9 Pathways to Recovery

Introduction

The overarching message of this chapter is that there is no single right way to recover from the disease of addiction. Research and experience have demonstrated that recovery has many paths, and treatment providers, family members, and recovering persons should be open to using the methods that work best for the individual struggling with addiction. In short, although we might assume there is a single best way to do things, often many roads arrive at the same destination. This idea is critical to how we approach healing from addiction.

Recovery from addiction can include formal treatment, medication, dietary changes, increased exercise, meditation, mutual help groups, faith-based engagement, work with a counselor or therapist, and more. As the U. S. Surgeon General’s Report from 2016 acknowledges: There are many paths to recovery. People will choose their pathway based on their cultural values, their socioeconomic status, their psychological and behavioral needs, and the nature of their substance use disorder.

At the same time, we do not need to have limitless choices. Successful outcomes can be grouped into clusters that represent a relatively brief menu of effective options for recovery. In this chapter, we emphasize principles of addiction treatment, evidence-based approaches, medication-assisted treatment, mutual help groups including Alcoholics Anonymous, and holistic approaches that incorporate diet, exercise, and spiritual practices.

Evidence-Based Approaches to Drug Addiction Treatment

Buprenorphine

Buprenorphine is a synthetic opioid medication that acts as a partial agonist at opioid receptors—it does not produce the euphoria and sedation caused by heroin or other opioids but is able to reduce or eliminate withdrawal symptoms associated with opioid dependence and carries a low risk of overdose.

Buprenorphine is currently available in two formulations that are taken sublingually: (1) a pure form of the drug and (2) a more commonly prescribed formulation called Suboxone, which combines buprenorphine with the drug naloxone, an antagonist (or blocker) at opioid receptors. Naloxone has no effect when Suboxone is taken as prescribed, but if an addicted individual attempts to inject Suboxone, the naloxone will produce severe withdrawal symptoms. Thus, this formulation lessens the likelihood that the drug will be abused or diverted to others.

Buprenorphine treatment for detoxification and/or maintenance can be provided in office-based settings by qualified physicians who have received a waiver from the Drug Enforcement Administration (DEA), allowing them to prescribe it. The availability of office-based treatment for opioid addiction is a cost-effective approach that increases the reach of treatment and the options available to patients.

Buprenorphine is also available as in an implant and injection. The U.S. Food and Drug Administration (FDA) approved a 6-month subdermal buprenorphine implant in May 2016 and a once-monthly buprenorphine injection in November 2017.

Naltrexone

Naltrexone is a synthetic opioid antagonist—it blocks opioids from binding to their receptors and thereby prevents their euphoric and other effects. It has been used for many years to reverse opioid overdose and is also approved for treating opioid addiction. The theory behind this treatment is that the repeated absence of the desired effects and the perceived futility of abusing opioids will gradually diminish craving and addiction. Naltrexone itself has no subjective effects following detoxification (that is, a person does not perceive any particular drug effect), it has no potential for abuse, and it is not addictive.

Naltrexone as a treatment for opioid addiction is usually prescribed in outpatient medical settings, although the treatment should begin after medical detoxification in a residential setting in order to prevent withdrawal symptoms.

Naltrexone must be taken orally—either daily or three times a week—but noncompliance with treatment is a common problem. Many experienced clinicians have found naltrexone best suited for highly motivated, recently detoxified patients who desire total abstinence because of external circumstances—for instance, professionals or parolees. Recently, a long-acting injectable version of naltrexone, called Vivitrol, was approved to treat opioid addiction. Because it only needs to be delivered once a month, this version of the drug can facilitate compliance and offers an alternative for those who do not wish to be placed on agonist/partial agonist medications.

Comparing Buprenorphine and Naltrexone

A NIDA study comparing the effectiveness of a buprenorphine/naloxone combination and an extended release naltrexone formulation on treating opioid use disorder has found that both medications are similarly effective in treating opioid use disorder once treatment is initiated. Because naltrexone requires full detoxification, initiating treatment among active opioid users was more difficult with this medication. However, once detoxification was complete, the naltrexone formulation had a similar effectiveness as the buprenorphine/naloxone combination.

