Literacy-Free 12 Step Expressive Arts Curriculum Enhances Engagement and Treatment Outcomes for Dually Diagnosed Substance Use and Mental Health Disorders

ABSTRACT

This study evaluated the efficacy of the Literacy-Free 12 Step Expressive Arts Therapy© curriculum in enhancing personal change and treatment outcomes for populations dually diagnosed with substance use and mental health disorders. It supplemented standard rehabilitation treatment for 47 individuals in a U.S. facility by incorporating 12 Step guidelines, cognitive behavioral therapy, rational emotive behavior therapy, and expressive arts activities. Pre-session and post-session participant ratings revealed positive increases for commitment to recovery, attitude toward making lifestyle changes, and hopefulness. Compared to 101 inpatients at the same facility, curriculum participants evidenced less drop-out, higher treatment completion, and greater personal investment in recovery.

KEYWORDS:

• 12 Steps
• expressive arts
• substance use disorder
• addiction
• dual diagnosis
• opiates
• alcohol
• bipolar
• post-traumatic stress disorder
• depression
• illiteracy

Introduction

Addiction is a multifaceted problem manifesting in a diagnosable pattern of behavior and common trajectory. Reviewing the nature of the global substance use crisis and the success of 12 Step programs paired with formal therapy, this paper addresses the need for creative, integrative treatment to bolster outcomes by evaluating the Literacy-Free 12 Step Expressive Arts Therapy© curriculum (Stuebing, 2015) as a supplement to enhance treatment engagement and outcomes.

Findings across 187 countries show that mental health disorders and substance use disorders (SUD) together account for the highest proportion of years living with a disability (Whiteford, Ferrari, Degenhardt, Feigin, & Vos, 2015). Thirty-nine percent of people in the United States diagnosed with a SUD experienced another diagnosable mental illness the prior year (SAMHSA, 2015). Together, these conditions are referred to as dual diagnosis. People with dual diagnosis in the United States often receive treatment either for their SUD or for their other mental health disorders (Todd et al., 2014). Only 15% of the state programs offer integrated treatment (McGovern, Lambert-Harris, Gotham, Claus, & Xie, 2014) even though research provides evidence for their benefit. For example, 26 controlled studies of psychosocial interventions for the treatment of dual disorders found that the most successful interventions had integrated approaches (Drake, Mueser, Brunette, & McHugo, 2004).

While multiple therapeutic interventions have shown positive results in addiction recovery, the most commonly used approach in the United States is the 12 Step program (SAMHSA, 2014). The American Psychological Association (2007) Dictionary of Psychology summarizes the 12 Steps as: admitting powerlessness over addiction (Step 1); recognizing a higher power can provide strength (Steps 2, 3, 7, & 11); taking an honest inventory of strengths and weaknesses including past errors (Steps 4, 5, 6, & 7); making amends for errors (Steps 8 & 9); and learning to live with a new code of behavior, including helping others (Steps 10 & 12).

Research shows the advantages of 12 Step programs. The most prominent benefits include increased abstinence (Kaskutas, 2009; Tonigan, Connors, & Miller, 2003) as well as lowered relapse rates, and reduced appetitive behavior (Buckingham, Frings, & Albery, 2013). Moos and Moos (2006) found alcoholics who attended at least 27 weeks of the 12 Step program had better 16-year outcomes than those who did not attend 12 Step meetings. There is some controversy over whether formal therapy or 12 Step programs are more efficacious. Some researchers argue that continued participation in 12 Step groups is a stronger determinant of long-term outcomes than the initial session of formal treatment with a professional counselor, which substantiates the value of sharing in a peer-support setting (Fiorentine & Hillhouse, 2000; Ritsher, Moos, & Finney, 2002). Overall, it appears that participating in a 12 Step program and formal therapy may provide better outcomes than just one alone. Fiorentine and Hillhouse (2000) concluded that those who attended both exhibited higher rates of abstinence than those who only participated in one of the two.

The study at hand explored the therapeutic impact of supplementing the 12 Step program and formal therapy with expressive arts. Going beyond traditional talking therapies, expressive arts encourage imagination, mind-body connectivity, and personal expression in the context of active participation (Malchiodi, 2005) to aid the psychological healing process. Employing tactile, proprioceptive, and visual senses, expressive arts allow for alternative self-expression which may uniquely shift self-awareness (Bucciarelli, 2016). The incorporation of expressive arts enables group participation for those not yet ready to share verbally. Expression through visual metaphors allows for a new perspective and a less threatening form of communication than direct verbal statements (Moon, 2007).

