Skipping Steps But Meeting Goals
Despite the demonstrated benefits of 12-step participation during recovery, the 12-step approach may not be a good fit for everyone. This study compares the effectiveness of secular mutual help organizations to 12-step groups.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
The efficacy of 12-step groups has been amply demonstrated, and they are the most commonly sought recovery support including both professional and non-professional services. Nevertheless, a large proportion of those with alcohol use disorder never attend 12-step mutual-help, or do not maintain involvement with such groups long enough for participation to be beneficial. This might be due in part to a poor match between the individual and the 12-step program philosophy, which emphasizes, complete abstinence, and spiritual and emotional growth, and may be perceived to have a religious slant by some.
Secular mutual help organizations have not been as well studied but could be a viable alternative for individuals interested in community-based recovery engagement and are not interested in 12-step groups. A head-to-head comparison of different mutual help organizations with different philosophical approaches might help determine whether different approaches are equivalent in effectiveness.
HOW WAS THIS STUDY CONDUCTED?
This is a naturalistic longitudinal comparative study over 12 months (the Peer Alternatives in Addiction or PAL study) that compared abstinence and alcohol and drug use outcomes in members of different mutual help organizations.
- READ MORE ON STUDY METHODS
Outcomes for members of 12-step groups were compared previously to members of secular groups such as Women for Sobriety (WFS), LifeRing and SMART Recovery. This was a survey-based study of a total of 647 adults with a lifetime alcohol use disorder, with surveys administered at baseline (in 2015), 6 month and 12 month follow-up.
The initial cohort of respondents completing the baseline surveys was 1064 cases, which was ‘scrubbed’ to eliminate suspicious and inconsistent cases, leaving 647 participants included in the study. The participants at enrollment had attended in person one of the groups studied (12-step, WFS, LifeRing or SMART) within the prior 30 days. Of note, the participants included a range of recovery times as the study was not limited to those in early recovery. Surveys measured mutual help participation, substance use, psychiatric and clinical variables, current alcohol recovery goal and demographics. The response rate at six months was 81% and at 12 months was 83%, with those lost to follow-up more likely to have lower lifetime alcohol use disorder symptom counts.
WHAT DID THIS STUDY FIND?
An alcohol goal of lifetime total abstinence and higher group involvement at baseline were both strongly associated with better outcomes: Of note, 12-step participants reported the highest levels of having lifetime total abstinence goal, and the authors’ baseline study shows that the 12-step members show higher rates of in-person attendance than the other 3 groups studied. Thus 12-step participants would be favored to show the highest success rates. However, the difference across the four types of support groups was non-significant for LifeRing (as compared with 12-step) or small (for Women For Sobriety and SMART). Participants with a lifetime total abstinence goal had 5.2 times the odds of obtaining alcohol abstinence and 3.7 times the odds for obtaining total abstinence at the 12-month time point.
All four groups showed high success rates: (> 75% reported no problematic drinking and >55% reported total abstinence at 12 months regardless of primary group affiliation). That being said, the abstinence rates for SMART Recovery was statistically lower at the six month time point, and lower for both SMART and Women For Sobriety at the 12-month time point as compared with 12-step participants. However, when analyzed by primary group involvement at the six-month time point, the results tentatively suggest equivalent efficacy for Women For Sobriety, LifeRing and SMART when compared to 12-step groups.
Alcohol recovery goals varied across the groups: Lifetime abstinence for all substances of misuse was the reported goal for 72% of the 12-step members, 67% of the Women For Sobriety members, 58% of LifeRing members, and only 40% for SMART Recovery members. When the model used in this study was adjusted for baseline alcohol recovery goal, the baseline group affiliation effects on outcomes became non-significant.
Other predictors of better substance use outcomes: older age, married status, fewer alcohol use disorder symptoms over the past 12 months, fewer past-12 month drug problems, fewer psychiatric symptoms/severity, and no substance use disorder treatments in the past 12 months.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
There is much research support for participation in 12-step groups as a part of recovery. However, the benefits of 12-step participation may apply also to other mutual help groups, including the secular groups analyzed here. Having an abstinence goal and strong group involvement, regardless of the group type, are the strongest predictors of sobriety. Having a broader range of groups shown to be effective in recovery will likely allow better matching between participant and group, thus increasing group involvement, a key mediator of the efficacy of mutual help group participation.
