Clay Hightower, LMSW
“It works if you work it.”
These are words that many have either heard for themselves at a 12-step meeting or have had someone else tell them about the 12-step program. However, I know that I have met countless individuals in my work that have stated that it did not work for them for one reason or another. I have had these conversations with individuals who have both moved on to other options after singular experiences and have really “worked the program” for periods of time with success. As a result, I do not think it would be fair to lump all of these individuals into some of the frequent explanations about not finding the right sponsor or home group, nor do I think that it is fair to say that these individuals had not hit “rock bottom” yet. The spiritual component of the program is one frequently cited reason, particularly in the US South where it can sometimes take the form of Christian-based beliefs. The frequency of suggested meetings and focus on sustained abstinence are other frequently cited reasons. At the same time, I have also met individuals who are heavily involved with the 12-step program, who plan to continue going to meetings as long as they continue to feel the benefit, and those who used it as a part, but not all, of their plan for sobriety. Some of these individuals credit the 12-step program, and the relationships created within it, with saving their lives. When I remember these stories, it only seems natural that they would be strongly encouraging those who are also struggling to do the same. So, how can one tell if it will work for them or not?
As a therapist who is not in recovery, conversations with individuals about the experience of the 12-step program, and all other mutual help organizations, can be difficult. I was asked to attend 12-step meetings as a part of my education for becoming a therapist, which I considered intrusive even then, and I have since become a certified SMART Recovery facilitator. While this has given me more understanding of what it feels like to participate in a self-help meeting, I have not gone through the experience of trying to find the right program, the right home group, or the right approach to recovery. I cannot always give recommendations beyond “try it and see if it works for you.” This is not always the most encouraging statement to hear, even if it is the correct recommendation. Sometimes, in the absence of personal experience, I can lean on research to help support my recommendations for clients. I can share statistics and models to help them understand what to expect and to normalize the experience. In an effort to stay up to date with the latest research in the field, I recently poured through a handful of studies that sought to measure the efficacy of as many mutual help organizations as I could find, not just the 12-step program. These studies ranged from smaller sample-sized cohorts asked to complete self-reported surveys all the way up to peer reviewed articles with high sample size, which are supposed to provide some of the highest quality information. While these studies provide helpful information, they can be difficult to sift through to find meaningful and practical application.
As I read through each of the articles, I began to notice similarities in the ways that researchers tried to prove or disprove efficacy, and some of the similarities seemed to mirror the conversations that I had with individuals mentioned above. It became apparent that I would not be able to find a study that I felt confident in sharing with individuals in either direction, but I still want to share the findings. Some of the findings did show meaningful results, and I believe that they can help provide a roadmap to making the decision for anyone who may be trying to find their fit within a mutual help organization. First, I want to address issues that I found in these articles to help present a fuller picture around the data, and then I want to speak directly to some of the numbers and how I see them being applicable on a personal basis. My intent is to be respectful and inclusive of all mutual help organizations, as I believe each is valuable, while trying to understand why it can be so difficult to measure their efficacy.
Check back next week for my deeper dive into the results of these articles and why I believe it can make the decision even more difficult at times!
Part 2
The most notable aspect of these studies, which is present with nearly all voluntary sociological and psychological research, is validity surrounding sample size and sampling. While I will address this more from an application standpoint later, it is important to lead with this information. Since (almost) all mutual help organizations are primarily voluntary, and all are anonymous, very few studies will be able to randomly sample. Frequently, researchers will reach out to the local meeting chapters and obtain permission to post flyers in the meeting space or post links to the study on social media, meaning that individuals have to volunteer to participate in research within a voluntary organization. If one is pulling information from a handful of local home groups, for example, the sample is likely to skew towards those who have regularly attended the meetings for some time and have found it beneficial. It is expected that one would end up randomly sampling some newcomers as well, but it is not possible to gather information on individuals who are not present, like those who did not find the meetings that helpful or did not align with the ideology. While this does not mean that one has to throw this information out entirely, it is simply a reminder to always look at how individuals are chosen for sample and where the sample came from. It can also be helpful to read some of the introduction and abstract to see if the researchers are coming in with a hypothesis in favor of one particular organization. I noticed that these two factors helped create a positive skew for all of the mutual help organizations, not just the 12-step program, that does not align seem to align with more accepted overall success rates for addiction recovery.