Expressive arts have a history of use with diverse diagnostic populations, yet limited scientific research addresses their measurable impact on people with dually diagnosed with substance use and mental health disorders. Art therapy, which involves painting, sculpting, drawing, and crafts, may encourage the recovery process. Case approaches demonstrate that therapeutic art-making assists in understanding ambivalent feelings and enhance self-efficacy during initial stages of substance use treatment (Holt & Kaiser, 2009; Horay, 2006). A systematic review exploring the efficacy of music therapy with substance users found that a single session can decrease cravings and increase treatment readiness, contemplation, and motivation for abstinence (Megranahan & Lynskey, 2018). Multiple studies suggest a link between listening to music, mood, and substance cravings (Dingle, Kelly, Flynn, & Baker, 2015; Stamou et al., 2017). Drama therapy, the expression of different viewpoints through role play, seems to enhance wellbeing and reduce irrational beliefs in substance users (Nikzadeh & Soudani, 2016) and can help participants explore the guidelines of the 12 Steps on a creative level (Miller, 2013). Horticultural therapy, nature-based activities such as the cultivation of plants as a rehabilitation tool (Sandel, 2004), reduces vulnerability to addiction as shown through measurable decreases in psychological symptoms (Richards & Kefami, 1999) and is a therapeutic resource to people facing hardship, including addiction (Berger & Berger, 2017).

The incorporation of expressive arts is becoming more common in the United States. A study of 299 U.S. substance abuse treatment programs found that 36.8% utilize art and 14.7% incorporate music into their treatment (Aletraris, Paino, Edmond, Roman, & Bride, 2014). While it is becoming more widespread, there is insufficient quantitative research on the effectiveness of this practice. The current study quantitatively evaluates the effectiveness of a novel expressive arts curriculum as an intervention for dually diagnosed individuals. The curriculum is a literacy-free group counseling manual that incorporates cognitive behavioral therapy (CBT) and rational emotive behavioral therapy (REBT) techniques. It explores the 12 Steps and psychoeducational topics through expressive arts activities in music, dance, drama, horticulture, games, art, and handicrafts.

We hypothesized that exposure to the curriculum would produce positive change in perspective when comparing responses before and after individual sessions, as well as overall, from first to last session per participant. The change was defined as self-reported differences in (a) commitment to recovery, (b) attitude toward lifestyle changes, and (c) hopefulness. These motivational variables (a, b, and c) can serve as indicators of successful treatment outcomes. It has been shown that motivational readiness predicts successful alcohol abstinence over time while lower motivation predicts greater severity of alcohol or drug use (Korcha, Polcin, Bond, Lapp, & Galloway, 2011; Megranahan & Lynskey, 2018). We also explored which sessions were most subjectively meaningful to participants.

The second hypothesis was that participants in the curriculum sample would have higher treatment retention and be more likely to seek aftercare in comparison to inpatients at the same facility who were not exposed to the curriculum sessions. Factors like not leaving the facility against medical advice, fully completing the standard treatment program, and committing to halfway housing were evaluated because these are common indicators of long-term recovery (Arbour, Hambley, & Ho, 2011; Xie, Drake, McHugo, Xie, & Mohandas, 2010).

Materials and methods

Participants

The sample was drawn from an inpatient rehabilitation facility in Maryland, U.S. that treats dually diagnosed substance use and mental health disorders. Inclusion criteria only required a willingness to attend sessions with permission from one’s primary counselor. There were no exclusion criteria. There were 47 voluntary participants, 21 males, and 26 females, with ages evenly ranging from 18 to 50 years. Thirty-nine were Caucasian American, six were African American, one was Asian American, and one was Latino American.

