For nearly five decades, Rudolf Moos, PhD, has focused on questions of great import to addiction counselors and the individuals and families they serve. His published studies (15 books and more than 450 articles) have dramatically expanded our knowledge of addiction treatment and the processes of long-term addiction recovery. Dr. Moos served as a professor of psychiatry and behavioral sciences at Stanford University and led (now as Emeritus Director) the Center for Health Care Evaluation at the Veterans Affairs Health Care System and Stanford University Medical Center in Palo Alto, California. In this abridged 2011 interview, Dr. Moos discusses those studies he has conducted that have the greatest bearing on the practice of addiction counseling. The complete interview with full citations of the referenced studies, including expanded discussions of his research on women, people with co-occurring disorders and older adults, is posted at www.williamwhitepapers.com (under Leadership Interviews).

Follow-up studies of addiction treatment confirm the generally positive effects of acute treatment episodes, but these same studies also document wide variability in post-treatment adjustment and the erosion of treatment effects over time. Studies of the potentially prolonged course of severe alcohol and other drug (AOD) problems (sometimes referred to as “addiction careers”), combined with studies confirming the high rates (more than 50 percent) of resumed AOD use following treatment and high rates of multiple treatment admissions (64 percent of all patients entering treatment), have produced two significant shifts in the field. The first is a more clinically sophisticated conceptualization of addiction as a potentially chronic disorder (Dennis & Scott, 2007; McLellan, Lewis, O’Brien & Kleber, 2000; White & McLellan, 2008); the second is a call to shift addiction treatment from a model of acute biopsychosocial stabilization to a model of sustained recovery management (White, 2008).

The behaviors of addicted individuals persistently suggest that they are self-destructive (Khantzian, 1995). That is, the well-known deadly effects of addictive drugs and behaviors and all the associated dangers do not seem to deter susceptible individuals from the “compulsion” to use them. Such individuals seem oblivious to, or not caring about, the dangers of addictive drug use and behaviors. This carelessness suggests the presence of conscious or unconscious self-destructive or suicidal motives, so much so that some have cynically referred to addictive behavior as “suicide on the installment” and psychoanalysts of an era past have invoked “death instincts” (Meninger, 1938; Tabachnik, 1976) to explain the deadly consequences of addictions.

In recent years, there have been growing calls to shift the organizing center of the addiction and mental health fields from pathology and intervention paradigms to a recovery paradigm and to begin this evolution with a recovery-focused research agenda. Dr. Stephanie Brown is a pioneer who has advocated this focus on resilience and recovery. I consider her developmental models of personal and family recovery as among the most important in the modern era of addiction treatment. In this interview conducted in late 2010, Dr. Brown talks about her life, her work and her legacy.

Among physicians, there is a lifetime prevalence of substance use disorders (SUDs) of approximately 10 to 12 percent, similar to the general population rate (Flaherty et al., 1993; SAMHSA, 2006). Specialty care and supervision for addicted physicians was initially proposed and initiated in 1973 by the American Medical Association (AMA) to help physicians and to protect the public with the publication of “The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence,” which encouraged the growth of specialized, state Physician Health Programs (PHPs) in 49 states, managed via authority typically granted under charter from the state Licensing Boards, “… to provide advocacy for physicians and . . . to protect the public”(www.ama-assn.org/go/fsphp; White et al., in press). The AMA has been active in support of PHP care management since that time.

Tonya woke up again to the sound of her own screams. The nightmares about the rape just won’t go away. She hadn’t had a full night of sleep since it happened and was exhausted. She got up out of bed and poured herself another glass of vodka, this glass a little more full than the last. Maybe this one will let her get a few more hours of rest.

Flashbacks, nightmares, disruptive sleep and avoiding people and places all are common symptoms of Post-Traumatic Stress Disorder (PTSD), which may affect individuals exposed to traumatic events. Individuals suffering from untreated symptoms of PTSD, like Tonya, may choose to self-medicate with alcohol and/or other drugs of abuse. Substance abuse counselors then must decide how to treat the two disorders.

Long-held misconceptions may make counselors reluctant to treat the PTSD and substance abuse simultaneously. A common myth is that addressing the trauma would open “Pandora’s box,” resulting in overwhelming feelings and memories that can lead to relapse in alcohol and/or drug use. Many believe that substance abuse must be treated before trauma work can begin. In addition, substance abuse counselors are typically not trained in trauma treatment, although the need to address these issues is increasingly being recognized by counselors in the field.

Many women entering substance abuse treatment have been exposed to traumatic experiences, such as childhood physical or sexual abuse, interpersonal violence as an adult, including domestic violence and assault, and sexual assault or rape. Research suggests that up to 80 percent of women entering substance abuse treatment have experienced traumatic events in the form of physical or sexual abuse (Dansky, et al., 1995; Hien et al., 1996; Paone et al., 1992). Alcohol and substance abuse increase the risk of developing PTSD after exposure to a trauma (Chilcoat & Breslau, 1998); and approximately 43 to 59 percent of women in substance abuse treatment meet criteria for PTSD (Back et al., 2000; Dansky et al., 1996; Fullilove et al., 1993; Jacobsen, Southwick, Kosten, 2001). PTSD is a debilitating anxiety disorder which includes symptoms of avoidance, thought intrusions and obsessions, restricted emotional responses, nightmares, sleep disruption, flashbacks or reliving of the trauma, impaired concentration and an exaggerated startle response. These symptoms can certainly interfere with substance abuse treatment, resulting in attrition and/or treatment failure. Studies have shown that substance abusing individuals with untreated PTSD have poorer outcomes than those without PTSD (Ouimette, et al., 1999; Brady et al., 1994). Such high prevalence rates and the inter-relatedness of these two disorders emphasize the importance of addressing trauma symptoms in substance abuse treatment.