Tobacco Addiction: Nicotine Replacement Therapy (NRT)

A variety of formulations of nicotine replacement therapies (NRTs) now exist, including the transdermal nicotine patch, nicotine spray, nicotine gum, and nicotine lozenges. Because nicotine is the main addictive ingredient in tobacco, the rationale for NRT is that stable low levels of nicotine will prevent withdrawal symptoms—which often drive continued tobacco use—and help keep people motivated to quit. Research shows that combining the patch with another replacement therapy is more effective than a single therapy alone.

Bupropion (Zyban®)

Bupropion was originally marketed as an antidepressant (Wellbutrin). It produces mild stimulant effects by blocking the reuptake of certain neurotransmitters, especially norepinephrine and dopamine. A serendipitous observation among depressed patients was that the medication was also effective in suppressing tobacco craving, helping them quit smoking without also gaining weight. Although bupropion’s exact mechanisms of action in facilitating smoking cessation are unclear, it has FDA approval as a smoking cessation treatment.

Varenicline (Chantix®)

Varenicline is the most recently FDA-approved medication for smoking cessation. It acts on a subset of nicotinic receptors in the brain thought to be involved in the rewarding effects of nicotine. Varenicline acts as a partial agonist/antagonist at these receptors—this means that it midly stimulates the nicotine receptor but not sufficiently to trigger the release of dopamine, which is important for the rewarding effects of nicotine. As an antagonist, varenicline also blocks the ability of nicotine to activate dopamine, interfering with the reinforcing effects of smoking, thereby reducing cravings and supporting abstinence from smoking.

Combined With Behavioral Treatment

Each of the above pharmacotherapies is recommended for use in combination with behavioral interventions, including group and individual therapies, as well as telephone quitlines. Behavioral approaches complement most tobacco addiction treatment programs. They can amplify the effects of medications by teaching people how to manage stress, recognize and avoid high-risk situations for smoking relapse, and develop alternative coping strategies (e.g., cigarette refusal skills, assertiveness, and time management skills) that they can practice in treatment, social, and work settings. Combined treatment is urged because behavioral and pharmacological treatments are thought to operate by different yet complementary mechanisms that can have additive effects.

Alcohol Addiction

Naltrexone

Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and the craving for alcohol. It has been shown to reduce relapse to problem drinking in some patients. An extended release version, Vivitrol—administered once a month by injection—is also FDA-approved for treating alcoholism, and may offer benefits regarding compliance.

Acamprosate

Acamprosate (Campral®) acts on the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems and is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria. Acamprosate has been shown to help dependent drinkers maintain abstinence for several weeks to months, and it may be more effective in patients with severe dependence.

Disulfiram

Disulfiram (Antabuse®) interferes with degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and plapitations if a person drinks alcohol. The utility and effectiveness of disulfiram are considered limited because compliance is generally poor. However, among patients who are highly motivated, disulfiram can be effective, and some patients use it episodically for high-risk situations, such as social occasions where alcohol is present. It can also be administered in a monitored fashion, such as in a clinic or by a spouse, improving its efficacy.

Topiramate

Topiramate is thought to work by increasing inhibitory (GABA) neurotransmission and reducing stimulatory (glutamate) neurotransmission, although its precise mechanism of action is not known. Although topiramate has not yet received FDA approval for treating alcohol addiction, it is sometimes used off-label for this purpose. Topiramate has been shown in studies to significantly improve multiple drinking outcomes, compared with a placebo.

Combined With Behavioral Treatment

While a number of behavioral treatments have been shown to be effective in the treatment of alcohol addiction, it does not appear that an additive effect exists between behavioral treatments and pharmacotherapy. Studies have shown that just getting help is one of the most important factors in treating alcohol addiction; the precise type of treatment received is not as important.

Behavioral Therapies

Behavioral approaches help engage people in drug abuse treatment, provide incentives for them to remain abstinent, modify their attitudes and behaviors related to drug abuse, and increase their life skills to handle stressful circumstances and environmental cues that may trigger intense craving for drugs and prompt another cycle of compulsive abuse. Below are a number of behavioral therapies shown to be effective in addressing substance abuse (effectiveness with particular drugs of abuse is denoted in parentheses).

