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Metacognition as the Result: How the 12-Step
Recovery Model Works
Sonia Peterson
San Diego State University
Peterson
Emerging research has indicated that membership in Alcoholics
Anonymous (AA) is more effective than therapy in supporting ab-
stinence from alcohol use (Kelly et al., 2020). Promoting the use of
12 step recovery as part of a holistic therapeutic approach to the
treatment of co-occurring substance use and other psychiatric dis-
orders emphasizes client autonomy, peer support, strategies to
maintain wellness, and may uncover previously unidentified sup-
ports that will lead to greater self-perceived recovery and more
successful employment outcomes for this population. Specific
12-step training and activity resources can be incorporated into
vocational rehabilitation (VR) service-delivery. 12-step resources
are free, available virtually, and are accessible for clients in the
current COVID-19 environment. Recommendations for VR ser-
vice-delivery are discussed.
Metacognition as the Result: How the 12-Step Recovery Model Works
Individuals with substance use disorders (SUD) and other psychiatric disabilities have been histori-
cally underserved by Vocational Rehabilitation (VR) service-delivery systems and have poorer em-
ployment outcomes compared to individuals with other types of disabilities (Ackerman &
McReynolds, 2005; Andrews et al., 1992; Anthony, 1994; Cimera, 2009; Dutta et al., 2008; Finch &
Wheaton, 1999; Kaya & Chan, 2017; Marshak et al., 1990; Peterson & Olney, 2021; Rosenthal et al.,
2007; Salzer et al., 2011; Schaller & Yang, 2007; Sevak & Khan, 2017; White, 2011). Yet, nearly half of
the individuals who recently sought services in state VR agencies had a SUD or other psychiatric dis-
ability coded as a primary or secondary disability (Peterson & Olney, 2021). For youth, the Centers for
Disease Control (2020) estimates that rates of co-occurring SUD and mental illness are close to 60%.
Individuals seeking services who have co-occurring disorders are largely unidentified in the state VR
system (Peterson & Olney, 2021). Chronic use of alcohol has been associated with increased health
risks and suicide attempts (Felitti et al., 1998; Moss, 2013; SAMHSA, 2010a). SAMHSA (2010a) advo-
cates for abstinence from street drugs and alcohol for individuals who have been diagnosed with a
SUD and co-occurring psychiatric disability, and emerging research from Stanford University has in-
dicated that membership in Alcoholics Anonymous (AA) has been more effective than therapy in sup-
porting abstinence from alcohol use (Kelly et al., 2020). AA is a peer support group that provides so-
cial support for individuals with a self-identified alcohol use disorder to be able to learn how to
participate in all aspects of life without drinking alcohol (AA, 2019a).
Promoting the use of 12 step recovery as part of a holistic therapeutic approach to the treatment of
co-occurring disorders emphasizes client autonomy, peer support, strategies to maintain wellness,
and may uncover previously unidentified supports that will lead to greater self-perceived recovery
and more successful employment outcomes for this population (Peterson et al., 2021). Specific 12-step
training and activity resources can be incorporated into vocational rehabilitation (VR) service-deliv-
ery. 12-step resources are free, available virtually, and are accessible for clients in the current
COVID-19 environment (AA, 2022).
The Rehabilitation Professional, 30(2), pp. 39–50
The Recovery Model
Recovery has been defined as a “process of change through which individuals improve their health
and wellness, live a self-directed life, and strive to reach their full potential” (SAMHSA, 2016, p.3).
The Psychiatric Rehabilitation Association (PRA) (2022) has advocated for the use of recovery-ori-
ented and evidence-based practices that are well coordinated and integrated with other psychiatric,
medical, and holistic treatments for individuals living with SUD and other psychiatric disabilities in
our communities. VR experts have advocated for the use of similarly constructed services for individ-
uals with SUD and other psychiatric disabilities that are known to improve wellness and employment
outcomes for this population (Lusk et al., 2016; Peterson & Olney, 2021; Peterson et al., 2021;
SAMHSA, 2010a; SAMHSA, 2010b).