All participants were diagnosed with an SUD. Over half of all participants, 28 of 47, were addicted to more than one substance (this is why the overall substance use percentage is over 100). The specific substances included opiates (63.8%), cocaine (42.6%), alcohol (38.3%), cannabis (25.5%), benzodiazepines (21.3%), and methamphetamines (2.1%). Opiates, cocaine, and alcohol were the three most commonly used primary substances, with a majority of users admitting poly-substance abuse; 21 of the 30 opiate users, 17 of the 20 cocaine users, and 11 of the 18 alcohol users stated use of at least one other drug in combination with their primary drug of choice. In addition to having a SUD, the majority of participants (39 out of 47) were dually diagnosed with at least one other mental health diagnosis. By percentage of the entire sample, bipolar I (25.5%), depression not otherwise specified (25.5%), posttraumatic stress disorder (21.3%), and anxiety disorder not otherwise specified (12.8%) were the most represented mental health diagnoses in participants. Any other diagnoses were present in fewer than five participants. See Table 1 for an overview.

Table 1. Percent of sample by substance used and mental health diagnosis.

	Percent of sample (%)
Substance used
Opiates	63.8
Cocaine	42.6
Alcohol	38.3
Cannabis	25.5
Benzodiazepines	21.3
Methamphetamines	2.1
Mental health diagnosis
Bipolar I	25.5
Depression NOS	25.5
Posttraumatic stress disorder	21.3
Anxiety disorder NOS	12.8

Sixty percent of participants were addicted to more than one substance which is why the overall substance use percentage is over 100. NOS = not otherwise specified.

Curriculum participants were compared to a control group of 101 non-participants who were also inpatients at the time of the study and opted to attend talk therapy groups during the time of curriculum sessions. All non-participants were diagnosed with one or more SUD, with the majority being addicted to opioids. Many were also diagnosed with one or more mental health disorders. The group was predominantly Caucasian-American and composed of both males and females. The participant length of standard treatment was variable, which could be 10–21 days depending on program type and insurance coverage.

Intervention

The Literacy-Free 12 Step Expressive Arts Therapy© curriculum was used in group treatment sessions. It is endorsed by the Maryland Board of Professional Counselors and Therapists for continuing education. Each lesson and activity of the curriculum manual is scripted out for leaders, making content and activities easily replicable. Table 2 outlines the curriculum from the 60-page manual and which of the 12 Steps, topics, therapeutic techniques, and expressive arts mediums are covered in offered sessions. Materials included standard arts and crafts supplies, gourds, gardening materials, and percussion instruments.

Table 2. Steps, therapeutic method, and expressive arts modalities represented in the curriculum.

Number	12 Steps	Title	Therapy	Expression
1	Step 1*	Powerlessness	REBT	Art
2	Psychoeducation	Effects of Drug and Alcohol Use	REBT	Play
3	Steps 2 & 3*	Higher Power	REBT	Meditation, Art
4	Psychoeducation	Relapse Triggers and Coping Skills	CBT, REBT	Art, Drama
5	Steps 4 & 5*	Moral Inventory	CBT	Drama, Art Horticulture
6	Steps 6 & 7*	Change My Heart	CBT	Music
7	Steps 8 & 9*	Forgiving Others and Ourselves	CBT	Horticulture, Art
8	Steps 10 & 11	Changing the Ending to My Story	CBT, REBT	Drama
9	Step 12	Sharing the Message of Recovery and Sober Support	CBT	Dance
10	Peer Support*	Recovery Friendship	CBT, REBT	Handicrafts
	Addendum	Defense Mechanisms	REBT	Drama

Asterisks indicate the lessons utilized as sessions in this study. An abbreviated version of the curriculum was used which consisted of 6 out of the original 10 sessions and did not review Steps 10–12, addendum or psychoeducational lessons to avoid topically overlapping content already offered by the facility where the study took place.

To avoid topically overlapping with content already offered by the facility, an abbreviated version of the curriculum was used. The abbreviated curriculum consisted of 6 out of the 10 lessons, covering Step 1 through 9 of the 12 Steps. The first session involved admitting one’s powerlessness over addiction and unmanageability of one’s life (Step 1). REBT principles focused on activating events and circumstances surrounding when substance use began. These concepts were explored by using art to map out significant life events. The second session inspired moral insight and a spiritual sense (Steps 2 and 3). REBT concepts identified feelings around substance use and consequences. This was applied through a guided meditation on spiritual concepts of darkness and light, while responsively painting and finger painting. The third session conducted a moral inventory of strengths and weaknesses (Steps 4 and 5). CBT principles focused on both reinforcing positive attributes and making plans to change negative attributes. These principles were enforced through group drama, followed by a horticultural exercise involving individual gardening, and a discussion of immediate personal goals and plans for self-care manifested through art. The fourth session emphasized a commitment to change behaviors (Steps 6 and 7) revealed in the previous session’s moral inventory. CBT concepts addressed the need for help in formulating self-care and recovery plans. Roles that fears and resentments play in the formation of maladaptive behaviors were demonstrated musically through a drum circle. The fifth session explored making amends with others as part of the therapeutic process for recovery (Steps 8 and 9). CBT principles focused on forgiveness by admitting the need for behavior change. Horticultural mediums were used to symbolically make amends through an adaptation of traditional African gourd art. During the sixth session, the importance of self-care, spirituality, and community was discussed. The previous Steps were revisited. REBT and CBT principles from all previous lessons were also reviewed. Bracelets were woven to symbolize what participants planned to work on after treatment.

