Introduction
Twelve-step mutual-help groups, often also called self-help or support groups, are an important component of the system of care for individuals with substance use disorders. Individuals make more visits to mutual-help groups for help with their own or family members’ substance use and psychiatric problems than to all mental health professionals combined. About 9% of adults in the United States have been to an Alcoholics Anonymous meeting at some time in their life, and almost 80% of adults who seek help for alcohol use disorders participate in Alcoholics Anonymous. Moreover, many substance use disorder treatment providers have adopted 12-step principles in treatment, and the majority of them refer clients to mutual-help groups.
Mutual-help groups offer a forum wherein members can express their feelings in a safe, structured setting, improve communication and interpersonal skills, better understand the reasons for their unhealthy substance use, learn self-control, and identify new activities and life goals. Accordingly, the American Psychiatric Association and several other professional and health care organizations recommend referrals to mutual-help groups as an adjunct to the treatment of individuals with substance use disorders.
Major Types of Substance Use-Focused Mutual-Help Groups
The majority of the literature on mutual-help groups that address substance use focuses on traditional 12-step groups for individuals using alcohol and drugs or for their family members and friends. The most prevalent traditional 12-step groups are Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, and Al-Anon Family Groups; other important substance-use–focused mutual-help groups include Secular Organizations for Sobriety, SMART Recovery (Self-Management and Recovery Training), Moderation Management, and LifeRing. These groups are briefly described next. Women for Sobriety, Double Trouble in Recovery, and Dual Recovery Anonymous are described in the sections on women and individuals with substance use and psychiatric disorders.
Alcoholics Anonymous
Alcoholics Anonymous is a fellowship with the primary purpose of helping individuals with alcohol-related problems maintain sobriety. It is structured around the 12 Steps (e.g., admission of powerlessness over alcohol, belief in a higher power) and 12 Traditions (e.g., an emphasis on the common welfare and recognition that personal recovery depends on Alcoholics Anonymous unity). (See www.aa.org/pdf/products/p-42_abriefguidetoaa.pdf for the Twelve Steps and Twelve Traditions.) Other key aspects of Alcoholics Anonymous involve open and closed group meetings and literature that describes Alcoholics Anonymous, shares its tenets, and provides guidance to recovering individuals. Estimated Alcoholics Anonymous membership is about 1,300,000 members and 60,000 groups in the United States, and about 2,041,000 members and 115,000 groups worldwide; about 38% of the members are women (see www.aa.org ).
Narcotics Anonymous and Cocaine Anonymous
Narcotics Anonymous is a fellowship of recovering individuals with drug use disorders. It grew out of and is similar to Alcoholics Anonymous in that it provides a structured support network in which members share information about overcoming addiction and living productive, drug-free lives through adherence to the 12 Steps and 12 Traditions. Narcotics Anonymous encourages complete abstinence from all drugs, including alcohol, but, like Alcoholics Anonymous, accepts the use of prescribed medications for psychiatric and medical disorders. Narcotics Anonymous has about 63,000 weekly meetings in more than 130 countries worldwide; about 76% of the members are Caucasian and 43% are women (see www.na.org ).
Cocaine Anonymous is a fellowship open to individuals who want to stop using cocaine, including crack cocaine and other mind-altering substances. Its program of recovery was adapted from Alcoholics Anonymous and uses the 12-step recovery approach. There are an estimated 30,000 members and more than 2000 groups (see www.ca.org ).
Al-Anon and Nar-Anon
The purpose of Al-Anon Family Groups, a mutual-help organization more commonly known as Al-Anon, is to support people who are affected by another person’s drinking and/or drug use. The history of Al-Anon is intertwined with that of Alcoholics Anonymous. Alateen is the affiliate of Al-Anon for young people (mainly adolescents) who are affected by another’s substance use. Al-Anon is the most widely used form of help for concerned family members and friends in the United States. Currently, there are more than 28,000 Al-Anon groups and over 24,000 Alateen groups in 130 countries (see www.al-anon.org ). Of Al-Anon members in the United States and Canada, 83% are women and 93% are white; on average, members are 56 years old. Nar-Anon Family Groups (Nar-Anon) was begun to help with another’s addiction to drugs other than alcohol. It is a worldwide fellowship adapted from Narcotics Anonymous.
Secular Organizations for Sobriety
Secular Organizations for Sobriety provides support for individuals who seek to achieve and maintain sobriety, a forum to express thoughts and feelings about recovery, and a nonreligious or secular approach that does not depend on the 12 Steps or 12 Traditions. Members are expected to acknowledge their addiction and take responsibility for achieving and maintaining sobriety. Members tend to be well-educated individuals who have been in professional treatment and have attended and continue to attend Alcoholics Anonymous. The majority of the members are men (see www.secularsobriety.org ).