- It is unclear if the sample studied here is a representative sample given that participant selection was biased towards very involved group members across groups. For example, an 83% retention rate at 12-months for a survey-only study seems quite high further suggesting that the participants are more engaged in sobriety and in these mutual-help organizations than perhaps the average group participant. We do not know from this study how well each organization is able to engage and retain new members staring a new recovery attempt.
- The baseline data for the 3 outcome measures (six month alcohol abstinence, absence of alcohol problems and six month total abstinence) was not listed by primary group affiliation. Looking at the demographics shown in their earlier publication of the PAL baseline study it suggests that AA and LifeRing members start off with a 30% higher 12-month alcohol and drug abstinence rate than WFS and SMART members, thus representing an additional cofounder. However, taking that into account might also further decrease the differences in outcomes between the different group participants.
- The entry criteria is a lifetime alcohol use disorder, not a primary alcohol use disorder, thus confounding the results. For example, the 12-step group pooled members of Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, Marijuana Anonymous and Methadone Anonymous.
- The interventions being compared are very different sized organizations. Nationwide, there are about 62 peer-led WFS meetings, 163 LifeRing meetings, 874 SMART Recovery meetings as compared with 106,202 AA meetings and xxx,xxx NA meetings worldwide. The 12-step members were recruited from an online forum whereas the members of the other mutual help organizations were recruited in collaboration with the Executive Directors of those organizations. This difference in recruitment may underlie a difference in strength of affiliation with the group as the members of the three secular groups were essentially recruited vs the 12-step members who were offered enrollment online.
- The statistical power of this study (4 groups, 2 time points, 2 primary and 1 secondary outcome) was limited which may have contributed to the finding that only 1 of 15 interactions studied was significant at the p<0.05 level. The number of participants per group also varied (208 12-step, 177 Women For Sobriety, 99 LifeRing and 167 SMART recovery).
- For individuals & families seeking recovery: Participating in a mutual help group over time is an important dimension to sustained recovery for many. Although research has been focused on the 12-step groups (in part due to their status as the first and for many years only mutual-help organizations available), it seems that other mutual help groups could offer similar recovery, at least for established members. Those pursuing sobriety or controlled use should explore different mutual help groups with different approaches to identify the group that is most appealing and most likely to sustain participation over time. Also, setting a target of abstinence (vs controlled use) is more likely to lead to successful outcomes.
- For scientists: Given that four different types of meetings with different philosophies and different meeting structures seem to show similar benefits in terms of recovery benefits for established members, further studies comparing across groups will allow a more in-depth and detailed analysis of which components of meeting structures are most strongly associated with good outcomes. More longitudinal studies of mutual help group involvement are needed, especially following participants from first entry into the group to determine dropout and engagement rates and derived benefits.
- For policy makers: To increase the availability of secular mutual help organizations will require the support of secular organizations in terms of making space available and accessible throughout the day and night. A focus on increasing accessibility to public spaces outside of standard work hours will foster the expansion of secular mutual help organizations, which will in turn offer those seeking recovery a broader array of options to enhance their recovery. SMART Recovery is now broadening its reach by having an active online community and online meetings, another important way to increase access to this treatment modality.
- For treatment professionals and treatment systems: Substance use treatment providers have made great strides in including 12-step participation as part of the recovery program recommended for patients. The language used and resources provided should be further expanded on a routine basis to include the broader array of mutual help organizations available within that geographical area. Discussions about the different approaches used by these different groups should begin while the patient is in active treatment to help them identify the mutual help organization that aligns most closely with their outlook and thus increase the chances of their long-term involvement in these groups.
Zemore, S. E., Lui, C., Mericle, A., Hemberg, J., & Kaskutas, L. A. (2018). A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD. Journal of substance abuse treatment, 88, 18-26.