Test measure

A feedback form approved by the Commission on Accreditation of Rehabilitation Facilities (CARF) International already in use at the facility was modified with an added question about hopefulness. The form was administered to participants throughout the entire treatment period to assess the efficacy of different curriculum sessions. Not wanting literacy to be a barrier, participants could alternatively have the questions read aloud privately. The following questions were given at the beginning and end of each group: (1) How committed do I feel to my recovery?; (2) My current attitude to lifestyle changes is … ; and (3) How hopeful do I feel right now? Additionally, two post-measure questions were designed to gauge subjective reflections of participants: How helpful was this group?; and My level of participation was … All questions were answered by participants using a Likert scale of 1–5 where 1 was poor/low and 5 was excellent/high. Space was available for participants to make comments at the end of the posttest form. Non-participants did not complete this form. Three retention/aftercare variables were collected: completing the standard treatment program; committing to halfway housing; and leaving against medical advice.

Procedure

The study was approved by the Institutional Review Board and the director of the facility where the study took place. For recruitment, the daily schedule and counselors made clients aware of the option to attend curriculum groups in place of talk therapy groups. All participants were informed of the voluntary nature of the study and gave informed consent. Researchers compiled demographic and diagnostic information using client files and in consultation with each client’s primary counselor. Diagnoses were given directly or verified by the psychiatrist on site. All clients received standard treatment provided by the facility including access to medical detoxification services, psychiatric care, psychoeducational groups, individual and group counseling utilizing CBT techniques, and individualized treatment plans. Participants received the curriculum intervention in addition to standard treatment during the same time that non-participants engaged in small talk therapy groups with their primary counselors.

Curriculum sessions were conducted across a 3-month period, twice a week, for 1–2 hours. Size of the groups varied by session. Because participants’ length of stay varied by insurance and program type, there was no minimum attendance commitment to qualify for curriculum groups. Participants were present for 1 to 5 of the six groups offered, with the most common number of groups attended being two. Sessions were facilitated by a psychology intern under the supervision of the primary investigator. The primary investigator is the lead counselor for a crisis program for those with dually diagnosed substance use and mental health disorders and is also licensed as a Certified Associate Counselor – Alcohol and Drug (CAC-AD). Both investigators are trained in this curriculum.

Retention and aftercare statistics were acquired from the facility director to compare curriculum participants to inpatients who did not experience the curriculum. For all clients, the facility defined the completion of standard treatment as when treatment plan objectives are met; this includes completing the length of stay (variable by program/insurance), ongoing abstinence while in treatment, attending 75% of groups and individual counseling, and preparing discharge plans.

Results

To address the first hypothesis that exposure to the Literacy-Free 12 Step Expressive Arts Therapy© curriculum would lead to positive changes in perspective, ratings from participants were taken before their first group and compared to their ratings after last attended group. Measuring the self-reported overall change in perspective within all paired samples at a 95% confidence level, statistically significant positive change existed for all three variables addressed by the test measure. There was a small, yet significant, increase in commitment to a drug and alcohol free life, t(46) = −2.12, p = .040, d = 0.31, a large effect size for development of a positive attitude toward lifestyle changes, t(46) = −6.42, p < .001, d = 0.94, and a moderate rise in feelings of overall hopefulness, t(46) = −4.66, p < .001, d = 0.68. See Figure 1.

