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!!!!!!
Title&Below&please&list&the&title&of&this&resource.&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
!Building!Recovery!Capital:!Addiction,!Recovery,!and!Recovery!Support!Services!Among!Young!
Adults!
!
Author&Below&please&list&the&author(s)&of&this&resource."
!John!F.!Kelly,!Ph.D.!
!
Citation&Below&please&cite&this&resource&in&APA&style.&For&guidance&on&citation&format,&please&visit&
http://owl.english.purdue.edu/owl/resource/560/01/&
!Kelly,!John!F.!(2013).!Proceedings!from!the!4th!Annual!Collegiate!Recovery!Conference:! Building"
Recovery"Capital:"Addiction,"Recovery,"and"Recovery"Support"Services"Among"Young"Adults.!Lubbock,!
TX.!
!
Summary&Below&please&provide&a&brief&summary&of&this&resource.&If&an&abstract&is&available,&feel&free&to©&and&paste&it&here.&
!
John!F.!Kelly!of!Massachusetts!General!Hospital!and!Harvard!Medical!School!Department!of!Psychiatry!gave!this!presentation!during!the!4th!Annual!Collegiate!Recovery!Conference!held!at!
Texas!Tech!University,!April!35!2013.!
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!!!!!!
12step/community!mutualhelp!participation,!on!which!many!CRCs!are!based,!can!enhance!short!and!longterm!recovery!outcomes!and!simultaneously!reduce!health!care!costs!by!
reducing!reliance!on!professional!services!!
More!research!is!needed!specifically!on!young!adults!regarding!whether!they!may!benefit!more!or!less!from!different!types!of!services!and!supports,!including!optimal!levels!of!mutualhelp!
and!continuing!care!engagement!over!time!after!FSR!!!
!
!
!
!
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BUILDING RECOVERYCAPITAL:
ADDICTION, RECOVERY, AND
RECOVERYSUPPORT SERVICES
AMONGYOUNGADULTS
John F. Kelly, Ph.D.
Massachusetts General HospitalandHarvard Medical School
Department of Psychiatry
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OVERVIEW
A Brief word onterminology
Background andcontext
Recovery andRecovery Capital
and the Importanceof Education as
Recovery Capital
Theories ofRemission and
Recovery
Mutual-helporganization
research, recoverytheory, andimplications for
CRCs
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A WORDON TERMINOLOGYAND STIGMA
SUDs most stigmatized of all social/health problemsMost
Stigmatized
National surveys show stigma one of main reasons people withSUD do not seek specialty care (SAMHSA, 2009)Nationally
WHO examined 18 most stigmatized conditions (eg. criminal,HIV, homeless) across 14 different countries (Room et al 2001)
Drug addiction- #1 - most stigmatizedAlcohol addiction- 4th most stigmatizedInternationally
Ambivalence driven by stigma why only 10% seek specialtycarePoor access
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How we talk and write about these conditions andindividuals suffering them does matter
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TWOCOMMONLYUSEDTERMS
Referring to someone as
a substance abuser
having a substance use
disorder
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Substance-Related
TermSelf-Regulation(can they controlit?)
Causal Attribution(is it their own
fault?)
Social Distance/Social Danger(arethey dangerous?)
Punishment/
Treatment
3 Subscales: 1. Perpetrator- Punishment2. Social threat3.Victim-treatment
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Mr. Williams is a substance abuser and is attending a treatment programthrough the court. As part of the program Mr. Williams is required to remain
abstinent from alcohol and other drugs. He has been doing extremely well, untilone month ago, when he was found to have two positive urine toxicologyscreens which revealed drug use and a breathalyzer reading which revealedalcohol consumption. Within the past month there was a further urine toxicologyscreen revealing drug use. Mr. Williams has been a substance abuser for thepast six years. He now awaits his appointment with the judge to determine his
status.
Mr. Williams has a substance use disorder and is attending a treatmentprogram through the court. As part of the program Mr. Williams is required toremain abstinent from alcohol and other drugs. He has been doing extremelywell, until one month ago, when he was found to have two positive urine
toxicology screens which revealed drug use and a breathalyzer reading whichrevealed alcohol consumption. Within the past month there was a further urinetoxicology screen revealing drug use. Mr. Williams has had a substance usedisorder for the past six years. He now awaits his appointment with the judgeto determine his status.
Doctoral-level clinicians (n=516) randomized to receive one of two terms.
