Book Review
Substance Abuse 
Circles of Recovery: Self-Help
Organizations for Addictions Keith Humphreys. Cambridge (UK): Cambridge University Press; 2004. 228 p. US$25.00
Reviewer
rating*: Excellent
Review by: Douglas H Frayn, MD, FRCPC
Toronto, Ontario
This is a volume from the International Research Monographs in the Addictions series that presents both clinical and public health applications of biological, behavioural, and statistical addiction research. Keith Humphreys, from the Department of Psychiatry, Stanford University, Stanford, California, has written extensively about self-help groups and outcome research over the past decade.
This small book attempts to list, describe, and integrate the literature on all the registered self-help addiction groups worldwide. Reading it is like reading a dictionary: it has interesting, but often unrelated, individual items. It is also a tough read, since there is no consistent theme and the groups described are frequently unconnected, as is common with reference texts.
The book’s scope is broad and provides a general introduction to numerous addiction-related self-help groups. Humphreys’ goal was to illustrate the range of societal involvement in chemical dependencies, along with professional and lay responses to the worldwide problem of addictions. However, the book sacrifices depth, which it might have achieved if Humphreys had focused on the largest such organization: Alcoholics Anonymous (AA).
Certain groups (for example, AA, Blue Cross, Narcotics Anonymous, and Links) see substance abuse as a physical, spiritual, and moral problem. Conversely, others such as Rational Recovery and SMART Recovery, view it as primarily an unhealthy behaviour problem. Global cross-cultural issues also exist, both in the type of intoxicants preferred and in the philosophy of therapy given. For instance, it is assumed that alcoholism is rare in Asian and Semitic populations, owing to genetics and to having close family structures that may make drinking physically unpleasant or unacceptable. That said, these populations are well represented in the use of other addictive drugs, and some individuals within them feel doubly excluded because of their community’s disbelief that they could suffer from alcoholism.
With regard to alcoholism, high rates of drinking can be found by measuring population consumption levels, but an even more accurate method is to assess the degree of liver cirrhosis (for example, Ireland, Scotland, and Italy, among other countries, have high rates). In most modern cities, however, it is the rule rather than the exception that, although over 10% of the general population abuse alcohol, people with addictions depend on multiple drugs.
It is beyond the scope of this review to discuss all the different self-help addiction groups available, but it is sufficient to say that 50% are located in the US and 5% in Canada. Worldwide, AA alone has over 100 000 groups and 2 million members who attend regularly. It is estimated that 3 times this number have some contact with a group, without necessarily joining. What makes self-help groups so popular? Humans tend to gather together, accumulate resources, and solve shared threats. Most group members seek professional help; however, as with most chronic problems, it is not the acute problem that presents the major disability but the chronic, ongoing one.
Physicians and self-help groups share something in common—mutual distrust! Some members have had bad experiences with conditioning and behavioural techniques as well as with newer medications that proved later to have abuse potential. Professionals find it difficult to believe that a leaderless, nonprofessional group has something more to offer than availability and less expense. Conversely, self-help groups often feel that professionals are basically ignorant of the ongoing problems facing individuals in recovery. Health consumer movements have significantly criticized institutional–medical–legal addiction models as ineffectual, hopelessly expensive, and unavailable to a significant percentage of the afflicted population.
The central messages of most substance abuse self-help groups seem lost to many physicians: abstinence, not moderation, is the only realistic and practical solution for most patients with addictions, with the possible exception of some younger early users; relationship contacts should replace chemical use; no future time exists at which formerly dependant patients can safely experiment with their addictive drugs; cross addiction is the rule rather than the exception, which becomes most obvious when the drug of choice is restricted; and finally, physicians are welcome to most “open” meetings, but as informed individuals rather than as leadership models.
With regard to the formation of organizations devoted to helping drug-dependant patients, conflicting convictions about the importance of spirituality, abstinence, confrontation, and anonymity have played a role. Of equal importance has been the formation of self-help groups based on race, culture, religion, sex, and sexual preference. Statistically speaking, however, AA is the only self-help organization large enough to potentially produce population-level effects.
Humphreys summarizes his account with the observation that many self-help groups have similar effects to those desired of professional treatment programs—reduced alcohol and drug use, diminished depression and anxiety, and improved social functioning. In addition to reduced addiction-related issues, group members list spirituality, new identity, fellowship networking, and empowerment through activism as features attained through continued group participation. Perhaps of greater interest to politicians and government agencies, the most reliably demonstrated effect of self-help group participation is its power to sharply reduce addiction-related health care costs.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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