolific
and advanced areas for understanding mechanisms of behav-
ior change through which interventions produce beneficial
effects has been in the area of mutual help. Several of the
most prominent of these research teams present their work
here.
Some of the highlights of this special issue include up-
dates on novel mechanisms and potential moderators of AA’s
effects; analyses of whether commonly prescribed AA activ-
ities, such as regular meeting attendance, sponsorship, and
reading and meditation result in increased benefits; and long-
term 7- and 10-year follow-ups examining relations between
AA participation and alcohol and other drug use outcomes
among adolescent and adult samples following treatment.
Dr. Daniel Blonigan and colleagues provide results from
a unique and highly innovative examination of the role of
impulsivity as a mechanism of behavior change in AA. Par-
ticularly intriguing about their contribution is their focus
on understanding whether the mechanisms through which
AA helps individuals recover differ depending on particular
patients’ characteristics (i.e., moderated mediation). Their
finding that AA may lead to improved outcomes through
reductions in impulsivity, but only among young adults, un-
derscores the reality that there are likely many pathways to
recovery even within the same organization.
A further study of the mechanisms of behavior change
mobilized by AA participation is presented by Dr. Scott
Tonigan and colleagues. Their investigation is important in
several ways. The sample is quite novel, since they included
only new AA affiliates with less than 16 weeks of prior life-
time AA participation and recruited these individuals from
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2SUBSTANCE ABUSE
the community, from AA clubhouses, as well as from the
more usual treatment settings. It also examines the effect
of AA participation on the character trait of “selfishness,”
which according to AA is purported to be the most high-risk
personality trait, which if not attenuated, will inevitably lead
to relapse (25). The study found that compared with a large
general population sample, the sample of AA attendees was
substantially higher on selfishness. The sophisticated media-
tional analyses, however, did not find support for AA-related
reductions in this trait and therefore it was not found to
be the mechanism through which AA led to better alcohol
outcomes. The authors are careful to place their findings in
the broader context and note that the measures used in their
study may not be optimal in validly assessing this potentially
important construct. These provocative findings provide im-
portant data that should stimulate the development and use
of more refined measurement to investigate this hypothesis
further.
Dr. Amy Krentzman and colleagues tackle the intriguing
issue of spirituality as a mechanism of behavior change in
AA using a sophisticated fully lagged prospective design. Of
note, the authors provide a thorough critical analysis of prior
work in this area, placing their own work within this broader
picture. They also examine the effects of active AA involve-
ment in addition to AA attendance on 6 different facets of
spirituality and 2 drinking outcomes (percent days abstinent
and drinks per drinking day). Employing state-of-the-art mul-
tiple mediator analyses, they carefully unravel some of the
complexities and find support for a distinct spiritual pathway
through which AA participation leads to better outcomes.
Their sensitivity to important nuances in this area offers sev-
eral compelling additional hypotheses to be tested in future
work.
Felicia Chi and colleagues and Matthew Worley and col-
leagues each provide quite different examples of the influ-
ence of psychiatric comorbidity on the derived benefits from
AA. First, Chi and colleagues provide results from an unusu-
ally long 7-year follow-up of a diverse adolescent treatment
sample examining whether, compared with youth suffering
from substance use disorder (SUD) only, youth suffering
from both SUD and a comorbid psychiatric condition par-
ticipate as much in 12-step groups and derive equal benefit.
Across the follow-up period, adolescents in the comorbid
group attended more 12-step meetings and were more ac-
tive in these organizations at 1- and 3-year follow-ups; the
groups were equivalent at the 5- and 7-year follow-ups. Also,
the comorbid group attendees were found to benefit as much
from 12-step mutual-help group meetings as those with SUD
only. Among 12-step attendees in either group, abstinence
rates were at least 3 times higher than nonattendees, high-
lighting the potential recovery-related benefits that might be
obtained from these resources by young people across the
challenging transitional life stage of young adulthood where
support for abstinence and recovery may be lower than at any
other time in the adult life span (26).