Figure 1. Overall self-reported changes in the perspective of curriculum sample. Data from before and after the curriculum sessions revealed increases in variables that may be associated with more successful recovery. Attendance varied so the data includes the first pretest and last posttest taken from each client. Means (with standard deviations in parentheses) are provided for each variable at pretest and posttest: commitment to a drug and alcohol free life pre-M = 4.02 (0.87) and post-M = 4.26 (0.67); attitude toward lifestyle changes pre-M = 3.66 (1.07) and post-M = 4.36 (0.85); and feelings of hopefulness pre-M = 3.40 (1.12) and post-M = 4.00 (1.08). Error bars show standard error of measurement.

To explore the impact of individual sessions on the same three dependent variables using paired sample t-tests, the p-value cutoff was designated as .01 instead of .05 to account for the multiple t-test comparisons. Three out of the six sessions offered showed some aspect of significant positive change from pre- to post-ratings on the three variables from the feedback form. Table 3 summarizes the findings. Large effect sizes are displayed for multiple pre- to post-comparisons. While no clear increases in “commitment to recovery” were detected, statistically significant increases in “positive attitude towards lifestyle changes” were identified in three sessions: Step 1: Powerlessness (art); Steps 4 and 5: Moral Inventory (drama, horticulture, art); and Peer Support: Recovery Friendship (handicrafts). Statistically significant increases in “feelings of hopefulness” were found in Steps 4 and 5: Moral Inventory (drama, horticulture, art), and Peer Support: Recovery Friendship (handicrafts).

Table 3. Paired samples t-test and descriptive statistics by curriculum sessions.

	M		SD	SEM	t	df	2-tailed p	Cohen’s d
Step 1: Powerlessness/Art
Pre Commitment to Recovery	4.22		.81	.19
Post Commitment to Recovery	4.33		.84	.20	−1.00	17	.331	.24
Pre Attitude Toward Lifestyle Changes	3.72		1.13	.27
Post Attitude Toward Lifestyle Changes	4.22		.89	.21	−3.43	17	.003*	.81
Pre Hopefulness	3.50		1.10	.26
Post Hopefulness	3.75		1.06	.25	−1.16	17	.261	.27
Steps 2 & 3: Higher Power/Meditation & Art
Pre Commitment to Recovery	3.90		.91	.20
Post Commitment to Recovery	4.05		.76	.17	−1.37	19	.186	.31
Pre Attitude Toward Lifestyle Changes	3.80		1.10	.25
Post Attitude Toward Lifestyle Changes	3.85		1.09	.24	−.44	19	.666	.10
Pre Hopefulness	3.60		1.14	.26
Post Hopefulness	3.50		1.05	.24	.53	19	.606	.12
Steps 4 & 5: Moral Inventory/Drama, Horticulture & Art
Pre Commitment to Recovery	4.12		.78	.16
Post Commitment to Recovery	4.40		.58	.12	−2.59	24	.016	.52
Pre Attitude Toward Lifestyle Changes	3.92		.85	.17
Post Attitude Toward Lifestyle Changes	4.38		.70	.14	−4.63	25	<.001*	.91
Pre Hopefulness	3.54		1.03	.20
Post Hopefulness	4.15		.88	.17	−4.92	25	<.001*	.97
Steps 6 & 7: Change My Heart/Music
Pre Commitment to Recovery	4.44		.53	.18
Post Commitment to Recovery	4.67		.50	.17	−1.51	8	.169	.50
Pre Attitude Toward Lifestyle Changes	4.11		.78	.26
Post Attitude Toward Lifestyle Changes	4.78		.44	.15	−2.83	8	.022	.94
Pre Hopefulness	3.44		.73	.24
Post Hopefulness	4.11		.93	.31	−2.83	8	.022	.94
Steps 8 & 9: Forgiving Others & Ourselves/Horticulture & Art
Pre Commitment to Recovery	4.09		.94	.29
Post Commitment to Recovery	4.27		.79	.24	−1.00	10	.341	.30
Pre Attitude Toward Lifestyle Changes	3.91		.94	.28
Post Attitude Toward Lifestyle Changes	4.09		1.04	.31	−.80	10	.441	.24
Pre Hopefulness	3.73		1.19	.36
Post Hopefulness	4.18		1.08	.33	−2.89	10	.016	.87
Peer Support: Recovery Friendship/Art: Handicrafts
Pre Commitment to Recovery	4.07		.88	.23
Post Commitment to Recovery	4.40		.83	.21	−2.65	14	.019	.68
Pre Attitude Toward Lifestyle Changes	3.88		.89	.22
Post Attitude Toward Lifestyle Changes	4.50		.63	.16	−5.00	15	<.001*	1.25
Pre Hopefulness	3.81		1.05	.26
Post Hopefulness	4.38		.72	.18	−3.58	15	.003*	.89

