12-step self-help group participation as a predictor of marijuana abstinence

This study examined the associations between 12-step self-help group participation following substance abuse treatment and abstinence from marijuana use at 1-, 2-, and 5-years post-treatment. These associations were examined among 1288 male patients of the Department of Veterans Affairs who used marijuana within the 3 months prior to admission to treatment and discontinued use at treatment discharge. Consistent with expectation, 12-step self-help group attendance during the 3 months prior to each follow-up was significantly related to corresponding rates of abstinence at each follow-up time point. Additionally, 12-step self-help group attendance predicted more distal marijuana abstinence and recent attendance added to the prediction. Subsidiary analyses indicated that self-help attendance was important both for the maintenance of marijuana abstinence and for the re-initiation of abstinence after a relapse. Results are discussed in relation to better understanding the role of 12-step self-help group attendance in the initiation and maintenance of marijuana abstinence.     

Short-term alcohol and drug treatment outcomes predict long-term outcome

INTRODUCTION: Although addiction is recognized as a chronic, relapsing condition, few treatment studies, and none in a commercially insured managed care population, have measured long-term outcomes. We examined the relationship of 6-month treatment outcomes to abstinence 5 years post-treatment, and whether the predictors of abstinence at 5 years were different for those who were, and were not, abstinent at 6 months. METHODS: The sample (N=784) is from an outpatient (day hospital and traditional outpatient) managed care chemical dependency program. Subjects were interviewed at baseline, 6 months, and 5 years. Logistic regression analysis was used to assess which individual, treatment and extra-treatment characteristics predicted alcohol and drug abstinence at 5 years. RESULTS: Abstinence at 6 months was an important predictor of abstinence at 5 years. Among those abstinent at 6 months, predictors of abstinence at 5 years were older age, being female, 12-step meeting attendance, and recovery-oriented social networks. Among those not abstinent at 6 months, being alcohol dependent rather than drug dependent, 12-step meeting attendance, treatment readmission, and recovery-oriented social networks predicted abstinence at 5 years. CONCLUSION: Our findings demonstrate a clear association between short-term and long-term treatment success. In addition, these results strongly support the importance of recovery-oriented social networks for those with good short-term outcomes, and the beneficial impact of readmission for those not initially successful in treatment.     

Patients' abstinence status affects the benefits of 12-step self-help group participation on substance use disorder outcomes

BackgroundStudies measuring the effectiveness of 12-step self-help group attendance have yielded mixed results but none of the prior studies have accounted for the potential impact of interim abstinence status.MethodsParticipants were 1683 patients with substance use disorders (SUD) from 88 community residential facilities. Self-report data were collected at baseline and 1- and 4-year follow-ups, and included measures of SUD severity, social resources, coping, and 12-step self-help group attendance. We tested the hypothesis that 12-step self-help group attendance is more effective for non-abstinent patients than for abstinent patients. We also controlled for self-selection effects by using propensity score analyses and we cross-validated our results in a second sample of patients (N = 2173).ResultsSample 1. Patients abstinent at 1-year post-treatment who attended 12-step self-help group meetings were no more likely to be abstinent at 4 years than abstinent patients who did not attend. However, for patients not abstinent at 1 year, a significant improvement in abstinence rates at 4 years emerged for those who attended 12-step self-help groups compared to those who did not (42% vs. 28.9%). A similar pattern emerged for SUD problems. There were no benefits from 12-step self-help group attendance for patients abstinent at 1 year, but non-abstinent patients who attended 12-step self-help groups had significantly fewer problems at 4 years. Sample 2. The cross-validation yielded consistent results as 12-step self-help group attendance led to higher abstinence rates and fewer SUD problems only among patients non-abstinent at interim assessment.ConclusionsIndividual's abstinence status should be considered when evaluating the potential influence of 12-step self-help group attendance on SUD outcomes. In addition, increased clinical resources should focus on assessing patients after discharge and on improving linkage of non-abstinent patients to self-help groups.     

Stimulant abuser groups to engage in 12-Step: A multisite trial in the National Institute on Drug Abuse Clinical Trials Network

Aims

The study evaluated the effectiveness of an 8-week combined group plus individual 12-step facilitative intervention on stimulant drug use and 12-step meeting attendance and service.

