by William L. White, MA
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).
Alcoholics Anonymous and other 12-Step Self-Help Groups
Bill White: The question of the effects of participation in Alcoholics Anonymous on long-term recovery outcomes continues to be a subject of considerable scientific controversy, and yet the conclusions of your studies are consistent on this question.
Dr. Moos: There may be less controversy now than in the past about the positive benefits of participation in AA and other 12-step self-help groups. In fact, there is remarkable generality in the association between participation in 12-step self-help groups and better substance use outcomes. This finding holds for individuals with alcohol and/or drug use disorders after inpatient treatment, day-hospital treatment and outpatient treatment, as well as for patients in continuing telephone care. It also holds for individuals who have both substance use and psychiatric disorders, and for women, youth and older adults.
Another consistent finding is that individuals who continue to attend self-help groups over a longer interval are more likely to maintain abstinence than are individuals who stop attending. For example, our prospective study of individuals with alcohol use disorders showed that a longer duration of AA attendance in the first year after seeking help was associated with a higher likelihood of one-year, eightyear and sixteen-year abstinence. After controlling for the duration of AA attendance in year one, the duration of attendance in years two to three and four to eight was related to a higher likelihood of sixteen-year abstinence. Thus, individuals who continued to attend AA regularly over the long term tended to experience better substance use outcomes than those who did not.
Bill White: How do the effects of AA and treatment combined differ from their effects in isolation?
Dr. Moos: In general, participation in AA seems to confer more benefit than participation in treatment. Individuals who participate in treatment and AA do not appear to obtain much more long-term benefit than do individuals who participate only in AA. However, these conclusions are based on individuals who self-selected participation in treatment and/or AA. Moreover, many individuals find treatment more palatable than AA and either do not enter AA or drop out of AA. Accordingly, treatment is important for those individuals who choose it as the most suitable option for obtaining help.
Bill White: You and Keith Humphreys have conducted one of the few studies on the cost-effectiveness of AA.
Dr. Moos: One of our studies examined differences in outcomes, alcoholism treatment utilization and costs between individuals with alcohol use disorders and no prior treatment history who chose to attend AA or to seek help from a professional outpatient treatment provider. Over the three-year study, per-person treatment costs for the AA group were 45 percent (or $1,826) lower than were costs for the outpatient treatment group. Despite the lower costs, both one-year and three-year substance use outcomes for the AA group were comparable to those of the outpatient treatment group. These findings held even though, at baseline, individuals who chose to attend AA had lower incomes and less education, and experienced more adverse consequences of drinking than did those who sought outpatient care, indicating somewhat worse prognoses for the AA group. This suggests that voluntary participation in AA may significantly reduce professional treatment costs.
Another study evaluated whether, compared to patients in cognitivebehavioral (CB) programs, patients treated in 12-step programs—which more strongly emphasize participation in AA—relied less on professionally provided services and more on self-help groups after discharge, thereby reducing long-term healthcare costs. Compared with patients treated in CB programs, matched patients treated in 12-step programs were more involved in self-help groups at one-year follow-up. In contrast, patients treated in CB programs averaged almost twice as many outpatient continuing care visits after discharge than did patients treated in 12-step programs, and they also received more days of inpatient care, resulting in 64 percent higher annual costs in CB programs, or $4,279 per patient. Substance use and psychiatric outcomes were comparable across treatments, except that 12-step patients had higher rates of abstinence at one-year follow-up. The findings were comparable at two-year follow-up. Thus, professional treatment programs that emphasize self-help approaches appear to increase their patients’ reliance on cost-free self-help groups and thereby lower subsequent healthcare costs.
Remission and Recovery
Bill White: Most addiction-related research focuses on the study of addiction-related pathologies, treatment effects and relapse processes. In contrast, your work has emphasized how people recover. How did you come to develop this recovery perspective?
Dr. Moos: This developed from my experiences as a child and young adult and, perhaps unexpectedly in light of these experiences, from an underlying optimistic view of life. My early years were difficult ones, as I was separated from my parents and lived in several places before we were able to come to the United States. I knew many people who lived through substantial traumas, such as the loss of all their possessions, sudden imprisonment in a concentration camp, forced emigration from their motherland, the experience of abject poverty, and the need to learn a new vocation and establish an entirely new life in a distant country. Nevertheless, the majority of these people confronted and surmounted their problems. This left me with the feeling that most life crises can be overcome and that there always is hope for the future. In my clinical work with substance use and psychiatric disorders, I felt that this same principle applied.
Bill White:What do we know scientifically about the prevalence of recovery in the United States?