Note. * indicates p < .01

Meaningfulness of specific sessions was explored through two post-session subjective reflection questions. All sessions were rated above the mid-point of 3 in how helpful the session was perceived to be, ranging from means of 3.85 to 4.67, with the highest mean rating being for Steps 6 and 7: Change My Heart (music). Each session was also rated above 3 in self-perceived participation levels with a low of 3.80 and a high of 4.63 in Peer Support: Recovery Friendship (handicrafts) groups. The lowest ranking of the six sessions offered was Steps 2 and 3: Higher Power (meditation and art), a session that utilized finger painting. While some participants reported enjoying this activity in the comment section of the feedback form, others expressed that finger-painting was “childish” or “too messy.”

To address the second hypothesis that the curriculum may be associated with indicators of long-term recovery, the 47 participants in the curriculum sample were compared to 101 inpatients at the same facility who did not volunteer for curriculum sessions. Chi-square contingency tables compared the frequency of curriculum participants to the frequency of non-participants on the three retention/aftercare variables. Positive outcomes consistently occurred more often in the curriculum group. Standard treatment completion at the facility, χ²(1) = 9.49, p = .002, and committing to halfway housing, χ²(1) = 43.91, p < .001, yielded higher ratios in the curriculum group. Conversely, leaving against medical advice, χ²(1) = 8.16, p = .004, was more common in the non-participants. Figure 2 describes the outcomes in terms of percentages.

Figure 2. Outcomes for the curriculum sample (n = 47) compared to those treated at the same facility but who did not experience the curriculum (n = 101) by percentages of those who completed treatment, who left treatment against medical advice (AMA), and who sought follow-up services in halfway housing.

Discussion

This study analyzed the efficacy of the Literacy-Free 12 Step Expressive Arts Therapy© curriculum to supplement standard treatment for people with SUDs and mental health disorders. The two main hypotheses were supported. First, exposure to curriculum sessions was associated with positive self-reported change in perspective (i.e., greater commitment to recovery, more positive attitude toward making lifestyle changes, and increased hopefulness). In combination, these changes appear to indicate increased treatment motivation for recovery, which has been associated with greater abstinence and recovery success (Megranahan & Lynskey, 2018). Second, retention and aftercare outcomes were consistently better for curriculum participants as opposed to inpatients who did not experience curriculum sessions. Those exposed to the curriculum alongside standard services were more likely to complete treatment and sign up for follow-up care. Previous studies have associated these factors with long-term recovery (Arbour et al., 2011; Xie et al., 2010).

Findings suggest that experiencing sessions from this curriculum may result in a more positive treatment outcome than standard treatment alone. This may be because these clients have the opportunity to learn beyond talk therapy through different mediums such as music, horticulture, drama, art, and handicrafts – allowing for a greater possibility of expression. Treatment that borrows from diverse methods and means of artistic expression can allow clients a new way to characterize their experiences and emotions when they may not easily find the words to do so (Malchiodi, 2005; Moon, 2007). Self-expression difficulties are common for those with diagnosed mental disorders, particularly PTSD (Malchiodi, 2012). By creating art in a safe environment, exposure to traumatic thoughts becomes tolerable, giving voice to mental health symptoms (Spiegel, Malchiodi, Backos, & Collie, 2006), which may be why participants had higher success rates than those who did not participate in the curriculum.

The unique treatment format of the Literacy-Free 12 Step Expressive Arts Therapy© curriculum engages people dually diagnosed with substance use and mental health disorders, which may include illiterate and learning disabled populations. Substance use curricula often rely on interactive journaling and written reflections (Miller, 2014), leaving clients with low literacy largely underserved. Having a standardized curriculum manual that solely encourages expression through artistic and unwritten means removes literacy as a factor in receiving treatment. It allows unseen illiterate and low-literate populations to participate freely in treatment groups with others without the shame of stigma.