Design

Multisite randomized controlled trial, with assessments at baseline, mid-treatment, end of treatment, and 3- and 6-month post-randomization follow-ups (FUs).

Setting

Intensive outpatient substance treatment programs.

Participants

Individuals with stimulant use disorders (n = 471) randomly assigned to treatment as usual (TAU) or TAU into which the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention was integrated.

Measurements

Urinalysis and self-reports of substance use and 12-step attendance and activities.

Intervention

Group sessions focused on increasing acceptance of 12-step principles; individual sessions incorporated an intensive referral procedure connecting participants to 12-step volunteers.

Findings

Compared with TAU, STAGE-12 participants had significantly greater odds of self-reported stimulant abstinence during the active 8-week treatment phase; however, among those who had not achieved abstinence during this period, STAGE-12 participants had more days of use. STAGE-12 participants had lower Addiction Severity Index Drug Composite scores at and a significant reduction from baseline to the 3-month FU, attended 12-step meetings on a greater number of days during the early phase of active treatment, engaged in more other types of 12-step activities throughout the active treatment phase and the entire FU period, and had more days of self-reported service at meetings from mid-treatment through the 6-month FU.

Conclusions

The present findings are mixed with respect to the impact of integrating the STAGE-12 intervention into intensive outpatient drug treatment compared with TAU on stimulant drug use. However, the results more clearly indicate that individuals in STAGE-12 had higher rates of 12-step meeting attendance and were engaged in more related activities throughout both the active treatment phase and the entire 6-month FU period than did those in TAU.     

End-of-treatment outcomes in cognitive-behavioral treatment and 12-step substance use treatment programs: Do they differ and do they predict 1-year outcomes?

This study examined changes in treatment-related proximal outcomes from intake to follow-up, associations between continuing care and maintenance of proximal outcome gains, correlations between specific proximal outcomes and substance use outcomes, and potential mediators of treatment effects for 12-step versus cognitive-behavioral (CB) substance use disorder (SUD) treatment. The participants were 1,873 male veterans seeking SUD treatment at five CB-oriented and five 12-step-oriented VA inpatient/residential SUD programs. Patterns of change in proximal outcomes were similar across the two program types. After discharge, attendance at 12-step groups, but not outpatient treatment, was associated with greater maintenance on most proximal outcomes. Only a few proximal outcomes at discharge were associated with 1-year substance use; most 1-year proximal outcomes were associated with 1-year substance use. Having a sponsor, reading 12-step materials, attending 12-step meetings, and having an abstinence goal appeared to mediate the greater effects of 12-step programs (relative to CB programs) on abstinence.     

Do 12-step meeting attendance trajectories over 9 years predict abstinence?

This study grouped treatment-seeking individuals (n = 1825) by common patterns of 12-step attendance using 5 waves of data (75% interviewed Year 9) to isolate unique characteristics and use-related outcomes distinguishing each class profile. The "high" class reported the highest attendance and abstention. The "descending" class reported high baseline alcohol severity, long treatment episodes, and high initial attendance and abstinence, but by Year 5, their attendance and abstinence dropped. The "early-drop" class, which started with high attendance and abstinence but with low problem severity, reported no attendance after Year 1. The "rising" class, with fairly high alcohol and psychiatric severity throughout, reported initially low attendance, followed by increasing attendance paralleling their abstention. Last, the "low" and "no" classes, which reported low problem severity and very low/no attendance, had the lowest abstention. Female gender and high alcohol severity predicted attendance all years. Consistent with a sustained benefit for 12-step exposure, abstinence patterns aligned much like attendance profiles.     

Training psychiatric residents in addiction

ABSTRACT

12-Step attendance is associated with increased abstinence. A strong claim made in 12-step literature is that alcoholics are pathologically selfish and that working the 12 steps reduces this selfishness, which, in turn, leads to sustained alcohol abstinence. This study tested this assumption by investigating the linkages between 12-step attendance, pathological narcissism, and drinking. One hundred thirty early Alcohol Anonymous (AA) affiliates with limited AA and treatment histories were recruited from treatment and community-based AA. A majority of the sample was alcohol dependent and reported illicit drug use before recruitment. Participants were interviewed at intake and at 3, 6, and 9 months. A majority of participants attended AA meetings throughout follow-up and such attendance predicted increased abstinence and reduced drinking intensity. 12-Step affiliates were significantly higher on pathological narcissism (PN) relative to general population samples and their PN remained elevated. Contrary to predictions, PN was unrelated to 12-step meeting attendance and did not predict later abstinence or drinking intensity. The findings did not support the hypothesis that reductions in PN explain 12-step benefit. An alternative function for the emphasis placed on pathological selfishness in 12-step programs is discussed and a recommendation is made to use unobtrusive measures of selfishness in future research.     