It is also important for VR counselors to be trained to understand and implement such approaches
(Ackerman & McReynolds, 2005; Heinemann et al., 2014; Kobrin, 2018; Lusk et al., 2016; Olney &
Emery-Flores; 2017; Olney et al., 2014; PRA, 2022; Peterson & Olney, 2021; Peterson, Saia, et al.,
2021; Rosenthal et al., 2007; SAMHSA, 2021a; SAMHSA, 2014; SAMHSA, 2021b; SAMHSA, 2010;
Topitzes et al., 2019; Waynor et al., 2018). It is also important to understand bias against individuals
with severe mental illness (SMI) within the VR system, the symptoms and psychosocial aspects of
SMI, and how symptoms impact employment in order to improve employment services within the VR
service-delivery system for this population (Ackerman & McReynolds, 2005; Andrews et al., 1992; An-
thony, 1994; Cimera, 2009; Dutta et al., 2008; Finch & Wheaton, 1999; Kaya & Chan, 2017; Leahy et
al., 2018; Marshak et al., 1990; Peterson & Olney, 2021; Rosenthal et al., 2007; Salzer et al., 2011;
Schaller & Yang, 2007; Sevak & Khan, 2017; White, 2011). Advocates for the evidence-based Individ-
ual Placement and Support (IPS) model of supported employment strongly promote the integration of
recovery-oriented mental health treatment and vocational services (Bond et al., 2004; Drake et al.,
2012; Drake et al., 2016). A holistic approach to working with clients that have co-occurring SUD and
other psychiatric disabilities that includes peer-facilitated and evidence-based case management
strategies, addiction treatment methods, medical interventions, psychotherapy approaches,
psychoeducation methods, community integration, and peer-led recovery supports is endorsed by the
PRA (2022).
Evidence-Based Peer Support Strategies
The use of peer support in mental health service-delivery has been found to reduce symptoms of men-
tal illness, reduce hospitalizations, and increase quality of life for patients (Bellamy et al., 2017;
Repper & Carter, 2011). Peer support strategies are found in a variety of well-established services
and recovery support groups in our communities are endorsed by the PRA (2022). Recovery-oriented
support groups include Self-Management and Recovery Training (SMART) recovery, Buddhist recov-
ery, and other peer support groups (American Addiction Centers, 2022; Buddhist Recovery Network,
2022; Carnes, 2012; National Alliance on Mental Illness, 2022). The utilization of certified peer sup-
port specialists in mental health service-delivery has been found to reduce symptoms of mental ill-
ness, reduce psychiatric hospitalizations, and increase self-perceived recovery, hope, empowerment,
and quality of life for patients and clients in treatment settings (Bellamy et al., 2017; Repper &
Carter, 2011). Wellness Recovery Action Plan (WRAP) classes are an evidence-based, peer-facilitated,
structured group approach to illness self-management that is widely used within mental health ser-
vice delivery systems (Copeland, 2011; Copeland, 2020). WRAP has been found to reduce clinical
symptoms, reduce hospitalizations, and increase self-perceived recovery for participants (Canacott et
al., 2019; Cook et al., 2013; Fukui et al., 2011).
Integrated treatment. Experts advocate for integrated treatment which includes the integration of
professional mental health treatment with participation in recovery-based, peer-led support groups
in the community (SAMHSA, 2010a; PRA, 2022; NAMI, 2022). Connecting with peers who are thriv-
ing in recovery is often the catalyst that empowers an individual to begin to talk about their experi-
ences, begin to venture out of social isolation, start combatting the stigma associated with the lived
40 Peterson
experience of a psychiatric disability, and begin the process of developing wellness strategies to live in
recovery (Copeland, 2022; NAMI, 2022; PRA, 2022).