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14
Figure 1. Subscales comparing the substance abuser and substance use disorder descriptive labels
Kelly, JF, Dow, SJ, Westerhoff, C. Does our choice of substance-related terms influence perceptions of treatmentneed? An empirical investigation with two commonly used terms (2010) Journal of Drug Issues
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IMPLICATIONS
Even without being consciously aware of it, well traineddoctoral level clinicians judged the sameindividualdifferently and more punitively dependingon which termthey were exposed to
Use of the abuser term may activate a negativecognitive schema that perpetuates stigmatizing attitudes these could have broad stroke societal ramificationsfor treatment/funding
Individuals with eating related problems are uniformlydescribed as having an eating disorder NOT as foodabusers
Referring to individuals as suffering from substance usedisorders is likely to diminish stigma and may enhancetreatment and recovery
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OVERVIEW
A Brief word onterminology
Background andcontext
Recovery andRecovery Capital
and the Importanceof Education as
Recovery Capital
Theories ofRemission and
Recovery
Mutual-helporganization
research, recoverytheory, and
implications forCRCs
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DRUGAND ALCOHOLIMPACT
#1 public health problem (Institute for HealthPolicy, 2001; CASA, 2011)
Of all disease, disability, and deaths due to allpsych conditions, AUD alone = 36%
Public health
$500 billion in US each year (lost productivity,criminal justice, medical costs)
Excessive alcohol consumption costs society $2per drink (CDC, 2011)
Financial
SUD leading cause of mortality - alcohol leadingrisk factor worldwide among males 15-59
Opiate overdose leading cause of accidentaldeath nationwideMortality
Onset of long-term problems occur duringadolescence/young adulthood
90% adults with dependence start using before age18
50% of adults start using before age 15
Prevention
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Comparison of the magnitude of the ten leading diseases and injuries and the tenleading risk factors based on the percentage of global deaths and the percentage ofglobal DALYs, 2010
Figure shows 25 total diseases, injuries, and risk factors because some of the largest contributors to disability-adjusted life years (DALYs) were not in the top ten for deaths, and vice versa.
DALYs=disability-adjusted life years. IHD=Ischaemic heart disease. LRI=Lower respiratory infections. COPD=chronic obstructive pulmonary disease. HAP=household air pollution from solid fuels.BMI=body mass index. FPG=fasting plasma glucose. PM2.5Amb=ambient particular matter pollution. *Tobacco smoking, including second-hand smoke. (t)Physical inactivity and low physicalactivity
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ECONOMICCOSTSTOSOCIETY
Bouchery et al. (2011), CDC (2012), US Department of Justice (2011)
$0
$50
$100
$150
$200
$250
$300
$350
$400
$450
Alcohol and Illicitdrugs
Diabetes Obesity Smoking Heart disease
Economic cost (in billions)
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% USINGPRIORTOAGE 15
0%
5%
10%
15%
20%
25%
30%
35%
1934-1944 1945-1955 1956-1960 1961-1965 1966-1970 1971-1975 1976-1980 1981-1985 1986-1990
%u
sing Alcohol use
Marijuana
Cocaine
Hallucinogens
Adapted from: Johnson and Gerstein (1998) Am Jnl Public Health, 88, 1, 27-33
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PREVENTION
% MEETING DSM III R LIFETIME ALCOHOL
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% MEETING DSM-III-R LIFETIMEALCOHOLDEPENDENCECRITERIA
Adapted from: Rice, J. P., Neuman, R. J., Saccone, N. L., Corbett, J., Rochberg, N., Hesselbrock, V., & ... Reich, T. (2003).Alcoholism: Clinical And Experimental Research, 27(1), 93-99.
0%
5%
10%
15%
20%
25%
30%
35%
1910-1929 1930-1939 1940-1949 1950-1959 1960-1979
Male (n=509)
Female (n=545)
Birth Cohort
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SUBSTANCE USE DISORDERS (SUD) INTHE PAST
YEAR AMONG PERSONS AGE 12 OR OLDER
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PREVALENCEOF DSM-IV ALCOHOL DEPENDENCE
ACROSSTHE LIFESPAN (NESARC)
Source: Grant, Dawson et al, 2004
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SUBSTANCE USEAND PROBLEM ONSETAND OFFSET
NSDUH and Dennis & Scott
0
10
20
30
40
50
60
70
80
90
100
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
65+
No Alcohol or Drug Use
Light Alcohol Use Only
Any Infrequent Drug Use
Regular AOD Use
Abuse
Dependence
National Survey on Drug Use and Health (NSDUH) Age Groups
Severity Category
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SERIOUS PSYCHOLOGICAL DISTRESS(NSDUH, 2007)
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10
14
25 25
18
13
10
87
65
0
5
10
15
20
25
30
15-17 18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64
age
% Residential Change
GENERAL MOBILITY: 2011-2012 U.S. CENSUS
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WHYDOES SUD ONSETINYOUNGPEOPLE?DEVELOPMENTAL CONSIDERATIONS & RISKS
Desire forbidden (fermented) fruit associated with being grown up
New social freedoms with age of majority (i.e., 18 yrs = right to vote,serve on jury/military/marry) independent living (e.g., college),employment/$$$
Exhilarating abrupt cognitive shift in perceived control and self-determination, but objective psychobiological reality =continues to begradual developmental changes - impulse control, self-regulation, riskappraisal (Giedd et al, 1999).