Matthew Worley and colleagues provide results from an
18-month investigation of 12-step meeting attendance and
affiliation, and their effects on alcohol and other drug use out-
comes in a sample of veterans with comorbid substance de-
pendence and major depression initially assigned to receive
6 months of either a group-delivered Twelve-Step Facilita-
tion (TSF) intervention or an integrated cognitive-behavioral
treatment (ICBT) intervention. In keeping with other studies
examining TSF interventions (e.g., Tonigan et al. 27), those
participants assigned to TSF had greater community 12-step
meeting attendance and involvement during treatment. How-
ever, this declined following the withdrawal of the TSF inter-
vention. Also, similar to other study findings, greater 12-step
participation was associated with better outcomes indepen-
dent of treatment group. In terms of treatment main effects,
although there were not differences between treatment con-
ditions on drug use outcomes, patients assigned to the TSF
condition has significantly worse alcohol use outcomes over
time. Further analyses indicated that the greater relative in-
creases in alcohol use for the TSF patients were mediated
by their greater relative decreases in 12-step participation.
These findings provide valuable information on potentially
important moderators of the benefits derived from both TSF
interventions and community 12-step meeting participation.
Specifically, as found in prior work with individuals with
psychotic spectrum illness and among other samples of mili-
tary veterans (28), the presence of major depressive disorder
(MDD) in addition to substance dependence may attenuate
12-step related benefits for this important population.
In a rare long-term follow-up, Dr. Maria Pagano and col-
leagues present 10-year alcohol use outcomes in relation
to AA attendance, AA helping (AAH), and working AA’s
12 steps. Using data from the New Mexico subsample of
outpatients initially participating in Project MATCH—a ran-
domized controlled trial in which patients were randomly
assigned to receive either individually delivered cognitive-
behavioral therapy (CBT), motivational enhancement ther-
apy (MET), or Twelve-Step Facilitation (TSF) therapy, the
authors found that, overall, AA meeting attendance, AA help-
ing, and working AA’s 12 steps was apparent in only a mi-
nority of participants. However, in keeping with prior reports
showing that clinicians can make a difference in the like-
lihood of patients’ AA engagement, patients receiving the
Project MATCH TSF treatment showed more AA attendance
and greater AA involvement. The well-controlled prospec-
tive analyses conducted by Pagano and colleagues found
support for significant beneficial effects from AA meeting
attendance and AA-related helping on drinking outcomes
over the 10-year period. The sophisticated prospective de-
sign and analyses covering such a long time frame adds valu-
able information to our understanding of the clinical course
for those suffering from alcohol use disorder in relation to
12-step activities.
Finally, Dr. Sarah Zemore and colleagues tackle the highly
practical issue of which particular 12-step activities, such as
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INTRODUCTION 3
having and using an AA sponsor, having more 12-step mem-
bers among your friends, and reading AA literature, impact
outcomes and therefore might be more strongly prescribed
in professionally delivered TSF interventions. Using the data
from the MAAEZ intervention study (29), the authors found
that whereas some 12-step activity variables were associated
with outcomes at various follow-up points, it was only AA
meeting attendance and using an AA sponsor that consis-
tently predicted better outcomes over the 12-month follow-
up period. These findings highlight the importance of both
AA meeting attendance and the close social relationship,
oversight, and accountability that a sponsor may provide
for many seeking recovery. Findings raise further questions
about whether certain other types of 12-step activities may
have critical periods of influence (e.g., reading AA litera-
ture may be important early on to increase basic knowledge,
understanding, and acceptance) exerting more or less effect
depending on when in the recovery process such activities are
performed.
Collectively, this special issue contains a unique collection
of complementary papers examining both controversial and
novel mechanisms and moderators of behavior change within
AA as well as long-term prospective analysis regarding how
AA may foster enduring recovery among both adolescents
and adults. The result is an intriguing and provocative set
of findings that is sure to stimulate debate and inform novel
areas for investigation.
REFERENCES
[1] UK Drug Strategy. Reducing Demand, Restricting Supply, Building
Recovery: Supporting People to Live a Drug-Free Life. London: HM
Government; 2010.