Dr. Moos: We do not have sufficient data to estimate the nationwide prevalence of recovery, assuming that recovery is defined as five years or more of stable remission. However, long-term follow-up studies of individuals with alcohol use disorders in community samples, who were largely untreated, have obtained remission rates varying from 27 percent to 69 percent, with an annualized rate of 3.4 percent. Long-term follow-ups of individuals treated for alcohol use disorders have identified remission rates ranging from 21 percent to 86 percent, with an annualized rate of 5.3 percent. (Note: the annualized rate is the percentage of all people who meet the criteria for alcohol or drug use disorder who achieved remission—no longer meeting diagnostic criteria for a substance use disorder—in a given year.) These findings suggest that remission rates for treated individuals with alcohol use disorders may be somewhat higher than for those who remain untreated; however, this conclusion needs to be tempered by the fact that there are many differences between these two groups of individuals other than their treated or untreated status. Long-term follow-ups of individuals dependent on drugs (primarily cocaine and opioids) have obtained remission rates varying from 30 percent to 90 percent, with an average annual rate of 4 percent. There do not appear to be any comparable longterm outcome studies of community samples (untreated) of individuals with these types of drug use disorders.
Bill White:A central question that pervades your work is why some people recover while others escalate their drinking with such tragic outcomes.
Dr. Moos: A host of factors helps to initiate and maintain the recovery process. One key triggering factor is cognitive evaluation and reappraisal, which guides and synthesizes efforts at problem identification and resolution. Some individuals reevaluate their behavior when they face severe problems related to substance misuse, such as a serious health, financial or legal problem; an accident; pressure from important people in their lives; personal humiliation; or a temporary loss of control. Inspiration can also come from the hope that change and a better life are possible.
Maintenance factors help to nurture and sustain the recovery process. These factors include support from a spouse or partner, extended family, an employer and friends; changes in lifestyle and social activities; less tolerance of and growing physical aversion to the abused substance; and an emerging sense of self-efficacy, commitment, accomplishment and pride at achieving sobriety. When individuals decide to change their lives, influences from treatment and self-help groups can serve as maintenance factors and help them (individuals in recovery) develop better personal and social resources.
Other factors in people’s lives, including life stressors, social resources and coping skills, also influence the resolution of addictive disorders. People’s active efforts to confront and manage their life circumstances are important. In this respect, individuals who rely more on approach coping (active problem solving, seeking guidance and support) and less on avoidance coping (cognitive avoidance, emotional discharge) tend to be more successful in managing life crises and their consequences and more likely to achieve stable remission and recovery.
Pathways to Recovery
Bill White:You were among the first researchers to study the durability of natural recovery versus recovery supported by participation in addiction treatment or a recovery mutual-aid society.
Dr. Moos: In our study of initially untreated individuals with alcohol use disorders, compared to those who obtained help, those who did not obtain help were less likely to achieve threeyear remission and subsequently were more likely to relapse. More specifically, by a three-year follow-up, 62 percent of individuals who obtained help (participated in treatment or AA) were remitted (no longer met DSM-IV criteria for an alcohol use disorder), compared with only 43 percent of those who obtained no help. By a sixteen-year follow-up, 61 percent of the three-year remitted individuals in the no help group had relapsed, compared with only 43 percent of three-year remitted individuals in the helped group. These findings support the idea that participation in professional treatment and/or self-help groups may heighten the likelihood of short-term and stable remission.
Predictors of Recovery
Bill White:One of the traditional predictors of recovery has been that of verbalized motivation to change. Is the ability or inability to verbalize motivation for recovery a predictor of long-term recovery outcome?
Dr. Moos: Clinical lore and some research suggest that individuals who verbalize strong motivation for recovery are more likely to achieve positive substance use outcomes. However, our studies have not found much if any association between an individual’s “stage of change” at baseline or entry to treatment and the likelihood of remission. Moreover, although these findings are somewhat controversial, individuals who are court-mandated to treatment (and therefore presumably have relatively little intrinsic motivation to change), appear to show substance use outcomes that are as good as those of individuals who enter treatment voluntarily (and therefore presumably have more motivation to change). I think that the verbalization of motivation to change at baseline or treatment entry is not a strong predictor of recovery because it is highly amenable to change over time.
Bill White: The addictions field has traditionally viewed predictors of recovery as residing within the individual, but your work suggests a complex interaction of personal characteristics, characteristics of the treatment milieu, and the nature of the post-treatment family and social environment.
Dr. Moos: We compared the predictive strength of these three sets of factors in one of our follow-ups of individuals with alcohol use disorders who were treated in residential programs. In brief, patient characteristics at treatment entry predicted only about 1 percent of the variance in six-month alcohol consumption and abstinence outcomes, whereas treatment characteristics predicted about 7 to 8 percent. The combination of patient and treatment factors predicted another 6 percent of the variance in outcome. Thus, the quality of the treatment environment in residential programs was a more important predictor of short-term alcohol-related outcomes than were patient characteristics at intake.