Substance abuse counselors are increasingly becoming aware of the need to address trauma-related symptoms. Over the past several years, a number of trauma- or PTSD-related interventions have been developed and implemented in substance abuse treatment programs. The question remains as to the level of empirical support these interventions have. Currently, counselors in the field are left to determine the type of intervention and the extent to which they explore trauma issues without jeopardizing recovery from substance use disorders (SUD) and without the guidance of readily available evidence-based practice. Even with an empirically supported treatment, another issue is to what extent counselors adhere to the fidelity of the intervention they implement. Many counselors may attend a training workshop but do not receive the necessary post-workshop supervision or technical assistance required to assure that the intervention is delivered with an acceptable level of adherence and competency. Recently, the National Institute of Drug Abuse (NIDA) Clinical Trials Network (CTN) implemented a multi-site research study to explore the feasibility and effectiveness of implementing a trauma focused intervention, Seeking Safety (SS), for women with comorbid PTSD and SUD enrolled in community substance abuse treatment programs (www.disseminationlibrary.org). This article explores the experiences and challenges related to implementing this intervention in one of the participating community treatment programs.

The intervention seeking Safety (SS) is a manualized cognitive behavioral treatment de­signed specifically for individuals with co-occurring PTSD and SUD (Najavits, 2002). It was developed to address the critical issue of safety as a priority; that is, focusing attention on dangerous situations, such as substance use, abusive relationships, risky sexual behavior, suicidality and other self-harm behaviors. This intervention does not explore specific traumatic experiences or involve psychodynamic work, which is often done in other PTSD treatments without comorbid SUD. Some preliminary studies have shown positive outcomes with this intervention. The SS intervention consists of 25 sessions that can be delivered in either group or individual format. Sessions follow a routine structured format which helps clients know what to expect each week. Four main components comprise each group session:

1. Check-in: During the check-in, clients report on how they are doing. Any unsafe behavior that they experience, as well as any safe coping is briefly discussed.
2. Quote: After the check-in has occurred, the counselor elicits feedback regarding a motivating quote that is related to the session topic.
3. Relating session topic to patients’ lives: Much of the session is focused on this component. Handouts specific to the week’s topic are reviewed and the group discusses it’s relatedness to specific experiences in their lives.
4. Check-out: During check out, the counselor has the opportunity to summarize the important highlights of the group. Clients verbalize the meaning they derived from the group, any problems with the group and what commitment they plan for the next session. Commitments are promised actions that encourage responsibility and empower clients. The counselor makes note of these commitments to follow up in the next session.

This group format is particularly suited for participation of all group members. The structure allows the counselor and group members to stay on the specific tasks associated with each session. This treatment does not explore clients’ specific trauma events and women are redirected if such events emerge during a session. Safe coping is an underlying theme for all sessions. One session—entitled “Grounding”—teaches the group members a specific coping tool that can be used to deal with intense emotional pain that often comes up in treatment. Grounding is a way to detach from these intense feelings by getting in touch with the here and now reality. For example, a distressed client may be instructed to focus
on her immediate surroundings, describing in detail everything in the room (i.e., color of the walls, fabric of the chair and number of books on a shelf).

For the purpose of the CTN study, 12 of the 25 original sessions were selected by the intervention developer and study team as being the core sessions to include in a shortened version of SS (Najavits, 2002). To assure the women received an adequate dose of the intervention, the 12 sessions were delivered over six weeks. Topics for the 12-session version included: Safety, PTSD: Taking Back your Power; When Substances Control You; Honesty; Setting Boundaries in Relationships; Compassion; Healing from Anger; Creating Meaning; Integrating the Split Self; Taking Good Care of Yourself; Red and Green Flags; and Detaching from Emotional Pain (Grounding).

Prior to the first group attendance, the counselor who delivered the intervention met with each client individually to orient them to the group format, rules and philosophy. To minimize wait time and be consistent with how standard treatment is conducted in community programs, there was an open group enrollment structure, whereby women were admitted to the groups at any point during the course of the 12 sessions. Thus, a woman could enter group at session four, ending treatment with session three.

Integrating the intervention into the community agency
Offering something new at an agency often creates a feeling of excitement for many, but for others, it can be met with resistance or reluctance. Concern often arises that the program will be changing its philosophy of treatment or forcing counselors to implement certain treatments with which they are unfamiliar. In addition, it is important to strike a balance between offering a potentially effective treatment for dually diagnosed clients while minimizing overuse of agency resources. One of the research sites for the SS study was a large, community-based substance abuse treatment center with 150 employees. This agency houses inpatient and outpatient treatment programs, serving populations with varying degrees of substance abuse severity. The agency staff was reminded by the administrative and research staff that their clients would have the opportunity to participate in an innovative treatment, and that staff would have the opportunity to stay abreast of current best practice approaches. Creating a sense of excitement in this area helped to facilitate staff “buy-in.” Involving agency counselors in the actual implementation of the research study, as well as the planning stages of the implementation process, was crucial not only for favorable acceptance, but for future adoption of the intervention following the study.

Training to implement the intervention
Counselors and supervisors from the community treatment program were selected to be trained and certified in the intervention. Participation in the study would require a significant time commitment and involve balancing current workload and study demands, making counselor recruitment challenging. Despite these concerns, counselors did volunteer to participate in the study, viewing it as an opportunity for professional development that would benefit their clients. Supervisors supported these counselors by assisting them with balancing their agency and study responsibilities (i.e., decreased client caseloads). Two of the agency counselors participated in a rigorous training process that involved a three-day workshop for initial training, followed by certification in the treatment by successful completion of at least a four-session pilot group. Following certification, throughout the study, all treatment sessions were video taped for review and rated by supervisors. In addition, a subset of tapes was co-rated by the national experts to monitor the reliability of supervisor ratings. All counselors participated in intensive weekly supervision throughout the intervention phase of the study (approximately 18 months).