While random sampling and sample sizing will likely always be the biggest barrier to evaluating mutual help organizations, I believe that the following issue has the potential to skew much of the research done on mutual help organizations moving forward. Many of the articles that I read focused on the 12-step programs and their related work, which makes sense as it is the most prevalent organization. However, once I began reading the articles, I noticed that some were using the abbreviation “TSF” when trying to talk about those organizations. “TSF” stands for “twelve-step facilitated,” and it is distinctly different than an actual 12-step meeting. TSF treatment or therapy is a methodology used in many 12-step based treatment programs. It was designed to follow the beginning steps of the program, develop motivation for sustained abstinence, and help clients make the transition to consistent 12-step involvement.
The importance of the distinction between AA and TSF was most notable when comparing two particular articles. Humphrey & Kelly’s findings, which appear to be the most thorough, would suggest that both AA AND TSF produce higher outcomes than other mutual help organizations. However, in their article, Carroll & Sholomskas very intentionally state that AA and TSF are different methodologies. The cohort of therapists in their study, who had an average of 11 years of clinical experience working with substance abuse, failed to meet the benchmarks for training certification and competent practice for the TSF manual in a pre-training test. It is important to note that more than a third of these clinicians had also received prior treatment for their own substance use, so they could reasonably be expected to understand and discuss the 12-step program principles. While the entire cohort showed significant improvement in their benchmark scores and comfortability with the manualized approach, it does raise an important question: Do these clinicians really lack an effective understanding of the 12-step program, or is there a significant difference between the experience of attendance and involvement in 12-step meetings and the experience of attendance and involvement in TSF treatment? And if there is a significant difference, how much confidence can one put in results that effectively treats them as a singular approach when it comes to making choices about their own recovery?
While it did use results from studies that combined 12-step meetings and TSF in its measurements, I still believe that there is some interesting information in Humphrey & Kelly’s article worth exploring. As I previously discussed with random sampling and positive skew, the outcomes show that 12-step meetings and TSF produced better outcomes for sustained abstinence at their initial measurement and each of their follow up intervals in comparison to a standard clinical intervention like Cognitive Behavioral Therapy. As many know, the primary goal of the 12-step program is sustained abstinence from certain substances and behaviors. Depending on the particular 12-step meeting that one is attending, the group may be more or less strict about who gets to share and how much one is allowed to share based on their experience and recovery. My understanding is that this can vary widely between meetings, but it is a common piece of information that I have received from clients.
The interesting bit of data comes from measurements of drinking behavior other than abstinence vs non-abstinence. They used three other key measurements: Longest Period of Abstinence (LPA), Percentage Days Abstinent (PDA), and Drinks per Drinking Day (DDD). When compared to Cognitive Behavioral Therapy, it produces outcomes statistically equivalent in each of these measurements. While this might seem like a natural byproduct of striving for sustained abstinence, it sticks out to me because some parts of the 12-step community may not consider those improvements a “success.” I do feel confident that if I asked most individuals in any 12-step meeting whether these improvements were a positive sign, the answer would be yes. However, the idea of “successful moderation” being a goal would conflict with the larger ideology of the program. Also, as I have previously covered, they would only be able to sample individuals who were continuing to attend 12-step meetings during the recovery process and would not account for individuals who may have shown similar results in reducing drinking behavior but did not continue attending meetings to strive for sustained abstinence for whatever reason.
This leads me to wonder whether particular 12-step meetings that are more inclusive of those early in the process of getting sober, both in terms of participation and acceptance to the fellowship, cast a wider net and allow for more opportunities at success. The natural argument, which I have heard before, is that accepting a wider range of outcomes as “successful” could diminish the success of those who are striving for complete abstinent and send a message of permission to newcomers. It seems unlikely that it is possible to answer this question in such a direct manner, as it would either require the creation of a new mutual help organization that follows this ideology or the willingness of current mutual help organizations to change their ideology on a scale larger than individual meetings. Both of those ideas seem unlikely to gain traction for a number of reasons, so it seems more feasible to focus on other metrics produced by the research while still keeping these ideas in mind. In my next post, I will highlight these other metrics, which I believe has more practical application when it comes to an individual determining their preferred mutual help organization. Check back in next week!
Part 3
While much of the focus to this point has been on better understanding what the data in these research articles cannot accurately show about different recovery programs, there is one article that specifically focused on measuring other aspects of the organizations. I believe that these aspects may more useful to understanding the options on a more personal level, and they also seem more connected to concepts that I have seen used before in other modalities. As I discussed in my previous post, when the articles looked at success rates in terms of drinking behaviors across all of the mutual help organizations, the various approaches seem roughly statistically equivalent. I also highlighted how particular mutual help organizations may view the results of those measurements of drinking behavior differently in terms of “successfulness.” The perspective thus far has been viewing the success of individuals in these programs from the outside. While this is, of course, the more objective way to measure effectiveness, it can undercut the important aspect of one’s own choice over their recovery program.