[2] Centers for Disease Control and Prevention. Binge drinking. Vital
Signs. Atlanta, GA: Center for Disease Control and Prevention. 2012.
[3] Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. Eco-
nomic costs of excessive alcohol consumption in the U.S. 2006. Am J
Prev Med. 2011;41:516–524.
[4] US Department of Justice. The economic impact of illicit drug use on
American society. US Department of Justice, National Drug Intelli-
gence Center, Product No. 2011-Q0317-602. 2011.
[5] Office of National Drug Control Policy. National drug control strategy.
Office of National Drug Control Policy, Washington, DC. 2011.
[6] Humphreys K. Circles of Recovery: Self-Help Organizations for Ad-
dictions. Cambridge, UK: Cambridge University Press; 2004.
[7] Kelly JF, Yeterian JD. Mutual-help groups. In: O’Donohue W, Cun-
ningham JA, eds. Evidence-Based Adjunctive Treatments.NewYork:
Elsevier; 2008:61–106.
[8] Kelly JF, White WL. Broadening the base of addiction mutual-
help group organizations. J Groups Addict Recov. 2012;7:2–4,
82–101.
[9] Room R, Greenfield T. Alcoholics anonymous, other 12-step move-
ments and psychotherapy in the US population, 1990. Addiction.
1993;88:555–562.
[10] Greenfield TK, Weisner C. Drinking problems and self-reported crim-
inal behavior, arrests and convictions: 1990 US alcohol and 1989
county surveys. Addiction. 1995;90:361–373.
[11] Substance Abuse and Mental Health Services Administration. The
NSDUH Report: Participation in Self-Help Groups for Alcohol and
Illicit Drug Use: 2006 and 2007. Rockville, MD: Office of Applied
Studies; 2008.
[12] Institute of Medicine. Broadening the Base of Treatment for Alcohol
Problems. Washington, DC: National Academy Press; 1990.
[13] Emrick CD, Tonigan JS, Montgomery H, Little L. Alcoholics Anony-
mous: what is currently known? Research on Alcoholics Anonymous:
Opportunities and Alternatives. 1993:41–76.
[14] Kaskutas LA. Alcoholics anonymous effectiveness: faith meets sci-
ence. J Addict Dis. 2009;28:145–157.
[15] Kelly JF. Mutual-help for substance use disorders: history, effective-
ness, knowledge gaps and research opportunities. Clin Psychol Rev.
2003;23:639–663.
[16] Tonigan JS, Toscova R, Miller WR. Meta-analysis of the literature on
Alcoholics Anonymous: sample and study characteristics moderate
findings. J Stud Alcohol. 1996;57:65–72.
[17] Kownacki RJ, Shadish WR. Does Alcoholics Anonymous work? The
results from a meta-analysis of controlled experiments. Subst Use
Misuse. 1999;34:1897–1916.
[18] Ferri M, Amato L, Davoli M. Alcoholics Anonymous and other 12-
step programmes for alcohol dependence. Cochrane Database Syst
Rev. 2006;(3):CD005032.
[19] White WL. Peer-Based Addiction Recovery Support: History, Theory,
Practice, and Scientific Evaluation. Chicago, IL: Great Lakes Ad-
diction Technology Transfer Center and Philadelphia Department of
Behavioral Health and Mental Retardation Services; 2009.
[20] Humphreys K, Moos R. Can encouraging substance abuse pa-
tients to participate in self-help groups reduce demand for health
care? A quasi-experimental study. Alcohol Clin Exp Res. 2001;25:
711–716.
[21] Humphreys K, Moos RH. Encouraging posttreatment self-help group
involvement to reduce demand for continuing care services: two-
year clinical and utilization outcomes. Alcohol Clin Exp Res.
2007;31:64–68.
[22] Kelly JF, Yeterian JD. Empirical awakening: the new science on mu-
tual help and implications for cost containment under health care
reform. J Subst Abuse. 2012;33:85–91.
[23] Kelly JF, Magill M, Stout RL. How do people recover from alcohol
dependence? A systematic review of the research on mechanisms
of behavior change in Alcoholics Anonymous. Addict Res Theory.
