J Happiness Stud

DOI 10.1007/s10902-014-9609-1

RESEARCH PAPER

Beyond Abstinence: An Examination of Psychological

Well-Being in Members of Narcotics Anonymous

Christian DeLucia • Brandon G. Bergman • Danette Beitra •

Hillary L. Howrey • Stephanie Seibert • Amy E. Ellis •

Jessica Mizrachi

Ó Springer Science+Business Media Dordrecht 2015

Abstract While a growing body of literature supports the role of mutual help organi-
zations in helping members achieve abstinence, fellowships other than Alcoholics Anon-
ymous and outcomes beyond abstinence have been studied far less often. The current study
examined recovery-related correlates of psychological well-being in a sample of Narcotics
Anonymous (NA) members. Participants (N = 128) were self-identified NA members
from across the United States who completed an online survey assessing an array of
psychosocial outcomes. Hierarchical regression models assessed whether abstinence
duration and other recovery-related variables accounted for significant incremental vari-
ance in psychological well-being, over and above several covariates. As a block, absti-
nence duration and the recovery predictors accounted for significant incremental variance
in three of four psychological well-being domains. As a complement to studies on short-
term benefits of mutual help organizations, these data suggest ongoing recovery involve-
ment may be positively associated with subjective psychological well-being in NA
members.

Keywords Narcotics Anonymous
12-Step recovery
Mutual help
Self-help
Recovery

practices
Psychological well-being

1 Introduction

Twelve-step mutual-help organizations (MHOs) for individuals with substance use prob-
lems—such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA)—are con-
sidered evidence-based practices for substance-related and other clinical outcomes (e.g.,
reduced health care costs) (Humphreys and Moos 2001, 2007; Humphreys et al. 2004;
Kelly and White 2012). In addition, MHOs are the most commonly sought recovery

C. DeLucia (&)
B. G. Bergman
D. Beitra
H. L. Howrey
S. Seibert
A. E. Ellis
J. Mizrachi

Nova Southeastern University, Fort Lauderdale, FL, USA
e-mail: [email protected]

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management options for individuals with substance use disorders (Cohen et al. 2007;
Compton et al. 2007; Weisner et al. 1995).
The AA-related outcome literature has evolved over the past several decades in terms of
focus, methodological rigor, and practical importance (Kelly 2013). However, outcomes
beyond abstinence are examined less often (Tonigan 2008). Moreover, research has
focused on problem drinkers who affiliate with AA. As such, relatively less is known about
individuals who affiliate primarily with NA and other 12-step organizations—despite
promising preliminary findings (e.g., Toumbourou et al. 2002). The current study fills these
two important gaps by examining correlates of psychological well-being among NA
members.
NA is an international community-based 12-step organization for individuals who self-
identify with a substance use problem. The organization was founded in southern Cali-
fornia during the 1950s and today holds over 63,000 meetings weekly in 132 countries
(Narcotics Anonymous World services 2013). Core features of NA and similar organiza-
tions include (a) abstinence as the substance-related goal (as opposed to a moderation
goal); (b) members attending non-professional, peer-led recovery meetings in which
individuals share their experiences and support one another in their attempts to maintain
recovery; (c) engagement in reciprocal or mutual helping; (d) enhancement of one’s
spirituality by incorporating principles embedded in the 12-step philosophy into one’s life;
and (e) utilizing recovery principles and supports to facilitate personal change goals (see
Humphreys 2004 for discussion of elements of 12-step organizations). These core features
suggest that NA and similar organizations can be conceptualized as ‘‘positive organiza-
tions’’ in that they ostensibly create contexts in which individuals flourish (see Krentzman
2013, p. 156). Researchers have offered similar observations when describing the possible
benefits of AA- (Galanter 2007) and NA-related recovery (DeLucia et al. 2015). Consistent
with this conceptual framework, the current study highlights possible areas of overlap
between the study of 12-step recovery and positive psychology.