A counselor’s experience
Working with dually diagnosed clients can be a challenge for counselors. Najavits (2002) noted that counselors working with clients with comorbid PTSD and SUD reported concerns related to self-destructiveness and dependency issues, and reported having to provide more intensive case management services. However, counselors felt gratified in developing expertise in this integrated treatment and helping clients develop more adaptive coping skills.

In the CTN study, the SS counselor who delivered the intervention at the community-based substance abuse treatment center mirrored the views from the Najavits study. In a focus group that was held at the end of the study, the trained counselor reported that adhering to the structure of the manualized format of SS was a challenge. Keeping clients focused on the session content was difficult at times, as some clients wanted to process the details of their trauma in group. SS is not designed to process trauma experiences, but rather, works with clients to develop skills to deal with the impact of the trauma. At times, the counselor reported, the clients became angry when they were redirected to skill practicing and the counselor had to be cognizant of managing emotional levels while adhering to the manual.

Despite the challenges of working with clients dually diagnosed with PTSD and SUD, the counselor stated this was one of her favorite groups. Not only did she feel greatly rewarded through offering useful skills to clients who really needed them, she enjoyed the personal and professional growth she experienced as a result of three years of training, ongoing intensive supervision and feedback from session tape reviews. Initially, receiving feedback from a supervisor on video taped clinical performance was difficult and often frustrating. However, being able to take corrective action and successfully incorporate feedback into subsequent sessions was rewarding and empowering. The SS counselor felt more prepared and capable of dealing with difficult issues that came up in group. Further, she saw the benefit of utilizing a manualized treatment versus starting a group session without an organized plan or “flying from the seat of one’s pants.” In the end, with the supervision model used in this study, the counselor felt that she gained a very high level of expertise in delivering the intervention, and was prepared to handle difficult
situations that came up in group. Becoming the agency expert in this intervention was beneficial for integrating the treatment into the curriculum following the completion of the study.

The supervision model was a critical component to assure that the intervention was delivered competently and as intended. Interestingly, this type of supervision has been successfully used in many of the CTN behavioral intervention studies. The SS supervisor was trained in rating taped therapy sessions for adherence and competency. Part of this training focused on gaining inter-rater reliability, whereby supervisor ratings are matched with the ratings of national experts for concordance. The supervisor conducted weekly supervision with the counselor which included giving feedback from rated tapes. It was also the responsibility of the supervisor to address any clinical issues and explore any missed opportunities that may have come up in the sessions. The supervisor had regular supervision conference calls with the national experts to maintain supervision skill levels, and on a regular basis, counselor tapes were randomly rated by the experts to monitor reliability with the supervisor. Despite the challenges of having increased clinical workload, the supervisor reported that her experiences with this study enabled her to provide more effective and substantive supervision in her clinical practice.

Staff challenges
Staff at the community treatment program was excited about having the opportunity to host a new integrated treatment intervention, however, several concerns arose during planning meetings. The most immediate concern was a fear that clients would have an increase in PTSD symptoms with subsequent relapse to alcohol and other drug use. Research staff provided findings that addressed these safety concerns. Also, research staff assured counselors that clients who reported increased PTSD symptoms would be assessed individually prior to leaving the agency for the day. Safety reports from the study indicated that SS did not increase relapse potential or exacerbate PTSD symptoms any more than usual substance abuse treatment (Killeen, et al., 2008).

Many counselors are accustomed to unstructured process-oriented therapy. The use of a manual to deliver therapy is often perceived as counterintuitive to the development of the therapeutic relationship. The structure of the SS approach proved to maximize therapy/skill development within the limited time clients are in treatment and without adversely affecting the therapeutic relationship. Initially perceived as time consuming and resource intensive, staff recognized that the organization, structure and consistency of the groups more aptly met the special needs of these women. Staff recognized that the group was well received by the women, and it addressed the relevant issues in their lives which were less likely to be addressed in the standard treatment program. In the end, having an integrative focused therapy that addresses both SUD and PTSD was embraced by the staff, who increasingly referred clients in their caseloads to participate in the intervention study. Once the study was complete, staff in other agency programs was eager to implement the interventions with their clients as well.

Although the SS manualized therapy specifically avoids in-depth exploration or processing of the trauma, clients often have a fear of “rehashing” their traumas, and the very nature of being in a “trauma” group can invoke negative emotions. Once clients at the community treatment program who were randomized into the SS group began the intervention, they soon realized they did not have to focus on the specific event or retell their trauma story. The clients in the SS study informally reported to the research staff during their weekly assessment interviews that they enjoyed the more focused group approach and thought that it was easy to relate and offer support to each other. They also reported the topics were very helpful for trauma victims and addiction. Many stated that as a result of the intervention, they were able to recognize unsafe behaviors that they previously didn’t even realize were unsafe.

Dissemination—the future of Seeking Safety
Despite initial concerns regarding the implementation of a manualized treatment that addresses both trauma and substance abuse, providing clients with new ways of safe coping and minimizing the risk of re-victimization was rewarding and worth the challenge. Agency directors, clinical managers and counselors who are excited about the opportunity to provide innovative services to their clients can provide the momentum to get everyone “on-board.” After the study, the SS counselor completed additional training on this model for other counselors. She returned to the community treatment program and trained 23 counselors in the SS intervention and now provides ongoing supervision. The community treatment program now has SS-trained counselors in several inpatient and outpatient groups, and can more confidently treat clients who present to the agency with co-occurring substance use disorders and PTSD.

Additionally, these counselors are obtaining more intensive and focused supervision. While the study, overall, did not yield statistically significant differences between the SS intervention and the health education control group, all clients participating in the study showed significant improvements in their PTSD symptoms. The study did provide other significant benefits to the community treatment program by introducing an integrated PTSD/SUD treatment, and increasing knowledge and awareness of trauma and PTSD. The agency also was introduced to a new form of clinical supervision in which supervisors provide feedback based on observing counselor performance in clinical sessions.
In a time when resources are scarce and competitive, it has becomes necessary to demonstrate that treatment services are improving client outcomes and satisfaction. Successful adoption of such interventions as Seeking Safety provides a good example of an agency that is competently moving forward in the dissemination of new treatment modalities.