2009;17:236–259.
[24] Kelly JF, Hoeppner B, Stout RL, Pagano M. Determining the rel-
ative importance of the mechanisms of behavior change within
Alcoholics Anonymous: a multiple mediator analysis. Addiction.
2012;107:289–299.
[25] Alcoholics Anonymous. Alcoholics Anonymous: The Story of How
Thousands of Men and Women Have Recovered From Alcoholism. 4
ed. New York: Alcoholics Anonymous World Services; 2001.
[26] Kelly JF, Brown SA, Abrantes A, Kahler CW, Myers M. Social re-
covery model: an 8-year investigation of adolescent 12-step group
involvement following inpatient treatment. Alcohol Clin Exp Res.
2008;32:1468–1478.
[27] Tonigan JS, Connors GJ, Miller WR. Participation and involvement
in Alcoholics Anonymous. In: Babor T, DelBoca F, eds. Treatment
Matching in Alcoholism. New York: Cambridge University Press;
2003:184–204.
[28] Kelly JF, McKellar JD, Moos R. Major depression in patients with
substance use disorders: relationship to 12-Step self-help involvement
and substance use outcomes. Addiction. 2003;98:499–508.
[29] Kaskutas LA, Subbaraman MS, Witbrodt J, Zemore SE. Effective-
ness of making Alcoholics Anonymous easier: a group format 12-step
facilitation approach. J Subst Abuse Treat. 2009;37:228–239.
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... Alcoholism is one of the most serious health concerns in America in terms of the strain it places on the healthcare system, the impact it has on the economy, and the number of people who are directly affected by the disorder (National Institute on Drug Abuse, 2005). The 12-step program, Alcoholics Anonymous (AA), is the most widely used recovery support service (Substance Abuse and Mental Health Services Administration, 2016) and method of treatment for alcoholism (Room, 1993), and researchers have shown that the AA program is effective for helping members remain abstinent (Kaskutas, 2009;Kelly, Magill, & Stout, 2009;Kelly, 2013;Magura, McKean, Kosten, & Tonigan, 2013;Pagano, Friend, Tonigan, & Stout, 2004). A recent review of AA research over the last 25 years suggests that many of the benefits gained from AA can be attributed to social, cognitive, and affective mechanisms (Kelly, 2017). ...
Thesis
The idea that helping others and practicing gratitude is associated with lower selfishness among members of Alcoholics Anonymous (AA) is discussed at length in AA literature, in AA meetings, and among AA members. Specifically, helping others is described as “insurance” against relapse (Alcoholics Anonymous World Services Inc., 2001); gratitude is viewed as a character asset that should be continuously cultivated throughout life (Wilson, 1953); and selfishness is identified as the “root” of alcoholism (Alcoholics Anonymous World Services Inc., 2001). Despite the strong emphasis on these concepts in the literature, relationships between these concepts have not been scientifically investigated. In this study I employed longitudinal, daily diary research methodology to investigate whether helping others and feeling grateful were associated with lower selfishness among AA members over a period of 7 days (N = 113). Multi-level modeling analyses confirmed that on days when participants helped more people compared to their own weekly average, they reported lower selfishness than on days when they helped fewer people. Further, on days when participants were more grateful compared to their own weekly average, they reported lower selfishness than on days when they were less grateful. Lastly, on days when participants helped more people and were more grateful, they reported even lower selfishness. Uncovering evidence of an association between these key facets of AA provides valuable insight about the 12-step program.
... Hundreds of books and thousands of articles have been written on AA spanning its history, biographies of its founding leaders, member autobiographies, professional interpretations of its 12-Step program of alcoholism recovery, the integration of AA principles and practices within professionally directed addiction treatment, and recent scientific studies of AA's effectiveness and "active ingredients." Although quite contentious debates about the effectiveness of AA and the larger "12-Step Movement" rage in popular social media venues, there have been marked advances in the methodological rigor of scientific studies of AA (Humphreys, Blodgett & Wagner, 2014;Humphreys et al, 2004;Kaskutas, 2009;Kelly, 2013;Kelly & Yeterian, 2012). Given this voluminous body of formal and grey literature and its daily growth, it is difficult to separate the proverbial wheat from the chaff when it comes to understanding AA's place in recovery from alcohol dependence. ...