1.1 12-Step Recovery and Psychological Well-Being

There is general consensus that involvement in 12-step activities is associated with positive
outcomes over and above merely attending meetings (Montgomery et al. 1995; Weiss et al.
2005; Zemore et al. 2013). While recovery involvement is often conceptualized as the sum
of several dichotomous indicators (having a sponsor, service, step work, e.g., Kelly et al.
2013), it may be advantageous to examine the unique contributions of individual 12-step
practices. For example, in a sample of adults being followed after treatment, having a
sponsor and a home group–but not step work—were independently associated with
abstinence at 12 months (Zemore et al. 2013). In a sample of adolescents, regular contact
with one’s sponsor and verbal participation during 12-step meetings incrementally pre-
dicted a larger percentage of days abstinent (Kelly and Urbanoski 2012).
Although data are clear that active involvement bolsters shorter-term abstinence rates,
members of MHOs often distinguish substance-related abstinence from recovery. Specif-
ically, AA and NA literature suggest that recovery reflects an evolving process whereby
participation in these core activities ultimately enhances one’s spiritual, psychological, and
interpersonal functioning (e.g., Alcoholics Anonymous 2001, pp. 83–84, ‘‘The Promises’’).
Thus, the ecological validity of MHO research may be strengthened by examining psy-
chosocial outcomes beyond abstinence among more experienced members (see Laudet
2011). This study examines associations among recovery-related activities and

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psychological well-being. Below, we review prior empirical studies of 12-step recovery

that focused on related constructs (e.g., purpose in life).

1.2 12-Step Recovery and Purpose in Life

Prior work suggests that AA involvement is associated with a greater sense of purpose in
life. For example, in a longitudinal study of problem drinkers, post-treatment AA
involvement was positively associated with purpose in life (Montgomery et al. 1995;
Tonigan 2001). In a cross-sectional study of AA members, Step 11-related items and
meeting attendance significantly predicted purpose in life, over and above abstinence
duration and other covariates (Carroll 1993). In a study of individuals completing long-
term treatment, six AA behaviors (e.g., having an AA sponsor) accounted for 28 % of the
variance in existential well-being (Gomes and Hart 2009). Another study showed that AA
involvement was a positive correlate of purpose in life for longer-term AA members
(Oakes et al. 2000).

1.3 12-Step Recovery and Psychological Functioning

Several investigators have examined possible associations between abstinence duration and
various measures of psychopathology (e.g., depression). In a sample of AA members,
psychological distress improved significantly over a 4-year follow-up, for all individuals
with fewer than 10 years of abstinence (De Soto et al. 1989). In a cross-sectional study of
NA members, longer abstinence durations were associated with lower levels of anxiety
(Christo and Sutton 1994). More recent work showed a similar pattern of results. Problem
drinkers in ‘‘sustained’’ recovery generally reported more favorable psychological out-
comes relative to those in ‘‘early’’ recovery (Hibbert and Best 2011).
In a longitudinal follow-up of Veterans Administration inpatients, meeting attendance
and whether one had a sponsor predicted lower levels of psychological distress. Con-
temporaneous and 3-year lagged effects were observed after controlling for prior psy-
chological distress and other person-level characteristics (Lemke and Moos 2003b), but
4-year lagged effects were no longer significant (Lemke and Moos 2003a). In a longitu-
dinal follow-up of Project MATCH (Matching Alcoholism Treatment to Client Hetero-
geneity) participants, the unique contemporaneous effects of AA attendance on depression
were eliminated with control for concomitant drinking—suggesting that effects of AA
attendance on depression might be mediated by reductions in alcohol consumption (Kelly
et al. 2010).

1.4 The Present Study

These studies suggest positive benefits of AA-related involvement on psychological

functioning—a finding supported by prior meta-analytic work (e.g., Emrick et al. 1993).
As noted above, similar effects were observed in a sample of NA members in which
anxiety and abstinence duration were negatively associated (Christo and Sutton 1994).
Several conclusions can be noted. First, the vast majority of studies include problem
drinkers who affiliate with AA. Second, assessment of psychological functioning is often
limited to facets of psychopathology. When adaptive psychological functioning is mea-
sured, construct coverage is often fairly narrow (e.g., purpose in life). Third, in the
studies reviewed above, researchers rarely focused on different facets of 12-step recovery

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in a single study (an observation also noted by Zemore et al. 2013). As such, the unique
associations among abstinence duration, meeting attendance, and other recovery practices
(e.g., participation in one’s home group) and positive psychological outcomes are not
well understood. This study fills these gaps by examining associations among recovery-
related predictors and psychological well-being in a sample of NA members. More
specifically, we examined whether abstinence duration and other recovery practices
would be positively associated with psychological well-being—over and above several
covariates (e.g., neuroticism).