Acknowledgements: We thank Charleston Center for allowing the implementation of this study at their clinical treatment center. Supported by the National Institute of Drug Abuse’s (NIDA) Clinical Trials Network.

Dr. Chanda Brown is Senior Program Manager at the Charleston Center where she helps manage clinical supervision, training, auditing, performance outcome measurement, process improvement and diversity initiatives. She has worked in the field of addictions since 1993 in various capacities to include inpatient and outpatient counseling, family therapy, and implementing research with Medical University of South Carolina and the
National Institute on Drug Abuse.

Therese Killeen, PhD, APRN, BC, an Associate Professor of Psychiatry and Behavioral Science in the Department of Psychiatry at the Medical University of South Carolina, has worked as both clinician and researcher in the addiction and co-occurring disorder field for over 20 years. Dr. Killeen has a long history of serving as Principal and co-investigator for numerous behavioral and pharmacotherapy studies for substance use and comorbid disorders including PTSD.  

Louise Haynes, MSW, an Adjunct Assistant Professor in the Department of Psychiatry at the Medical University of South Carolina, has over 20 years of experience in the substance abuse field, and is the current Southern Consortium Node Community Treatment Program Representative for the NIDA Clinical Trials Network. In addition to her research experience, Ms Haynes has worked in both clinical and administrative roles in SC.

References
Back, S., Dansky, B. S., Coffey, S. F., Saladin, M. E., Sonne, S. & Brady, K.T. (2000). Cocaine Dependence with and without Post-traumatic Stress Disorder: A Comparison of Substance Use, Trauma History and Psychiatric Comorbidity. American Journal on Addictions, 9:1, 51–62.
Brady, K. T., Killeen, T. Saladin, M. E., Dansky, B. & Becker, S. (1994) Comorbid substance abuse and posttraumatic stress disorder: characteristics of women in treastment. American Journal on Addictions, 3, 160–163.
Chilcoat, H. D. & Breslau, N. (1998). Investigations of causal pathways between PTSD and drug use disorders. Addictive Behaviors, 23(6): 827–840.
Dansky, B. S., Brady, K.T., Saladin, M. E., Killeen, T., Becker & S., Roitzsch, J. (1996). Victimization and PTSD in individuals with substance use disorders: gender and racial differences. American Juornal of Drug and Alcohol Abuse, 22(1): 75–93.
Fullilove, M. T., Fullilove, R. E., Smith, M., Winkler, K., Michael, C., Panzer, P. G., Wallace, R. (1993). Violence, trauma and posttraumatic stress disorder among women drug users. Journal of Traumatic Stress, 6(4), 85–96.
Hien, D. & Scheier, J. (1996). Trauma and short-term outcome for women in detoxification. Journal of Substance Abuse Treatment, 13: 227–231.
Jacobsen, L.K., Southwick, S. M. & Kosten, T. R. (2001). Substance use disorders in patients with posttraumatic stress disorder: a review of the literature. American Journal of Psychiatry, 158, 1184–1190.
Killeen, T., et al. (2008). Adverse events in an integrated trauma focused intervention for women in community substance abuse treatment. Journal of Substance Abuse Treatment. In press.
Knudsen, H. K., Ducharme, L. J. & Roman, P.M. (2007). Research network involvment and addiction treatment center staff: Counselor attitudes toward Buprenorphine. American Journal on Addiction, 16:5, 365–371.
Najavits, L.M. (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford.
Najavits, L. M. (2002) Clinicians’views on treating posttraumatic stress disorder and substance use disorder. Journal of Substance Abuse Treatment 22(2002) 79–85.
Ouimette, P. C., Finney, J. W. & Moos, R. H. (1999). Two-year posttreatment functioning and coping of substance abuse patients with posttraumatic stress disorder. Psychology of Addictive Behaviors, 13, 105–114.

Addiction recovery mutual aid societies have played a significant role in the resolution of severe alcohol and other drug problems throughout the world and have exerted a particularly profound influence on the professional treatment of addiction (Humphreys, 2004; White, 2004). The purpose of this article is to discuss five current contextual influences that will influence the future of Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and other addiction recovery mutual aid groups. First, we will place that future within its historical context.

The story of peer-based recovery mutual aid societies in the United States begins with Native American religious and cultural revitalization movements (early, 1730–1830, recovery circles, prophet movements and sobriety-based Indian religions) and extends through the histories of the Washingtonians, numerous fraternal temperance societies, the ribbon reform clubs, the Drunkard’s Club, the Business­men’s Moderation Society, institutional support groups like the Ollapod Club and the Keeley Leagues, and groups emerging from recovery-focused religious ministries (e.g., the United Order of Ex-Boozers and the Jacoby Club) (Coyhis & White, 2006; White, 1998, 2001, 2004, 2009). Two foundational points from this history are critical to this article. First, a large number of recovery mutual aid societies existed prior to the birth of AA in 1935. Second, while all of these societies provided a viable recovery mutual aid framework for their members for a period of time, none outside of Native America retained a recovery-focused mission or survived their founding generation.

Addiction professionals and representatives of alternative recovery mutual aid groups ask, sometimes resentfully, why AA constitutes the standard by which all other recovery support groups are measured. That status at present is based on AA’s size (measured by total membership and number of groups); the scope of its international dispersion; the range of its adaptation to address other problems; its influence on the design
professionally-directed addiction treat­ment; the quantity and increasing quality of AA-related scientific research; and AA’s growing visibility as a cultural institution. But even more than these, AA has earned this benchmark status by its survival, raising the question of why AA survived and thrived when its predecessors collapsed or were diverted from their recovery-focused missions.