Cognitive-Behavioral Therapy (Alcohol, Marijuana, Cocaine, Methamphetamine, Nicotine)

Cognitive-Behavioral Therapy (CBT) was developed as a method to prevent relapse when treating problem drinking, and later it was adapted for cocaine-addicted individuals. Cognitive-behavioral strategies are based on the theory that in the development of maladaptive behavioral patterns like substance abuse, learning processes play a critical role. Individuals in CBT learn to identify and correct problematic behaviors by applying a range of different skills that can be used to stop drug abuse and to address a range of other problems that often co-occur with it.

A central element of CBT is anticipating likely problems and enhancing patients’ self-control by helping them develop effective coping strategies. Specific techniques include exploring the positive and negative consequences of continued drug use, self-monitoring to recognize cravings early and identify situations that might put one at risk for use, and developing strategies for coping with cravings and avoiding those high-risk situations.

Research indicates that the skills individuals learn through cognitive-behavioral approaches remain after the completion of treatment. Current research focuses on how to produce even more powerful effects by combining CBT with medications for drug abuse and with other types of behavioral therapies. A computer-based CBT system has also been developed and has been shown to be effective in helping reduce drug use following standard drug abuse treatment.

Contingency Management Interventions/Motivational Incentives (Alcohol, Stimulants, Opioids, Marijuana, Nicotine)

Research has demonstrated the effectiveness of treatment approaches using contingency management (CM) principles, which involve giving patients tangible rewards to reinforce positive behaviors such as abstinence. Studies conducted in both methadone programs and psychosocial counseling treatment programs demonstrate that incentive-based interventions are highly effective in increasing treatment retention and promoting abstinence from drugs.

Voucher-Based Reinforcement (VBR) augments other community-based treatments for adults who primarily abuse opioids (especially heroin) or stimulants (especially cocaine) or both. In VBR, the patient receives a voucher for every drug-free urine sample provided. The voucher has monetary value that can be exchanged for food items, movie passes, or other goods or services that are consistent with a drug-free lifestyle. The voucher values are low at first, but increase as the number of consecutive drug-free urine samples increases; positive urine samples reset the value of the vouchers to the initial low value. VBR has been shown to be effective in promoting abstinence from opioids and cocaine in patients undergoing methadone detoxification.

Prize Incentives CM applies similar principles as VBR but uses chances to win cash prizes instead of vouchers. Over the course of the program (at least 3 months, one or more times weekly), participants supplying drug-negative urine or breath tests draw from a bowl for the chance to win a prize worth between $1 and $100. Participants may also receive draws for attending counseling sessions and completing weekly goal-related activities. The number of draws starts at one and increases with consecutive negative drug tests and/or counseling sessions attended but resets to one with any drug-positive sample or unexcused absence. The practitioner community has raised concerns that this intervention could promote gambling—as it contains an element of chance—and that pathological gambling and substance use disorders can be comorbid. However, studies examining this concern found that Prize Incentives CM did not promote gambling behavior.

Community Reinforcement Approach Plus Vouchers (Alcohol, Cocaine, Opioids)

Community Reinforcement Approach (CRA) Plus Vouchers is an intensive 24-week outpatient therapy for treating people addicted to cocaine and alcohol. It uses a range of recreational, familial, social, and vocational reinforcers, along with material incentives, to make a non-drug-using lifestyle more rewarding than substance use. The treatment goals are twofold:

To maintain abstinence long enough for patients to learn new life skills to help sustain it; and To reduce alcohol consumption for patients whose drinking is associated with cocaine use

Patients attend one or two individual counseling sessions each week, where they focus on improving family relations, learn a variety of skills to minimize drug use, receive vocational counseling, and develop new recreational activities and social networks. Those who also abuse alcohol receive clinic- monitored disulfiram (Antabuse) therapy. Patients submit urine samples two or three times each week and receive vouchers for cocaine-negative samples. As in VBR, the value of the vouchers increases with consecutive clean samples, and the vouchers may be exchanged for retail goods that are consistent with a drug-free lifestyle. Studies in both urban and rural areas have found that this approach facilitates patients’ engagement in treatment and successfully aids them in gaining substantial periods of cocaine abstinence.