SMART Recovery
SMART Recovery (or Self-Management and Recovery Training) espouses a rational treatment orientation and focuses on teaching individuals new coping skills and more logical ways of thinking and acting. Using trained facilitators in about 2000 groups, it emphasizes practical methods of changing maladaptive behavior rather than a 12-step or spiritual approach. SMART Recovery’s 4-point program includes: (1) building and maintaining motivation to abstain; (2) learning how to cope with urges; (3) managing thoughts, feelings, and behavior; and (4) balancing momentary and enduring satisfactions (see www.smartrecovery.org ). A comparison of three groups of SMART Recovery participants—those only attending meetings in person, those using only a web application of the program, and those attending meetings and employing the web application—found that these interventions were equally effective. That is, participants in all three groups were significantly more likely at follow-up to be abstinent and to have fewer drinking- and substance-related problems.
Moderation Management
Moderation Management construes problem drinking as a habit that can be controlled by applying principles of cognitive-behavioral therapy in the context of a network of supportive peers. It provides an alternative to the spiritually oriented disease model of traditional 12-step mutual-help groups and to an abstinence goal; it allows members a choice of abstinence or moderate drinking goals. Moderation Management members tend to emphasize the value of self-control, insight, personal responsibility and choice, and rationality. Most Moderation Management members are Caucasian; they tend to be married, college educated, and employed, and more than half are women (see www.moderation.com ).
LifeRing
LifeRing Secular Recovery is an organization of people who share practical experiences and sobriety support, embracing what works for each individual. LifeRing believes that each individual has the desire to find lasting sobriety, thought of as the Sober Self. With addiction, the Sober Self has been submerged, but still exists. People also have an Addict Self that tries to control decision-making and leads to substance use. LifeRing supports efforts to strengthen the Sober Self and weaken the Addict Self by sharing advice, understanding, and encouragement. It is thought to work by positive social reinforcement. The membership is primarily male (57%), white (96%), college educated (91%), and not religious (56%) ( www.lifering.org ).
Participation in Mutual-Help Groups and Substance Use Outcomes
Individuals with substance use disorders who participate in 12-step mutual-help groups, especially Alcoholics Anonymous and Narcotics Anonymous, tend to experience better alcohol and drug use outcomes than do individuals who do not participate in these groups. The most common index of participation has been attendance at group meetings; however, attention has also focused on aspects of involvement, such as reading 12-step literature, working the steps, obtaining a sponsor, and doing service work.
Attendance and Substance Use Outcomes
People who attend Alcoholics Anonymous in the first few weeks or months after treatment tend to experience good short-term substance use outcomes. For example, Project MATCH was a large clinical trial that compared 12-step facilitation, cognitive-behavioral, and motivational enhancement treatment for individuals with alcohol use disorders. Participants who attended Alcoholics Anonymous more often in each of the 3-month intervals after treatment were more likely to maintain abstinence from alcohol in that interval. In addition, more frequent Alcoholics Anonymous attendance in the first 3 months after treatment was related to a higher likelihood of abstinence and fewer alcohol-related consequences in the subsequent 3 months; these findings held for participants in each of the three types of treatment.
Comparable findings were obtained in two projects conducted among individuals with substance use disorders who were treated in residential programs. Among individuals in hospital-based programs, those who participated in 12-step mutual-help groups in the 3 months before 1-year follow-up were more likely to be abstinent, in remission, and free of dependence symptoms. Clients who attended more group meetings experienced better outcomes than did clients who attended fewer meetings. Among individuals in community-based programs, those who attended more 12-step mutual-help group meetings in the 3 months prior to a 1-year follow-up were more likely to be abstinent at follow-up.
Individuals who continue to attend mutual-help groups for a longer interval are more likely to maintain abstinence than are individuals who stop attending. In a 9-year follow-up of individuals with substance use disorders who entered treatment, Witbrodt et al. found that 12-step meeting attendance trajectories were aligned with abstinence patterns. Individuals who had continuing high attendance rates were more likely to be abstinent. Individuals who initially had high attendance rates were likely to be abstinent, but as their attendance declined by year 5, so did their likelihood of abstinence. Individuals who initially had high attendance and abstinence rates but no attendance after year 1 had a sharply declining rate of abstinence. Individuals who initially had low attendance, but then increased their attendance, also increased their abstinence rates. As expected, individuals who reported low or no attendance had the lowest abstinence rates. In a companion study, Witbrodt et al. tested causal relationships between posttreatment 12-step group attendance and abstinence over 9 years. More 12-step attendance during years 1 and 5 was causally related to past-30-day abstinence at years 5 and 7, respectively, suggesting that 12-step attendance leads to abstinence well into the posttreatment period.
Another prospective study of individuals with alcohol use disorders showed that a longer duration of attendance in Alcoholics Anonymous in the first year after help-seeking was associated with a higher likelihood of 1-, 8-, and 16-year abstinence. These findings were based on better outcomes for individuals who attended Alcoholics Anonymous for 17 weeks or more. Individuals who attended Alcoholics Anonymous for only 1–16 weeks had no better outcomes than nonattendees did. Moreover, after controlling for the duration of Alcoholics Anonymous attendance in year 1, the duration of attendance in years 2–3 and 4–8 was related to a higher likelihood of 16-year abstinence.
Despite findings that more 12-step group attendance is associated with better outcomes, it is possible that self-selection bias (i.e., individuals who attend meetings are more motivated to change) inflates estimates of the benefits of attendance. Humphreys et al. employed instrumental variables models with six data sets to derive an estimate free of selection bias of the impact of Alcoholics Anonymous attendance. Increased attendance that could not be attributed to self-selection was associated with higher rates of abstinence.