2 Method

2.1 Recruitment and Procedures

Participants (N = 128) were recruited using two different methods. First, initial contact
persons within NA (N = 10) from five states were contacted and asked to share a
recruitment email with other individuals in the organization. After 50 participants were
recruited in this way, recruitment information was posted to a social networking site for
individuals in 12-step recovery. Entry into the survey was organized by sex (53.1 %
female) and abstinence duration class (1–5, 6–10, 11–15 years, 16 or more years) to ensure
fairly equal percentages of respondents across relevant strata. Individuals interested in
participating were directed to a webpage with several survey links and were asked to click
on the link that matched their sex and abstinence duration class (e.g., women with
1–5 years of abstinence). Upon completion of the online survey, respondents emailed an
email account affiliated with the project requesting payment. Thirty dollar Amazon gift
cards were emailed to the respondent’s specified email account within 48 h. Data col-
lection occurred between April and June of 2011. All study procedures were approved by
our university’s Institutional Review Board, and all participants indicated their consent to
participate.
Recruitment procedures and online survey completion were purposely designed to
sample respondents from many different NA communities, potentially increasing the
generalizability of the findings beyond individuals attending a handful of NA groups. We
also purposely sampled respondents across a wide range of abstinence duration classes
because much prior work tends to focus on individuals in their first several years of
recovery and we were interested in positive psychological functioning, which might
emerge over a more protracted period of time (Dennis et al. 2007).

2.2 Participants

Participants reported being from 28 US States (n = 123), the United Kingdom (n = 2),
Canada (n = 1), and two additional respondents failed to provide an answer to this
question. The three most well-represented US states were Florida (n = 26), California
(n = 22), and Illinois (n = 15). Initial recruit persons were used in each of these states.
Participant age ranged from 22 to 64 years (M = 45.65, SD = 10.84). Additional partic-
ipant characteristics are presented in Table 1. The majority of the sample was not presently
married or living as married. The majority of the sample identified as Caucasian, with
approximately 20 % of the sample identifying as a member of an ethnic minority group. In
terms of educational attainment, just over one-third of the sample held a 4-year or graduate
degree—suggesting higher levels of education in our sample. It is worth noting that

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Table 1 Participant demo-

Variable N %
graphic characteristics (N = 128)
Sex
Female 68 53.1
Male 60 46.9
Marital statusa
Single 42 33.1
Married 40 31.5
Living as married 12 9.4
Separated 8 6.3
Divorced 25 19.7
Ethnicity
Caucasian 101 79.5
African American 16 12.6
Other 7 5.5
Hispanic 3 2.4
Educational attainment
Did not graduate high school 1 .8
High school graduate 8 6.3
Technical school graduate 7 5.5
Some college credits 55 43.0
Associate’s degree 13 10.2
Bachelor’s degree 21 16.4
Graduate degree other than doctoral 19 14.8
Doctoral degree 4 3.1
Employment (hours per week)b
0 28 22.4
1–14 3 2.4
15–29 8 6.4
30–39 26 20.8
40 36 28.8
a b
41 and over 24 19.2
N = 127; N = 125

approximately 40 % of the sample reported upward educational mobility during their

current recovery episode. With respect to work hours, just over 20 % of the sample was not
working at the time of the survey and just over two-thirds of the sample was working 30 or
more hours per week.

2.3 Study Measures

The full survey assessed a broad array of recovery-related practices and psychosocial
outcomes. The following items/measures are a subset of constructs assessed.

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2.3.1 NA Knowledge Quiz

Given the focus of this study was on correlates of psychological well-being among NA
members, seven questions were used to assess NA knowledge and respondents who per-
formed poorly were excluded from the study. NA members helped generate the items.
Respondents who scored at least 5 out of 7 were included in this study (chance perfor-
mance was 3 out of 7). Twenty individuals were excluded because of low performance on
the NA knowledge quiz. It is possible that these individuals hold primary membership in
another organization like AA, a possibility we plan to explore further. Our sample size of
128 does not count these excluded individuals.

2.3.2 Demographics

Sex (0 = female, 1 = male) was included in analyses as a covariate. Although descriptive

data on ethnicity, educational attainment, and work hours are provided in Table 1, these
variables were not included in analyses because they were generally uncorrelated with all
outcomes and reduced the sample size (due to non-response).

2.3.3 Unrealistic Favorable Presentation

Unrealistic favorable presentation was measured by the 15-item Lie subscale of the
Minnesota Multiphasic Personality Inventory—Second Edition (MMPI-2; Butcher et al.
2001). The scale score is the sum of the 15 items with higher scores reflecting higher levels
of unrealistic favorable presentation. Sixty-five percent of our participants scored below
the normative sample mean (suggesting more willingness to admit common personal flaws
compared to a normative sample).