Threats to early AA and other recovery societies
AA faced many of the same threats that confronted and mortally wounded its predecessors—threats that today’s other recovery mutual aid societies face in their own efforts to survive and grow. Such threats include:
• transitioning from charismatic leadership (and the character foibles of such leaders) to peer leadership development and leadership rotation;
• surviving the disengagement, fall from grace (most often from relapse) or death of founders/leaders;
• failing to define a program of recovery prior to the experience of rapid growth (with a resulting dilution/corruption of the program);
• defining the limits of membership too restrictively or too inclusively;
• professionalizing peer support (e.g., the crisis in AA provoked by Bill Wilson’s offer of employment at Towns Hospital);
• money (too much, too little, ill-timed, tainted) and property (e.g., early vision of AA hospitals);
• managing critics, credibility challenges and relationship with the media; and
• escaping the divisive power of religious, political and professional controversies.

The attributes of AA that gain the most attention among both supporters and critics of AA are the 12 Steps, but I have long argued that the key to AA’s vibrancy as an organization rests not with the Steps but with the 12 Traditions. The Traditions were AA’s response to the threats that fatally wounded AA’s predecessors and that could have similarly destroyed AA.
AA survived because of 12 core ideas and principles that have remained unchanged and have governed AA’s organizational life since the 1940s.

These core ideas/principles:
• affirm the link between group unity and personal recovery;
• establish governance by group conscience and servant leadership;
• define a singular membership requirement (“desire to stop drinking”);
• assure the autonomy of each AA group;
• proclaim a singularity of purpose (“carrying its message to the alcoholic who still suffers”), thus minimizing the risk of co-optation and providing a rationale for long-term affiliation and leadership development;
• commit AA to a relational strategy of cooperation without affiliation or endorsement of outside enterprises;
• pledge AA to a policy of financial self-sufficiency/corporate poverty (eschewing the accumulation of money and property that had long served as standards for measuring organizational success);
• promise that AA’s mutual support will remain forever free and non-professional;
• dictate organizational minimalism (“the least possible organization”) and a system of rotational leadership;
• assert that AA has “no views whatsoever” on outside issues, particularly those related to “politics, alcohol reform or sectarian religion”;
• assure a public relations strategy based on attraction rather than promotion and extol personal anonymity at the media level; and
• posit anonymity (“principles before personalities”) as the spiritual foundation of all of the Traditions (Alcoholics Anonymous, 1953/1989).

When the larger cultural influence of AA is written in the centuries to come, these radical principles of organizational management may well be celebrated as a contribution even greater than AA’s framework of alcoholism recovery (Room, 1993). AA’s 12 Steps exist within a pre-existing tradition of alcoholism recovery movements, but the 12 Traditions fueled a fundamentally new type of organization—one that broke all the prevailing rules about how organizations must be structured and managed.

The importance of context
The birth of each recovery mutual aid group is rooted in a particular historical context that shapes its character and culture. Recovery support groups must “work” at personal/family levels in order to provide sense-making metaphors that can serve as catalysts for change, but they must also work at broader cultural levels.

AA’s birth in 1935 and many of its core ideas (e.g., powerlessness, unmanageability, hope and service) were rooted in the economic/spiritual crash of the 1930s. AA historian Ernest Kurtz (1991) has suggested that AA and its unique program of recovery could only have sprung from the unique circumstances of the Depression era. AA also arrived in the wake of the repeal of Prohibition and a century-long, culturally divisive debate between Wet and Dry political opponents. AA provided an escape from this contentious debate by shifting the focus from the product (alcohol) to the unique vulnerabilities of a subpopulation of drinkers (alcoholics).

NA was birthed within the rising epidemic of heroin addiction emerging in the wake of World War II and the social response to that epidemic. Draconian federal and state anti-narcotics laws of the 1950s dramatically escalated criminal penalties for drug possession and sales, filling courts and prisons with an ever-growing legion of addicts. NA’s birth (1947), rebirth (1953), near death (1959) and slow early growth until the 1980s unfolded in the context of subterranean drug subcultures, “loitering addict” ordinances that prohibited known addicts from associating with each other under penalty of arrest, and the need for “rabbit meetings” (meetings that shifted from home to home) to avoid police harassment.
AA and NA’s existences as separate institutions and the distinctiveness of their separate cultures reflect the policy dichotomy of “good drugs” and “bad drugs.” One implication of this understanding is that any cultural shift away from such dichotomous thinking would have potentially profound effects on the future of AA and NA.

The future growth or decay of AA, NA and other recovery mutual aid organizations will be greatly influenced by the presence or absence of core values of organizational management, the nature of those values and principles, and the degree to which they can be refined and reinterpreted in the face of changing cultural contexts. Five emerging contexts will exert a profound influence on AA, NA and other recovery mutual aid organizations:

1. The growing varieties of recovery experience
2. The cultural and political awakening of American communities of recovery
3. The commercialization of recovery support
4. Technological innovation and recovery support
5. An emerging science of recovery

As we will see, each of these contexts will pose threats to and opportunities for recovery mutual aid societies.

The growing varieties of recovery experience
The most important trend in the modern history of recovery mutual aid societies is the growing varieties of recovery experience (White & Kurtz, 2006). The most significant threat to the future of these societies involves the unique interpersonal chemistry of mutual identification. Mutual identification stands as the critical precursor to mutual support, continued participation and service to others within a mutual aid society. Such mutual identification combines the experiences of choosing and being chosen.

The “secret” of Alcoholics Anonymous, the thing that makes A.A. work, is identification. As Marty Mann is reputed to have said to her fellow sanitarium inmate on returning to Blythewood from her visit to the Wilson home in Brooklyn Heights for her first A.A. meeting: “Grennie, we aren’t alone any more.” (Kurtz, 2002)

AA co-founder Bill Wilson was himself a student of this identification process. In a March 30, 1954, letter to Betty Thom, who represented the Habit Forming Drug Group—a pre-NA group that often met in tandem with AA meetings—Wilson posed the following question:
Do any of your recoveries who were strict addiction cases find difficulty in identifying themselves with other AA members? I have noticed in many alcoholics a marked aversion to dope addicts—and vice versa.