A computer-based version of CRA Plus Vouchers called the Therapeutic Education System (TES) was found to be nearly as effective as treatment administered by a therapist in promoting abstinence from opioids and cocaine among opioid-dependent individuals in outpatient treatment. A version of CRA for adolescents addresses problem-solving, coping, and communication skills and encourages active participation in positive social and recreational activities.

Motivational Enhancement Therapy (Alcohol, Marijuana, Nicotine)

Motivational Enhancement Therapy (MET) is a counseling approach that helps individuals resolve their ambivalence about engaging in treatment and stopping their drug use. This approach aims to evoke rapid and internally motivated change, rather than guide the patient stepwise through the recovery process. This therapy consists of an initial assessment battery session, followed by two to four individual treatment sessions with a therapist. In the first treatment session, the therapist provides feedback to the initial assessment, stimulating discussion about personal substance use and eliciting self-motivational statements. Motivational interviewing principles are used to strengthen motivation and build a plan for change. Coping strategies for high-risk situations are suggested and discussed with the patient. In subsequent sessions, the therapist monitors change, reviews cessation strategies being used, and continues to encourage commitment to change or sustained abstinence. Patients sometimes are encouraged to bring a significant other to sessions.

Research on MET suggests that its effects depend on the type of drug used by participants and on the goal of the intervention. This approach has been used successfully with people addicted to alcohol to both improve their engagement in treatment and reduce their problem drinking. MET has also been used successfully with marijuana-dependent adults when combined with cognitive-behavioral therapy, constituting a more comprehensive treatment approach. The results of MET are mixed for people abusing other drugs (e.g., heroin, cocaine, nicotine) and for adolescents who tend to use multiple drugs. In general, MET seems to be more effective for engaging drug abusers in treatment than for producing changes in drug use.

The Matrix Model (Stimulants)

The Matrix Model provides a framework for engaging stimulant (e.g., methamphetamine and cocaine) abusers in treatment and helping them achieve abstinence. Patients learn about issues critical to addiction and relapse, receive direction and support from a trained therapist, and become familiar with self-help programs. Patients are monitored for drug use through urine testing.

The therapist functions simultaneously as teacher and coach, fostering a positive, encouraging relationship with the patient and using that relationship to reinforce positive behavior change. The interaction between the therapist and the patient is authentic and direct but not confrontational or parental. Therapists are trained to conduct treatment sessions in a way that promotes the patient’s self-esteem, dignity, and self-worth. A positive relationship between patient and therapist is critical to patient retention.

Treatment materials draw heavily on other tested treatment approaches and, thus, include elements of relapse prevention, family and group therapies, drug education, and self-help participation. Detailed treatment manuals contain worksheets for individual sessions; other components include family education groups, early recovery skills groups, relapse prevention groups, combined sessions, urine tests, 12-step programs, relapse analysis, and social support groups.

A number of studies have demonstrated that participants treated using the Matrix Model show statistically significant reductions in drug and alcohol use, improvements in psychological indicators, and reduced risky sexual behaviors associated with HIV transmission.

12-Step Facilitation Therapy (Alcohol, Stimulants, Opiates)

Twelve-step facilitation therapy is an active engagement strategy designed to increase the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups, thereby promoting abstinence. Three key ideas predominate: (1) acceptance, which includes the realization that drug addiction is a chronic, progressive disease over which one has no control, that life has become unmanageable because of drugs, that willpower alone is insufficient to overcome the problem, and that abstinence is the only alternative; (2) surrender, which involves giving oneself over to a higher power, accepting the fellowship and support structure of other recovering addicted individuals, and following the recovery activities laid out by the 12-step program; and (3) active involvement in 12-step meetings and related activities. While the efficacy of 12-step programs (and 12- step facilitation) in treating alcohol dependence has been established, the research on its usefulness for other forms of substance abuse is more preliminary, but the treatment appears promising for helping drug abusers sustain recovery.

Family Behavior Therapy

Family Behavior Therapy (FBT), which has demonstrated positive results in both adults and adolescents, is aimed at addressing not only substance use problems but other co-occurring problems as well, such as conduct disorders, child mistreatment, depression, family conflict, and unemployment. FBT combines behavioral contracting with contingency management.