Twelve-step recovery programs can easily be integrated with professional treatment to facilitate posi-
tive behavior and personality changes for individuals diagnosed with SUD and other addictions. The
12-step model incorporates elements of Cognitive Behavioral Therapy (CBT) and other evi-
dence-based approaches that promote wellness and recovery (McGrath, 2022, Peterson et al., 2021).
Research has been conducted on participants in 12-step programs to assess outcomes related to be-
havior changes and personality characteristics (Kelly et al., 2018; Kelly et al., 2020; LaBelle &
Edelstein, 2018; Zemore et al., 2018; Webb & Toussaint, 2018).
The 12-Step Support Group Model
The peer-led fellowship of AA is the original 12-step program and has been in existence since 1935
(AA, 2001; Brown & Brown, 2005). Many 12-step fellowships have emerged from AA (American Ad-
diction Centers, 2022; Nakken, 2009). These fellowships all have a common language and a well-es-
tablished, no-cost, peer-led support network available internationally (American Addiction Centers,
2022). These 12-step fellowship groups are a readily available resource for VR clients who are seeking
support for polysubstance use disorders, other addictive behaviors, and relationship issues.
The12Steps
The 12 Steps outline a series of actions designed to elicit a mental, emotional, and spiritual shift in
perception (Alcoholics Anonymous, 2001; American Addiction Centers, 2022):
1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them
or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we un-
derstood Him, praying only for knowledge of His Will for us and the power to carry that out.
12. Having had a spiritual awakening as the results of these Steps, we tried to carry this message
to alcoholics, and to practice these principles in all our affairs.
The 12 Step recovery community promotes reliance on a spiritual foundation, but groups and spon-
sors encourage individual members to choose their own version of a “Higher Power.” Individuals in
the 12 step recovery community encourage newcomers to join a group or meeting that will give them a
sense of community, help them to connect with others in recovery, and help them to abstain from the
substance or behavior they are addicted to one day at a time (AA, 2019b). Newcomers are encouraged
to find a sponsor who will help them connect with others in recovery and who will provide 12 step
homework. Sponsors help newcomers to explore themes of acceptance, powerlessness, and surrender.
Sponsors help newcomers reflect on what a Higher Power means to them and learn to recognize de-
fense mechanisms that keep them stuck in addictive patterns (American Addiction Centers, 2022).
The daily reinforcement of recovery promoted by peers in 12-step fellowships, integration with other
complimentary treatment approaches, and evidence-based strategies that exist in the process of
“working the steps” with a sponsor can be a valuable and free resource for our clients.
Metacognition and 12-Step 41
Is the 12-step fellowship perfect? Absolutely not. Meetings are not always accessible for individuals
with disabilities (AA, 2022). Authors have identified the need to make AA more inclusive (Matsuzaka,
2018). AA is a peer-led fellowship of individuals who self-identify as having alcohol use disorders.
Most members are lay people, not medical professionals or trained mental health practitioners. There
is a potential for members to share misinformation about medical conditions, misinformation about
co-occurring SUD and mental health disorders, and opportunities for spiritual abuse. A myriad of
challenges, conflicts, and the potential for bullying are typically found in groups of individuals, but
participation in a group can be transformational for group members when they are dedicated to a
common purpose (Gladding, 2020). Negative elements exist in the group of AA, but certainly the
shared common purpose of maintaining abstinence from alcohol has had a positive impact on mem-
bers who use the AA group for this purpose (Kelly, 2020).
The purpose of this paper is to inform VR counselors and other rehabilitation professionals on how
much 12-step groups, public perception of addiction, and treatments have improved over the past 75
years. By learning the history, principles, values, and language of the 12-step fellowships, rehabilita-
tion professionals can help clients see opportunities for service to make meetings more inclusive, a
place to connect with others who have had similar experiences, and encourage recovery.