In a two-year follow-up of a portion of this sample, patient characteristics at intake accounted for 7 percent of the variance in the alcohol-related outcome criteria, treatment factors accounted for about 2 percent, and life context and coping factors accounted for an added 15 percent. These findings are consistent with the growing literature in this area, which shows that treatment has some short-term positive influence on outcome, but that this modest effect diminishes over time. Consideration of life context and coping factors more than doubled the explained variance in two-year outcome over that accounted for by patient characteristics at baseline and treatment factors.
Role of Family and Community in Recovery
Bill White: Could you highlight your work on the influence of the family and social milieu on recovery outcomes?
Dr. Moos: Our findings have highlighted the importance of individuals’ life contexts in helping to shape the recovery process. Our initial work found that family cohesion, expressiveness and organization predicted better long-term outcomes. In subsequent studies, we showed that better relationships with friends, spouse/ partner and extended family members predicted a higher likelihood of remission. Conversely, when there were more interpersonal stressors in relationships with a partner, and the partner had a substance use problem, patients experienced poorer substance use outcomes.
We recently examined indices of personal and social resources as predictors of medium- and long-term alcohol use disorder outcomes. In general, protective resources associated with social learning (self-efficacy and approach coping), behavioral economics (health and financial resources and resources associated with AA) and social control theory (bonding with family members, friends and coworkers) predicted better alcohol-related and psychosocial outcomes.
Bill White: If we as a field truly understood this influence, how might we be “treating” the family and the community environment of each patient?
Dr. Moos: We know that substance use treatment is quite successful in achieving cessation or reduction in substance use and improvements in other areas of functioning in the short run, but that these positive changes do not tend to be maintained over time. Patients’ life contexts and coping skills often are thought to be peripheral to treatment, but they continue long after treatment, are more pervasive and intense and have a stronger impact on outcome. Thus, treatment should be oriented more toward strengthening natural recovery processes and improving patients’ life contexts and their ability to manage these contexts.
I recommend more emphasis on identifying potentially alterable characteristics of patients and their life contexts and using this information in the treatment process to promote better outcome. In addition, because patients and their family members and friends influence each other, we need to regularly evaluate the status of the patients’ family and social system.
Bill White: How would you describe the potential role of addiction treatment in long-term recovery?
Dr. Moos: Intensive residential treatment and continuing halfway house and/or outpatient care can play an important role in increasing the likelihood of short-term and stable remission. Participation in treatment can strengthen an individual’s motivation to change; provide role models who espouse abstinence-oriented norms and effective coping skills; establish a supportive, goal-directed and structured environment that can serve as a respite from a stressful life context; offer rewarding activities that can take the place of substance use; and promote improvement in an individual’s self-efficacy and coping skills. In general, however, treatment can only provide these benefits in the short-term, although newer approaches of adaptive and continuing care may help support individuals over more extended time intervals. In the long-term, however, personal and life context factors, such as supportive, goal-directed and well-organized family and social settings, hold the key to stable remission and recovery.
Bill White: You have been involved in studies of the relative effectiveness of cognitive behavioral and 12-step facilitation treatments. What were the major findings of these studies?
Dr. Moos: We studied over 3,000 patients from 15 residential substance use treatment programs in the Department of Veterans Affairs (VA). On average, patients showed considerable improvement at one-year, two-year and five-year follow-ups. Patients in 12-step programs, compared to those in cognitive-behavioral (CB) and eclectic programs were somewhat more likely to be abstinent and free of substance use problems at the oneyear follow-up, as were patients with more extended continuing outpatient mental health care and 12-step selfhelp group involvement. Consistent with their better one-year outcomes, patients in 12-step programs improved more between intake and discharge than did CB patients on proximal outcomes assumed to be specific to 12-step treatment (e.g., disease model beliefs), and as much or more on proximal outcomes assumed to be specific to CB programs (e.g., self-efficacy and coping skills). These findings are consistent with the fact that we did not find any patient-program matching effects; that is, there was no evidence that 12-step or CB treatment was more beneficial for certain types of patients.
Potentially Harmful Effects of Treatment
Bill White: You are one of the few researchers to study the potential for harm in the name of help within the addiction treatment arena. How prevalent are such iatrogenic effects in addiction treatment?
Dr. Moos: If we believe that treatment has curative power and contributes to patients’ improvement, we must consider the possibility that, at times, treatment may have iatrogenic effects and contribute to patients’ deterioration. In a review of relevant studies, we found that between 7 percent and 15 percent of patients who participate in psychosocial treatment for substance use disorders may be worse off subsequent to treatment than before. Probable intervention-related predictors of deterioration include lack of bonding; lack of monitoring; confrontation, criticism and high emotional arousal; modeling of substance use and aspects of deviant behavior; and stigma, low or inappropriate expectations and lack of challenge.
Bill White: What actions can addiction professionals take to avoid such injuries to their patients?
