Circles of Recovery: An Interview with Keith Humphreys, PhD

Keith Humphreys’ sustained clinical, research, consulting, policy development and prolific writing activities qualify him as a pioneer in the modern history of addiction treatment and recovery. His work has bridged the worlds of clinical research, clinical practice, social policy and the lived experience of addiction recovery. His studies, perhaps more than the contributions of any other scientist, have illuminated the role of community, particularly indigenous recovery communities, in recovery initiation and long-term recovery maintenance. Please join us in an engaging conversation about his life and work. (The complete interview and full citations to the studies discussed are posted at www.williamwhitepapers.com).

Bill White: How did you get from the mountain country of West Virginia to the study of psychology at Michigan State University and the University of Illinois?

Dr. Humphreys: I formed this idea as a teenager that I wanted to be a psychologist, which in retrospect, was a strange decision given the men in my family’s background as miners, electricians, steelworkers, engineers and soldiers. I found that psychology brought together for me the “brain stuff” (figuring out puzzles, understanding complex things) and the “heart stuff” (connecting with people, helping others heal) in a way none of the other careers I considered could do.

Bill White: What influences led you into the addictions field?

Dr. Humphreys: I enjoy saying, “Like most people, I got into the field for the money.” When I was flipping burgers at Wendy’s for minimum wage ($3.35 an hour) as an undergraduate, a friend a few years ahead of me in the psychology program suggested I apply for her soon-to-be-vacated job on a research project in the psychiatry department. When she informed me the research project was about addiction and that it paid $4.40 an hour, I said, “For $4.40 an hour, I love addiction.” That’s a true story, but the greater truth lies in why I stayed with something that I started in such a serendipitous fashion. Clinically, I found that I liked addicted patients. And I found that every important part of the human drama is there in addiction: hope, fear, struggles with control, death, spirituality, love, relationships and the possibility of redemption.

Recovery Research

Bill White: How did you develop a focus on recovery research before most of your peers had recognized this as a legitimate arena for scientific research?

Dr. Humphreys: During my undergraduate days, I absorbed the prevailing academic prejudice that doctors know best, therefore self-help groups couldn’t be of any real value—after all, their members didn’t even have advanced degrees! But in the job I had working for Bertram Stöffelmayr at Michigan State University (starting at $4.40 an hour), I was exposed to 12-step programs. As I hung around people in recovery and attended open meetings, I recognized that the prevailing academic prejudice was just that. I wanted to subject that prejudice to tests. At the same time, other scientists around the country and at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) were independently coming to the conclusion that 12-step groups and recovery had been underappreciated and misunderstood. When 12-step facilitation counseling showed such good results in Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), it did more to legitimize recovery-oriented addiction research than I have ever done in my own efforts.

Bill White: How far have we advanced in scientifically mapping the multiple pathways of long-term addiction recovery?

Dr. Humphreys: I am not overwhelmed by what we know. I can point to examples of pathways and research that describe what those pathways are like, but not a systematic study of how everyone ends up recovered and in what proportion. Measurement is fundamental to science, and you can’t measure something until you agree what it is. I don’t think we got to such an agreement until the Betty Ford Institute consensus conference and the CSAT (Center for Substance Abuse Treatment) Summit on Recovery, and since then, there has not been a carefully-designed national survey asking how many people meet that criteria. We can answer that question for abstinence, but not for this broader definition of recovery.

Bill White: How can we measure recovery prevalence?

Dr. Humphreys: We can pull together from good surveys that there are at most 20 to 25 million Americans who met the formal DSM substance-dependence criteria and are now not using drugs or alcohol. But not all those people would consider themselves in recovery. If you start with recovery organizations’ membership and do some bootstrapping, you can assure yourself that the number isn’t any lower than 5 to 10 million. The truth is probably in between those two ranges, but we need to incorporate recovery measures into existing national surveys.

Bill White: Between 2003 and 2008, you served as an advisor to the White House Office of Faith-Based and Community Initiatives. What did you take from this experience?

Dr. Humphreys: The Bush administration was loathed in much of academia, but by any objective standard, with the President’s New Freedom Commission, the Access to Recovery Initiative and the Wellstone-Domenici Mental Health Parity Law, the Bush administration was a great time for the treatment of addiction and mental health problems.