The community-based, peer-led support groups can be an important resource for VR counselors to re-
inforce recovery strategies for clients on a daily basis. Specifically, 12-step recovery programs in
which a member is guided through 12-step homework by a sponsor may share affinity with several
holistic, evidence-based recovery strategies and principles endorsed by the PRA (2022). Effective
12-step recovery communities can provide natural recovery supports that are easily integrated with
and complement the following therapeutic approaches:
Peer Support
Twelve-step meetings are all facilitated by peers who volunteer to lead and provide other services to
facilitate meetings and make sure that meetings are available on a regular basis (AA, 1971).
Therapeutic or Working Alliance
Creating a therapeutic or working alliance with a client is the major determinant of successful out-
comes in counseling relationships (Muran & Barber, 2011). Counselors strive to convey empathy and
develop trust with the client in order to create a therapeutic alliance (Corey, 2020). In 12-step spon-
sor/sponsee relationships, a similar dynamic exists. Sponsors develop a working alliance with the in-
dividuals that they guide through the 12-step homework.
CBT Strategies
CBT is a popular and evidence-based counseling strategy in which counselors provide clients with
homework to identify maladaptive thoughts, feelings, and behaviors in order to develop new behav-
iors that lead to improved emotional states and thought patterns (Corey, 2020). CBT strategies may
be a complementary approach that can be easily integrated and reinforced with the 12-step model.
The process of working through the 12-steps with a sponsor helps individuals to identify maladaptive
behaviors, identify thoughts, identify feelings, and intentionally develop new behaviors. In steps 6
and 7, 12-step participants actively strive to do the opposite behaviors of the “character defects” that
they have identified in steps 4 and 5 (AA, 2018; AA, 1981).
Mindfulness Strategies
Mindfulness-Based Stress Reduction (MBSR) strategies involve meditation practices and are evi-
dence-based to reduce symptoms of anxiety (Grossman et al., 2004). MBSR strategies may be inte-
grated easily with 12-step model approaches. Practicing prayer and meditation is the 11th step (AA,
2018; AA, 1981).
42 Peterson
Wellness and Self-Care Strategies
The Wellness Recovery Action Plan (WRAP) is an evidence-based and peer-led intervention that has
been shown to reduce symptoms of SMI, reduce hospitalizations, and improve self-perceived recovery
(Copeland, 2011; Copeland, 2022). Elements from a WRAP plan that address trauma, treatment, and
employment may be integrated into a comprehensive rehabilitation counseling plan (Peterson et al,
2021). Ninety percent of individuals with psychiatric disabilities have experienced trauma, and re-
searchers recommend that trauma-informed practices are incorporated into service delivery (Classen
& Clark, 2017; Koch et al., 2020; Van der Kolk, 2015). Encouraging clients to participate in a WRAP
class may be a complementary approach that can be easily integrated and reinforced with the 12-step
model. A daily self-care inventory is the essence of step 10 in the 12-Step recovery model (Carnes,
2012; Co-Dependents Anonymous, 2007).
ACT Model Daily Recovery Reinforcements
The Assertive Community Treatment (ACT) model is an evidence-based case management strategy
in which professionals who are part of a service-delivery team contact clients several times a week to
reinforce recovery behaviors, help clients to maintain safe housing, and assist with medical needs
(Pratt et al., 2013). This strategy is effective for individuals with co-occurring SUD and other psychi-
atric disabilities who are new in recovery and who are struggling to maintain wellness and independ-
ent living needs. Encouraging a client to participate in ACT model case management services may be
a complementary approach that can be easily integrated and reinforced with the 12-step model. In
12-step fellowships, peers can provide daily recovery support in the form of daily contact with a spon-
sor and/or other peers from meetings. Peers in 12-step fellowships who have had similar struggles can
share their experience, strength, and hope with individuals who are new to recovery.
Integrated Services
The PRA (2022) has advocated for integrated SUD and mental health treatment services. Many indi-
viduals in society and in 12-step fellowships have co-occurring SUD and other psychiatric disabilities
(CDC, 2020; SAMHSA, 2010a). In 12-step fellowships, members with long-term recovery and who are
in remission from symptoms of serious psychiatric disabilities share and recommend mental health
recovery strategies that have worked for them with newcomers (AA, 2018). The integration of SUD
and mental illness treatment may be a complementary approach that can be easily integrated and re-
inforced with the 12-step model for clients with co-occurring disorders.