Another question is the extent to which Alcoholics Anonymous is helpful to individuals using substances other than alcohol. Individuals with drug use problems are most likely to attend Alcoholics Anonymous, which has many easily accessible groups, even though the less easily accessible Narcotics Anonymous was created to enhance recovery from drug addiction. A study of young adults found that patients with drug use problems who attended more Alcoholics Anonymous than Narcotics Anonymous meetings were as likely to be abstinent as those who attended mainly Narcotics Anonymous meetings. These findings suggest that patients with drug use problems may obtain as much benefit from participation in Alcoholics Anonymous relative to Narcotics Anonymous, boosting clinical confidence in making Alcoholics Anonymous referrals for these individuals when Narcotics Anonymous is less available.
Although many in the addiction field see 12-step group participation and medication-assisted treatment for substance addiction as compatible, individuals using such treatment who attend 12-step meetings may experience conflicts or pressures to discontinue medications. Despite such concerns, one study found improved long-term outcomes (between 18 months and 4 years) for patients using medication-assisted treatment who also attended 12-step groups. Similarly, Monico and colleagues found that more 12-step meeting attendance during the first 6 months of medication-assisted treatment did not precipitate treatment discontinuation and was associated with superior abstinence outcomes. Even so, treatment providers may need to help patients navigate using both medications and 12-step groups to achieve recovery; for example, patients may be encouraged to seek groups that are more accepting of medication treatments.
Involvement and Substance Use Outcomes
Attendance is an important indicator of mutual-help participation, but it may not adequately reflect an individual’s level of group involvement, as shown by such indices as acceptance of 12-step ideology, having a spiritual awakening, giving Alcoholics Anonymous talks, socializing with Alcoholics Anonymous members, becoming a sponsor, and self-identification as a group member. These aspects of group involvement may be associated with substance use outcomes independent of the duration and frequency of attendance per se.
In support of this idea, individuals who held stronger beliefs in 12-step ideology were more likely to be abstinent independent of their 12-step group attendance. In the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, individuals who increased their 12-step involvement in the first 3 months of treatment had better cocaine and other drug use outcomes in the next 3 months. Individuals who regularly engaged in 12-step activities but attended meetings inconsistently had better drug use outcomes than did individuals who attended consistently but did not regularly engage in 12-step activities.
Caldwell and Cutter identified a group of individuals who showed substantial attendance at meetings but mixed involvement in Alcoholics Anonymous practices. These individuals were less enthusiastic about the concept of a higher power and Alcoholics Anonymous literature and were less involved with other Alcoholics Anonymous members. They also had high relapse rates. Individuals who attend mutual-help groups but are unable to embrace key aspects of the program appear to be less likely to benefit from it.
Participation and Outcomes Other Than Substance Use
Participation in mutual-help groups is associated primarily with better substance use outcomes; however, it has also been linked with more self-efficacy and spirituality and less distress, better social support and functioning, and enhanced coping skills and community participation.
Participation in mutual-help groups has been associated with stronger self-efficacy for abstinence, less distress and depression, and fewer psychiatric symptoms. Compared with individuals who had not worked all 12 steps, those who had worked all 12 steps had more self-esteem and social confidence and were more optimistic and trusting. In addition, some studies have shown an association between participation in mutual-help groups and higher levels of spirituality and perceived meaning of life.
There is a relatively robust relationship between mutual-help group involvement and better social support and functioning. For example, individuals with alcohol use disorders who attended more Alcoholics Anonymous meetings over a 3-year interval had more friend-related support; individuals who attended Alcoholics Anonymous longer over 1-year and 8-year intervals also reported more support from friends. Similarly, individuals who attended Narcotics Anonymous once a week or more had more friends than did individuals who did not attend Narcotics Anonymous or attended infrequently.
In a review of this area, Groh and colleagues concluded that more involvement in Alcoholics Anonymous was associated with larger friendship networks, primarily due to acquiring an Alcoholics Anonymous sponsor and the development of new 12-step friends. Involvement in Alcoholics Anonymous was also linked to more specific support for abstinence from friends and to higher quality friendships and more general support. It is important to note that the strength of affiliation among Alcoholics Anonymous members may be comparable to or even stronger than feelings for close friends and family members.
Affiliation with 12-step mutual-help groups tends to promote more reliance on approach coping and behaviorally oriented substance use coping processes. For example, Snow and colleagues found that individuals who were more involved in Alcoholics Anonymous were more likely to rely on coping responses aimed toward reducing substance use, such as spending time with nondrinking friends, talking to someone about their drinking problems, rewarding themselves for trying to stop drinking, and becoming more aware of social efforts to help people stop drinking. In addition, individuals who attend Alcoholics Anonymous for longer intervals tend to rely more on approach coping and less on avoidance coping.
There has been speculation that the admonition against public self-identification as a member of Alcoholics Anonymous or Narcotics Anonymous may discourage participation in community activities. However, many long-term Alcoholics Anonymous and Narcotics Anonymous members are active in established neighborhood organizations and civic groups, such as homeless coalitions and parent-teacher associations. Similarly, Alcoholics Anonymous participation has been associated with community helping activities, such as mentoring youngsters or doing volunteer work among alcoholic individuals in recovery.