Lower sensitivity to (psychomotor) negative impairments than adults(BUT, more sensitive to memory impairments)
So, desire for forbidden fruit & self-expression coupled withincongruency between subjective perceptions and objective realitycreates new risks & challenges particularly regarding alcohol/drugs
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REGIONAL VARIATION IN RATES OF PROBLEM USE
29
Figure 5.3 Alcohol Dependence or Abuse in Past Year among PersonsAged 18 to 25, by State: Percentages, Annual Averages Based on 2008and 2009 NSDUHs
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2008 and 2009
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REGIONAL VARIATION IN RATES OF PROBLEM USE
30
Figure 2.3 Illicit Drug Use in Past Month among Persons Aged 18 to 25,by State: Percentages, Annual Averages Based on 2008 and 2009NSDUHs
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2008 and 2009.
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COLLEGE YOUTH NATIONAL PREVALENCEOFSUBSTANCE USE
Full-time students: 49% engage in hazardoususe & 25% meet criteria for SUD (8.5% ingeneral population)
Consequences of substance misuse in
students: alcohol-related deaths/injuries, arrests, unplanned sex, sexualviolence, fights, poorer health, academic problems
College campus considered a pro-drug cultureand substance use is viewed as a harmlessrite of passage
37% of college students fear seeking helpbecause of social stigma, and of those whomeet the SUD criteria only 6% sought help(10% in general populations)
(Bell et al, 2009)
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Developmental Milestones: SUD in
emerging adults by College Enrollment
NSDUH: Heavy Alcohol Use among Adults Aged 18 to 22, by College Enrollment: 2002-2005
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HELP-SEEKINGBEHAVIORBYCURRENTCOLLEGEENROLLMENTSTATUS
Research Question: What is the utilization andperceived need for alcohol treatment servicesamong college-age young adults according to theireducational status?
Sample: 11,337 young adults (18-22 yrs) who wereeither full-time college students, part-time collegestudents, non-college students or nonstudents in
the United States
Study Design: Cross-sectional data from theNational Survey on Drug Use and Health (2002)
Wu L, Pilowsky DJ, Schlenger WE & Hasin D, (2007), Alcohol use disorders and the use oftreatment services among college-age adults Psychiatr Serv, 58(2): 192-200.
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LIKELIHOODOFTREATMENTUTILIZATIONAMONGYOUNGADULTSWHOMETCRITERIAFOR PPY AUD
Full-Time College
Part-Time College
Noncollege
Nonstudent
Odds of Treatment Utilization
Adjusted Odds Ratio
1.0 1.5 2.0 2.5 3.0
1.67
2.87
*
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OVERVIEW
A Brief word onterminology
Background andcontext
Recovery andRecovery Capital
and the Importanceof Education as
Recovery Capital
Theories ofRemission and
Recovery
Mutual-helporganization
research, recoverytheory, and
implications forCRCs
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Recovery capital (RC) is definedas the breadth and depth of
internal and external resourcesthat can be drawn upon to initiateand sustain recovery (Granfield &
Cloud, 1999; Cloud & Granfield,2004).
A
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Substance-related
Problems(physical and mental
health, housing, socialrelations, education and
employment, meaning and
purpose in life)
Addiction Severity
Recovery Capital(physical and mental
health, housing, social
relations, education andemployment, meaning and
purpose in life)
Addiction Remission
A
B
R CO CO S E C O B S R CO
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RECOVERYCONTEXTS: EDUCATION BASED RECOVERYSUPPORTS
College education trumped
money and social prestigeas the pathway to healthand happiness (Vaillant,2011)
Despite big differences
between core city sample andHarvard sample in parentalsocial class, college-testedintelligence, current incomeand job status, health declineof inner-city men who
obtained a collegeeducation was same asHarvard sample
Education representsimportant recovery capital
for young people (Vaillant & Mukamal, 2001, Am. Jnl. Of
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What are Recovery support services?
Why are they so important?
Residential recovery homes (e.g., OxfordHouses)
Recovery community centers (RCCs)
Peer-based Recovery support Education-based recovery support: high
school and college based recovery support for
young people Mutual-help organizations, like AA, NA, and
SMART Recovery
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AddictionOnset
HelpSeeking
Full SustainedRemission (1
year
abstinent)
Relapse Riskdrops below
15%
4-5 years 8 years 5 years
Self-
initiated
cessation
attempts
4-5
Treatment
episodes/mutual-
help
Continuing
care/
mutual-
help
Educational Recovery Capital (and CRCs) important given the
typical Clinical Course for Substance Dependence and Recovery
Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005).
Dennis, M. L., Scott, C. K., Funk, R., & Foss, M. A. (2005).De Soto, C.B., ODonnell, W.E., & De Soto, J.L. (1989).