2.3.4 Neuroticism

Neuroticism, or negative emotional reactivity, was measured by the 2-item Neuroticism

subscale of the Big Five Inventory-10 item short form (BFI-10; i.e., ‘‘I am relaxed, I
handle stress well’’—reverse scored; ‘‘I get nervous easily’’; Rammstedt 2007). The
shortened version is highly correlated with the 9-item original scale (r = .85–.88; John
et al. 1991). Items were assessed using a 5-point response scale ranging from 1 (disagree
strongly) to 5 (agree strongly). Items were moderately correlated, r(127) = .47,
p \ .001. More than 75 % of the current sample fell below the normative mean on the
44-item scale (Srivastava et al. 2003)—suggesting somewhat lower levels of negative
emotional reactivity.

2.3.5 Recovery-Related Predictors

Empirically, recovery involvement is often operationalized as the sum of several

dichotomous items (see Zemore et al. 2013 for a discussion of some relevant method-
ological issues). Measurement of recovery involvement in this study was more dimen-
sional because frequency, rather than presence/absence, was assessed. Also, individual
items were included as distinct predictors, which allows for the assessment of unique
effects.

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2.3.5.1 Abstinence Duration Abstinence duration, in years, was computed by subtracting

the respondent’s self-reported date of last substance use from the interview date.

2.3.5.2 Frequency of Past Year NA Meeting Attendance Past year NA meeting atten-
dance was assessed by the item, ‘‘In the past year, how often did you attend NA meet-
ings?’’ Response options ranged from 0 (never) to 8 (6–7 times per week).

2.3.5.3 Lifetime Frequency of Step Work Lifetime frequency of step work was assessed
by the item, ‘‘How many times have you worked NA’s 12-steps with the assistance of an
NA sponsor?’’

2.3.5.4 Frequency of Past Year Contact with Sponsor A composite measure of contact
with one’s sponsor was created by averaging four items (e.g., ‘‘In the past year, how often
have you called your sponsor?’’). Response options for all items ranged from 0 (never) to 8
(6–7 times a week). Cronbach’s alpha (a) was .81. Individuals without sponsors were set to
the minimum values of the items, an issue discussed further in the Sect. 3.

2.3.5.5 Home Group Comfort Home group comfort was assessed by averaging two
items: (a) ‘‘I feel very comfortable at my home group’’ and (b) ‘‘I have a strong connection
to others at my home group’’ [r(127) = .88, p \ .001]. Response options for these items
ranged from 1 (never/almost never) to 4 (always/almost always). Individuals without home
groups were set to the minimum value of each subscale, an issue discussed further in the
Sect. 3.

2.3.5.6 Years of NA-Related Service NA-related service was assessed by adapting NA’s
World Pool Information Form (Narcotics Anonymous World Services 2012), a form the
organization uses to assess member service involvement. Respondents reported on the
number of positions they held across service levels (e.g., home group, area) and number of
years of service in these various positions. Total number of years of NA service was
computed.

2.3.6 Psychological Well-Being

Psychological well-being was measured using Ryff’s (1995) 54-item scale, which was
created to capture six inter-related facets of positive psychological functioning—each
measured on a 6-point response scale ranging from 1 (strongly disagree) to 6 (strongly
agree). The present study focused on the following four subscales (i.e., self-acceptance,
personal growth, purpose in life, and positive relations with others) as they appeared to
map directly on domains of functioning discussed in NA organization literature (Narcotics
Anonymous World Services 2008). Self-acceptance is the tendency to have a positive
attitude toward one’s self (e.g., ‘‘When I look at the story of my life, I am pleased with how
things have turned out,’’ a = .88). Personal growth is the extent to which one has a sense
of continued development and self-improvement (e.g., ‘‘I am not interested in activities
that will expand my horizons’’—reverse scored; a = .76). Purpose in life is the extent to
which one holds beliefs that give life meaning (e.g., ‘‘I enjoy making plans for the future
and working to make them a reality,’’ a = .76). Positive relations with others captures
one’s belief of having satisfying, trusting relationships with others (e.g., ‘‘Maintaining
close relationships has been difficult and frustrating for me’’—reverse scored; a = .83).

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3 Results

3.1 Substance- and Mental Health-Related Characteristics

First, we present some additional descriptive data on respondents and their recovery-
related practices. As expected, participant substance use was consistent with a high-
risk trajectory indicated by early age of onset (Grant and Dawson 1997) and prob-
lematic use of multiple substances. Of the 13 substances assessed, the most frequently
used substances were alcohol (98 %), cannabis (98 %), and cocaine (91 %). Median
ages of onset for alcohol, cannabis, and cocaine were 12, 14, and 19, respectively.
The vast majority of respondents reported problematic use of four or more substances
(77 %). Because recruitment did not occur in professional treatment settings, a sizable
minority of participants, 34 %, indicated they had not received prior substance use
treatment.