Narrative Therapy Approaches
Researchers have noted the benefits of Narrative Therapy approaches in professional counseling set-
tings (Clark, 2014; Gallagher, 2019; McGrath, 2022). A major component of the 12-step model is
members sharing their stories, their experiences, and their hope with others in and outside of 12-step
recovery meetings. Narrative Therapy approaches in counseling may be easily integrated and rein-
forced with the 12-step model. (McGrath, 2022).
Suicide Prevention Strategies
Alcoholic use is associated with suicide attempts (SAMHSA, 2010a). Researchers have noted the im-
portance of providing suicide prevention strategies in VR settings (Lund et al., 2017; Moses, 2018).
Members with long-term recovery in 12-step fellowships can be a resource for newcomers to recovery
who are often struggling with overwhelming life circumstances and emotions. Many cities have
24-hour AA hotlines in which volunteer 12-step members are available to answer the phone, similar
to other crisis and suicide prevention hotlines. PRA (2022) recommends integrated SUD and mental
health services, and the peer support that individuals new in recovery can get from 12-step fellow-
ships can enhance interventions provided by trained mental health professionals.
Metacognition and 12-Step 43
Work Behaviors and Skills
In traditional VR service-delivery, individuals with psychiatric disabilities are only about 30% likely
to gain employment after seeking services, however when this same population has received evi-
dence-based Individual Placement and Support (IPS) model employment services, 60-70% achieved
successful employment (Peterson et al., 2021; Twamley et al., 2008; Twamley et al., 2012). Work en-
hances recovery and is therapeutic for individuals with psychiatric disabilities (IPS Employment
Center, 2020; Olney & Flores, 2017). Skills developed in volunteer service that is performed in 12-step
meetings can be applied to real work environments. Individuals involved in 12-step fellowships may
lead meetings, provide literature to newcomers, volunteer to answer phones, or organize 12-step
events (AA, 2022). A client’s chosen treatment providers, chosen community rehabilitation providers,
employment preferences, peer-based support groups including 12-step fellowships, and wellness
practices listed in a WRAP plan all have the potential to contribute to employment success and are el-
ements that support IPS model employment services (Peterson et al., 2021).
Further supporting a holistic approach to recovery, the 12 steps have been applied to other life areas,
substances, compulsive behaviors, and addictions such as smoking, overeating, compulsive gambling,
and codependency/addiction to abusive relationships. A myriad of 12-step fellowships exist, and
many meetings are available on line with peer support available by phone. Members routinely share
their phone numbers with each other (12Step.org, 2022).
Metacognition as the Result of Working the 12 Steps
Metacognition is the awareness and understanding of one’s own thought processes that can be gained
with psychotherapeutic approaches (Moritz et al., 2018). In 12-step language, the 12th step is de-
scribed as “having had a spiritual awakening as the result of these steps” (AA, 1981, p. 106). When in-
dividuals finish the 12-step homework suggested by their sponsor or other peers in the 12-step fellow-
ship, they generally have gained a better understanding of their own thought processes that before
recovery continued to lead them to the obsession and compulsive behavior that they identified in step
one. Elements of working the steps that included identifying the addictive behavior, writing about
thoughts, writing about feelings, talking with a peer, intentionally changing behaviors, and estab-
lishing a daily practice of connecting with peers in recovery has led to a state of metacognition, which
is typically described in the 12-step recovery community as a “spiritual awakening”.
Professional Responsibilities
It is crucial for rehabilitation professionals to promote recovery-oriented, trauma-informed, and evi-
dence-based strategies for vocational success for individuals with psychiatric disabilities in line with
our ethical principles of autonomy, beneficence, fidelity, justice, nonmaleficence, and veracity (CRCC,
2017). Lusk, Koch, and Paul (2016) have advocated for providing more recovery-oriented VR services
to increase the participation of individuals with psychiatric disabilities including SUD in the VR pro-
cess, facilitate recovery, and improve VR outcomes.