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Despite education important to longterm health/well-being, college
environment recovery unfriendly -activities organized aroundalcohol/parties; recovery statussecret
Collegiate Recovery Communities(CRCs) provide safe place; sobriety-friendly network
Founding college programs:- Augsburg College
- Texas Tech University
- Rutgers (1st to offer on-campus residence hall forrecovering students)
Schools provide academic services
and assistance with recovery andcontinuing care, but they are nottreatment centers
No experimental/comparativeeffectiveness trials to estimateextent and nature of benefits
TEXAS TECH UNIVERSITY: SINGLE GROUP PRE
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TEXAS TECH UNIVERSITY: SINGLEGROUP PRE-POST DESIGN
To enter the CRC, students need to have 1 year of recovery,
attend at least 1 12-step on campus meeting per week, andsucceed in their classes
evaluation of the program: 2004-2005, N=82, (18-53 yrs old)
relapse rate within a semester was 4.4%; most maintainedhigh GPA
Source: Cleveland et al. (2007)
AUGSBURG COLLEGE
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AUGSBURG COLLEGESTEPUPPROGRAM
Support groups and sobriety-specific houses Outcomes Annual
avg relapserateacross13 yrs = 13%,
Down to abou7% in recent
R R H
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RUTGERS RECOVERY HOUSEDATA2008-2011
Source: Laitman & McLaughlin (2011)
Annualavg relapserateacross13 yrs = 6%
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DATAFROMRECOVERYHIGHSCHOOLS
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RECOVERY-RELATEDOUTCOMESAMONG 72RECOVERYHIGHSCHOOLGRADUATES
Surveys sent to Serenity High School alumnigraduating between 2000-2010
39% reported no drug/alcohol use in last 30 days(state of the art CYT study=25%)
More than 90% of participants reported enrolling incollege
Collegiate recovery environment may normalizeand destigmatize addiction/recovery increasing thechances of ongoing recovery or re-engagementwith recovery
Lanham CC & Tirado JA, (2011). Lessons in sobriety: an exploratory study of graduate outcomes at a recovery high school. Journalof Groups in Addiction and Recovery, 6:245-263.
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OVERVIEW
A Brief word onterminology
Background and
context
Recovery andRecovery Capital
and the Importanceof Education as
Recovery Capital
Theories ofRemission and
Recovery
Mutual-helporganization
research, recovery
theory, andimplications for
CRCs
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HOWDO CRCSAND RECOVERYSUPPORTSERVICESHELP? THEORIESOF REMISSIONAND RECOVERY
Studies of treatment are often theory-based (e.g,Longabaugh and Morgenstern, 2002; Moos, 2007)
However, studies of SUD remission and recoveryare very seldom theory-based
But, there are empirically supported theories thathelp explain the onset of substance use and SUD
These same theories may be useful in helpingexplain SUD remission and recovery
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The social contexts that underlie the
initiation and maintenance of substance
misuse may hold within them thepotential for resolution of the problems
they create
(Moos, 2011)
Parallels in the onset and offset of
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People want to use
substances for 4 main
reasons (NIDA, 2005):To feel good
To feel better
To do better
Because others are
doing it
Parallels in the onset and offset ofSUD
Parallels in the onset and offset of
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People want to use
substances for 4 main
reasons (NIDA, 2005):
People want to stop using
substances and recover for
the same 4 main reasons:To feel good To feel good
To feel better To feel better
To do better To do better
Because others are
doing it
Because others are
doing it
Parallels in the onset and offset ofSUD
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Theory Key process mechanisms for
Substance use Recovery
SocialControl Lack of strong bonds with family,friends, work, religion, other aspects
traditional society
Goal-direction, structure and monitoring,shaping behavior to adaptive social bonds
Social
Learning
Modeling and observation and
imitation of substance use, social
reinforcement for and expectations
of positive consequences from use;
positive norms for use
Social network composed of individuals
who espouse abstinence, reinforce negative
expectations about effects of substances,
provide models of effective sober living
Stress and
coping
life stressors (e.g.,
social/work/financial problems,
phys/sex abuse) lead to substance
use especially those lacking coping
and avoid problems; substance use
form of avoidance coping, self-
medication
Effective coping enhances self-confidence
and self-esteem
Behavioral
economics
Lack of alternative rewards provided
by activities other than substance
use
Effective access to alternative, competing,
rewards through involvement in
educational, work, religious,
social/recreational pursuits
Source: Moos, RH (2011) Processes that promote recovery from addictive disorders.
