What’s essential for recovery to happen?

March 27, 2021
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I would tell them straight, recovery does not happen in isolation 

Recovery group member

We know mutual aid works to help people with substance use disorders achieve their goals. The recent Cochrane Review[1], which analysed the evidence for Alcoholics Anonymous reported pretty impressive results. John F Kelly, Keith Humphreys and Marica Ferri “determined that AA was nearly always found to be more effective than psychotherapy in achieving abstinence. In addition, most studies showed that AA participation lowered health care costs.’[2]

Although the focus of the research has been more on AA than other types of mutual aid, Humphreys said that their review was ‘certainly suggestive that these methods work for people who use heroin or cocaine’. In fact, these days, in my practice, it’s much more common to see people with problematic poly-drug use, so it would help to know more about the range of supports available.

So, we know that mutual aid works to help people achieve their goals, but how much do we know about how it works? In his 2008 review[3], Rudolph Moos identified ten key ‘ingredients’ at the heart of the process in 12-step groups.

  1. Bonding
  2. Direction
  3. Structure
  4. Observation and imitation of norms and role-models
  5. Expectation of positive and negative consequences
  6. Involvement in protective activities
  7. Effective rewards
  8. Identification of high risk situations and stressors
  9. Building self efficacy/confidence
  10. Developing coping skills

 So, it looks as if we know quite a bit about how it works too, but we are still learning new things. 

Some of this new learning was captured in a recently published study[4] from the UK. Hannah Rettie, Lee Hogan and Miles Cox wanted to know if such processes might also apply in non-12-step groups and whether there might be anything else relevant that wasn’t on the above list. They had the sensible notion to ask the people who had experience of such groups how important they felt these components were.  

Using social media, flyers and active recruitments through the groups, they attracted 151 participants from 30 groups, including but not limited to, 12-step, SMART Recovery and non-structured lived experience community groups. Participants had to be alcohol or drug free, with a previous history of dependence and regular attendees. On average the subjects had been members for more than two years and had a mean age of just over 42 years. Thirty percent had previously had an alcohol problem, 20% a drugs problem and the rest had used both alcohol and drugs problematically.

They asked the participants to think about their group and to score how important each ingredient on the list was to them and how much that component was represented in the group they were a member of. They were also asked a couple of open questions. The researchers divided one of the ingredients (no. 4) into two – ‘presence of role models’ and ‘following a sober lifestyle’ and added another ingredient ‘giving back to others’.

They teased out five pertinent themes from the open-ended questions:

  1. Perspective taking: e.g., getting a new angle on a problem through discussion with others
  2. Being connected to others: e.g., strong bonds, reciprocal support, not doing it alone
  3. Developing skills: e.g., coping skills, confidence, useful outside of the group too
  4. The value of group activities: e.g., replacing using and drinking time, hobbies and areas of interest
  5. A change in the self: e.g., from rock bottom to recovery, gaining hope, new lease of life

These themes were apparent in both 12-step and non-12-step groups. 

Testing out the list of key components of recovery success, the researchers found that across the variety of groups, every ingredient was both offered by the group and rated highly by the group members. Interestingly ‘gaining rewards’ was not rated as highly as other factors. The type of group, length of time of membership and time in recovery did not influence the ratings. 

The team updated the original table of important components of recovery groups to look like this:

  1. Bonding and support
  2. Goal direction
  3. Structure to follow
  4. Following a sober lifestyle
  5. Available role models
  6. Expectations of positive and negative consequences
  7. Involvement in protective activities
  8. Effective rewards
  9. Identifying high-risk situations
  10. Building self-confidence
  11. Developing coping skills
  12. Giving back
  13. Presence of like-minded individuals
  14. Developing self-awareness and reflection skills

Encouragingly, these findings suggest universal experiences in mutual aid and lived experience recovery organisations, though not whether these experiences translate into longer term quality of life and sobriety outcomes relating to type of support. It’s important to note that the authors acknowledge potential bias due to recruitment methods, so this might not in fact be applicable to all recovery groups, though it rings true. I did wonder if there was crossover in the sample, given that it’s possible to be a member of a 12-step group, a SMART Recovery group and an activity-focussed recovery group at the same time.

I like this research. I like the respect the researchers have for those with lived-experience (‘true experts’) – something that’s not universal. Mutual and and wider lived experience recovery organisation research is pretty rare in the UK. This really helps add to our understanding of what the important features in recovery groups are. It adds to our previous understanding. It also gives support to the ‘many pathways to recovery’ perspective.

Connection is at the heart of the recovery process. In my experience, many recovering people are members of more than one lived experience recovery organisation, including mutual aid. I believe that every extra recovery connection is likely to advance and support an individual’s recovery and help them flourish, and that we should be promoting and actively connecting service users to a diverse range of groups.

The researchers’ bottom line:

The current study provided support for Moos’ original components, and identified that these components are universal across a diverse range of recovery groups, and stable across time. The findings offer an in-depth, person-focused perspective into what makes recovery groups successful, utilising the voices of the true experts of addiction recovery groups.

Rettie, Hogan & Cox, 2021

Continue the discussion on Twitter: @DocDavidM

[1] Kelly  JF, Humphreys  K, Ferri  M. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database of Systematic Reviews 2020, Issue 3. 

[2] https://med.stanford.edu/news/all-news/2020/03/alcoholics-anonymous-most-effective-path-to-alcohol-abstinence.html

[3] Moos RH. Active ingredients of substance use-focused self-help groups. Addiction. 2008 Mar;103(3):387-96. 

[4] Hannah. C. Rettie, Lee. M. Hogan & W. Miles. Cox (2021): Identifying the Main Components of Substance-Related Addiction Recovery Groups, Substance Use & Misuse 

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