The principle of equifinality, which states that the same developmental endpoint can be achieved by many different means, applies well to addiction recovery. A single pathway model of recovery from alcohol use disorder (AUDs)--hit bottom, treatment, lifelong affiliation with Alcoholics Anonymous (AA), and sustained abstinence--has given way to multiple pathway models. We now know from cumulative scientific studies that: 1) people with an AUD do not have to perceive "hitting bottom" to initiate recovery, 2) people with an AUD may initiate and sustain recovery without specialized addiction treatment, 3) some people with an AUD, particularly those with lower problem severity, complexity, and chronicity, may achieve remission through deceleration of alcohol use rather than through abstinence, and 4) individuals with an AUD may initiate and sustain recovery with or without involvement in the growing network of secular, spiritual, and religious recovery mutual aid meetings.
As a follow-up to the last blog exploring acultural styles of addiction recovery (recovery without involvement with others in recovery), this short communication describes people who initiate recovery within a recovery mutual aid organization but later sustain recovery without active involvement in mutual aid meetings. While such eventual disengagement is expected and even encouraged in some recovery mutual aid organizations (e.g., Women for Sobriety, SMART Recovery), the general expectation within 12-Step fellowships is that of lifelong participation--an expectation reinforced by people returning to AA stating that the beginning of their return to drinking was the point at which they stopped attending meetings. There are, however, anecdotal reports and research studies suggesting that AUD recurrence is not the inevitable trajectory for all those who cease AA meeting attendance.
On July 24, 1969, AA co-founder Bill Wilson, in testimony before a U.S. congressional committee, reported the following: "Our last census, that is to say, reports of our group sessions, shows that we have 15,000 AA groups throughout the world and an active membership of 285,000. Besides the 285,000 there are hundreds of thousands - maybe 200,000, for all we know, 300,000 recovered AA's on the sidelines who do not get caught up in the active statistics, people who have remained for the greater part sober, who are carrying AA attitudes and practices and philosophies into the community life." Wilson's comments raise the question of the prevalence of AA members who use active AA involvement as an aid to recovery initiation and then disengage from AA meetings while sustaining long-term recovery.
In 1989 and 1993, Robin Room led studies of help-seeking for alcohol problems among the general population of the United States. Alcoholics Anonymous was the most frequently cited resource accessed for alcohol problems in the 1989 study, with 2.0% of those surveyed reporting lifetime contact with AA and 0.8% reporting current AA contact. In the 1993, study 5.0% of survey respondents reported lifetime help-seeking within AA, and 2.4% reported past year AA involvement. What is unclear in these early population studies and in most subsequent studies of AA is whether initial AA meeting attendance has a positive, neutral, or negative affect on long-term drinking outcomes among those who report lifetime contact but no current contact with AA. In contrast to dire warnings of the fate of those who disengage from AA, is there a population of people who achieve continued recovery stability and quality of life following AA disengagement? While dozens of studies have focused on the linkage between stable post-treatment abstinence and AA involvement, only a few studies have addressed the potential of an AA-disengaged style of recovery maintenance following recovery initiation in AA.
In 2003, Dr. Heath Hoffman published a study in Contemporary Drug Problems on recovery careers in AA. He describes various "Insider" roles in AA (AA Regulars, AA Rank and File members, Bleeding Deacons, Elder Statesmen, and Circuit Speakers) and those that follow an alternative "outsider" AA career (the Tourist, the Relapse Career, and the Graduate Career). Hoffman described the Graduate as someone who achieves abstinence in AA and then leaves AA and continues abstinence (or successfully achieves a sustained moderated drinking pattern) without continued participation in AA meetings. No data on the prevalence or long-term sustainability of the Graduate role were provided in the Hoffman study.
In 2005, Dr. Lee Ann Kaskutas led a study published in Alcoholism: Clinical and Experimental Research on patterns of AA involvement following alcoholism treatment. Her team found that patterns of AA attendance changed in four potential directions in the five years following treatment, including those intensely involved in AA during early years of their recovery but who significantly decelerate AA meeting attendance by year five. The rate of abstinence in this declining AA involvement group was 79% at one year follow-up and about 60% at year three and year five follow-up, suggesting both the potential risk of recovery mutual aid disengagement but also a substantial level of abstinence following disengagement. The Kaskutas team concluded, "...contrary to AA lore, many who connect only for a while do well afterwards."
In looking for evidence of this same phenomenon in Narcotics Anonymous, Cocaine Anonymous, and other 12-Step groups, Dr. Roger Weiss led a 2005 report from the National Institute in Drug Abuse Collaborative Cocaine Treatment Study (NCCTS) on the effects of 12-Step participation on post-treatment recovery outcomes published in Drug and Alcohol Dependence. The NCCTS study found a group of non-attending participators"--persons with inconsistent 12-Step meeting participation but who consistently participated in other 12-Step activities (e.g., sponsorship contact, reading program literature). What was noteworthy for our present discussion was the finding that the non-attending participators had recovery outcomes comparable to those consistently attending 12-Step meetings.
Here are a few preliminary conclusions and implications we draw from this meager body of research to date.
- Three broad patterns of mutual aid involvement seem evident: a) continual, prolonged involvement with varying patterns of intensity over time, b) involvement followed by permanent meeting disengagement, with or without continued use of other program ideas and daily activities, and c) cyclical episodes of involvement with increased contact during periods of heightened vulnerability and sudden or progressive disengagement during periods of recovery and emotional stability.