Effects of 12-step mutual support and professional outpatient services on short-term substance use outcomes among adults who received inpatient treatment

BackgroundContinuing care is increasingly prioritized in the treatment of substance use disorders (SUDs). Ongoing engagement in continuing care, including mutual support (e.g., 12-step groups) and/or professional outpatient services, may enhance treatment outcomes and facilitate recovery.ObjectiveThis study investigates how engagement in 12-step mutual support and professional outpatient services is associated with short-term substance use outcomes in a sample of patients who completed inpatient SUDs treatment.MethodsAs part of the Recovery Journey Project – a longitudinal cohort study – participants completed questionnaires upon admission to an inpatient SUDs treatment program, and at 1- and/or 3-months post-discharge (n = 379). Baseline data were collected by self-administered, electronic questionnaires. Follow up data were collected by phone or email. Analyses involved multivariate Generalized Estimating Equations separately modelling self-reported abstinence and percent days abstinent (PDA) over the three time periods.ResultsOverall, rates of self-reported abstinence and PDA increased significantly from baseline to 1- and 3-months follow up. Engagement in 12-step activities (i.e., attended 30 meetings in 30 days, had a home group, had a sponsor, did service work) and professional outpatient substance use support were each significantly associated with abstinence and PDA. Participants who reported a higher degree of 12-step involvement (defined as engagement in more 12-step activities) were also more likely to report being abstinence and greater PDA.ConclusionsEngagement in continuing care, including 12-step activities and professional outpatient substance use support, was highly associated with substance use. Clinical teams should encourage participation in such activities to optimize treatment outcomes.     

The importance of age composition of 12-step meetings as a moderating factor in the relation between young adults’ 12-step participation and abstinence

Background

Participation in 12-step mutual help organizations (MHO) is a common continuing care recommendation for adults; however, little is known about the effects of MHO participation among young adults (i.e., ages 18–25 years) for whom the typically older age composition at meetings may serve as a barrier to engagement and benefits. This study examined whether the age composition of 12-step meetings moderated the recovery benefits derived from attending MHOs.

Method

Young adults (n = 302; 18–24 years; 26% female; 94% White) enrolled in a naturalistic study of residential treatment effectiveness were assessed at intake, and 3, 6, and 12 months later on 12-step attendance, age composition of attended 12-step groups, and treatment outcome (Percent Days Abstinent [PDA]). Hierarchical linear models (HLM) tested the moderating effect of age composition on PDA concurrently and in lagged models controlling for confounds.

Results

A significant three-way interaction between attendance, age composition, and time was detected in the concurrent (p = 0.002), but not lagged, model (b = 0.38, p = 0.46). Specifically, a similar age composition was helpful early post-treatment among low 12-step attendees, but became detrimental over time.

Conclusions

Treatment and other referral agencies might enhance the likelihood of successful remission and recovery among young adults by locating and initially linking such individuals to age appropriate groups. Once engaged, however, it may be prudent to encourage gradual integration into the broader mixed-age range of 12-step meetings, wherein it is possible that older members may provide the depth and length of sober experience needed to carry young adults forward into long-term recovery.     

Determinants of 12-step group affiliation and moderators of the affiliation-abstinence relationship

This study examined characteristics of substance use disorder (SUD) outpatients at intake to treatment (N=345) that were associated with more 12-step group attendance and involvement, Steps worked, and acceptance of 12-step philosophy at a 6-month follow-up (N=281, 81.4%). Patient characteristics covered the domains of sociodemographics, SUD severity, personal functioning, and previous help received. Distinguishing baseline characteristics of patients who attended more 12-step group meetings during follow-up were being less-educated, more engaged in religious practices, and more extroverted and interpersonally competent, and having had more previous 12-step group exposure. These patient characteristics were generally similar to those associated with more 12-step meeting involvement and philosophy acceptance. More 12-step meeting attendance and involvement were related to abstinence at 6 months. Associations of attendance with abstinence were stronger among patients who were younger, white, less-educated, unstably employed, less religious, and less interpersonally skilled. These patients may have had fewer available social resources and so benefitted more from the fellowship and support for abstinence that 12-step group members often provide. We suggest methods by which treatment providers may encourage 12-step group affiliation among patients likely to benefit from it on substance use outcomes.     