Dr. Moos: Clinicians should be especially attentive to adverse effects when they employ high-risk treatment procedures, such as confrontation and personal criticism, or highly expressive and emotion arousing interventions, such as encouraging patients to re-experience personal traumas. These interventions may elicit sharp increases in anxiety and anger and exacerbate substance use and symptoms, especially among vulnerable and disturbed patients. More broadly, patient safety standards and monitoring procedures should be developed to routinely obtain information about specific adverse events (in addition to the intent to harm oneself and other people) and potential iatrogenic effects associated with psychosocial interventions, as is the practice for pharmacological treatment.
Dropout from Treatment and AA
Bill White: You have also conducted studies that examined factors related to people dropping out of treatment and AA.
Dr. Moos: In studies of residential treatment, we found that programs that are low on involvement and support, do not emphasize patient personal growth—especially autonomy— and unstructured, and have relatively few social activities and little emphasis on detailed planning of patients’ activities. Overall, these programs lack support, goal direction and structure.
With respect to 12-step self-help groups, we found that 40 percent of patients who attended these groups had dropped out by one-year follow-up. A number of patient characteristics at baseline predicted dropout, including less motivation to change, less belief in the disease model of addiction, less prior 12-step self-help involvement, and less social and religious involvement. Importantly, patients at high risk for dropout were less likely to drop out when they were treated in a more supportive environment. Clinicians may decrease the likelihood of dropout directly by screening for baseline risk factors for dropout and focusing facilitation efforts accordingly, and indirectly by increasing the supportiveness of the treatment environment and facilitating 12-step involvement during treatment.
Principles of Addiction Treatment and Recovery
Bill White: Are there underlying principles that are emerging from your research studies on addiction treatment and recovery?
Dr. Moos: I would summarize my earlier comments by highlighting three general principles based on my own work and that of other investigators.
Principle 1. Treated or untreated, an addiction is not an island unto itself.
People with addictive disorders exist in a complex web of social forces. Formal treatment can be a compelling force for change, but it typically has only an ephemeral influence. In contrast, relatively stable factors in people’s lives, such as informal help and ongoing social resources, tend to play a more enduring role. The fact that the evolving conditions of life play an essential role in the process of remission from addictive disorders is a hopeful sign. It implies that these disorders need not become chronic, that individuals who are able to establish and maintain relatively positive social contexts are likely to recover and that treatment directed toward improving individuals’ life circumstances is likely to be helpful.
Principle 2. Common dynamics underlie the process of problem resolution that occurs in formal treatment, informal care and “natural” recovery.
Individuals trying to resolve substance use problems usually begin by using one or more sources of informal help, such as a family member or friend, a physician or member of the clergy or AA or another self-help group. If such attempts fail repeatedly, some individuals enter formal treatment. On average, these individuals have more severe problems and more difficult life contexts, and are more impaired than individuals who resolve problems on their own or with informal help; outside help may be especially needed when an individual has few personal or social resources on which to base a recovery. Nevertheless, the cognitive and social processes that underlie the resolution of addictive problems are common to formal treatment and informal help, and the other dynamics of change are likely to be similar, regardless of the context in which they occur.
Principle 3. The duration and continuity of care are more closely related to treatment outcome than is the amount or intensity of care.
Although patients with substance use disorders who receive more outpatient mental health care tend to have better short-term outcomes, there is growing evidence that the duration of care is more important than the amount of care. In a sample of more than 20,000 patients who participated in a nationwide program to monitor the quality of care in the Department of Veterans Affairs, we found that patients who had a longer episode of mental health care had better risk-adjusted substance use, family and legal outcomes than did those who had a shorter episode. These findings held after the intensity of care was controlled. Drug-dependent patients with longer episodes of residential or outpatient care experience have better substance use and crimerelated outcomes than do patients with shorter episodes. Thus, low-intensity, telephone-based case monitoring may be an effective long-term treatment strategy for many patients.
My recent thinking in these areas has led me to speculate that comparable processes underlie successful treatment and self-help groups, as well as long-term recovery. These common social processes include:
• Support, goal direction and structure
• An emphasis on rewards that compete with substance use
• A focus on abstinenceoriented norms and models
• Attempts to develop selfefficacy and coping skills
I believe that effective psychosocial treatments for substance use disorders (such as motivational enhancement therapy, 12-step facilitation treatment, cognitive behavioral treatment and behavioral family counseling, and contingency management and community reinforcement) incorporate these common processes. Moreover, I think that self-help groups incorporate these same active ingredients.
Bill White: Dr. Moos, thank you for participating in this interview, and thank you for all you have done for the field and for the individuals, families and communities we serve.
William White is a Senior Research Consultant at Chestnut Health Systems and author of Recovery Management and Recovery-Oriented Systems of Care: Scientific Rationale and Promising Practices.