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COLLEGIATERECOVERYCOMMUNITIESTheory Key process mechanisms for
Substance use RecoverySocial
Control
Lack of strong bonds with family,
friends, work, religion, other aspects
traditional society
Goal-direction, structure and monitoring,
shaping behavior to adaptive social bonds
Social
Learning
Modeling and observation and
imitation of substance use, social
reinforcement for and expectations
of positive consequences from use;positive norms for use
Social network composed of individuals
who espouse abstinence, reinforce negative
expectations about effects of substances,
provide models of effective sober living
Stress and
coping
life stressors (e.g.,
social/work/financial problems,
phys/sex abuse) lead to substance
use especially those lacking coping
and avoid problems; substance use
form of avoidance coping, self-medication
Effective coping enhances self-confidence
and self-esteem
Behavioral
economics
Lack of alternative rewards provided
by activities other than substance
use
Effective access to alternative, competing,
rewards through involvement in
educational, work, religious,
social/recreational pursuits
Source: Moos, RH (2011) Processes the promote recovery from addictive disorders.
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ADDICTION RECOVERY MUTUALAIDORGANIZATIONSTheory Key process mechanisms for
Substance use RecoverySocial
Control
Lack of strong bonds with family,
friends, work, religion, other aspects
traditional society
Goal-direction, structure and monitoring,
shaping behavior to adaptive social bonds
Social
Learning
Modeling and observation and
imitation of substance use, social
reinforcement for and expectations
of positive consequences from use;positive norms for use
Social network composed of individuals
who espouse abstinence, reinforce negative
expectations about effects of substances,
provide models of effective sober living
Stress and
coping
life stressors (e.g.,
social/work/financial problems,
phys/sex abuse) lead to substance
use especially those lacking coping
and avoid problems; substance use
form of avoidance coping, self-medication
Effective coping enhances self-confidence
and self-esteem
Behavioral
economics
Lack of alternative rewards provided
by activities other than substance
use
Effective access to alternative, competing,
rewards through involvement in
educational, work, religious,
social/recreational pursuits
Source: Moos, RH (2011) Processes the promote recovery from addictive disorders.
SOCIALSUPPORTINCOLLEGIATERECOVERY
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COMMUNITIESMAYBEANALOGOUSTOTHEMEDIATINGEFFECTSSEENIN 12-STEPRESEARCH
Humphreys K, Mankowski ES, Moos RH & Finney JW (1999). The effect of self-help
groups on substance abuse?. Ann Behav Med 21(1):54-60
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AAATTENDANCEANDTHE % CHANGEINBOTHPRO-ABSTINENTANDPRO-DRINKINGNETWORKTIESFROMTREATMENTINTAKETOTHE 9-M
(OP SAMPLE)
Source: Kelly et al, 2011, Drug and Alcohol Dependence
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AAATTENDANCEANDTHE % CHANGEINBOTHPRO-ABSTINENTANDPRO-DRINKINGNETWORKTIESFROMTREATMENTINTAKETOTHE 9-M
(AC SAMPLE)
Source: Kelly et al, 2011, Drug and Alcohol Dependence
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IS THE SOCIAL SUPPORT MODEL APPLICABLE
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ISTHESOCIALSUPPORTMODELAPPLICABLETOCOLLEGIATERECOVERYCOMMUNITIES?
Sample: 84 students participating in acollegiate recovery community (4 sites)
Study Design: cross-sectional survey
CastiraghiAM (2012). Students perceptions of social support and recovery:
The social support model used in replicating collegiate recovery communities.M.S. Thesis, Texas Tech University
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CASIRAGHITHESISSOCIALSUPPORTSUBGROUPS
Appraisal: emotional support consisting of caring,empathy, trust and love; having someone readilyavailable to talk to about your problems
Belonging: companionship; establishment of mutually
valuable relationships through participation in socialactivities
Tangible: instrumental support consisting of materialitems (e.g. food, clothing, furniture, financial help, orspecific behavioral aid such as transportation)
Validation: expression that optimistically influences apersons sense of self worth; confirmation of theappropriateness or normalcy of a persons behaviorthrough social comparison
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ISSOCIALSUPPORTASSOCIATEDWITHRECOVERYQUALITYINCOLLEGIATERECOVERYCOMMUNITIES?
Sub-groups of social support (e.g. appraisal, belonging,tangible, validation)werent independently predictive ofrecovery quality
Overall social support was directly associated withrecovery quality
Younger students perceived greater amounts of
recovery
Conclusion: A holistic approach to social supportinvolving all 4 elements of support may benefitrecovering students
CastiraghiAM (2012). Students perceptions of social support and recovery: The social support model used in replicating collegiate recoverycommunities. M.S. Thesis, Texas Tech University
THEORYBASEDCOMPARISONBETWEENCOLLEGEAS
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USUAL VS. CRC FORRECOVERINGSTUDENTSCollege-as-usual CRC
Socialcontrol
Maladaptive social bonds;hazardous/harmful substanceuse; antisocial behavior; let itall hang out
Adaptive social bonds; pro-socialnorms; monitoring/supervision;emphasis on education andachievement
Social
learning
Norm is party; alc/drug use
modeled and reinforced;stigma associated with help-seeking
Norm is sobriety and recovery;
abstinence reinforced; stigma/shamereduced with validation and praise forrecovery status; help-seeking stronglyencouraged
Stress andcoping
Substance use is predominantcoping strategy; substance
induced confidence; avoidancecoping
Community predominant copingstrategy; genuine confidence; approach
coping; focus on positive experienceand academic achievement
Behavioraleconomic
Substance use predominantreinforcer for commiseration orcelebration
Effective provision of alternativerewarding behaviors; successexperience; validation
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OVERVIEW
A Brief word onterminology
Background and
context
Recovery andRecovery Capital
and the Importanceof Education as
Recovery Capital
Theories ofRemission and
Recovery
Mutual-helporganization
research, recovery
theory, andimplications for
CRCs
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CRCs and building Social Recovery
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CRCs and building Social Recovery
Capital
Most CRCs are based on 12-step principlesand require 12-step attendance
Does 12-step participation help young people?How much participation should berecommended?