Exploratory analyses provided insight into which sessions were most meaningful for the participants. Two sessions, Steps 4 and 5: Moral Inventory (drama, horticulture, art) and Peer Support: Recovery Friendship (handicrafts), were perceived by participants as the most powerful adjuncts to traditional treatment, with significant improvement in attitude toward lifestyle changes and feelings of hopefulness. The content of these two sessions emphasized reflection on personal changes. Recognizing personal growth in treatment was balanced with goals for the future and ongoing self-care. Responses to subjective reflection questions revealed that clients will participate more if they enjoy a session and find it to be subjectively helpful. These results reaffirm what other studies have found. For example, Winkelman (2003) observed that music therapy increases wellbeing and releases emotional stress in substance abusers. The two sessions with the highest ratings for personal helpfulness and participation were Steps 6 and 7: Change My Heart (music) which explored a drum circle activity and Peer Support: Recovery Friendship (handicrafts) which involved bracelet weaving. The subject matter of both centered on the importance of seeking emotional support and connection both spiritually and socially to foster personal growth and accountability. The expressive mediums are highly kinesthetic and interactive. Participants drum in such a way that not only releases intense emotions but also necessitates listening to one another. Participants weave bracelets with a partner in a manner that requires personal reflection, physical concentration, and listening to their partner.

Limitations and future study

While results are promising, there were methodological challenges. Single-item feedback questions were used to measure treatment outcome. Validated questionnaires rather than single-item questions would contribute to the validity and reliability of the findings. Another limitation was that no one participated in all curriculum sessions offered. Variable length of standard treatment at the facility (which could be 10–21 days depending on program type and insurance coverage), strictly bi-weekly offerings of the curriculum sessions at set times, and necessity of seeking permission from primary counselors limited opportunities for attendance. Further, because group attendance was voluntary and not randomly allocated, self-selection bias could have influenced findings, meaning that the curriculum sample may predominantly consist of clients who wanted to be viewed favorably by the treatment staff, who especially enjoy creative arts, or who were most open to change. Responses may also have been biased toward higher post-session ratings by virtue of the fact that clients were in treatment and may, therefore, want the sessions to have a positive impact on them. Another limitation is that primary outcome measures were not compared to a nonparticipating control sample. Nonetheless, the quantitative findings of retention and aftercare outcomes are significant in comparison to a nonparticipating control sample and are not dependent upon clients’ opinions.

Further study may investigate the impact of detoxification symptoms on participation, as many participants were receiving medically managed detoxification treatment during their initial session. Participation in curriculum groups while detoxing may promote early engagement in standard treatment, thus producing greater treatment completion rates. Many participants presented with at least one mental health disorder and were also poly-substance users, which made analysis of pure subgroups impossible. Relatedly, the impact of prescribed psychiatric medication was not explored due to the heterogeneous sample. Additionally, we were unable to perform a multivariate analysis of participants and non-participants exploring how differences between groups in retention rates, rates of leaving against medical advice, and commitment to halfway housing may be impacted by legal issues, educational level, insurance type, or other demographic factors. Future studies could attempt to compare the success of expressive arts exposure for these factors as well as different diagnoses, drugs of choice, psychotropic medications, number of previous relapses, and time-addicted. Insight is needed into the long-term influence of this intervention on relapse prevention.

Conclusion

Preliminary evidence supports the Literacy-Free 12 Step Expressive Arts Therapy© curriculum as a value-added supplement for more inclusive treatment offerings, better program engagement, enhanced retention, and positive outcomes. Comparison of curriculum participants to non-participants on measurable outcomes, such as treatment completion rates and follow-up services, demonstrate it as advantageous. Overall, this intervention may benefit dually diagnosed individuals by strengthening personal investment in recovery, bringing new motivation, and instilling hope that change and healing are possible.

Acknowledgments

We wish to thank the inpatients at A.F. Whitsitt Center and Kent County Crisis Beds Program who participated in this study as they sought recovery. We are grateful to Alice Barkley, LCSW-C, and Andrew M. Pons, M.S., CAC-AD, for their encouragement and assistance at the research site. We also want to thank Belinda Graham, DClinPsy, Greg Falkin, Ph.D., and Tia Murphy, Ph.D. for their valuable comments and editorial assistance on early drafts of this manuscript.

Disclosure statement

At the time of this research study, the primary investigator was employed by the facility where the study took place but received no incentives or benefits for doing the research. The primary investigator is the author of the curriculum being examined and the third author on this study provided editorial assistance previously on that curriculum. In an effort to maximize neutrality, treatment groups using the curriculum in the study were run by a psychology intern as described in the “Procedure” section.