3.2 Recovery-Related Characteristics

Table 2 provides inter-correlations, means, and standard deviations for abstinence duration
and five other recovery practices that were used as predictors in the hierarchical regression
models presented below. The average participant has been abstinent for nearly 12 years,
has completed NA’s 12 steps between two and three times, and has provided approxi-
mately 4 years of service to NA. The average participant has attended NA meetings
between one and three times weekly in the past year and has monthly contact with his/her
sponsor. As anticipated, abstinence duration was positively associated with activities that
accrue over time (e.g., years of NA service). Although data are not presented in Table 2,
the vast majority of the sample reported having a sponsor (89 %) and a home group
(87 %). Only 17 % of the sample reported weekly attendance of other substance-related
12-step meetings (like AA).

Table 2 Inter-correlations of the recovery-related predictors (with means and standard deviations)
1 2 3 4 5 6

1. Abstinence duration (years) –

2. NA meeting attendance (past year)a -.18* –
3. NA step work (lifetime count) .47* .06 –
4. Home group comfortb .00 .39* .02 –
5. Contact with sponsor (past year)a -.20* .45* .06 .31* –
6. Years of NA service (lifetime) .78* -.01 .42* .05 -.10 –
M 11.77 5.77 2.63 3.26 2.91 3.90
SD 7.92 1.17 2.67 1.06 1.61 3.36

* p \ .05
a
Responses were on a 8-point Likert scale: 1 (1–5 times), 2 (6–11 times), 3 (1 time a month), 4 (2–3 times a
month), 5 (1 time a week), 6 (2–3 times a week), 7 (4–5 times a week), and 8 (6–7 times a week)
b
Responses were on a 4-point Likert scale: 1 (never/almost never), 2 (sometimes), 3 (often), and 4 (always/
almost always)

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3.3 Hierarchical Regression Models

3.3.1 Overview

Hierarchical regression analyses were used to examine the primary study question—
whether recovery-related practices accounted for significant incremental variance in psy-
chological well-being, over and above the effects of several theoretically-informed sta-
tistical control variables (i.e., the covariates). In addition to information about overall
model fit and the unique contribution of the individual predictors from the final model,
which could be gleaned from a simultaneous regression analysis, the hierarchical approach
provides information about the incremental variance associated with relevant predictor
sets. Predictor sets entered earlier in the hierarchy are ‘‘favored’’ statistically because there
are fewer constraints placed on available outcome variance. In the final analyses presented,
there were two predictor sets. The covariates were entered in the first predictor set and
abstinence duration and the recovery practices were entered in the second predictor set. In
this context, the significance of the ‘‘recovery predictor’’ set suggests the recovery-related
predictors offer incremental prediction of psychological well-being, over and above the
covariates.
Four hierarchical regression models were estimated. Each model included nine pre-
dictors organized into two blocks. Given the modest sample size, we attempted to keep
models as parsimonious as possible. The first predictor block included sex, unrealistic
favorable presentation, and neuroticism. The second block included abstinence duration

Table 3 Unique effects from hierarchical regression models predicting four facets of psychological well-
being
Predictors Psychological well-being facets

SA PG PIL PR

Covariates .379 .221 .249 .301

Sex (0 = female, 1 = male) (-) .002 (-) .040 (-) .023 (-) .004
MMPI (Lie Scale) .013 .012 .000 .016
Neuroticism (-) .145 (-) .069 (-) .125 (-) .108
Recovery related predictors .106 .083 .104 .107
Abstinence duration .008 (-) .000 .036 .012
NA meeting attendance (past year) (-) .000 (-) .003 (-) .001 (-) .000
NA step work (lifetime count) .012 .002 .006 .004
Contact with sponsor (past year) .007 .003 .002 .008
Home group comfort .031 .054 .041 .052
Years of NA service (lifetime) .000 .006 (-) .036 (-) .001
R2 full model .485 .304 .353 .408
SA self-acceptance; PG personal growth; PIL purpose in life; PR positive relations with others; Entries in
un-indented rows (e.g., covariates) are R2 change values (i.e., DR2) for the predictor block. Entries in
indented rows (e.g., sex) are semi-partial r2 values (i.e., r2s ) for individual predictors from the final model.
The criterion for statistical significance was set to .013 (.05/4) for overall models and predictor blocks, and
to .05 for the individual predictors. Statistically significant entries are bolded and underlined. Negative signs
(in parentheses) indicate a negative association between the predictor and outcome; otherwise, associations
were positive