... In this context, it is worth mentioning the role that the Alcoholics Anonymous movement played in the emergence of recovery oriented treatment programs, not only in the field of substance abuse and addictions, but also in that of psychiatry [20]. For over two decades, the importance of the AA movement and of its ever growing number of descendants, or related organisations (other peer-based recovery support groups), as well as the clinical versions of its method, i.e. the Minnesota Model and Twelve Step Programs and Facilitations, have been acknowledged and placed under intense scientific scrutiny, especially in the Anglophone world [21], after having long been regarded with suspicion within the circles of the mainstream science [22]. The fact that the AA movementwhich counted two persons (in 1935), and now boasts over two million members around the world -has Christian roots [23] and promotes a program that is based on theist spirituality, is common knowledge and also a proof of the role Christianity still plays in the shaping and promoting human dignity. ...
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... Este remarcabil, în acest context, rolul pe care mişcarea Alcoolicilor Anonimi (AA) l-a jucat în apariţia programelor de tratament orientate spre recuperare, nu numai în domeniul consumului problematic şi adicţiilor, ci şi în cel al psihiatriei [20]. De mai bine de două decenii, mişcării AA, celorlalte grupuri de suport inspirate de AA, variantelor clinice ca Modelul Minnesota sau programele şi facilităţile de tip 12 Paşi, le este recunoscută importanţa în sănătatea publică, fiind supuse unei cercetări intense, îndeosebi în spaţiul anglofon [21], după ce mult timp au fost privite cu suspiciune în mediile ştiinţifice [22]. Faptul că mişcarea AA, pornită de la două persoane (în 1935) şi depăşind la ora actuală două milioane de membri în întreaga lume, are origini creştine [23] şi promovează un program bazat pe spiritualitate teistă, este, de asemenea, notoriu şi probează rolul creştinismului în formarea şi promovarea demnităţii omului. ...
... Furthermore, the principle of ''keeping it by giving it away'' speaks to a process whereby individuals protect their own ongoing recovery by helping others around them achieve this as well. A substantial proportion of the efficacy of AA in supporting recovery is therefore achieved not merely through attendance itself but rather through active participation at meetings (Kelly, 2013), thus embedding members within the group in ways that encourage them to embody and live out the group's norms and values. ...
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... Consequently, it is common for alcohol and drug treatment programs to refer adults and adolescents to these groups both during and after professional treatment (Drug Strategies, 2003;Janchill, 2000;Knudsen, Ducharme, Roman, & Johnson, 2008). Participation in such groups posttreatment is associated with reduced substance use (Kelly, 2013;Kelly, Stout, & Slaymaker, 2013;Pagano, White, Kelly, Stout, & Tonigan, 2013). Further, in our prior work predicting the timing of when people transition from use in the community toward recovery, treatment was one of the biggest predictors; but when we examined who sustained recovery, self-help involvement was the major predictor . ...
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... In this context, it is worth mentioning the role that the Alcoholics Anonymous movement played in the emergence of recovery oriented treatment programs, not only in the field of substance abuse and addictions, but also in that of psychiatry [20]. For over two decades, the importance of the AA movement and of its ever growing number of descendants, or related organisations (other peer-based recovery support groups), as well as the clinical versions of its method, i.e. the Minnesota Model and Twelve Step Programs and Facilitations, have been acknowledged and placed under intense scientific scrutiny, especially in the Anglophone world [21], after having long been regarded with suspicion within the circles of the mainstream science [22]. The fact that the AA movementwhich counted two persons (in 1935), and now boasts over two million members around the world-has Christian roots [23] and promotes a program that is based on theist spirituality, is common knowledge and also a proof of the role Christianity still plays in the shaping and promoting human dignity. ...
