Non-clinical Recovery Pathways
Recently we discussed Secretary Kennedy’s proposal for therapeutic communities. We did not minimize those approaches but expressed concerns that this promotion, not unlike other efforts by the Secretary, might interfere with progress on evidenced-based treatments. We noted three pathways to recovery. Last week we discussed self-managed approaches. This week we discuss so-called non-clinical pathways. (Note: much of the material herein is a report about Recovery Pathways from the Recovery Research Institute and our personal knowledge. That report can be found through Pathways to Recovery – Recovery Research Institute)
Generally speaking these recovery processes do not involve a trained clinician, but are often community-based and utilize peer support. We recognize that Peer Support Specialist certifications are becoming much more common and they do involve training to be more than a “sponsor” but are not, typically, considered clinicians. The evolution of this certificate bears watching for potential expansion of recovery opportunities that are today, sadly, limited.
12-step organizations like Alcoholics Anonymous (AA) are the largest and most widely accessible mutual-help organizations in communities around the world. Founded in 1935 by Bill Wilson and Dr. Bob Smith, AA and its offspring have been the mainstay in recovery since 1935 and millions have recovered (they may prefer recovering) through these communities.
Today AA has an estimated 67,000 groups serving 1.4 million members across the U.S. and Canada. NA is comparatively smaller than AA, with 67,000 groups in total across 139 countries. Twelve Step groups find guidance from organizations such as AA World Services. Meeting structure suggestions are offered and the groups are guided by Twelve Traditions. Meetings are “open” meaning anyone can attend or “closed” only for qualified members meaning avowed alcoholics or addicts. There are sometimes special meetings for sub-groups such as LBGTQ+, women, and individuals with disabilities, among others. The controversy over addicts attending AA and either GA or vice versa is hotly debated but rapidly disappearing.
Studies examining the effects of 12-step, mutual-help organizations have been controversial but generally show that participation is prospectively related to positive substance outcomes like abstinence over time. Overall, the more rigorous studies published in peer-reviewed journals consistently show that participation promotes better outcomes. It should be noted that these studies are much more prevalent for AA than others such as NA (narcotics) or GA (gambling).
A 2013 study published in “Social Work Public Health” (“12-Step Interventions and Mutual Support Programs for Substance Use Disorders: An Overview”, Dennis M. Donovan, Michelle H. Ingalsbe, James Benbow and Dennis C. Daly, August 2013) found twelve step participation effective. “The results from a number of recent empirical studies corroborate the results from these mutual support group membership surveys, supporting the clinical effectiveness of 12-Step approaches.” Importantly for our three week report on Recovery Pathways they continued, “Beginning 12-Step participation while in treatment, especially at group meetings held at the treatment program, and 12-Step attendance at the same time that one is enrolled in specialty treatment, are associated with better outcomes.”
Non-12-step mutual-help organizations are often called “secular” mutual-help organizations given their intentional focus on non-religious aspects of addiction recovery. AA and many offspring communities specifically recommend the Third Step, “Turned our will and our lives over to the care of God as we understand him” (“Alcoholics Anonymous”; Third Step). At the founding of AA both founders had participated in the Oxford Group, founded by a Lutheran minister offering a pathway to recovery through “no plan but God’s plan”. Both founders had been reared in Christian faiths. Today America is increasingly secular and many organizations have evolved to offer secular alternatives. The notable, though modest, growth of secular mutual-help so far, coupled with the need to identify alternatives to 12-step mutual-help, has led to increased attention paid to these organizations in communities and clinical programs.
Regarding prevalence, their reach and accessibility are limited compared to AA and NA as we might expect given their relatively recent emergence. Among the largest secular mutual-help organizations is SMART Recovery with 3200 weekly meetings worldwide and 2000 in the United States, 32 meetings online, with these meetings being run by trained facilitators. We reported about SMART in our article about self-managed recovery but repeat here for comprehensiveness’ sake.
SMART Recovery (Self-Management and Recovery Training) was founded in 1994 and is designed to allow for self-tailored approaches as opposed to what many think of as one-size-fits-all approaches in twelve step programs. From their web page, “SMART Recovery is an evidenced-informed recovery method grounded in Rational Emotive Behavioral Therapy (REBT) and Cognitive Behavioral Therapy (CBT), that supports people with substance dependencies or problem behaviors to build and maintain motivation, cope with urges and cravings, manage thoughts, feelings and behaviors, and live a balanced life”. SMART Recovery provides a variety of tools and options including group meetings, online tool kits, and publications.