Al-Anon Participation and Outcomes
Empirical studies of Al-Anon, some of which were conducted in the 1980s and 1990s, reported that more attendance was associated with better outcomes. Al-Anon members reported improvements in understanding alcoholism, and in depression, assertiveness, self-acceptance, and relationships. Several studies have involved family members (known as Concerned Others) concerned about individuals with alcohol use disorders who were resistant to treatment. Compared to wait-list controls, Concerned Others who were referred to therapy based on Al-Anon concepts or to Al-Anon reported reduced personal problems and emotional distress (depression, anxiety, anger), and increased self-esteem, coping behaviors, and relationship happiness.
At a 6-month follow-up of newcomers to Al-Anon, both those who sustained attendance and those who stopped attending reported gains from Al-Anon. However, sustained attendees were more likely than those who stopped attending to report benefits in a number of domains, including learning how to handle problems due to the drinker, general well-being, functioning, and psychological symptoms. Attendees were also more likely than those who stopped attending to report increases in daily, in-person contact with the drinker. The main issues that prompted Concerned Others to initiate Al-Anon attendance were problems with overall quality of life, the drinker, stress, and anger; Al-Anon helps Concerned Others with these main concerns. Longer-term members were more likely than newcomers to report better functioning in these domains. A recent study in Iran also found that women attending Al-Anon for 6 months or longer were better off than women attending their first Al-Anon meeting on measures of problem solving and quality of life.
Connections Between Mutual-Help Groups and Treatment
Many individuals who enter professional treatment also participate in mutual-help groups; in fact, 50%–80% of individuals in substance use disorder treatment also participate in mutual-help groups, and 60%–80% of Alcoholics Anonymous members have participated in treatment. These two sources of help could contribute independently to better outcomes, or they could either bolster or detract from each other.
Participation in Treatment and Mutual-Help Groups
In general, individuals who enter treatment are more likely to participate in mutual-help groups than are individuals who do not enter treatment. Compared with help-seeking individuals who entered only Alcoholics Anonymous, individuals who entered both treatment and Alcoholics Anonymous participated as much or more in Alcoholics Anonymous in the subsequent 15 years. Individuals who stayed in treatment longer in the first year after seeking help subsequently showed more sustained participation in Alcoholics Anonymous. More extended treatment later in individuals’ help-seeking careers was not associated with subsequent participation in Alcoholics Anonymous, which suggests that treatment providers’ referrals to Alcoholics Anonymous have more influence in the context of an initial treatment episode.
Moreover, individuals who participate in mutual-help groups are more likely to enter and complete treatment. Clients with drug use disorders who attended mutual-help groups weekly before treatment stayed in treatment longer and were more likely to complete treatment. In turn, clients who stayed in treatment longer subsequently were more likely to attend Alcoholics Anonymous at least weekly. In a study of individuals with alcohol use disorders, those who participated in both treatment and Alcoholics Anonymous attended more treatment sessions and more Alcoholics Anonymous meetings than did those who participated only in treatment or only in Alcoholics Anonymous.
Several studies have shown a more specific link, in that individuals who participate in 12-step treatment, which introduces clients to 12-step philosophy and encourages them to join a group, are more likely to affiliate with mutual-help groups than are individuals who participate in treatment that is not oriented toward 12-step principles. In Project MATCH, participants in 12-step facilitation treatment were more likely to attend and affiliate with Alcoholics Anonymous than were those in cognitive-behavioral treatment or motivational enhancement treatment. Similarly, in another multisite study, participants in 12-step facilitation programs affiliated more with 12-step mutual-help groups after treatment than did persons who were treated in cognitive-behavioral treatment programs.
Twelve-step facilitation treatment may enhance the effectiveness of 12-step mutual-help groups. Humphreys and colleagues identified a stronger relationship between 12-step mutual-help group participation and better substance use outcomes among clients from 12-step facilitation treatment programs than among those from cognitive-behavioral treatment or eclectic programs. Posttreatment mutual-help group involvement partially explained the higher rates of abstinence among individuals from 12-step programs than among those from cognitive-behavioral treatment programs.
A supportive and spiritually oriented treatment environment can enhance participation in 12-step activities. Clients in more supportive treatment environments increased more in 12-step involvement during treatment; that is, they were more likely to acquire a sponsor and 12-step friends and to read 12-step literature. Moreover, when clients who had a high risk of discontinuing attendance at mutual-help groups after treatment were treated in a more supportive environment, their risk of discontinuing declined.
These findings suggest that referral and alliance processes contribute to an association between participation in treatment and subsequent participation in mutual-help groups. A positive treatment alliance may enhance clients’ motivation for recovery and underlie the impact of counselors’ recommendations to attend mutual-help groups. Treatment that highlights the value of 12-step mutual-help groups in recovery encourages more mutual-help group involvement than treatment that does not highlight this value.