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and five additional recovery-related predictors (i.e., meeting attendance, frequency of

12-step work, connection with one’s sponsor, comfort at one’s home group, and years of
NA service). Because the outcomes were correlated, we adjusted our original criterion for
statistical significance (.05) by dividing it by the number of models (4), resulting in a more
conservative criterion of .013. This more conservative criterion for statistical significance
was used to evaluate the overall models and predictor blocks for significance. Given our
modest sample size, however, we used the traditional .05 criterion to examine the unique
effects of individual predictors. Effect size estimates for the full models, predictor sets, and
individual predictors are presented in Table 3. Effect size estimates for predictor sets are
DR2 estimates. Effect size estimates for individual predictors are the squares of the semi-
partial correlations (r2s ) from the final model, which represent the incremental variance
associated with the predictor in question, over and above all other predictors in the model.

3.3.2 Overall Models

The full set of predictors accounted for significant variance in all four subscales of psy-
chological well-being, with overall R2 values ranging from .30 (for personal growth) to .49
(for self-acceptance, M = .39, SD = .08).

3.3.3 Predictor Blocks

The covariates—entered on the first predictor block—accounted for significant variance in

all subscales of psychological well-being with R2 values ranging from .22 (for personal
growth) to .38 (for self-acceptance, M = .29, SD = .07). The recovery-related predic-
tors—entered on the second predictor block—accounted for significant incremental vari-
ance in three of four dimensions of psychological well-being including self-acceptance
(DR2 = .11), purpose in life (DR2 = .10), and positive relations with others (DR2 = .11).

3.3.4 Individual Predictors

One recovery-related predictor, comfort at one’s home group, and two covariates (par-
ticipant sex and neuroticism) were significant predictors in at least two models. Home
group comfort was positively associated with all four psychological well-being subscales,
with r2s ranging from .03 (for self-acceptance) to .05 (for personal growth and positive
relations with others, M = .05, SD = .01). Relative to men, women reported higher levels
of personal growth (r2s = .04) and purpose in life (r2s = .02). Neuroticism was negatively
associated with all four psychological well-being subscales, with r2s ranging from .07 (for
personal growth) to .15 (for self-acceptance, M = .11, SD = .03).
Two additional recovery-related predictors (i.e., abstinence duration and years of NA
service) were significant predictors in a single model. Abstinence duration was positively
associated with purpose in life (r2s = .04), while years of NA service was negatively
associated with purpose in life (an unexpected finding, r2s = .04).

3.3.5 Additional Analyses and Analytical Considerations

Among the 128 participants, 13 (3.1 %) participants did not currently have a home group,
10 (7.8 %) participants did not currently have a sponsor, and four (3.1 %) participants had
neither. In order to retain these 27 individuals in the hierarchical regression models

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described above, we set them equal to the low point on the sponsor- and home group-
related predictors. To examine the impact this decision had on the regression models, we
repeated all analyses with these individuals deleted from the data file. Results were largely
unchanged and the more robust effects in the original analyses (e.g., home group comfort)
remained robust effects in the analyses with these cases deleted. Therefore, we retained
these individuals because they provided valid observations on all remaining variables and
increased statistical power.
We also examined whether the nesting of participants within states violated the classic
independence assumption of standard inferential statistical procedures. Intraclass correla-
tions suggested a violation in the self-acceptance model (ICC = .09), so analyses were
repeated using a random effects regression model and results were unchanged. In addition,
primary results described above were replicated across models that included additional
covariates (e.g., psychotropic medication usage during recovery episode, substance use
severity, and age) and in latent variable models in which the outcomes were latent vari-
ables and the predictors were observed variables. Given the relative consistency of effects
across these related analyses, we presented the results from the most parsimonious models.