Available studies have compared SMART with other modalities of recovery. They have found that comparative success depends on the motivation of the participant. When motivation is similar the results are similar across modalities including SMART. However, it is fair to report from these early studies that SMART Recovery has similar success to twelve step programs under certain circumstances.
There are other secular self-help approaches though they do not have as many participants as SMART. A short list might include:
· Life Ring Secular Recovery: established in 2001 focusing on positive advice and living in the present. Where AA focuses on powerlessness Life Ring believes that everyone has the power to overcome their addiction
· Women for Sobriety: Jean Kirkpatrick founded WFS in 1976 uncomfortable with 12-Step’s premise of being “powerless”. The organization helps empower women to recover from alcoholism and other addictions
· Rational Recovery: uses the Addictive Voice Recognition Technique (AVRT), a method for addicted individuals to recognize thoughts that lead to substance abuse objectively
· Secular Organization for Sobriety: was started for those who were uneasy with AA's spiritual dependence. SOS gives the credit for achieving sobriety to the individual rather than to a Higher Power.
· Refuge Recovery: is an abstinence-based path and philosophy that uses mindfulness and Buddhist principles as key features of its recovery approach.
Tied together by their separation from 12-step models of how people recover, secular mutual-help organizations vary in the degree to which their recovery programs are delineated.
On the opposite end of the mutual-help spectrum from secular groups are religiously affiliated mutual-help and recovery support organizations. Faith-based recovery support services vary across houses of worship that integrate their religious beliefs and varying forms of spirituality into addiction recovery. These efforts often involve sponsorship of recovery groups, housing other twelve step meetings, development of recovery-friendly churches, and integration of recovery pastors.
Among the largest and most well-known is Celebrate Recovery, a Christian-based recovery support organization with 17,000 groups worldwide. Unlike other recovery-related mutual-help organizations, in which meeting attendees typically remain together for the duration of any given meeting, Celebrate Recovery may break into smaller, gender-specific groups targeting a variety of issues. While it is relatively easy to start an AA or NA meeting, individual Celebrate Recovery meetings are closely monitored by the national organization.
While the growth of religiously-affiliated groups like Celebrate Recovery suggest individuals may perceive it as helpful, little is known scientifically about these types of mutual-help organizations
Overall, each of these three types of mutual-help organizations are quite different in terms of their philosophy on how to help individuals recover from substance use disorder. At the same time, they virtually all share a central tenet of abstinence from alcohol and other drugs as the recovery goal.
Education-based recovery support services are designed to help individuals in early substance use disorder recovery achieve their educational goals while also focusing on the areas of their social, emotional, spiritual, and physical well-being needed to help sustain recovery. Education-based recovery support services are offered both at university and high school levels. Although teen use of alcohol, schedule one narcotics and nicotine has been decreasing for many years, some estimates are that teen alcohol and drug use is double or triple that of American adults. Hence the interest in attending to these issues earlier in the abuse and addiction cycle.
Collegiate Recovery Programs provide seamless access to recovery-related social and other educational supports for college students. While the services provided may vary by location, many programs offer onsite sober housing, mutual-help meetings, individual counseling, sober events, and seminars on topics relevant to their day-to-day needs. These activities are intended to help college students meet their educational goals while maintaining a focus on their emotional and physical well-being, all in the context of substance use disorder recovery.
Recovery high schools are designed to integrate academic instructions with social-emotional skills acquisition and support for teenage high school students in recovery from substance use disorder. Recovery high schools differ in their scope of services and support, but there are three primary aims shared by these education-based recovery support services:
· Educate all available and eligible students who are in recovery from substance use disorder or co-occurring disorders
· Meet state requirements for awarding a secondary school diploma
· Support students in working a fulfilling program of recovery.
Like other, recent developments in non-clinical approaches the research supporting education-based program effectiveness is yet scant. While students involved in collegiate programs typically have low documented relapse rates, comparing participants to non-participants also in substance use disorder recovery has not been measured. Systematic, rigorous evaluations of these potentially critical recovery support services for college-aged youth are needed.
Little empirical measurement exists about the outcomes of students attending recovery high schools. One rigorous study showed that adolescents with substance use disorder post-treatment attending these recovery support services were 4 times more likely to report complete abstinence from alcohol, marijuana, and other drugs at 6-month follow-up versus those attending standard high schools.