A mountain of evidence attests that religious faith of any kind is a protective factor that helps kids avoid addiction, and a spiritual or religious experience is essential to how some Americans recover from addiction. There was never any question scientifically of whether a contribution could be made by faithbased organizations to recovery; it was more a political and cultural question of how we do that in a pluralistic society with a Constitutional commitment to separation of church and state.

Bill White: What do you feel are the other most important areas of recovery research to be explored in the coming decades?

Dr. Humphreys: My colleague Chris Timko just received a grant to study Al-Anon, which is the second-largest mutual-help organization in the field and has received precious little study. The new grant will also give her the chance to study women, who as a population are understudied across recovery research. I would like to see more research as well on people of color. Finally, I think we need to understand later-stage recovery—what lives are like 10 years on, for example.

Role of Community in Recovery

Bill White: Your work has been profoundly influenced by the writings and mentorship of such persons as Seymour Sarason, Julian Rappaport and Rudy Moos. What have you taken from their work about the role of natural community resources in long-term addiction recovery?

Dr. Humphreys: Treatment is a very good thing; and I have provided it, taught it and advocated for it. But what all three of those great thinkers (and I would put my friend Griffith Edwards in here as well) make clear is that in the long-term, most people are made by the broader world and not by short-term treatments. No matter how much I may like a patient, I can’t become his or her lifelong friend or employer or advisor or spouse or child. All of those naturally occurring phenomenon will shape the patient’s life more than I will. To their credit, the founders of AA figured this out a long time ago: you usually can’t eliminate a problem that has developed over years and become deeply woven into someone’s life without weaving something positive and enduring into his or her life to replace the addiction.

Recovery Mutual Aid Societies

Bill White: What was your view of Alcoholics Anonymous (AA) before you began studying it as a research scientist?

Dr. Humphreys: I viewed it, as did most of the professors I looked up to, as a wellmeaning bunch of amateurs who didn’t know what they were doing. I am grateful that I actually met some AA members before I was too far along in my education to learn anything.

Bill White: How would you characterize the evolution in the quality of scientific research on AA?

Dr. Humphreys: There has been very good ethnographic, anthropological, sociological, historical and participant observation research on AA going back half a century and continuing today. But in terms of convincing outcome studies— e.g., do people actually drink less—that’s more recent.

About 20 years ago, in no small part due to NIAAA getting involved, there was a quantum leap in the quality of AA outcome research. Studies routinely became longitudinal and prospective and most had comparison groups. AA affiliation, a broader concept than just a count of meetings, was better conceptualized and well-measured. More recently, high quality randomized clinical trials replaced the methodologically weaker trials conducted in the 1960s and 1970s. As the methods have gotten better, the scientific case for AA’s effectiveness has gotten stronger rather than weaker. In short, AA really is a quality intervention for alcohol problems, and that’s a hard-nosed, evidence-based statement.

Anyone who says AA is ineffective either does not know the science or is grinding an ideological axe. We have as good evidence for AA and 12-step facilitation counseling as we do for any other ambulatory intervention in the alcohol field. Period. As recently as last year, the Washington Post published an article by a researcher asserting that there were no randomized clinical trials of 12-step groups. I published a rebuttal noting multiple randomized, National Institutes of Health (NIH)–supported studies in top-tier journals. The science indicates that for people who want something ambulatory and have an abstinence goal, AA should be their first port of call. Does that mean it works for everyone? Of course not—nothing does.

Bill White: You have conducted several studies related to the question of AA’s cost-effectiveness. What were the major conclusions of these studies?

Dr. Humphreys: If AA were for sale for a billion dollars, the country should buy it in a heartbeat—what a bargain! What Rudy Moos and I found in those cost studies is that when people get involved in AA, their health care utilization drops by as much as 40 percent. We did a Veteran’s Administration (VA) study that found a savings of about $6,000 per patient the first year after treatment if the treatment program really pushed AA/NA involvement. The VA treats over 120,000 addicted veterans a year—imagine the cost impact of knocking six grand off the health care bill of that many people a year, and the VA is just a small part of the healthcare system.