Participation in mutual-help groups may reduce the need for some costly treatment services. A 3-year prospective study of individuals with alcohol use disorders found that those who chose to attend only Alcoholics Anonymous had treatment costs that were 45% lower than costs for people who chose to attend outpatient treatment; outcomes were similar for both groups. A multisite study found that patients who received cognitive behavioral therapy made more use of treatment, whereas patients who received 12-step–oriented treatment attended more Alcoholics Anonymous meetings. Accordingly, at 1-year and 2-year follow-ups, annual treatment costs for the patients who had received 12-step–oriented treatment were 64% lower, and they had higher abstinence rates. A 7-year follow-up of adolescents treated for substance use disorders found that each additional 12-step meeting attended was associated with an incremental medical cost reduction of 4.7% ($145 per year in 2010 US dollars). The medical cost offset was largely due to reductions in hospital inpatient days, psychiatric visits, and addiction treatment.
Treatment, Mutual-Help Groups, and Substance Use Outcomes
Participation in treatment and participation in mutual-help groups have independent effects on substance use outcomes that tend to augment each other. Individuals who participated more intensively in mutual-help groups after treatment experienced better substance use outcomes, even after controlling for the effects of treatment completion and continuing care. This finding was also obtained in follow-ups of individuals discharged from residential care.
More importantly, participation in each of these two modalities of help can independently contribute to better outcomes. In a nationwide sample of alcohol-dependent individuals, persons who participated in 12-step mutual-help groups in addition to treatment were more than twice as likely to achieve an abstinent recovery as were individuals who participated in treatment alone. Similarly, among clients with drug use disorders, longer episodes of treatment and weekly or more frequent mutual-help group attendance during and after treatment were each independently associated with 6-month abstinence.
Participation in mutual-help groups may compensate for the lack of services provided in treatment. Among dually diagnosed participants in residential programs, the benefits of 12-step mutual-help group attendance depended on the intensity of treatment services. More 12-step mutual-help group attendance during treatment was associated with better alcohol and drug outcomes at discharge, only among individuals treated in low-service-intensity programs. More 12-step mutual-help group attendance after discharge from treatment was associated with better mental health and family/social functioning at 1 year, only among individuals receiving low-service-intensity care.
Interventions to Enhance 12-Step Group Participation
Due in part to the convincing evidence that mutual-help group attendance and involvement are related to better substance use disorder outcomes, evidence-based interventions to facilitate 12-step group participation are now available. Twelve-step facilitation therapy, used in Project MATCH and now offered in both individual and group approaches, focuses on the first three of the 12 steps. Its goals are to facilitate patients’ acceptance of having lost control over their substance use and the goal of abstinence, as well as patients’ hope for recovery, faith in a Higher Power, and acknowledgment of the 12-step fellowship as instrumental in recovery. Project MATCH found that patients in Twelve-Step Facilitation, compared to those in motivational enhancement or cognitive behavioral therapy, attended more meetings and had better outcomes.
Building on an earlier facilitation approach to connect 12-step volunteers with individuals with alcohol use disorders, Timko et al. found support for Intensive Referral, a brief facilitation intervention. Consisting of three sessions, Intensive Referral provides information about 12-step approaches, discusses patients’ views of them, and links patients with 12-step volunteers to attend meetings together. Treatment providers or peer specialists follow up to reinforce attendance and involvement, including obtaining a sponsor. Patients who were assigned to Intensive Referral rather than standard referral had more 12-step group participation and less substance use at a 1-year postintervention follow-up. Intensive Referral was adapted and empirically supported in a study of patients with co-occurring substance use and mental health disorders.
Making AA Easier (MAAEZ) is designed to familiarize individuals with the culture of 12-Step meetings and help them anticipate and deal with concerns that could deter participation. It is a manualized intervention consisting of six, 90-minute group sessions led by a counselor who is in recovery and has extensive personal experience with 12-step programs. Compared to patients in usual care only, patients in usual care plus MAAEZ were more likely to be abstinent at 1-year follow-up.
Finally, Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) was developed for individuals who use cocaine and amphetamines. It is composed of eight individual and group sessions that combine 12-step facilitation and intensive referral, in that they incorporate linkage with a 12-step volunteer and a focus on the first three of the 12 steps. During the 8-week intervention period, individuals who used stimulants receiving STAGE-12 as part of outpatient treatment were more likely to abstain from stimulants than were those who received usual care. The STAGE-12 group also reduced their drug use severity more at a 3-month follow-up. Among patients receiving STAGE-12, those with more exposure to the intervention were more likely to be abstinent.
Personal Factors, Participation, and Mutual-Help Group Outcomes
In an attempt to identify individuals who may be especially well-suited for participation in mutual-help groups, researchers have considered a range of personal factors, including severity and impairment related to substance use, and disease model beliefs and religious and spiritual orientation. In addition, studies have examined the suitability of mutual-help groups for individuals with substance use and psychiatric disorders, women, older adults, adolescents and emerging adults, and members of racial and ethnic minority groups.
Severity and Impairment
In general, individuals who use substances more heavily are more dependent on substances, have more substance-related problems, and lack control over substance use are more likely to affiliate with mutual-help groups. Clients with more impairment are more likely to continue mutual-help group attendance and less likely to drop out after treatment. Among individuals with alcohol use disorders, compared with type A individuals in 12-step treatment, type B individuals, who have more severe alcohol-related problems, were more likely to attend Alcoholics Anonymous in the 12 months after treatment. Moreover, the type A individuals were more than twice as likely to stop attending Alcoholics Anonymous after treatment.
