and best known of the 12-step programs, has
more than 2,000,000 members in more than
114,000 groups in more than 180 different
countries.^371
Other examples of mutual support programs that
do not follow the traditional 12-steps approach
and that are secular in nature include SMART
Recovery (Self-Management and Recovery
Training),^372 Secular Organizations for Sobriety
(SOS), Women for Sobriety and LifeRing
Secular Recovery.^373 Groups vary based on the
population they serve.^374
Participation in mutual support programs--
including 12-step and secular-based programs--
has been associated with improved
psychological functioning, reduced substance
use and reduced health-care costs and
utilization.^375 However, there are
methodological limitations to the effectiveness
studies that examine mutual support programs,
restricting the extent to which their ability to
curb substance use and help manage addiction
can be determined.^376 Most are not randomized
controlled studies, research on the programs is
difficult to conduct due to the anonymous nature
of group membership^377 and there may be an
inherent bias in the research in that AA and
other 12-step groups may attract patients who
are more motivated to change.^378 Despite the
limited empirical evidence demonstrating the
effectiveness of mutual support programs like
AA, anecdotal evidence of their effectiveness
abounds.^379
One finding that emerges consistently from the
available research is that patients who had been
in addiction treatment and then followed up with
involvement in mutual support programs fare
better than those who do not.^380 A study that
followed treatment patients with addiction
involving alcohol for three years found that
those who were more involved with mutual
support programs* were likelier than other
patients to be abstinent the next year. Mutual
support program members who were not
abstinent the year following group participation
- Including, but not limited to, AA, SMART
Recovery and Women for Sobriety.
still drank less on the days that they did consume
alcohol.^381 Other research finds that those who
attend AA or another 12-step group following
treatment have about twice the rate of abstinence
as those who do not participate in these mutual
support programs.^382Reviews of the research on the effectiveness of
mutual support programs suggest that it may not
be the specific content of the programs or their
processes that are associated with positive
outcomes, but rather the fact that they provide
free, long-term and easily-accessible exposure to
people and messages that support recovery,^383
which is a key element of chronic disease
management.^384Twelve Step Facilitation. Twelve Step
Facilitation (TSF) is a formalization and
professionalization of the 12-step mutual support
model which involves a brief, structured and
manual-driven approach implemented over the
course of 12 to 15 sessions by a trained
counselor or treatment provider.^385 During these
sessions, providers will advocate abstinence,
explain the basic concepts of the 12-steps and
actively support and facilitate the patient’s
involvement in 12-step programs. TSF can be
implemented in an individual or group format or
including the patient’s significant other. It has
been used in acute treatment and as a method of
providing support services for chronic disease
management.^386TSF has been used to address addiction
involving alcohol,^387 marijuana and
stimulants.^388 Evaluations of TSF are limited;
however, several studies have found it to be
comparable in effectiveness to psychosocial
treatments such as CBT and MET.^389 It is listed
in SAMHSA’s National Registry of Evidence-
based Programs and Practices^390 and as an
evidence-based approach by the National
Institute on Drug Abuse (NIDA).^391Residential Programs. Some mutual support
approaches, such as the Therapeutic Community
(TC) model, are residential and incorporate
elements of treatment. Other residential
programs such as recovery homes or sober living
houses provide mutual support only. These