- A decline or even cessation of mutual aid meeting attendance for those in sustained recovery does not necessarily mean a decline in broader recovery support activities or cessation of personal identification with such an organization. There is a clear pattern of positive disengagement from 12-Step meetings in evidence within the Hoffman and, Kaskutas- and Weiss-led studies. People with AUDs may initiate recovery within a mutual aid group like AA and then disengage from active mutual aid participation while successfully maintaining AUD remission via other recovery support mechanisms.
- The size of the population of persons in this disengaged style of recovery is unknown, as is what distinguishes those who leave AA and maintain stable remission and those who leave AA and experience AUD recurrence and its harmful consequences. These critical recovery research questions have yet to be definitively answered, leaving scientists and clinicians in a quandary when asked,"What will happen if I stop attending recovery support meetings?" Opinions abound, but the scientific evidence is limited.
- Areas of mutual aid involvement beyond meeting attendance (e.g., using program concepts and principles to help guide daily decision-making, daily recovery-focused centering rituals, reading program literature, having a recovery mentor, helping others) may be more predictive of recovery stabilization and long-term maintenance than simply looking at meeting attendance. Future studies need to distinguish the effects of meeting disengagement from the effects of disengaging from this larger cluster of recovery support activities.
- The variations in long-term trajectories of recovery maintenance noted above warrant further elucidation as such variations have profound implications for the design of addiction treatment continuing care as well as on strategies of recovery self-management.
- AA's impact on alcohol problems is often evaluated by citing AA's current membership and the degree of geographical availability of AA meetings. If, as the above studies suggests, there is a population of people who initiate recovery from AUDs within AA, subsequently disengage from active AA involvement, and successfully maintains remission from AUDs; then AA's positive societal impact on alcohol problems is far greater than that indicated by its current membership numbers at any point in time.
- Prolonged, if not lifelong, attendance at mutual aid meetings may not be a universal precondition for successful recovery maintenance, but it may be crucial for the long-term survival of recovery mutual aid organizations and assurance of future support for people seeking recovery. Without individuals committed to long-term mutual aid involvement and carrying recovery to others, recovery mutual aid organizations could well collapse from member attrition, leaving no resource available for the next generation of help-seekers.
While the reporting of these different recovery initiation and maintenance pathways has been scarce, the potential for further elucidation in this area is immense given the large number of available completed studies and related datasets that could investigate these phenomena. Further questions in this regard could be directed at whether adolescents and young adults who achieve recovery using AA or other mutual aid organizations, may be less likely to need lifelong attendance and more likely to experience positive disengagement from mutual aid. Also of import is whether positive disengagement may be more likely among women or men, or among those without other drug use disorders or mental health challenges. Another important question is how long the positive effects from a period of AA engagement may last following eventual disengagement (and whether such prolonged positive effects are correlated with the length or intensity of initial AA engagement) and whether there are shifts (either positive of negative) in other quality of life indicators including a more distal risk of resumption of excessive drinking and AUD reinstatement. As a field, we have been so obsessed with mapping pathways into substance use disorders that we have neglected the comparable and inestimable value of mapping the pathways through which such disorders are successfully resolved or self-managed over the life course. As long-tenured researchers in this area, we continue to be awed by the diversity of such pathways and styles of recovery and their variability over time.
About the Authors: William White is Emeritus Senior Research Consultant within the Research Division of Chestnut Health Systems. Dr. John Kelly is the Elizabeth R. Spallin Associate Professor of Psychiatry in Addiction Medicine at Harvard Medical School, the founder and Director of the Recovery Research Institute at the Massachusetts General Hospital (MGH), and a past President of the American Psychological Association (APA) Society of Addiction Psychology.Dr. Kelly and William White co-edited the book Addiction Recovery Management: Theory, Research and Practice.
Hoffmann, H. C. (2003). Recovery careers of people in Alcoholics Anonymous: Moral careers revisited. Contemporary Drug Problems, 30, 647-682.
Kaskutas, L. A., Ammon, L., Delucchi, K., Room, R., Bond, J., & Weisner, C. (2005). Alcoholics Anonymous careers: Patterns of AA involvement five years after treatment entry. Alcoholism: Clinical and Experimental Research, 29(11), 1983-1990.
Room, R. (1989). The U.S. general population's experiences of responding to alcohol problems. British Journal of Addiction, 84, 1291-1304.
Room, R., & Greenfield, T. (1993). Alcoholics Anonymous, other 12-step movements and psychotherapy in the US population, 1990. Addiction, 88(4), 555-562.
Weiss, R.D., Griffin, M., Gallop, R.J., Najavits, L.M., Arlene, F., Crits-Christoph, P., Thase, M.E., Blaine, J., Gastfriend, D.R., Daley, D., & Luborsky, L. (2005). The effect of 12-Step self-help group attendance and participation on drug use outcomes among cocaine-dependent patients. Drug and Alcohol Dependence, 77(2), 177-184.
Wilson, W. (1969). Testimony before Special Subcommittee on Alcoholism and Narcotics of the Committee on Labor and Public Welfare, July 24, Washington, D.C., Chaired by Senator Harold E. Hughes, Accessed February 1, 2016 at? http://silkworth.net/aahistory/print/congress1969_2.html