Bill White: What have we learned about the so-called “active ingredients” of AA— those elements of AA participation that seem particularly linked to long-term recovery outcomes?

Dr. Humphreys: There are a large number of studies that identify “active ingredients” or “mediators” of AA’s effect, including an increase in abstinence- supporting friends, greater generic social support, better coping skills, greater self-confidence and more motivation to change. In the longer term, spiritual change, altruism and sponsoring others seem particularly powerful in helping people to attain a lasting, enriching recovery.

Bill White: There have been suggestions that AA was inappropriate for women, people of color, people with co-occurring disorders and other populations. What did you find when you tested such suggestions?

Dr. Humphreys: When I studied those assertions in diverse samples across diverse communities, they didn’t stand up to scrutiny. I was working on the lower east side of Detroit during the crack cocaine epidemic in the 1980s and with Bertram’s invaluable assistance, got a chance to look at sizable data sets of people of color and women in the fellowships. That work showed that if you looked in a predominantly African American part of town, African Americans were more likely to attend than were whites. In contrast, you saw the reverse pattern in predominantly white communities. We also found that women were more likely than men to attend groups. Years later, Rudy Moos, Andy Winzelberg and I studied the religion question and found that when clinicians refer patients who are atheists or agnostics to 12-step self-help groups, they are as likely to attend as are religious patients.

Bill White: Your 2004 book, Circles of Recovery, which was just released in paperback, stands as the best summation of the status of modern addiction recovery mutual-aid groups. Many readers have been struck by the great diversity of religious, spiritual and secular recovery mutual-aid groups you describe. Were you also struck by such diversity through your research for this book?

Dr. Humphreys: The diversity of mutualaid organizations is amazing, and I would broaden that even more than you might have been thinking when you asked the question. That is, not only are organizations different from each other, but the diversity of groups within any one organization is enormous.

Bill White: How much do we know scientifically about the adaptations and alternatives to AA?

Dr. Humphreys: NA research has grown and gotten better in recent years, and I think Al-Anon research looks promising in the near future. But we lack any good outcome studies of SMART Recovery, LifeRing Secular Recovery, Women for Sobriety and many other organizations. Some of the AA research must generalize since, after all, there are group influence effects and social support effects in all of them. But there must be some differences as well, and we don’t yet know what those are.

Bill White: What are your thoughts on the rapid growth of online recovery support services and the future of Internet-based recovery support meetings and services?

Dr. Humphreys: That whole phenomenon makes me feel old because I wouldn’t go online for support about an emotional problem. But what some of our research found is that the current generation of young adults relishes this sort of support, and their attitudes are becoming more normative as time goes on. For that reason, I expect continuing growth in these groups, as well as of professionally operated services that have an online component.

Addiction Treatment

Bill White: You have been involved in many addiction treatment outcome studies. What conclusions have you drawn about the degree of effectiveness of various approaches to addiction treatment?

Dr. Humphreys: To my mind, the research shows that the things most researchers obsess about—e.g., is cognitive-behavioral therapy better than purely behavioral therapy versus purely cognitive therapy—are not where the action is. Good treatments have common elements, including a relationship with someone who cares about you, some persistence of the treatment over time and some changes in your environment such that abstinence becomes easier and more rewarding than continued use. Some clinical people are uncomfortable with this idea, but the research shows that some accountability in the environment is very good for people. That includes, for example, drug testing with immediate, certain consequences such as you see in drug courts.

Bill White: In one of your published commentaries in Addiction, you suggested the need to shift from a focus on treatment intensity to a focus on treatment extensity. What would that shift entail?

Dr. Humphreys: That paper came about from pulling together two ideas that many people before me had discussed. The first is that it takes as much money to do a short-term intensive intervention (e.g., inpatient detox) as it does to do a long-term or extensive intervention with less contact at each point (e.g., recovery management checkups). The second is that addiction tends to have a chronic course. That led me to think we should reallocate resources away from intensive interventions and into extensive ones. Recovery coaches, extended outpatient care and recovery management checkups are all ways to do that. In the best systems, the dollars those interventions save by reducing acute care utilization would be returned to them to support more extensity in care.