4 Discussion

4.1 Recovery-Related Predictors

This study’s primary purpose was to examine whether abstinence duration and five dif-
ferent recovery practices accounted for significant incremental variance in psychological
well-being, over and above the effects of several covariates (e.g., neuroticism). These
recovery-related predictors accounted for significant incremental variance in three of four
facets of psychological well-being. These findings contribute to our knowledge of how
different aspects of 12-step involvement may correlate with psychological well-being
among NA members.
Comfort at one’s home group was a positive and significant unique predictor of psy-
chological well-being in all models. This finding is consistent with prior empirical findings
that directly assessed home group-related constructs (e.g., connection from MAAEZ study;
Subbaraman and Kaskutas 2012) and with broader and widely replicated findings sup-
porting the positive effects of social support and interpersonal connections on various
outcomes (Groh et al. 2008; Humphreys et al. 1999; Kelly et al. 2010). Perhaps the home
group experience provides a sought-after context for important interpersonal connections.
A possible clinical implication of these data is that professional facilitation of patients’
social engagement in 12-step groups and encouragement to select a home group may not
only increase their chances of continued abstinence, but also bolster their subjective
psychological well-being.
In addition to this pervasive effect of home group comfort, abstinence duration was
positively associated with purpose in life. Abstinence duration was not a significant unique
predictor in the other three models, however. Although it is possible that abstinence
duration has a specific effect on purpose in life that does not generalize to the other three
dimensions of psychological well-being, the absence of a more pronounced pattern of
effect leads us to consider the impact of abstinence duration cautiously. Additional studies
should continue to examine the impact of abstinence duration on outcomes in the context
of several other recovery practices to get a better sense of its unique impact. Abstinence
duration tautologically implies the absence of substance use, but does not necessarily imply

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the presence of other life enhancing behaviors, which might have a more proximal impact
on psychological well-being.
Years of NA service was negatively associated with purpose in life, a finding that was
unexpected. Similar to the abstinence duration effect, this effect was limited to a single
outcome. In addition, the unique effect of years of NA service accounted for \1 % of the
variance in each of the other three outcomes. Given its unexpected nature, we examined
this effect more closely. It appears that the association is driven in part by associations
among abstinence duration, years of NA service, and purpose in life. The zero-order
association between years of NA service and purpose in life is small and positive (r = .09).
The zero-order association between abstinence duration and purpose in life is moderate and
positive (r = .26). The zero-order association between years of NA service and abstinence
duration is large and positive (r = .77). When both abstinence duration and years of NA
service are included as predictors of purpose in life, the unique effect of abstinence
duration remains positive (and significant), while the unique effect of years of NA service
becomes negative and significant. It is possible that participation in NA service is driven by
a mixture of ‘‘positive’’ (e.g., abstinence duration) and ‘‘negative’’ (e.g., pathology)
selection factors and controlling for abstinence duration allows these negative effects to
surface.
The pattern of results with respect to the full set of recovery practices is interesting.
Although the recovery predictor block accounted for significant incremental variance in
three of four outcomes, only comfort at one’s home group emerged as a significant unique
predictor in at least two models. Does this imply that the rest of the recovery practices are
unimportant? This question is somewhat difficult to answer at the present time. In prior
studies, the effects of various recovery practices have been linked primarily with absti-
nence among individuals attending AA who are in their first year (or several years) of
recovery (e.g., Cloud et al. 2004). This study focused on positive psychological functioning
among NA members whose abstinence durations ranged from 1 to 33 years. With
increasing time in recovery, the various pathways to positive outcomes might become more
individualized and broaden beyond core 12-step activities. At the same time, however, it is
possible that comfort at one’s home group remains a fairly persistent goal of 12-step
members—making it a more robust predictor.
It is also worth noting that the typical practice of assessing the presence or absence of
various 12-step activities (e.g., whether one has a home group) might be more reasonable
in samples being followed beyond formal treatment. In such samples, the presence or
absence of engagement in these core 12-step activities might have reasonable predictive
power. In samples of community-based 12-step members varying widely in abstinence
durations, predictors similar to those used in the current study (e.g., degree of comfort at
one’s home group) seem more reasonable (see Zemore et al. 2013, for a similar point).

4.2 The Covariates

Although utilized as statistical control variables—to create a more conservative test of the
recovery-related predictors—participant sex and neuroticism were significant predictors in
at least two models. Female NA members reported higher levels of personal growth
relative to male NA members, replicating similar sex effects found in Ryff’s prior
empirical work (e.g., Ryff 1995; Ryff and Keyes 1995). Female NA members also reported
higher levels of purpose in life relative to male NA members—a finding Ryff has not
reported in prior work. Although it is possible that purpose in life as an outcome resonates
more with female MHO members, replication is warranted. While Ryff has found that