Compared with individuals with less severe substance use problems, those with more severe problems may benefit more from mutual-help group involvement. Morgenstern and colleagues found that individuals with more severe substance use and psychosocial problems who had high levels of mutual-help group affiliation had better 6-month substance use outcomes; outcomes were poor when group affiliation was low. For individuals with less-severe problems, levels of mutual-help group affiliation were not related to outcomes.
In Project MATCH, among less impaired patients, adaptive social network changes and increases in social abstinence self-efficacy primarily explained the effect of Alcoholics Anonymous attendance on better alcohol outcomes. Among more impaired patients, in addition to these explanatory mediators, increased spirituality and reduced negative affect led to better outcomes of Alcoholics Anonymous attendance. For more severe patients, attending Alcoholics Anonymous reduces drinking by simultaneously reducing depression symptoms and increasing confidence in individuals’ ability to resist alcohol when experiencing negative affect.
Disease Model Beliefs and Religious and Spiritual Orientation
Individuals whose beliefs are more consonant with the 12-step orientation are more likely to affiliate with 12-step mutual-help groups. More specifically, people who believe in the disease model of substance use, have an abstinence goal, and see themselves as alcoholics or addicts tend to become more involved in mutual-help groups after discharge from acute treatment and are less likely to stop attending.
Many individuals see a positive role for an emphasis on spirituality in mutual-help groups and focus on spirituality as a source of: (1) personal strength and self-protection (e.g., help in maintaining abstinence, reducing craving, and facing mortality) and (b) altruism and protection of others (e.g., not sharing drug paraphernalia or engaging in unsafe sexual practices). Individuals with stronger religious beliefs are more likely to attend and become involved in 12-step mutual-help groups during and after treatment. In contrast, less religious individuals, including those who profess atheistic and agnostic beliefs, are less likely to attend and more likely to drop out of 12-step mutual-help groups. Nevertheless, when they do become involved in mutual-help groups, less religious individuals appear to obtain as much or more benefit from them as more religious individuals do.
More generally, individuals whose religious and spiritual beliefs better match those of their primary mutual-help group tend to participate more in that group. More religious individuals are more likely to participate in 12-step than in other types of mutual-help groups; in contrast, religiosity does not seem to be associated with participation in SMART Recovery but is associated with less participation in Secular Organizations for Sobriety. Matching an individual’s spiritual and religious beliefs to those of a mutual-help group may increase the individual’s participation in the group and perhaps indirectly increase the likelihood of continued sobriety.
Individuals who profess a stronger religious and spiritual orientation may be better able to accept their craving and, therefore, become more involved in 12-step mutual-help groups. Consistent with this view, clients who professed stronger spiritual and religious beliefs at intake to treatment improved more in acceptance-based responding between baseline and a 1-year follow-up. These individuals became more aware of and able to acknowledge internal experiences, such as cravings and distress, and were able to rely more on adaptive coping responses to confront and manage these experiences. In turn, enhanced acceptance-based responding at a 1-year follow-up predicted increased subsequent mutual-help group involvement. Thus together with treatment, spirituality and religiosity may promote self-regulation skills that contribute to 12-step mutual-help group affiliation.
Whereas Alcoholics Anonymous and Narcotics Anonymous are spiritual 12-step groups, many religious congregations are now offering 12-step groups that incorporate a defined concept of higher power. For example, Saddleback Church in Southern California developed the faith-based Celebrate Recovery program using the 12 steps and adding ‘‘8 Recovery Principles’’ based on the Bible to define a Christian interpretation of higher power. These groups appeal to people who desire a specialized definition of higher power during 12-step participation. Celebrate Recovery reports over 500,000 participants and 10,000 participating churches worldwide from various Christian denominations (see www.celebraterecovery.com ). A study of Celebrate Recovery participants found that spirituality was a significant component of their confidence to resist substance use.
Individuals With Substance Use and Psychiatric Disorders
A high proportion of individuals with substance use disorders have co-occurring psychiatric disorders. With the exception of clients with psychotic disorders, these dually diagnosed individuals are as likely to attend 12-step mutual-help groups as are those with only substance use disorders. In general, individuals with dual diagnoses appear to benefit from substance-use–focused 12-step mutual-help groups as much as do those with only substance use disorders.
A few studies have focused on participants with specific psychiatric disorders, especially posttraumatic stress disorder and major depression. Individuals with substance use disorders and posttraumatic stress disorder participated as much in 12-step mutual-help groups after treatment as did those with only substance use disorders. The dually diagnosed individuals who participated more in mutual-help groups were more likely to be abstinent and experienced less distress; they also were more likely to maintain stable remission over a 2-year follow-up.
The situation may be different for clients who have substance use disorders and co-occurring major depression. Compared with individuals with only substance use disorders, those who also had major depression were less likely to become involved in 12-step mutual-help groups after treatment. At a 2-year follow-up, the association between mutual-help group involvement and abstinence was stronger for clients who had only substance use disorders than for those who also had major depression. These participants did not benefit as much from contact with a sponsor, 12-step friends, reading 12-step literature, and working the steps. Depressed individuals may have interpersonal problems that make it harder to develop friendships and to acquire and relate to a sponsor; thus they may need more support and guidance to become involved in and benefit from 12-step mutual-help groups.