A randomized controlled trial of intensive referral to 12-step self-help groups: one-year outcomes

OBJECTIVE: This study implemented and evaluated procedures to help clinicians make effective referrals to 12-step self-help groups (SHGs). METHODS: In this randomized controlled trial, individuals with substance use disorders (SUDs) entering a new outpatient treatment episode (N=345; 96% had previous SUD treatment) were randomly assigned to a standard referral or an intensive referral-to-self-help condition and provided self-reports of 12-step group attendance and involvement and substance use at baseline and at six-month and one-year follow-ups (93%). In standard referral, patients received a schedule for local 12-step SHG meetings and were encouraged to attend. Intensive referral had the key elements of counselors linking patients to 12-step volunteers and using 12-step journals to check on meeting attendance. RESULTS: Compared with patients who received standard referral, patients who received intensive referral were more likely to attend and be involved with 12-step groups during both the first and second six-month follow-up periods, and improved more on alcohol and drug use outcomes over the year. Specifically, during both follow-up periods, patients in intensive referral were more likely to attend at least one meeting per week (70% versus 61%, p=.049) and had higher SHG involvement (mean=4.9 versus 3.7, p=.021) and abstinence rates (51% versus 41%, p=.048). Twelve-step involvement mediated the association between referral condition and alcohol and drug outcomes, and was associated with better outcomes above and beyond group attendance. CONCLUSIONS: The intensive referral intervention was associated with improved 12-step group attendance and involvement and substance use outcomes. To most benefit patients, SUD treatment providers should focus 12-step referral procedures on encouraging broad 12-step group involvement, such as reading 12-step literature, doing service at meetings, and gaining self-identity as a SHG member.     

Do adolescents affiliate with 12-step groups? A multivariate process model of effects

OBJECTIVE: Research with adolescents has revealed salutary effects for 12-step attendance on substance use outcomes, but no studies have examined the effects of 12-step affiliation, or active involvement, beyond simple measures of attendance. Prior research with adults has shown that measures of affiliation are more predictive than measures of attendance. This study (1) assessed attributes that may influence 12-step attendance and affiliation; (2) tested whether 12-step affiliation in the first 3 months posttreatment possessed unique predictive power above that attributable to attendance alone; and (3) examined the extent to which motivation, coping and self-efficacy measured at 3 months mediated the relation between 12-step affiliation and substance use outcome in the ensuing 3 months. METHOD: Adolescent inpatients (N = 74, 62% female), who were aged 14-18 years (mean [SD] = 15.9 [1.19] years), were interviewed during treatment and at 3 and 6 months postdischarge. RESULTS: More severely substance-involved youth were more motivated for abstinence and more likely to attend and affiliate with 12-step groups. A high degree of collinearity between 12-step attendance and affiliation suggested that those attending were also likely to be those actively involved. As a consequence, affiliation did not predict outcome over and above frequency of attendance. Motivation was found to influence the relationship between 12-step affiliation and future substance use outcome. CONCLUSIONS: Given the widespread treatment recommendations for adolescent 12-step involvement, more study is needed to determine what kinds and what aspects of 12-step groups and fellowships are helpful to adolescent change efforts and what alternatives should be developed.     

Participation in specific treatment components predicts alcohol-specific and general coping skills

This study identified which aspects of substance abuse treatment in community residential facilities (CRFs) were correlated with patients' post-treatment coping. A total of 2376 patients supplied demographic information and completed measures at baseline (coping and abstinence self-efficacy) and one year after treatment (coping, level of drug and alcohol use, and substance-related problems). Staff provided information about treatment orientation and patients' participation in treatment (e.g., life skills training, vocational counseling). The data were used to predict coping 1 year after treatment. As expected, higher levels of general approach coping and alcohol-specific coping and lower levels of general avoidance coping were associated with less 1-year alcohol and drug use and fewer drinking problems. Patients' greater level of participation in life skills counseling predicted more approach coping at 1 year. In addition, positive social relationships and participation in 12-step self-help groups predicted less general avoidance coping and more alcohol-specific coping at 1 year post-treatment. Life skills training, 12-step self-help groups, and enhancement of supportive relationships during CRF treatment for substance abuse are related to healthy coping. Future research should examine the effect of these components in less intensive programs and with women.     