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women report higher levels of positive relations with others (Ryff 1989; Ryff and Keyes
1995), this effect was not observed in this NA sample. Perhaps the high premium that
MHOs place on interpersonal connections eradicates this sex difference observed in non-
MHO samples.
In the field of personality assessment, neuroticism reflects negative emotional reactivity,
a trait-level vulnerability to respond to stress or other life difficulties with unpleasant affect
(e.g., depression, anxiety, and/or anger; Costa and McCrae 1992; Costa et al. 1980). Thus,
we included neuroticism as a control variable in the present analyses to help ensure that the
effects of the recovery practices were not inflated as a function of shared variance. Indeed,
our finding that higher levels of neuroticism were associated with lower levels of psy-
chological well-being is consistent with previous work showing strong negative associa-
tions between neuroticism and both coping skills and psychological functioning among
SUD outpatients (Piedmont and Ciarrocchi 1999). A possible implication of these data is
that 12-step members with higher levels of neuroticism and lower levels of psychological
well-being might also benefit from additional supports (e.g., psychotherapy).
Finally, although not statistically significant in the present analyses, the effects of
presenting oneself in a favorable light (as operationalized by higher scores on the MMPI
Lie Scale) had a small and positive association across the models (on average accounting
for 1 % of unique outcome variance). This suggests that individuals more likely to present
themselves in a favorable light were also more likely to report higher levels of psycho-
logical well-being. Although the effects of this predictor were small in magnitude, its
retention in the final models adjusted the effects of the predictors of primary theoretical
interest accordingly, which is a strength of the current study.

4.3 Limitations and Future Directions

Although the current study had several strengths—as described above—a number of
limitations are worth noting. Our sample size was relatively modest and given the paucity
of prior work in the area, analyses were informative albeit exploratory in nature. In
addition, these data are cross-sectional, so temporal precedence cannot be established
between the predictor and outcome variables. Although our overarching theory is con-
sistent with the hypothesis that engagement in the recovery practices (e.g., home group
involvement) is predictive of psychological well-being, the present data do not unam-
biguously support this hypothesis. Future longitudinal studies, which can establish tem-
poral precedence between predictors and outcomes, can provide additional insight into this
issue. It is worth noting that in a prior study with both cross-sectional and longitudinal data
(De Soto et al. 1989), cross-sectional effects (of abstinence duration on positive outcomes)
were replicated in longitudinal analyses.
Also, it is possible that associations between the recovery practices and outcomes are
spurious and driven by third variables. To render these alternative explanations less
plausible, we included several covariates including neuroticism and unrealistic favorable
presentation. Inclusion of these covariates produced more conservative tests of the
recovery practices, which were the predictors of primary theoretical interest.
Finally, it is difficult to assess the representativeness of our sample in relation to the
population of NA members, a limitation shared by similar studies. Although organizations
like NA publish some basic member data (see http://www.na.org/admin/include/spaw2/
uploads/pdf/PR/NA_Membership_Survey.pdf), the representativeness of these data is
unknown, given that sophisticated random sampling procedures are not utilized in data
collection. Moreover, we cannot quantify the response rate in the present study because it

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is not possible to know how many NA members were exposed to our recruitment mes-
sages, yet decided not to participate. It is worth noting that in an attempt to broaden the
generalizability of our findings, we used two general recruitment methods (described
above), which enabled us to sample members from many different NA communities. In
addition to geographical locale, our sample is heterogeneous with respect to abstinence
duration, substance use severity, prior substance abuse treatment, receipt of mental health
treatment during current recovery episode, and many other characteristics that could
impact engagement in 12-step recovery and eventual psychological outcomes. Neverthe-
less, it seems reasonable to presume a set of selection factors impacted individuals’
decisions to participate, limiting the generalizability of the present data. As additional
studies are conducted with NA members, researchers will be able to bring more data to
bear on these important issues.

5 Conclusions

Overall, while a body of literature supports the role of MHOs in helping individuals
maintain abstinence, fellowships other than AA and outcomes other than abstinence have
been studied far less often. It seems reasonable to suspect that persisting involvement in
MHOs is related to benefits beyond substance-related abstinence (DeLucia et al. 2015;
Galanter 2007). The current data suggest that the subjective experience of positive psy-
chological functioning might be an important outcome worthy of clinical consideration and
further empirical study in MHO research. Examining the possible impact of MHO mem-
bership on other outcomes such as positive affect, spirituality, hope, and other character
strengths might have similar clinical significance (Galanter 2007). Historically, these
constructs have been examined empirically in the field of positive psychology. The current
study represents a bridge between MHO and positive psychology research. Additional
work in this area will likely lead to an expanded, shared theoretical and intervention
knowledge base from which both MHO and positive psychology researchers benefit.

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