The PRA (2022) core values and principles emphasize hope and respect, shared decision-making,
building on client strengths, and person-centered practices. Rehabilitation counselors should pro-
mote the development of personal support networks, community integration, self-determination, em-
powerment, and practices to help individuals improve the quality of occupational, social, and finan-
cial aspects of their lives. Individuals should be encouraged to develop and use individualized
wellness plans. The holistic integration of psychiatric, medical, and other evidence-based, promising,
and emerging best practices that produce outcomes congruent with personal recovery should be con-
sidered best practice. Participation in 12-step programs might be considered in conjunction with pro-
fessional counseling and other recovery-oriented strategies to improve wellness and employment for
this population. The 12-step model can be effective for a number of people, but not for everybody. Pro-
fessional counseling and various therapeutic approaches may not work for everyone. Knowing what
tools and options are available for a client is important, as is selecting carefully from those options.
44 Peterson
References
12Step.org. (2022). 12 Step Versions in Different Fellowships. https://12step.org/references/12
-step-versions/
Ackerman, G. W., & McReynolds, C. J. (2005). Strategies to promote successful employment of peo-
ple with psychiatric disabilities. Journal of Applied Rehabilitation Counseling, 36(4), 35–40.
Alcoholics Anonymous. (2018). A.A. as a Resource for the Health Care Professional.
https://www.aa.org/sites/default/files/literature/assets/p-23_aaasaresourceforhcp1.pdf
Alcoholics Anonymous. (2018). A.A. for Alcoholics with Mental Health Issues — and their sponsors.
https://www.aa.org/sites/default/files/literature/assets/p-87_AAforAlcoholicswithMentalHealt
hIssues.pdf
Alcoholics Anonymous. (2001). Alcoholics Anonymous: the story of how many thousands of men and
women have recovered from alcoholism. Alcoholics Anonymous World Services.
Alcoholics Anonymous. (2022). Have a Problem with Alcohol? There is a Solution. https://www.aa.org/
Alcoholics Anonymous. (2022). Literature Listing. https://www.aa.org/resources/literature
Alcoholics Anonymous. (2019a). Living Sober. Alcoholics Anonymous World Services.
Alcoholics Anonymous. (2019b). Questions and Answers on Sponsorship.
https://www.aa.org/sites/default/files/literature/assets/p-15_Q%26AonSpon.pdf Alcoholics Anony-
mous. (2018). The Twelve Steps Illustrated.
https://www.aa.org/sites/default/files/literature/assets/p-55_twelvestepsillustrated.pdf Alcoholics
Anonymous. (1971). The Twelve Traditions Illustrated.
https://www.aa.org/sites/default/files/literature/assets/p-43_thetwelvetradiillustrated.pdf
Alcoholics Anonymous. (1981). Twelve Steps and Twelve Traditions. Alcoholics Anonymous World
Services.
American Addiction Centers. (2022). Non 12 Step Rehabs Near You: Alternatives to AA & 12 Step
Programs. https://americanaddictioncenters.org/therapy-treatment/12-step-alternatives
Andrews, H., Barker, J., Pittman, J., Mars, L., Struening, E., & LaRocca, N. (1992). National trends
in vocational rehabilitation: A comparison of individuals with physical disabilities and individu-
als with psychiatric disabilities. Journal of Rehabilitation, 58(1), 7–16.
Anthony, W. A. (1994). Characteristics of people with psychiatric disabilities that are predictive of
entry into the rehabilitation process and successful employment. Psychosocial Rehabilitation
Journal, 17(3), 3–13.
Bellamy, C., Schmutte, T., & Davidson, L. (2017). An update on the growing evidence base for peer
support. Mental Health and Social Inclusion,21(3), 161–167.