Wilson understood that this process of identification profoundly influenced recovery outcomes as well as the fate of local mutual aid groups and the larger fellowship of which they were a part. Attempts to enhance this process of identification historically relied on the defining and enforcing membership criteria. Each recovery support group must wrestle with the twin risks of drawing that boundary of inclusion too narrowly—and shutting out many who are still suffering—or too broadly—and losing the chemistry of mutual identification critical to mutual support. It is a delicate balance. Currently, the changing characteristics of people in recovery and people seeking recovery are stretching and testing the capacity for such identification. When mutual identification weakens or is lost, groups shrink, dissipate, and die and/or spawn new groups.

Historically, weakened levels of mutual identification within AA and NA have produced new AA and NA groups based on all manner of member charac­teristics, experiences and meeting ­format ­preferences, and have spawned alternative or adjunctive anonymous groups (with founding dates noted below) based on:
• Drug choice: marijuana (1968, 1989), prescription drugs (1975, 1998), cocaine (1982), nicotine (1985), benzodiazepine (1989), methamphetamine (1995), heroin (2004), persons in recovery on methadone (1991) and generic groups (i.e., All Recoveries Anonymous (1955–1957), Recoveries Anonymous (1983), Chemical Dependent Anonymous (1988));
• Occupational identification: International Doctors in Alcoholics Anonymous (1949), Pilots (1975), Lawyers (1975), Anesthetists (1984), Nurses (1988) and Veterinarians (1990);
• Co-occurring problems: Dual Disorders Anonymous (1982), Dual Recovery Anonymous (1989) and Double Trouble in Recovery (1993);
• Religious affiliation: Calix Society (1947) and Jewish Alcoholics, Chemically Dependent People and Significant Others (JACS, 1979); and
• Family experience: Al-Anon (1951), Alateen (1957), Families Anonymous (1971), Recovering Couples Anonymous (1988) and Teen-Anon (1999).
    
To these groups have been added an increasingly diverse range of:
• spiritual adjuncts or alternatives: The Red Road to Wellbriety;
• religious frameworks of recovery: Alcoholics Victorious (1948), Alcoholics for Christ (1976), Liontamers Anonymous (1980), Free N’ One (1985), Overcomers in Christ (1987), Millati Islami (1989) and Celebrate Recovery (1991); and
• Secular frameworks of recovery: Women for Sobriety (1975), Secular Organization for Sobriety/Save Our Selves (1985), Rational Recovery (1986), Men for Sobriety (1988), SmartRecovery® (1994), Moderation Management (1994) and LifeRing Secular Recovery (1999).

Even more stunning than the growth of these recovery support options is the many people who are simultaneously participating in two or more recovery support structures—suggesting people are using different groups to meet different recovery support needs.

So what does this growing proliferation of religious, spiritual and secular recovery support groups and new patterns of co-attendance mean to the future of AA and NA? The clue to a potential looming crisis can be found by returning again to AA and NA’s historical origins. AA and NA are historically rooted in two distinctive patterns of addiction: late-stage gamma species alcoholism among white middle-aged Protestant men; and urban heroin addiction among young white ethnics and people of color. These patterns are diminishing through a process of aging out, with oldtimers lamenting the loss of “real” alcoholics/addicts. These earlier patterns are being replaced by a new generation of polydrug users whose patterns of alcohol and other drug (AOD) use render obsolete the concept of “primary drug.” Indicative of this shift, the latest treatment admissions data in the United States reveal that only 18 percent of those entering addiction treatment report “alcohol use only” as a primary problem and only 36 percent report “drug use only” (usually a combination of drugs), with only 13.6 percent reporting heroin as a primary drug choice (SAMHSA, 2008).

What will happen to boundaries of identification within AA and NA when nearly all persons seeking recovery bring patterns of multiple AOD use and no clear “primary drug” of choice? Rituals of qualification (the “what it was like” part of one’s story) have and will continue to evolve within AA and NA through these changing membership profiles. Looking decades ahead, one could anticipate the dilution or outright loss of distinctiveness be­tween AA and NA, the potential collapse and merger of some local groups, significant changes in AA and NA culture, and the resulting search by some for “real AA” and “real NA” (see Kurtz, 1999 for an excellent discussion of “real AA”).

The opportunities posed by these trends are that AA and NA could both expand in spite of their diminishing distinctiveness and that both fellowships could ­celebrate their growing diversity by re­-affirming Bill Wilson’s 1944 declaration: “The roads to recovery are many.” For the history watchers among us, the key will be to closely monitor how AA and NA reinterpret their 12 Traditions in light of changing addiction and recovery environments.

Groups established as an alternative to AA and NA will be similarly challenged to maintain their unique identities and niches within the global recovery community in light of both the changing patterns of AOD problems and the growing varieties of recovery experience within AA and NA. These groups have often criticized the narrowness of approach of the 12 Step fellowships, but it is actually the growing diversity within AA, NA and other 12 Step fellowships that most threatens the future growth of non-12 step recovery support groups.