Zemore chose not to measure drinking behavior at all and focused more on demographic differences between organizations and how members viewed their personal relationship with their organization of choice. Not only does this approach provide a different data set for us to examine, but one can also begin to draw connections between the findings and motivation-based theories. I believe that this more closely aligns with the idea that mutual help organizations are built on a principle of “attraction, not promotion.” They attempted to measure this concept of attraction through subjective questions around group participation, cohesion, and satisfaction, believing that this data set would help provide a fuller understanding for making recommendations to mutual help organizations. While some of the authors’ initial hypotheses about different mutual help organizations attracting different demographic groups were true, their findings narrowed it down to three distinct identifiers that were most predictive for the engagement metrics: religious self-identification, age, and stringency of one’s recovery goal. While this may seem obvious to some, as two of the three have already been discussed in earlier posts, it left the authors with a “chicken or egg” kind of question about how this predictive relationship came to be.
As I alluded to earlier, I attribute the predictive relationship to motivation-based principles. My experience working in addiction recovery has helped me to better understand the difference between compliance and success. Conventional thinking, usually rooted in a moralistic view of addiction, would think that as the consequences increased, the desire and effort for sobriety would also increase. While I do generally agree with this line of thinking, desire and effort do not always directly translate to results. Typically, the result seems to be that the individual feels internal and external pressure to figure out a plan and stick to it. It is a dynamic that I frequently see complicate the recovery process on both sides as consequences and pressure continue to mount. I have had clients ask me exactly what to do in order to get and stay sober, and they are not satisfied by the answer because there is no concrete singular program to work or list of things to do. Even as each of the research article headlines portrays some distinction between mutual help organizations, the data and content of the articles would seem to agree with the variability in success.
Motivation-based theories can begin to provide direction for programs to work and things to do. Current behavioral motivation theories have identified three different motivating factors when it comes to self-regulation: intrinsic, extrinsic, and introjected. I am sure that most are more familiar with the concept of intrinsic self-regulation that my behavior is tied to and rewarded by meanings and values that I attach to the end goal of the behavior. For example, I value my physical health and capabilities. When I first began exercising regularly, that was the primary motivating factor, and I made my decisions around what exercise I thought would produce those results best. My choice was running, and as I continued to do it more, the results that I wanted strengthened my motivation to run more. With enough time, the motivation shifted from the goal to the behavior. This is the foundation of any personal goal, hobby, or interest.
Extrinsic motivation, as one may imagine, has the opposite function. Extrinsic motivation is the creation of a behavior in response to someone else’s emotions or desires. The presence of the individual, and the emotion, is the stimulus for the behavior. These behaviors are less resilient because there is sometimes no internal positive reward associated with it, just the desire to change the other person’s emotions. Resentment can arise from these kinds of interactions in relationships, and the behavior is likely to end once the dynamic changes. Introjected regulation lies somewhere in the middle, and I believe it can be a common part of the recovery process.
Introjected regulation means that one does have an internal response and reinforcement to the behavior, but it is not a positive one. The avoidance of guilt and shame is the primary reinforcement of the behavior. While this can still have the effect of intrinsic motivation sometimes, it is less consistent. Since internal guilt and shame is already a common experience in addiction and recovery, the introduction of external consequences can heighten the experience. I believe that this can create a shift to the behavior being extrinsically focused and more about the compliance component that I mentioned previously. It leads me to wonder to what extent presenting certain mutual help organizations as “more effective” and using a specific mutual help organization involvement as a legal or interpersonal consequence can have on one’s decision and motivation.
I do want to be clear here that none of this means that I believe that consequences and boundaries have a negative effect on the recovery process. In fact, I believe that the opposite is true. Consequences and boundaries help to reinforce regulation. However, I do believe that it is important to be clear about which behavior elicits the consequence and what the end goal of the consequence is. Making it about attending any particular organization or recovery program in favor of the other likely changes the way that the motivation and engagement process works, with the result being that the engagement will be conditional on the consequence or external emotional still being present.
It is safe to say that this exploration of research did not end how I thought it would, but it did not seem sufficient to say “they are all essentially the same, go figure it out.” That undermines the intensity and immediacy that some individuals feel figuring out what will help them recover, as well as the intensity of the emotions that can come during the most difficult portions of the recovery process. It also does not fully capture the friction that can result between intrinsic goals for recovery and extrinsic accountability for the behaviors that occur in active addiction. I understand this may not provide a much clearer path for making the choice, but my hope is that it will help provide a different perspective to those currently trying to find a recovery program or trying to understand what they could gain from them in pursuit of their own recovery goals.