Bergman, B. G., Kelly, J. F., Fava, M., & Evins, A. E. (2021). Online recovery support meetings can
help mitigate the public health consequences of COVID-19 for individuals with substance use
disorder. Addictive behaviors,113, 106661.
Bond, G. (2016). Individual Placement and Support (IPS) supported employment. Oxford Bibliogra-
phies in Social Work. DOI: 10.1093/OBO/9780195389678-0202.
Bond, G. R., Salyers, M. P., Rollins, A. L., Rapp, C. A., & Zipple, A. M. (2004). How evidence-based
practices contribute to community integration. Community Mental Health Journal,40(6),
569–588.
Brown, S., & Brown, D. R. (2005). A biography of Mrs. Marty Mann: The first lady of Alcoholics
Anonymous. Hazelden Publishing.
Buddhist Recovery Network. (2022). BRN Online Meetings. https://www.buddhistrecovery.org/
Metacognition and 12-Step 45
Canacott, L., Moghaddam, N., & Tickle, A. (2019). Is the Wellness Recovery Action Plan (WRAP) ef-
ficacious for improving personal and clinical recovery outcomes? A systematic review and
meta-analysis. Psychiatric Rehabilitation Journal,42(4), 372–381.
Carnes, P. (2012). A Gentle Path through the Twelve Steps. Hazelden.
Centers for Disease Control. (2020). High-Risk Substance Use Among Youth.
https://www.cdc.gov/healthyyouth/substance-use/index.htm
Cimera, R. E. (2009). The outcomes and costs of public vocational rehabilitation consumers
withmental illnesses. Journal of Applied Rehabilitation Counseling, 40(2), 28–33.
Clark, A. A. (2014). Narrative therapy integration within substance abuse groups. Journal of Cre-
ativity in Mental Health,9(4), 511–522.
Classen, C. C., & Clark, C. S. (2017). Trauma-informed care. In S. N. Gold (Ed.), APA handbooks in
psychology. APA handbook of trauma psychology: Trauma practice (pp. 515–541). American
Psychological Association.
Co-Dependents Anonymous. (2007). The Twelve Steps & Twelve Traditions Workbook of Co-De-
pendents Anonymous. CoDA Resource Publishing.
Cook, J., Jonikas, J., Hamilton, M., Goldrick, V., Steigman, P., Grey, D., Burke, L., Carter, T.,
Razzano, L., & Copeland, M. (2013). Impact of Wellness Recovery Action Planning on service
utilization and need in a randomized controlled trial. Psychiatric Rehabilitation Journal,36(4),
250–257.
Copeland, M. E. (2011). Wellness recovery action plan. Brattleboro, VT: Peach Press.
Copeland, M. E. (2022). What is WRAP? Copeland Center.
https://copelandcenter.com/wellness-recovery-action-plan-wrap
Corey, G. (2020). Theory and Practice of Counseling and Psychotherapy (10th ed.). Belmont, CA:
Brooks/Cole.
CRCC. (2017). 2017 Code of Professional Ethics for Rehabilitation Counselors. Commission on Re-
habilitation Counselor Certification. https://www.crccertification.com/code-of-ethics-3
Drake, R. E., Bond, G. R., & Becker, D. R. (2012). Individual placement and support: An evi-
dence-based approach to supported employment. Oxford University Press.
Drake, R. E., Bond, G. R., Goldman, H. H., Hogan, M. F., & Karakus, M. (2016). Individual place-
ment and support services boost employment for people with serious mental illnesses, but fund-
ing is lacking. Health Affairs, 35(6), 1098–1105.
doi:10.1377/hlthaff.2016.0001
Dutta, A., Gervey, R., Chan, F., Chou, C. C., & Ditchman, N. (2008). Vocational rehabilitation ser-
vices and employment outcomes for people with disabilities: A United States study. Journal of
occupational rehabilitation, 18(4), 326–334.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J.
S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading
causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal
of Preventive Medicine,14(4), 245–258.