Traditional 12-step mutual-help groups may have some limitations for dually diagnosed individuals, who may be less able to bond with other members who do not share the experiences associated with psychiatric problems. Some group members may have ambivalent or negative attitudes about the use of medications to prevent relapse or alter mood. In addition, some dually diagnosed individuals may be alienated by 12-step philosophy, the emphasis on denial, and an apparent lack of empathy for individuals with psychiatric problems.
Given these issues, some dually diagnosed individuals may do better in dual-focused 12-step self-help groups, such as Double Trouble in Recovery. Double Trouble in Recovery is a 12-step fellowship adapted from the 12-step method of Alcoholics Anonymous; it is designed to meet the needs of individuals who have both substance use and psychiatric disorders. Double Trouble in Recovery specifically addresses the problems and benefits associated with psychiatric medications. It has amended steps 1 and 12 of the 12 steps to include mental health disorders so that, for example, step 1 is: “We admitted we were powerless over mental disorders and substance abuse—that our lives had become unmanageable” (see www.doubletroubleinrecovery.org ).
Individuals who experience more psychiatric symptoms and more severe consequences of drug use are more likely to maintain attendance in Double Trouble in Recovery. As found in a study of Dual Diagnosis Anonymous, also a peer-support program for people with co-occurring disorders, this may be because group members feel accepted by others in the group, learn about how each disorder affects the other, feel comfortable having open discussions, and experience a focus on hope and recovery for both their substance use and mental health disorders. With respect to outcomes, Double Trouble in Recovery members who engaged more in reciprocal learning and assuming a helping role were more likely to be abstinent at a 1-year follow-up. A 2-year follow-up showed that individuals who affiliated more strongly with Double Trouble in Recovery improved more in self-efficacy for recovery, leisure time activities, feelings of well-being, and social relationships.
In a subsequent study, a cohort of dually diagnosed individuals who did not have Double Trouble in Recovery available during treatment was compared with a cohort exposed to it after Double Trouble in Recovery meetings were instituted in the treatment program. Compared with the pre–Double Trouble in Recovery cohort, the post–Double Trouble in Recovery cohort had significantly fewer days of alcohol and drug use, more frequently attended traditional 12-step group meetings outside the program, and better adherence to their psychiatric medications at a 6-month follow-up.
In a randomized trial, Bogenschutz et al. found that dually diagnosed patients who received 12-step facilitation Therapy in addition to usual care in a dual diagnosis program participated more in 12-step groups than patients in usual care. More participation in 12-step groups was associated with better drinking outcomes. In another randomized trial, dually diagnosed patients assigned to Double Trouble in Recovery used alcohol and other substances less at a 6-month follow-up than did waitlist control patients. Twelve-step facilitation for dually diagnosed individuals is now a manualized treatment to help patients engage in Double Trouble in Recovery.
Women
Women with alcohol or drug use disorders are at least as likely as men to attend and affiliate with mutual-help groups. Compared with men, women may be more likely to read Alcoholics Anonymous literature, call an Alcoholics Anonymous member for help, and experience a spiritual awakening. In a study of individuals with alcohol use disorders, women were more likely than men to attend Alcoholics Anonymous and went to more Alcoholics Anonymous meetings in the first year after initiating help-seeking. More extended participation in Alcoholics Anonymous was associated with a higher likelihood of 1-year remission for both women and men; however, the positive association between a longer duration of Alcoholics Anonymous attendance and stable remission was stronger for women.
Compared with men, women may be more in tune with 12-step philosophy, which involves acceptance of powerlessness over the used substance and reliance on a higher power to attain sobriety. Mutual-help groups are nonhierarchical and nonauthoritarian and foster recovery in a relational, mutually enhancing, and safe context, which may especially appeal to women. In addition, compared with men, women may be more comfortable in mutual-help groups such as Alcoholics Anonymous because they are more interdependent with other people, more likely to gain self-esteem from developing and maintaining close relationships, and more at ease with emotional self-disclosure.
Even though many women attend and benefit from Alcoholics Anonymous or Narcotics Anonymous, the emphasis in these groups on powerlessness, humility, and surrender alienates some women, who express discomfort with face-to-face self-disclosure in group meetings populated mostly by men. Alcoholics Anonymous may be especially problematic for women who drink for reasons associated with sexuality and gender roles. Many women report feeling that they do not fit in at Alcoholics Anonymous, and that they find it to be too negative, dislike the primary focus on the past, and feel that interchanges in Alcoholics Anonymous are dominated primarily by men.
These issues led to the development of Women for Sobriety, which provides an alternative for women who prefer an emphasis on improving self-esteem, independence, and personal responsibility rather than powerlessness, humility, and surrender. Women for Sobriety shares Alcoholics Anonymous’ focus on meditation and spirituality but espouses the idea that sobriety is dependent on taking personal responsibility for one’s behavior rather than on a higher power. Women for Sobriety seems to be especially attractive to well-educated, middle-aged, and middle- and upper-class women, many of whom, nevertheless, continue to attend Alcoholics Anonymous (see www.womenforsobriety.org ).