FBT involves the patient along with at least one significant other such as a cohabiting partner or a parent (in the case of adolescents). Therapists seek to engage families in applying the behavioral strategies taught in sessions and in acquiring new skills to improve the home environment. Patients are encouraged to develop behavioral goals for preventing substance use and HIV infection, which are anchored to a contingency management system. Substance-abusing parents are prompted to set goals related to effective parenting behaviors. During each session, the behavioral goals are reviewed, with rewards provided by significant others when goals are accomplished. Patients participate in treatment planning, choosing specific interventions from a menu of evidence-based treatment options. In a series of comparisons involving adolescents with and without conduct disorder, FBT was found to be more effective than supportive counseling.

Behavioral Therapies Primarily for Adolescents

Drug-abusing and addicted adolescents have unique treatment needs. Research has shown that treatments designed for and tested in adult populations often need to be modified to be effective in adolescents. Family involvement is a particularly important component for interventions targeting youth. Below are examples of behavioral interventions that employ these principles and have shown efficacy for treating addiction in youth.

Multisystemic Therapy

Multisystemic Therapy (MST) addresses the factors associated with serious antisocial behavior in children and adolescents who abuse alcohol and other drugs. These factors include characteristics of the child or adolescent (e.g., favorable attitudes toward drug use), the family (poor discipline, family conflict, parental drug abuse), peers (positive attitudes toward drug use), school (dropout, poor performance), and neighborhood (criminal subculture). By participating in intensive treatment in natural environments (homes, schools, and neighborhood settings), most youths and families complete a full course of treatment. MST significantly reduces adolescent drug use during treatment and for at least 6 months after treatment. Fewer incarcerations and out-of-home juvenile placements offset the cost of providing this intensive service and maintaining the clinicians’ low caseloads.

Multidimensional Family Therapy

Multidimensional Family Therapy (MDFT) for adolescents is an outpatient, family-based treatment for teenagers who abuse alcohol or other drugs. MDFT views adolescent drug use in terms of a network of influences (individual, family, peer, community) and suggests that reducing unwanted behavior and increasing desirable behavior occur in multiple ways in different settings. Treatment includes individual and family sessions held in the clinic, in the home, or with family members at the family court, school, or other community locations.

During individual sessions, the therapist and adolescent work on important developmental tasks, such as developing decision-making, negotiation, and problem-solving skills. Teenagers acquire vocational skills and skills in communicating their thoughts and feelings to deal better with life stressors. Parallel sessions are held with family members. Parents examine their particular parenting styles, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on their children.

Brief Strategic Family Therapy

Brief Strategic Family Therapy (BSFT) targets family interactions that are thought to maintain or exacerbate adolescent drug abuse and other co-occurring problem behaviors. Such problem behaviors include conduct problems at home and at school, oppositional behavior, delinquency, associating with antisocial peers, aggressive and violent behavior, and risky sexual behavior. BSFT is based on a family systems approach to treatment, in which family members’ behaviors are assumed to be interdependent such that the symptoms of one member (the drug-abusing adolescent, for example) are indicative, at least in part, of what else is occurring in the family system. The role of the BSFT counselor is to identify the patterns of family interaction that are associated with the adolescent’s behavior problems and to assist in changing those problem-maintaining family patterns. BSFT is meant to be a flexible approach that can be adapted to a broad range of family situations in various settings (mental health clinics, drug abuse treatment programs, other social service settings, and families’ homes) and in various treatment modalities (as a primary outpatient intervention, in combination with residential or day treatment, and as an aftercare/continuing-care service following residential treatment).

Functional Family Therapy

Functional Family Therapy (FFT) is another treatment based on a family systems approach, in which an adolescent’s behavior problems are seen as being created or maintained by a family’s dysfunctional interaction patterns. FFT aims to reduce problem behaviors by improving communication, problem-solving, conflict resolution, and parenting skills. The intervention always includes the adolescent and at least one family member in each session. Principal treatment tactics include (1) engaging families in the treatment process and enhancing their motivation for change and (2) bringing about changes in family members’ behavior using contingency management techniques, communication and problem-solving, behavioral contracts, and other behavioral interventions.