The cultural and political awakening of ommunities of recovery
An earlier article in this column (White, 2008) recounted the growing cultural and political awakening of individuals and families in recovery. That awakening is being spawned by many factors, including the:
• growth and philosophical diversification of communities of recovery;
• emergence of an identity (person in recovery) that unites members of diverse recovery support fellowships and those in recovery outside those fellowships;
• rise of a new grassroots recovery advocacy movement (see www.facesandvoicesof recovery);
•  international spread of the re-covery advocacy movement; and
• rise of new recovery community institutions (recovery homes/colonies), industries, schools, ministries/churches, community centers, cafes, recovery community service organizations and sports teams, as well as new genres of recovery literature, art, music, dance, theatre and comedy.
In 1976, 52 prominent Americans publicly announced their long-term recovery from alcoholism as part of the National Council of Alcoholism’s Operation Under­standing. Their “coming out” was a landmark in the modern history of alcoholism recovery. In September 2009, more than 70,000 people in recovery participated in public Rally for Recovery events in cities across the United States—an achievement that would have been unthinkable only a few years ago. So what does this cultural and political awakening mean for recovery mutual aid societies? Several trends are already clear:
• Continued efforts will need to be made to define if and how public recovery advocacy can be pursued within the framework of the anonymity tradition of 12 Step fellowships. Conflict on this issue will increase and will likely create a nuanced distinction between anonymity related to one’s identity as an AA/NA member and one’s public advocacy as a person in recovery.
• Role confusion will develop for a time between recovery mutual aid societies, their linked institutions (e.g., clubhouses) and new recovery community institutions (e.g., recovery community service organizations, recovery community centers).
• There will be similar role ambiguity and conflict between the recovery mutual aid sponsor, the recovery coach (working in a volunteer or paid role in a recovery community organization) and the professional addictions counselor.

The threat posed by these developments is the potential division, distraction and disruption that can flow from such institutional and role conflicts. The opportunities posed by these new recovery community building activities will be two-fold. First, while recovery mutual aid members privately debate their relative merits and demerits, these new institutions will be assertively linking a growing number of people to these very mutual aid groups. Second, the broader menu of recovery supports being spawned by these new organizations will mean that some people who have struggled unsuccessfully to achieve stable recovery will now find and maintain that stability. Just as the resources of AA, NA and other recovery mutual aid societies enhanced outcomes of professional treatment, these new recovery support ­­institutions are enhancing the outcomes of both professional treatment and recovery support societies (see White, 2009 for a review of existing studies).

The history of recovery mutual aid societies, specialized addiction treatment and new recovery community organizations indicates a potential shift in focus from facilitating the intrapersonal recovery experience to creating supportive community environments in which such recoveries can flourish. This new understanding of the ecology of recovery will in­crease the transformative potency of professional treatment institutions and peer recovery support groups at the same time it sharpens their understanding of the social contexts in which addiction and recovery are nested.

There is a growing network of peer-based recovery support organizations funded by (or modeled on) the Center for Substance Abuse Treatment’s Recovery Community Services Program (RCSP) and Access to Recovery (ATR) program. These recovery support services have generated a new role (referred to variably as recovery coach / guide / mentor / specialist that offers a menu of support people that spans pre-recovery identification/
engagement (outreach), recovery initiation and stabilization, recovery maintenance (e.g., post-treatment recovery checkups) and enhancement of quality of personal/family life in long-term recovery. The most cursory online search of “recovery coach” also reveals the in­creased privatization of these services (e.g., recovery coaching offered for private fees). This seems to be a perceived zone of business growth by life coaches, those who previously provided intervention services for AOD problems and by addiction counselors disgruntled with treatment organizations they perceived as caring more about paper work than people work.

What is most significant for the future of recovery mutual aid fellowships is that this new role of recovery coach is being rapidly commodified, professionalized and commercialized. As noted above, this could have the potential of heightening ambiguity and conflict between the roles of sponsor, recovery coach and addiction counselor in the short run and, in the long run, potentially eroding the service ethic within communities of recovery. It will also stir heightened controversy about whether people are trying to “sell the program.” Any trend that increases paid recovery support at the expense of volunteer service work in support of one’s own recovery and as an expression of gratitude has the potential of injuring recovery mutual aid societies and the larger community.

The opportunities emerging from this trend are two-fold. First, we may well see elevated long-term recovery outcomes for persons with high problem severity/complexity and low recovery capital. People are now achieving stable recovery whose needs have transcended the time and emotional resources of both sponsors and professional addiction counselors. This achievement magnified over time will result in aggregate membership growth of recovery mutual aid societies. The rise of new peer-based recovery support roles also promises, at personal and at systems levels, a reconnection of acute addiction treatment to the larger and more en­during process of long-term recovery.

Technological innovation and recovery support
A quiet revolution is unfolding in the world of addiction recovery spawned by new media for interpersonal communication (e.g., cell phones, internet-based recovery support meetings and new social networking web sites). If there is a growth window shared by nearly all recovery mutual aid societies, it is in the arena of online recovery support. This new media has the potential to transcend many of the traditional barriers to face-to-face meeting participation: geographical inaccessibility, inconvenience, schedule conflicts, lack of transportation, lack of child care, social anxiety/phobia, fear regarding physical/psychological safety and fear of stigma and discrimination. Today, peer recovery support is a mouse click away. Imagine a day in the future when more people participate in online (or other electronic media) recovery support groups than attend face-to-face meetings. That day has already arrived for many non-12 Step recovery support groups, and that day could also arrive for AA and NA far faster than might be imagined.

The growth of “virtual recovery” raises many questions about the future of recovery and the future of recovery mutual aid societies.
• How will the online recovery support meeting experience for different populations compare to their experience of face-to-face meetings?
• How quickly will a media that seems particularly well-suited to special populations (e.g., women, status-conscious professionals, adolescents, persons with limited mobility, persons living in remote locations) spread through the mainstream cultures of AA, NA and other recovery support fellowships?
• Can key activities within recovery mutual aid societies be performed without or with only limited face-to-face contact? How will these activities be changed in this process?
• Will the Internet create a milieu in which secular and religious alternatives to AA and NA can compete with AA and NA in terms of accessibility and effectiveness for particular groups of people?
• The Internet provides opportunities for instant globalization of recovery support—allowing daily communi­cation with individuals in recovery from all
over the world. How will regular contact with recovering people from other countries/cultures influence the culture of recovery in the United States?
• Could text-based electronic communications emerge as an important alternative/adjunct to formal meetings for some recovery fellowship members?
• Are there areas of unforeseen harms that could befall certain individuals using electronic media for recovery support or harm that could occur to recovery mutual aid fellowships?
     