In contrast to Alcoholics Anonymous, Women for Sobriety is based on the idea that women need a positive program that reinforces optimistic thinking about their abilities and independence, reduces their guilt, and enhances their coping skills. Many women report that they attend Women for Sobriety for support and nurturance, a safe environment, sharing about women’s issues, and the positive emphasis on self-esteem. In this respect, there is an association between longer membership in Women for Sobriety and higher self-esteem.
Adolescents and Emerging Adults
Only 12% and 13% of Alcoholics Anonymous and Narcotics Anonymous members, respectively, are younger than age 30, and only about 1% in both groups are younger than age 21 ( www.aa.org ; www.na.org ). In addition, many youth may stop attending, possibly because they have difficulty accepting lifelong abstinence, relating to adults’ concerns (e.g., jobs, marriage, children), and accessing meetings (lack of transportation). Even so, youth and emerging adults who attend more 12-step groups have better substance use outcomes.
One study using data from the Drug Abuse Treatment Outcomes Studies for Adolescents (DATOS-A) found that, among adolescents with both drug and mental health disorders, participation in 12-step groups was positively associated with posttreatment abstinence. In another study, dually diagnosed adolescents participated in 12-step groups at comparable or higher levels than adolescents with only substance use disorders, over 7 years. For both groups, participation was associated with abstinence at follow-ups.
Older Adults
Late middle-aged and older adults participate in and benefit from 12-step mutual-help groups. In two studies, older clients (55+ years of age) with substance use disorders were matched with younger (aged 21–39) and middle-aged (aged 40–55) clients on the basis of race, education, marital status, and dual diagnosis status. These three groups of participants attended a comparable number of mutual-help group meetings during residential treatment and were equally likely to attend mutual-help groups in the first 2 years after treatment and to have a sponsor. Overall, individuals who attended more group meetings and those who obtained a sponsor in the first year experienced better 1-year alcohol and psychological distress outcomes. Participants who attended more meetings and had a sponsor in the second year reported less alcohol consumption at a 5-year follow-up. The three age groups did not differ in the associations between 12-step mutual-help group attendance and these outcomes.
In a similar study of clients in community residential care, the three age-matched groups showed comparable mutual-help group attendance during treatment and in the year after entering treatment. A comparable percentage had a sponsor. Overall, clients who attended more mutual-help group meetings and those who had a sponsor a year after entering treatment had better alcohol-related and psychological distress outcomes at 1-year and 4-year follow-ups. Again, the three age groups did not differ in the associations between 12-step mutual-help group involvement and these outcomes.
Race and Ethnicity
Compared with Caucasian clients, African American clients may be more likely to attend mutual-help groups as part of treatment and to increase their affiliation during treatment; in addition, they appear to be less likely to stop attending mutual-help groups after treatment. Certain characteristics of 12-step mutual-help groups may especially appeal to African American clients, including the fact that meetings are widely available and open to anyone, and have a strong social and spiritual component. African American clients seem to be more likely to identify as Alcoholics Anonymous members, experience a spiritual awakening in Alcoholics Anonymous, and perform service at Alcoholics Anonymous meetings. In contrast, Caucasian clients are more likely to read 12-step literature and have a sponsor.
In order to meet their unique recovery needs, African Americans appear to integrate cultural factors and a unique language and perspective in the process of affiliation with Alcoholics Anonymous. According to Durant, African Americans are more likely to associate their problems with racism and economic disadvantage than with unhealthy alcohol use; they are less likely to accept the disease concept of alcoholism. Nevertheless, they are able to contrast the negative aspects of drinking with the positive aspects of abstinence, to respond to modeling and support from mentors and sponsors, to modify the moral aspects of Alcoholics Anonymous to meet their spiritual needs, and to adapt the Alcoholics Anonymous worldview to better fit their racial and cultural background.
Compared with non-Hispanic white individuals, Hispanic individuals may be less likely to attend Alcoholics Anonymous after treatment, perhaps because they tend to turn to their existing support system. However, attendance at Alcoholics Anonymous appears to be similarly associated with decreased alcohol consumption among both Hispanics and non-Hispanic whites.
In Project MATCH, Hispanic individuals attended Alcoholics Anonymous less often after 12-step treatment than non-Hispanic white participants did. Nevertheless, as judged by self-identification as an Alcoholics Anonymous member, having an Alcoholics Anonymous sponsor, experiencing a spiritual awakening, and celebrating an Alcoholics Anonymous birthday, they were as committed to Alcoholics Anonymous as were non-Hispanic whites. Thus Hispanics’ lower Alcoholics Anonymous attendance does not necessarily mean that they are less favorably inclined toward Alcoholics Anonymous. However, Hispanic clients who were more involved in specific Alcoholics Anonymous practices were not more likely to achieve abstinence.
A comparison of urban Native American and non-Hispanic white attendees of Alcoholics Anonymous found that meeting attendance trajectories over a 9-month follow-up did not differ between the groups. American Indian participants discontinued attendance less often. For both groups, more attendance predicted abstinence.
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