Adolescent Community Reinforcement Approach and Assertive Continuing Care

The Adolescent Community Reinforcement Approach (A-CRA) is another comprehensive substance abuse treatment intervention that involves the adolescent and his or her family. It seeks to support the individual’s recovery by increasing family, social, and educational/vocational reinforcers. After assessing the adolescent’s needs and levels of functioning, the therapist chooses from among 17 A- CRA procedures to address problem-solving, coping, and communication skills and to encourage active participation in positive social and recreational activities. A-CRA skills training involves role-playing and behavioral rehearsal.

Assertive Continuing Care (ACC) is a home-based continuing-care approach to preventing relapse. Weekly home visits take place over a 12- to 14-week period after an adolescent is discharged from residential, intensive outpatient, or regular outpatient treatment. Using positive and negative reinforcement to shape behaviors, along with training in problem-solving and communication skills, ACC combines A-CRA and assertive case management services (e.g., use of a multidisciplinary team of professionals, round-the-clock coverage, assertive outreach) to help adolescents and their caregivers acquire the skills to engage in positive social activities.

Mutual Help Groups

12-Step Groups

To describe the impact and evolution of 12-step groups, let’s begin here:

It’s a warm spring afternoon in 1935, and Bill Wilson is out of town on a business trip. He paces impatiently in the lobby of his hotel in Akron, Ohio, hundreds of miles from his home in New York. He has concluded a series of unsuccessful meetings and feels frustrated and alone. 

Wilson has struggled with his sobriety since returning as an officer in the Great War (World War I) in 1919. He has been in and out of hospitals and psychiatric wards, repeatedly finding his way back to alcohol. Following a spiritual awakening, he now has several months sober, but he realizes he desperately needs to talk to someone else.

And not just any someone, but in particular, someone who can understand what he is going through. He needs someone who can listen to him without judgment, who won’t continuously interrupt to have him explain his experiences and feelings. Someone who will just KNOW what Wilson is going through as he feels the pangs of longing for just one sip of a drink.

There’s a well-stocked bar a few steps away. From inside, Wilson hears the friendly chatter of hotel guests enjoying a carefree afternoon. He sees rows of attractive bottles lining the walls as the bartender pours a crisp, refreshing beer into a cold glass for one of the patrons. Wilson begins to sweat, and his brain can only think about the pure delight of that first sip of alcohol touching his lips. Yet he resists the urge momentarily and has another idea.

Wilson begins pouring nickel after nickel into the payphone in the hotel’s lobby, looking to connect with a local who might guide him to another person who has experienced the struggle of sobriety. He eventually gets in touch with a pastor who gives him the name of Henrietta Seiberling, a local Oxford Group leader. Seiberling invites Wilson to meet with a nearby physician and known alcoholic, Dr. Bob Smith.

Wilson drives to Dr. Smith’s residence and approaches him tentatively. Wilson begins describing his desire to speak with someone about his drinking. At first, Smith mistakenly assumes Wilson has come to convince him of the need to seek help for Smith’s drinking problem, but the opposite is true. Wilson wants to be able to share openly about his own experiences and feelings, with Smith serving as audience and de facto therapist.

By the end of the afternoon, neither has taken a drink. A fast friendship develops, along with a growing desire to reach out to others by sharing their stories. Their collaboration leads to the emergence of the first meetings of a group called Alcoholics Anonymous (AA). The group eventually spreads to every state and nearly every country in the world, and it has spawned over 200 other groups that utilize the same 12 steps of AA, touching millions of lives along the way.^[1]

AA was not the first group to try and support people who wanted to quit drinking, but it was the most successful, and its staying power is a testament to the model. Before AA, organizations that tried to help people stay sober were primarily religious in nature. Just before AA’s founding, Bill Wilson attended the Oxford Group, which emphasized evangelical Christian principles along with meetings where members confessed their struggles with alcoholism while seeking guidance from senior group members.