... In addition to its focus on AA and its members, the empirical literature generally focuses on predictors of abstinence over relatively short-term follow-ups (Kelly, 2013). Yet recent membership data from both AA and NA suggest a large percentage of individuals reported more than 5 years of abstinence (e.g., 58% in NA; NA World Services, 2013). ...
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... The AA-related outcome literature has evolved over the past several decades in terms of focus, methodological rigor, and practical importance (Kelly 2013). However, outcomes beyond abstinence are examined less often (Tonigan 2008). ...
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Peer-led mutual-help organizations addressing substance use disorder (SUD) and related problems have had a long history in the United States. The modern epoch of addiction mutual help began in the postprohibition era of the 1930s with the birth of Alcoholics Anonymous (AA). Growing from 2 members to 2 million members, AA's reach and influence has drawn much public health attention as well as increasingly rigorous scientific investigation into its benefits and mechanisms. In turn, AA's growth and success have spurred the development of myriad additional mutual-help organizations. These alternatives may confer similar benefits to those found in studies of AA but have received only peripheral attention. Due to the prodigious economic, social, and medical burden attributable to substance-related problems and the diverse experiences and preferences of those attempting to recover from SUD, there is potentially immense value in societies maintaining and supporting the growth of a diverse array of mutual-help options. This article presents a concise overview of the origins, size, and state of the science on several of the largest of these alternative additional mutual-help organizations in an attempt to raise further awareness and help broaden the base of addiction mutual help.
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Rigorous reviews of the science on the effectiveness of Alcoholics Anonymous (AA) indicate that AA and related 12-step treatment are at least as helpful as other intervention approaches. Exactly how AA achieves these beneficial outcomes is less well understood, yet, greater elucidation of AA's mechanisms could inform our understanding of addiction recovery and the timing and content of alcohol-related interventions. Empirical studies examining AA's mechanisms were located from searches in Pubmed, Medline, PsycINFO, Social Service Abstracts and from published reference lists. Thirteen studies completed full mediational tests. A further six were included that had completed partial tests. Mechanisms examined fell into three domains: (1) Common processes; (2) AA-specific practices; and (3) Social and spiritual processes. Results suggest AA helps individuals recover through common process mechanisms associated with enhancing self-efficacy, coping skills, and motivation, and by facilitating adaptive social network changes. Little research or support was found for AA's specific practices or spiritual mechanisms. Conclusions are limited by between-study differences in sampling, measurement, and assessment time-points, and by insufficient theoretical elaboration of recovery-related change. Similar to the common finding that theoretically-distinct professional interventions do not result in differential patient outcomes, AA's effectiveness may not be due to its specific content or process. Rather, its chief strength may lie in its ability to provide free, long-term, easy access and exposure to recovery-related common therapeutic elements, the dose of which, can be adaptively self-regulated according to perceived need.
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This chapter describes the goals and key therapeutic processes of mutual-help groups (MHGs) presumed to facilitate improvement and/or maintenance of functioning. It reviews and evaluates available outcome data pertaining to MHGs' effectiveness in helping individuals manage or recover from their respective disorders, including any evidence in support of the key therapeutic processes. It describes the role MHGs plays in a formal treatment plan and describes how professionals facilitate and coordinate participation in these groups. It concludes by describing opportunities for further research and what might be done to help disseminate knowledge about MHGs and their potential utility. It provide information about various MHGs divided into three distinct problem areas—i.e., substance dependence (e.g., alcohol, cocaine), mental illness (e.g., schizophrenia, depression), and dual diagnosis (i.e., substance dependence in combination with mental illness). It provides summary tables containing brief descriptions of the MHGs, website and contact information, degree of evidence for the MHGs, and several other indices that facilitate easy comparisons of organizations along multiple lines. It also provides detailed MHG information in the text regarding other compulsive behaviors (e.g., gambling, sex, eating behaviors) and family-related MHGs.
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disciplines encountered [in this review] included anthropology, sociology, psychology, medicine, theology, and philosophy / participant-observational studies, epidemiological surveys, public opinion surveys, ethnographic investigations, and psychotherapy outcome studies were among the research strategies used in the sources (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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