Employment based recovery services are, as implied, based in or related to employers. Examples include:
· Programs set up to facilitate employment and workforce training for individuals in recovery
· Programs set up by employers to support current employees in accessing resources and treatment
· Organizations that have recovery-friendly policies
· Organizations or businesses set up by individuals in recovery that employ other individuals in recovery
Typically offered by large organizations, employee assistance programs (EAPs) are voluntary and confidential programs established to boost employees’ health outcomes and their subjective sense of personal well-being. They may include resources to address health and substance use disorders intended to benefit both the individuals receiving these services as well as the worksite or company overall.
For individuals in recovery, there may be barriers to obtaining and sustaining gainful employment due to a prior criminal record, negative educational histories, gaps in employment history, financial complications, and stigmatization. A number of programs and organizations including employers work to address one or more of these factors that bar individuals from gainful employment, whether that be through job coaching, placement, or skill development.
From the employer point of view these programs are part of the larger Employee Wellness movement that has many goals. Whether one appreciates it or not, a very important goal of these programs is to reduce cost and there the evidence is at best mixed. A famous study by the Rand Corporation (“Do Workplace Wellness Programs Save Employers Money?”, Soeren Mattke, Harry H. Liu, John P. Caloyeras, Christina Y. Huang, Kristin R. Van Busum, Dmitry Khodyakov, Victoria Shier, Ellen Exum, Megan Broderick, Rand Research Summary, January 2014) stated, “Employers offer the programs to improve the health and well-being of their employees, increase their productivity, reduce their risk of costly chronic diseases, and improve control of chronic conditions. The press and trade publications strongly endorse workplace wellness programs as a good investment for employers. A 2010 review by a Harvard economist stated that wellness programs returned three dollars in health care savings and three dollars in reduced absenteeism cost for every dollar invested. But our research tells a different story. The recently published RAND Wellness Programs Study, which included almost 600,000 employees at seven employers, showed that wellness programs are having little if any immediate effects on the amount employers spend on healthcare.”
As to substance abuse and addiction, focusing on recovery outcomes, preliminary research suggests that individuals receiving workplace interventions experience improved drinking, drinking-related and other health outcomes. One might logically conclude that there are related benefits such as employee morale, loyalty, absenteeism and turnover. However, the research is nascent, sometimes contradictory, and more is needed to determine optimal strategies to help individuals with substance use disorder in the workplace.
We could also include in this pathway various community based organizations. Transitional housing arrangements for instance offer continuing, stable housing with an abstinence based, mutual support environment usually for people newly exiting residential recovery treatment. Community centers either stand alone or based in organizations such as the YM/WCA or Goodwill may offer services such as employment search, house meetings or provide a safe space for activities.
There is no question that twelve step communities have been a godsend to millions of people with substance use disorder and their loved ones. AA World Services estimates that 1.4 million Americans were members of AA in 2021. Another 600,000 are estimated to be members in NA. Counts for GA will be much lower and counts for codependent groups are much less available. Regardless, it is thoroughly reasonable to assume that since the founding of AA nearly 90 years ago more than 50 million (unduplicated headcount ) Americans have found comfort, short term and long term recovery in AA and its offspring. Comparatively, this has also been the best path to recovery if defined by abstinence even if recovery rates are very low at less than 10%.
The advent of alternative self-help efforts can only be viewed as a positive outcome. AA and NA have rigorous adherence to their twelve steps in practice even if socially enforced. Many people will need an alternative. Caution is advised, however, as these efforts are organized with varying degrees of attention to the principles, evidenced based information and rigor. SMART for instance is based on extensive research. Others are formed around a particular need such as groups focused by gender or sexual identity and may not be as grounded in research. Of course, this was also true of Alcoholics Anonymous in 1935.
It is interesting to note that the research that is available spoke to individual motivation. Perhaps it is the case that the most important factor in recovery is the acceptance that something must be done. That “acceptance” has been preached by AA since its beginnings when it only worked with those who had fallen far down the scale. If the motivation is there then, perhaps, the key is to find the legitimate place where one finds comfort and compatibility.
Another note of interest is that most, perhaps all, of these groups promote abstinence. Today the “harm reduction” movement is in some instances suggesting that continued use is possible and a more effective strategy given that abstinence from day one has proven a high hurdle. We note this only as interesting and without prejudice to either approach.
Gene Gilchrist
April 2025