The threats posed by Internet and other electronic support media are at the moment overshadowed by the potential of this media to reach excep­tionally large numbers of new people in need of recovery support. I suspect the effects of this new recovery support media will be far more profound than any of us can currently visualize.

Emerging science of recovery
Addiction and addiction treatment research agendas are being extended by a growing interest in the scientific study of long-term recovery. This emerging recovery research agenda includes the application of methodologically sophisticated studies of recovery mutual aid fellowships. Most of what we know about these fellowships from the standpoint of science is at present based on studies of AA, but studies of other 12 Step fellowships as well as religious and secular alternatives are increasing. The questions raised by this increased scientific focus include:

1. How will the sometimes harsh light of science affect the cultural status of recovery mutual aid groups?
2. How will emerging science affect how these groups are seen by their own members and by those in need of recovery support?

The growth in scientific studies of recovery mutual aid groups is doing two things. First, it is confirming a lot of recovery fellowship folklore. For example, studies of AA are confirming internal AA folklore about the effectiveness of AA and the potent ingredients of AA participation (e.g., dose/intensity effects of participation and the value of Step work, sponsorship (being sponsored and sponsoring others), reading AA literature, having a home group, etc.) AA oldtimers read the findings of expensive scientific studies and smugly reflect, “I could have told them that for the price of a cup of coffee.” But one of the critical functions of science is to confirm or disconfirm tenets of experiential knowledge. Science is revealing such things as who responds and does not respond to AA, the most effective timing of AA participation, the best linkage procedures between addiction treatment and AA, and the value of matching individuals to particular fellowships and meetings.

Science also will spark controversies by challenging prevailing beliefs of recovery fellowship members. Research on the potential value of medication-assisted recovery is challenging and softening many AA members’ views about medication. One of the most controversial issues within NA in the coming decade will be the science-driven push to re-evaluate local group policies on methadone and other medications (e.g., denial of the right of more than 265,000 persons in methadone maintenance in the United States to speak at NA meetings, chair a meeting, or head a service committee—even by individuals with prolonged stabilization, no secondary drug use, and achievement of global health and positive citizenship.) Some will attempt to avoid this debate by declaring that scientific studies on methadone maintenance are an “outside issue,” but the growing weight of science will exert ­enormous pressure on NA as an institution, as it will all recovery mutual aid fellowships.

All recovery mutual aid societies will be scientifically evaluated in the coming decades on such dimensions as accessibility, attraction, engagement (affiliation and retention rates), short- and long-term effects on the course of AOD problems, effects on global health and functioning and the potential social cost offsets from such participation. Some groups will face this scrutiny and actually achieve heightened scientific credibility (as has happened with AA in the past decade); others will not withstand the effects of such scrutiny.

An issue most critical to the survival of recovery mutual aid groups is the question of how long members should continue to participate. While 12 Step fellowships have implicitly encouraged sustained if not lifelong participation, many of the alternatives to 12 Step Fellowships do not expect sustained member participation. Among the latter, members are expected to avail themselves of sufficient support to initiate stable recovery and then leave and get on with their lives.

Science is actually revealing that this latter position may work at an individual level. Recent studies of AA reveal a population of positively disengaged individuals who initiated recovery within AA, then later ceased active participation but continued to sustain their sobriety and emotional health over time (Kaskutas, Ammon, Delucchi et al., 2005). An interesting outcome of this finding is that the actual societal impact of AA may have been grossly underestimated, as its contributions have generally been measured by its active membership numbers—a figure that ignores the existence of this larger community of people positively affected by but no longer actively participating in AA. The same is likely true for other recovery fellowships.

Interestingly, the “participate as long as and for only as long as you need to” policy may work at a personal level for many individuals but may doom a recovery mutual aid group’s organizational viability. The future of any recovery mutual aid organization rests on its leadership development and long-term meeting maintenance capacity. The personal recovery outcomes of a recovery support group will not always distinguish those groups that will survive and thrive from those that will stagnate and die or regress to the status of a small ideological cult or commercial platform.
The threat science poses to recovery mutual aid groups lies in the intragroup controversies and schisms its findings can elicit, but science will add credence to much that has been learned within recovery mutual aid societies. It will also refine how such societies operate and, through that process, enhance the ability of these groups to support long-term recovery and to survive over time.

The birth and early survival of AA and NA were rooted within unique historical contexts, as were those recovery support fellowships that preceded and followed them. AA and NA (and all other addiction recovery mutual aid societies) are facing fundamentally new contexts in which they will have to reaffirm or redefine their identities. These new contexts include the expanding varieties of recovery experience, increased institution-building within the culture of recovery, the growing professionalization and commercialization of peer recovery support, radically new media for interpersonal communication, and an emerging science of addiction recovery. These contexts present both threats and opportunities to the future of AA, NA, and other recovery mutual aid groups.

Acknowledgement: This article is based on a presentation by the author at a conference entitled “How AA/NA Works: Interdisciplinary Perspectives” sponsored by the University of Michigan Substance Abuse Research Center, Ann Arbor Michigan, September 25, 2009.

William L. White, MA is a Senior Research Consultant at Chestnut Health Systems and author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America.

References
Alcoholics Anonymous. (1953/1989). Twelve steps and twelve traditions. New York: Alcoholics Anonymous World Services, Inc.
Coyhis, D., & White, W. (2006). Alcohol problems in Native America: The untold story of resistance and recovery—The truth about the lie. Colorado Springs, CO: White Bison, Inc.
Humphreys, K. (2004). Circles of recovery: Self-help organizations for addictions. Cambridge: Cambridge University Press.
Kaskutas, L. A., Ammon, L. N., Delucchi, K., Room, R., Bond, J., & Weisner, C. (2005). Alcoholics Anonymous