Bill White: You have studied both psychosocial treatments for addiction and medication-assisted treatment. Do you see these approaches as antagonistic?

Dr. Humphreys: I see no conflict at all. There is no other chronic disease I can think of where we even ask this question. Bill W. asked Vincent Dole, the methadone pioneer, if he could create a methadone for alcoholics. If Bill W. could be supportive of medication-assisted therapy, it seems to me we could all be equally open-minded.

Bill White: You have been deeply involved in evaluating and elevating the treatment of substance use disorders within the Veterans Affairs Health Care System. Are there innovations that have occurred within the VA approach to addiction treatment that you feel are worthy of widespread replication?

Dr. Humphreys: I think the VA is the best addiction treatment system in the country. First, unlike everywhere else, you don’t have to argue that treatment is a legitimate part of medicine in the VA. The programs are at hospitals; what hospitals do is medicine—end of discussion. Second, because the programs are in a medical system, you can get the supplementary services that just aren’t available in many community programs, such as liver tests and psychiatric evaluations. Third, the VA staff are more highly trained and better compensated than their peers in statesupported programs, which creates a basis for better quality (even though it doesn’t guarantee it).

Office of National Drug Control Policy

Bill White: In 2009, you took a leave of absence from the VA and Stanford to serve as senior policy advisor at the White House Office of National Drug Control Policy (ONDCP). How did this opportunity come about?

Dr. Humphreys: After President Obama was elected, Vice President Biden called my dear friend Tom McLellan and asked him to come help shape the administration’s drug policy. Biden knew Tom a bit personally, and countless people had correctly told the VP’s office what a great leader Tom is for our field. After the call with Biden, Tom called me because I had a reputation as a “policy guy.” He told me that he would only take the job if I would go with him and help him learn the policy ropes. That meant a lot to me and still does, and I was very willing to accept. Serving in ONDCP with Tom was one of the best experiences of my career.

Bill White: The President’s Drug Control Strategy that emerged under your tenure at ONDCP marked the first time that recovery was highlighted as a potential organizing framework at the policy level. How was this achieved and what are its implications?

Dr. Humphreys: A number of organizations and individuals, most prominently Faces and Voices of Recovery, had begun to pull together recovering people into a movement that demanded recognition. So, part of what we were doing was responding to them as citizens asserting their rights and their value— governments often do the right thing because the populace makes them.

We also had some tremendous structural advantages in establishing that office. The first one was that Gil Kerlikowske, the Director of ONDCP and a former police chief, supported the recovery concept. The second advantage is that there are an awful lot of powerful people in Washington who are in recovery or love someone in recovery: current and former elected officials, high-level appointees, policy advisors and lobbyists to name just a few. When the plan to add a recovery component to ONDCP went to Capitol Hill, it was very, very warmly received.

Bill White: What would our readers be most surprised about regarding the experience of working at that level of policy development?

Dr. Humphreys: I suspect they would be surprised at how, despite all the polarization, people with different political views can still find a bond of common humanity and work together. Before I went to DC, I helped Congress on the Mental Health Parity Act. That was sponsored by Senator Domenici, a conservative’s conservative; Senator Wellstone, a liberal’s liberal; Congressman Jim Ramstad, an independent-minded Republican; and Congressman Patrick Kennedy, the scion of one of America’s most famous Democratic families. How could four such diverse people agree on a consequential piece of legislation? Because they had all personally been put through the wringer by experience with mental health and/or substance use problems. That gave them a basis of common understanding that bridged their political differences.

Bill White: What do you most want to accomplish during your future years in the field? Is there a particular legacy you hope to leave the field?

Dr. Humphreys: What I hope to focus on primarily from here on out are the applications of addiction science in clinical work and even more so in public policy. I am not a grand theorist and will never make a contribution of that sort. But to help put laws, policies and programs in place that make it harder for people to become addicted and easier for them to recover is something I think I can do, and that is the legacy I want to have.

Bill White: Keith, thank you for your willingness to participate in this interview and for all you have done and are doing for our field.

Dr. Humphreys: It was a delight. Thank you, Bill.