How can CRCs benefit from the knowledgegained from 12-step research?
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Young Adults and Mutual-help
0rganization Participation
Youth Barriers to 12-step Mutual help
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Youth Barriers to 12-step Mutual help
participation
Only about 14% under the age of 30 in AA andNA
May create barriers to identification/sense of
belonging: Addiction specific (young adults more polydrug
use; less addiction severity/medical sequelae)
Different life stage/life context differences: less
likely to be married/have children Spiritual emphasis less appealing
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Adolescent 12-step Participation across 8
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Adolescent 12 step Participation across 8
Years into emerging adulthood
Participants (N=166; 40% female; M age 16;75% Caucasian) consecutive admits toadolescent 12-step oriented, inpatient, SUDprograms in San Diego (M stay = 4 wks)
Followed at 6m and 1, 2, 4, 6, and 8yrs (follow-up rates > 84%)
Neither demographic nor tx/clinical vars foundassociated with follow-up (ps>.27).
Source: Kelly, Brown, Abrantes et al, 2008; Alcoholism: Clinical Experimental Research
Results: Rates of Attendance
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Results: Rates of Attendance
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-6m 6m-1yr 1-2yr 2-4yr 4-6yr 6-8yr
Follow-Up
%A
ttending
AA/NA
Any
Monthly
Weekly
Any, Monthy, and Weekly AA/NA Attendance across 8 Years
Following Inpatient Treatment
Source: Kelly, J.F., Brown, S. A., Abrantes, A., Kahler, C. H., & Myers, M. (2008) Social Recovery Model: An 8-
year Investigation of adolescent 12-step group participation following inpatient treatment. Alcoholism:Clinical and Experimental Research.
Percent of Youth in Each Trajectory Outcome Group attending AA/NA at least Weekly
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0
10
20
30
40
50
60
70
80
90
100
6m 12m 24m 48m 72m 96m
%At
tendingAA/NAweekly
Time
Percent of Youth in Each Trajectory Outcome Group attending AA/NA at least Weeklyacross 8 Years
Abstainers
Infrequent User
worse with time
Frequent User
Lagged GEE Model of Youth Treatment Outcome in relation
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gg
to AA/NA attendance over 8 Years
Parameter Estimate Standard Error 95% Confidence
Limits
Z P
Intercept 37.3071 6.9601 23.6656 50.9486 5.36
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75
Kelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of Youth Treatment
Outcome in Relation to 12-step Group Involvement.Alcoholism: Clinical and Experimental Research, 2008, 32, 8
1468-1478.
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Results: Significant independent effects for attendance on abstinence from all drugs and
reduced heavy alcohol use, and stronger effects for 12-step involvement (lagged, controlled,
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prospective models)
Relation between Age Composition of Attended Meetings and
f
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All teensMostly teensEven mixMostly adultsAll adults
100
95
90
85
80
75
70
65
60
55
50
Days Abstinent (3m)
Days Abstinent (6m)
Percent Days Abstinent for Adolescents
Kelly, Myers & Brown, (2005)Journal of Child and Adolescent Substance Abuse
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I li i f CRC ?
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Implications for CRCs?
12-step participation, particularly active involvement, appears to help young adultsmaintain recovery across time
Homogeneity in terms of young adults may be helpful in terms of engaging youngpeople with CRCs, but being too exclusive on age may limit the benefits that eithergreater life experience or longer recovery confers
Having a mix of age (life-experience) and different lengths of recovery may beoptimally therapeutic
There are observed relationships between 3x/week attendance and completeabstinence early post treatment; recommended or required attendance frequencyafter achieving full sustained remission is unclear
However, given that the risk of relapse after full sustained remission doesnt dropbelow 15% until 5 yrs, regular, weekly or twice weekly attendance or more (especially in the first year re-enrolling in college) may provide continued recovery-specific support and help buffer stress of adapting to high risk environment
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CRCs: Cost-efficient Model of Recovery Support through
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facilitating 12-step involvement?