Involvement in 12-Step Activities and Treatment Outcomes

ABSTRACT

This study addresses the relative importance of specific 12-step activities to recovery, and how treatment affects participation in those activities. Data were from a clinical trial testing a 12-step facilitation intervention called MAAEZ (Making AA [Alcohol Anonymous] Easier). Participants (N = 508) were recruited at treatment entry. Analyses examined 8 activities measured at baseline, 7 weeks, 6 months, and 12 months. In simultaneous equations, meeting attendance and having a sponsor were the only strong and consistent predictors of abstinence across time points, though other activities (i.e., use of a home group, befriending members, service work, and reading the literature) were significant in some analyses. Treatment involvement had mixed effects on activity participation over time. Contradicting research suggesting that meeting attendance contributes little beyond other 12-step activities, the current results highlight the importance of consistent meeting attendance and sponsorship in recovery. The results suggest a need for enhanced facilitation of key activities even in typical 12-step–oriented treatment.     

12-Step involvement among a U.S. national sample of Oxford House residents

A longitudinal analysis was conducted among a U.S. national sample of persons affiliated with Alcoholics Anonymous and Narcotics Anonymous living in self-run recovery homes (Oxford Houses). Categorical involvement in a set of 12-step activities (i.e., having a sponsor, reading 12-step literature, doing service work, and calling other members for help) and averaged summary scores of involvement were examined in relation to abstinence and self-efficacy for abstinence. Participants who were categorically involved in all 12-step activities reported significantly higher levels of abstinence and self-efficacy for abstinence at 1 year compared with those who were less involved, whereas averaged summary scores of involvement were not a significant predictor of abstinence. Participants' number of days in Oxford Houses, but not rates of 12-step meeting attendance, was significantly related to increased abstinence. Findings suggest that categorical involvement in a number of 12-step activities equip persons with substance use disorders with resources for ongoing recovery.     

Predicting Suicide Ideation for Substance Users: The Role of Self-Esteem,Abstinence, and Attendance at 12-Step Meetings

This study tested if a three-way interaction between gender, abstinence, and self-esteem could predict the occurrence of suicidal thoughts in a sample of drug users who are one year post-treatment. It was expected that those who resolved their drug and alcohol problems and had higher self-esteem would have a lower risk of suicide ideation than those who had resolved their drug and alcohol problems (e.g. were abstinent) and had lower self-esteem, and that this effect would be stronger for women than men. Using a 3-step hierarchical logistic regression, results indicated a significant 2-way interaction between self-esteem and abstinence in the predicted direction, and no effect for gender. However, it was also found that those who had lower levels of self-esteem, regardless of abstinence or continued use, had virtually identical odds of suicidal ideation. Further, increased frequency of attendance at AA/NA meetings also predicted a higher risk of suicide ideation. This suggests that careful assessment of depression symptoms or suicidal ideation for drug users seeking assistance be completed before automatically urging attendance at 12-step meetings. Implications for clinical work with clients are presented.     

The Twelve Promises of Alcoholics Anonymous: Psychometric measure validation and mediational testing as a 12-step specific mechanism of behavior change

Background

Empirical support for the recovery utility of 12-step mutual-help organizations (MHOs) has led to increased investigation of how such organizations confer benefit. The Twelve Promises of Alcoholics Anonymous (AA) feature prominently in 12-step philosophy and culture and are one of the few documented explications of the cognitive, affective, and behavioral benefits that members might accrue. This study investigated the psychometric properties of a measure of AA's Twelve Promises and examined whether it mediated the effect of 12-step participation on abstinence.

Method

Young adults (N = 302, M age 20.4 [1.6], range 18–25; 27% female; 95% White) enrolled in an addiction treatment effectiveness study completed assessments at intake and 3-, 6-, and 12-months post treatment including a 26-item, Twelve Promises Scale (TPS). Factor analyses examined the TPS’ psychometrics and lagged mediational analyses tested the TPS as a mechanism of behavior change.