The roots of AA are clear to see in the tenets of the Oxford Group. In an essay he wrote in 1960, Bill Wilson acknowledged that most of the steps of AA “stem directly” from the Oxford Group’s principles. However, Wilson and Smith realized that a strict emphasis on religion would ultimately turn people away and fracture the group, so they developed an approach that mirrors many traditional Judeo-Christian teachings but invites people of all backgrounds to participate. The rapid spread of AA meetings, followed by the publication of the group’s official text (often referred to as ‘The Big Book‘) in 1939, laid the groundwork for what would become modern addiction treatment in America. Bill Wilson was actively involved in helping several treatment centers establish their programs, notably the flagship location of Hazelden in Center City, Minnesota.

In addition to 12-step groups, several other groups have emerged to support various types of recovery. These include Rational Recovery/SMART Recovery, Celebrate Recovery, Women for Sobriety, and Refuge Recovery. Interestingly, some of these groups vehemently eschew the role of spirituality in recovery (e.g. Rational Recovery), while others use it as their primary focus (e.g., Celebrate Recovery).

A brief list of examples of 12-step organizations:

Alcoholics Anonymous – founded in 1935, the original 12-step group focuses on helping its members to quit drinking and to spread their message to others

Al-Anon Family Groups – founded in 1951 as a group to support family members and loved ones of alcoholics

Narcotics Anonymous – founded in 1953 to help people quit using drugs other than alcohol

Gamblers Anonymous – founded in 1957 to help compulsive gamblers

Overeaters Anonymous – founded in 1960 to help people who have lost control over their eating

Emotions Anonymous – founded in 1971 for people who are working on emotional stability

In addition to the groups listed above, dozens of other problems have been targeted by 12-step fellowships. Each group applies the same steps to a particular issue that people are struggling with. This is consistent with the 12 traditions of AA, which include a narrow focus on helping others who have a problem with alcohol (tradition five) and avoidance of views on all outside issues (tradition ten).

Recovery Support Groups Not Based on the 12 Steps

While millions of people credit 12-step involvement for their sobriety, many have been unsuccessful in Alcoholics Anonymous or have sought other alternatives. Some of these groups are discussed below.

Women for Sobriety

Often cited as the first secular alternative to Alcoholics Anonymous, Women for Sobriety was established in the 1970s by sociologist Jean Kirkpatrick as a group seeking to create a program more friendly to women. The group developed their own steps called the New Life program that alter the language of AA’s 12 steps, notably removing the word “powerless” from the first step.

Rational Recovery

As an alternative to traditional Alcoholics Anonymous groups, Rational Recovery was founded in 1986 by Jack Trimpey based on self-help rather than mutual help. The model of Rational Recovery does away with all mentions of spirituality and does not hold meetings. Instead, Rational Recovery emphasizes identifying and labeling one’s addictive voice that perpetuates the using behavior. According to the program, once a person learns the foundational cognitive skills of the approach, he or she simply needs to apply them on a regular basis, thus the removal of spirituality and fellowship from the program.

SMART Recovery

SMART stands for self-management and recovery training. This group emerged in the 1990s as some members of Rational Recovery found they wanted to hold in-person meetings to discuss their recovery. They utilize cognitive-behavioral techniques to help members practice improved coping skills and resist urges to use. Their in-person and online meetings are run by a certified SMART trainer.

Celebrate Recovery

Founded in 1991, Celebrate Recovery is a dedicated Christian organization. Whereas the 12 steps make general reference to a higher power but do not promote any particular religious beliefs, Celebrate Recovery promotes a path to healing that incorporates teachings from the Bible. As their website explains, they are a “Christ-centered 12-step program.” There are other significant differences from 12-step groups that distinguish Celebrate Recovery. First, the group does not focus on a single issue; they allow people with all addictions to participate.  Members struggle with a range of problems the group describes as “hurts, hang-ups, and habits.” Second, there is an emphasis on naming your higher power as Jesus and an unapologetic push to make Christ the focal point of recovery.

Refuge Recovery

Like Celebrate Recovery, Refuge Recovery uses spiritual practices as a foundation for recovery. In this group, Buddhist beliefs and practices are used in a non-theistic way to support sobriety. The group’s principles are based in part on those of Alcoholics Anonymous. Practices include meditation and mindfulness training, along with the “Four Truths of Refuge Recovery”:

• Addiction creates suffering
• The cause of addiction is repetitive craving
• Recovery is possible
• The path to recovery is available