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HEALTH CARECOSTOFFSET
CBT VS 12 STEP RESIDENTIAL TREATMENT
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$12,129
$7,400
$5,735
$2,440
$17,864
$9,840
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000$14,000
$16,000
$18,000
$20,000
CBT TSF
Year 1
Year 2
Total
CBT VS 12-STEP RESIDENTIAL TREATMENT
Compared to CBT-
treated patients, 12-step treated patients
more likely to be in
recovery, at a $8,000
lower cost per pt
over 2 yrs ($15M
total savings)
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The first study to examine how 12-Step participation affectsmedical costs in adolescents with SUD
4 intensive outpatient programs
N = 403 adolescents, age 13-18
66% male; mean age 16.1; 49% White
Comorbid ADHD: 17%, depression: 36%
Follow-up: 6 months, 1, 3, 5, and 7 years
Difference-in-difference model was used
Source: Mundt, Parthasarathy, Chi, Sterling, Campbell (2012)
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Patients attending 12-step meetings had
better substance use outcomes
4.7% decrease in medical costs with each
additional 12-step meeting attended =
$145 annual savings per 12-step
meetings attended
Source: Mundt, Parthasarathy, Chi, Sterling, Campbell (2012)
How might MHOs like AA reduce relapse risk and aid the recovery process?Do these mechanisms differ for different people?
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89
Social
Psych
Bio-Neuro
RELAPSE
Cue Induced
Stress Induced
Drug Induced
Do these mechanisms differ for different people?
MHO
Path diagram of the lagged mediational model for inpatient vs. outpatient and men vs. women.
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90
(9-mo) Self-efficacyNegative Affect
Baseline (BL) CovariatesAge
Race
Marital status
Employment status
Prior alcohol treatment
MATCH treatment group
MATCH study site
Alcohol outcomes (PDA/DDD)
(15-mo) Alcohol Outcomes(PDA or DDD)
(3-mo) AA Attendance
(BL) Self-efficacyNegative Affect
(9-mo) Self-efficacyPositive Social
(BL) Self-efficacyPositive Social
(9-mo) Spiritual/ReligiousPractices
(BL) Spiritual/ReligiousPractices
(9-mo) Depression(BL) Depression
(9-mo) Social Networkpro-abstinence
(BL) Social Networkpro-abstinence
(9-mo) Social Networkpro-drinking
(BL) Social Networkpro-drinking
DOMOREANDLESSSEVERELYALCOHOLDEPENDENTINDIVIDUALSBENEFITFROM AA INTHESAMEORDIFFERENTWAYS?
ff t f AA
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Self-efficacy
(NA)
5%
Depression
3%
Spirit/Relig
23%
Self-efficacy
(Soc)
34%
SocNet: pro-
abst.
16%
SocNet: pro-drk.
24%
Aftercare (PDA)
Self-efficacy
(NA)
1%
Depression
2% Spirit/Relig
6%
Self-efficacy(Soc)
27%
SocNet: pro-
abst.
31%
SocNet: pro-drk.33%
Outpatient (PDA)
Self-efficacy
(NA)
20%
Depression
11%
Spirit/Relig
21%
Self-efficacy
(Soc)
21%
SocNet:
pro-abst.
11%
SocNet: pro-drk.16%
Aftercare (DDD)
Self-efficacy
(NA)
1%
Depression
5%
Spirit/Relig
9%
Self-efficacy
(Soc)
39%
SocNet: pro-
abst.
17%
SocNet: pro-drk.
29%
Outpatient (DDD)
91
effect of AA onalcohol use for
AC wasexplained bysocial factors
but also by S/Rand throughnegative affect(DDD only)
Majority ofeffect of AA onalcohol use forOP wasexplained bysocial factors
Source: Kelly, Hoeppner, Stout, Pagano (2012) , Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous:A multiple mediator analysis.Addiction 107(2):289-99
DOMENANDWOMENBENEFITFROM AA INTHESAMEWAYS?PERCENTAGEOFEFFECTOF AAATTENDANCEONOUTCOMES (PDA; DDD) FORMENANDWOMENACCOUNTED
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FORBYTHESIXMEDIATORS
92
MODERATED-MECHANISMS: AA EFFECTS
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MODERATED MECHANISMS: AA EFFECTSMODERATEDBY SEVERITYAND GENDER
CONCLUSIONS
Recovery benefits derived from AA differ in nature and magnitude betweenmore severely alcohol involved/impaired and less severely alcoholinvolved/impaired; and between men and women
These differences reflect differing needs based on recovery challengesrelated to differing symptom profiles, degree of subjective suffering andperceived severity/threat, recovery challenges, and gender-based socialroles & drinking contexts
Similar to psychotherapy literature (Bohart & Tollman, 1999) rather thanthinking about how AA or similar organizations work, better to think howindividuals use or make these organizations work for them to meettheir most urgent needs at any given phase of recovery
SO, COLLEGIATERECOVERYPARTICIPANTSMAYUSEDIFFERENT ASPECTS DIFFERENTLY
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DIFFERENTASPECTSDIFFERENTLYTheory Key process mechanisms for
Substance use Recovery
Social
Control
Lack of strong bonds with family,
friends, work, religion, other aspects
traditional society
Goal-direction, structure and monitoring,
shaping behavior to adaptive social bonds
Social
Learning
Modeling and observation and
imitation of substance use, social
reinforcement for and expectations
of positive consequences from use;positive norms for use
Social network composed of individuals
who espouse abstinence, reinforce negative
expectations about effects of substances,
provide models of effective sober living
Stress and
coping
life stressors (e.g.,
social/work/financial problems,
phys/sex abuse) lead to substance
use especially those lacking coping
and avoid problems; substance use
form of avoidance coping, self-medication
Effective coping enhances self-confidence
and self-esteem
Behavioral
economics
Lack of alternative rewards provided
by activities other than substance
use
Effective access to alternative, competing,
rewards through involvement in
educational, work, religious,
social/recreational pursuits
Source: Moos, RH (2011) Processes the promote recovery from addictive disorders.