Results

Robust principal axis factoring extraction with Varimax rotation revealed a 2-factor solution explaining 45–58% of the variance across three administrations (“Psychological Wellbeing” = 26–39%; “Freedom from Craving = 17–21%); internal consistency was high (alpha = .83–.93). Both factors were found to increase in relation to greater 12-step participation, but significant mediation was found only for the Freedom from Craving factor explaining 21–34% of the effect of 12-step participation in increasing abstinence.

Conclusions

The TPS shows potential as a conceptually relevant, and psychometrically sound measure and may be useful in helping elucidate the extent to which the Twelve Promises emerge as an independent benefit of 12-step participation and/or explain SUD remission and recovery.     

The effectiveness of two intensities of psychosocial treatment for cocaine dependence

Structured treatments for cocaine dependence have been shown to be effective despite high attrition rates. What is unclear is what level of treatment intensity is needed to improve and sustain patient outcomes, especially among low SES urban residents. This study evaluated whether there were differences between two levels of treatment intensities for cocaine dependence in reducing substance use and improving health and social indicators. Ninety-four cocaine dependent predominantly African-American male veterans were randomly assigned to either a 12 h/week day hospital program (DH12) or a 6 h/week outpatient program (OP6) and were evaluated at baseline, during treatment and at 4 and 7 months post-treatment. Both treatments stressed abstinence, behavior change and prosocial adjustment and only differed in level of treatment intensity. During treatment measures included urine toxicologies, program attendance, treatment completion and aftercare attendance. Participants reported a 52% reduction in days of cocaine use and experienced significant improvements in employment and psychiatric functioning at seven months post-treatment. However, there was no significant difference between the DH12 and OP6 programs in terms of abstinence during treatment, treatment completion, treatment or aftercare attendance or any Addiction Severity Index (ASI)-related variable assessing level of functioning at 4 and 7 months. While future research with a larger community-based sample that includes female clients is necessary, the current findings demonstrate that a 6 h/week program is just as effective and thus has a significant cost savings compared to a 12 h/week treatment modality for cocaine dependence.     

Does age at first treatment episode make a difference in outcomes over 11 years?

This study examines the associations between age at first substance use treatment entry and trajectory of outcomes over 11 years. We found significant differences in individual and treatment characteristics between adult intakes first treated during young adulthood (25 years or younger) and those first treated at an older age. Compared to their first treated older age counterparts matched on demographics and dependence type, those who entered first treatment during young adulthood had on average an earlier onset for substance use but a shorter duration between first substance use and first treatment entry; they also had worse alcohol and other drug outcomes 11 years post treatment entry. While subsequent substance use treatment and 12-step meeting attendance are important for both age groups in maintaining positive outcomes, relationships varied by age group. Findings underline the importance of different continuing care management strategies for those entering first treatment at different developmental stages.     

Sober living houses for alcohol and drug dependence: 18-Month outcomes

Objective

A major challenge facing many individuals attempting to abstain from substances is finding a stable living environment that supports sustained recovery. Sober living houses (SLHs) are alcohol- and drug-free living environments that support abstinence by emphasizing involvement in 12-step groups and social support for recovery. Among a number of advantages, they are financially self-sustaining and residents can stay as long as they wish. Although SLHs can be used as housing referrals after inpatient treatment, while clients attend outpatient treatment, after incarceration, or as an alternative to treatment, they have been understudied and underutilized.

Method

To describe outcomes of SLH residents, we interviewed 245 individuals within 1week of entering SLHs and at 6-, 12-, and 18-month follow-up. Eighty-nine percent completed at least one follow-up interview. Outcomes included the Addiction Severity Index (ASI), Brief Symptom Inventory (BSI), and measures of alcohol and drug use. Covariates included demographic characteristics, 12-step involvement, and substance use in the social network.

Results

Regardless of referral source, improvements were noted on ASI scales (alcohol, drug, and employment), psychiatric severity on the BSI, arrests, and alcohol and drug use. Substance use in the social network predicted nearly all outcome measures. Involvement in 12-step groups predicted fewer arrests and lower alcohol and drug use.

Conclusion

Residents of SLHs made improvements in a variety of areas. Additional studies should use randomized designs to establish causal effects of SLHs. Results support the importance of key components of the recovery model used by SLHs: (a) involvement in 12-step groups and (b) developing social support systems with fewer alcohol and drug users.