HOW MIGHTTHESEFINDINGSINFORMCOLLEGIATE
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RECOVERY RELAPSEPREVENTIONEFFORTS?
12-step basis and related TSF focus in CRCs may prove to be acost-efficient method for maintaining recovery over time
Perhaps the social relapse risks - although generally a morepotent precursor among youth than adults - is relatively more
important for males than females, whereas negative affect maybe a more important factor for females
More research is needed in this regard
However, in general, sensitivity to mood regulation needs amongwomen may reduce relapse risk and enhance quality of life;sensitivity to social risk needs among young men may boostsocial self-efficacy and reduce relapse risk
TSF Delivery ModesT
S
O
T
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TSF Delivery ModesSF
T
H
Component of a treatment package
(e.g., an additional group)Stand alone
Independent therapy
Integrated into an existing
therapy
As Modular appendagelinkage component
e.g., Timko et al, (2006; 2007;
2011); Kahler et al, (2005);
Sisson and Mallams, (1981)
e.g., Kaskutas et al, (2009)e.g., Walitzer et al, (2008);
Litt et al, (2009)
e.g., Project MATCH
Research Group (1997); Litt
et al, (2009)
Research on
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alternativeMHOs
scarce
It is likely that many of theti i di t i 12 t
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active ingredients in 12-stepMHOs are also active in
other MHOs and maymobilize the same kinds of
intrinsic processes as do 12-step
ARE SOCIAL NETWORKS A CAUSAL MECHANISM IN
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ARESOCIALNETWORKSACAUSALMECHANISMINRECOVERYPATHWAYS?
Employed propensity score stratification (e.g., Dehejia and Wahba,2002), designed to minimize impact of selection biases due to
measured covariates.
No statistical adjustment can completely eliminate chance that an
unknown factor is responsible for improvement/deterioration that
appears to be correlated with a change in social networks. However,propensity stratification methods represent the state of the
statistical art in this domain (Rubin, 2006), and have been rarely
utilized in addiction research
Source: Stout, Kelly, Magill, Pagano (2012) Journal of Studies on Alcohol and Drugs
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ARESOCIALNETWORKSACAUSALMECHANISMINRECOVERYPATHWAYS?
Predictor variables selected based on prior research or theoryindicative of an association between each proposed predictorvariable and at least one of the social network measures
23 baseline and 3m (AA only) predictors of social networks were
used in propensity analysis
If significant effect of the variable of interest after propensity scoreadjustment then there is stronger evidence that this plays a causal
role on the outcome; if not, then assumed that the variables
relationship to outcome is accounted for by other variables and is notcausal
100
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101
Pro-drinkers and pro-abstainer networkvariables were found toexert enduring influenceacross a 3yr period over
and above that of otherinfluential socialorganizations like AA
OVERVIEW
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OVERVIEW
A Brief word on
terminology
Background and
context
Recovery andRecovery Capitaland the Importance
of Education asRecovery Capital
Theories ofRemission and
Recovery
Mutual-helporganization
research, recovery
theory, andimplications forCRCs
SUMMARY
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SUMMARY The way we talk and write about individuals with substance-related problems may
trigger certain cognitive schemas that can have unwanted consequencesas withthe eating disorders field, use of substance use disorder terminology may helpreduce stigma and increase treatment access/engagement
Recovery capital is a key component of the recovery construct and education isassociated with building self-esteem and hope for a better future that may have
physicalas well as psychological and emotional health benefits (i.e., holistic)
CRCs provide young adults a de-stigmatizing and self-actualizing recoverynormative environment that promotes and provides adaptive social bonds, copingskills, and competing rewards as they attempt to achieve major milestones
12-step/community mutual-help participation, on which many CRCs are based, can
enhance short and long-term recovery outcomes and simultaneously reduce healthcare costs by reducing reliance on professional services
More research is needed specifically on young adults regarding whether they may