Finch, J. R., & Wheaton, J. E. (1999). Patterns of services to vocational rehabilitation consumers
with serious mental illness. Rehabilitation Counseling Bulletin.42(3), 214–227.
Fukui, S., Starnino, V. R., Susana, M., Davidson, L. J., Cook, K., Rapp, C. A., & Gowdy, E. A. (2011).
Effect of Wellness Recovery Action Plan (WRAP) participation on psychiatric symptoms, sense
of hope, and recovery. Psychiatric Rehabilitation Journal,34(3), 214–222.
Gallagher, S. (2019). An integrative dual diagnosis treatment model for first nation people: Weaving
indigenous psychology (beliefs, practices, & ceremonies) into Western-based practices (acceptance
46 Peterson
and commitment therapy, dialectical behavior therapy, narrative therapy, and the 12-step
model-white bison version) (Doctoral dissertation, ProQuest Information & Learning).
Gladding, S. T. (2020). Groups: A Counseling Specialty (8th ed.). Pearson.
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction
and health benefits: A meta-analysis. Journal of psychosomatic research,57(1), 35–43.
IPS Employment Center. (2020). The IPS Employment Center. International IPS Learning Commu-
nity at The Rockville Institute. https://ipsworks.org/
Kaya, C., & Chan, F. (2017). Vocational Rehabilitation Services and Outcomes for Working Age
People with Depression and Other Mood Disorders. Journal of Rehabilitation, 83(3), 44–52.
Kelly, J. F., Abry, A., Ferri, M., & Humphreys, K. (2020). Alcoholics anonymous and 12-step facilita-
tion treatments for alcohol use disorder: A distillation of a 2020 Cochrane review for clinicians
and policy makers. Alcohol and alcoholism,55(6), 641–651.
Kelly, J. F., Bergman, B. G., & Fallah-Sohy, N. (2018). Mechanisms of behavior change in 12-step
approaches to recovery in young adults. Current addiction reports,5(2), 134–145.
Kobrin, M. (2018). SAMHSA Encourages Use of Life-Changing Wellness Strategies. Substance
Abuse and Mental Health Services Administration.
https://mfpcc.samhsa.gov/ENewsArticles/Article03b_2018.aspx.
Koch, M. C., Vajda, A. J., & Koch, L. C. (2020). Trauma-Informed Rehabilitation Counseling. Jour-
nal of Applied Rehabilitation Counseling,51(3), 192–207.
Krentzman, A. R. (2021). Helping clients engage with remote mutual aid for addiction recovery dur-
ing COVID-19 and beyond. Alcoholism treatment quarterly,39(3), 348–365.
LaBelle, O. P., & Edelstein, R. S. (2018). Gratitude, insecure attachment, and positive outcomes
among 12-step recovery program participants. Addiction Research & Theory,26(2), 123–132.
Leahy, M. J., Del Valle, R. J., Landon, T. J., Iwanaga, K., Sherman, S. G., Reyes, A., & Chan, F.
(2018). Promising and evidence-based practices in vocational rehabilitation: Results of a na-
tional Delphi study. Journal of Vocational Rehabilitation, 48(1), 37–48.
Lund, E. M., Schultz, J. C., Nadorff, M. R., Galbraith, K., & Thomas, K. B. (2017). Experience,
knowledge, and perceived comfort and clinical competency in working with suicidal clients
among vocational rehabilitation counselors. Rehabilitation Counseling Bulletin,61(1), 54–63.
Lusk, S. L., Koch, L. C., & Paul, T. M. (2016). Recovery-oriented vocational rehabilitation services
for individuals with co-occurring psychiatric disabilities and substance use disorders. Rehabili-
tation Research, Policy, and Education,30(3), 243–258.
Matsuzaka, S. (2018). Alcoholics anonymous is a fellowship of people: A qualitative study. Alcohol-
ism Treatment Quarterly,36(2), 152–178.
McGrath, A. (2022, April). Telling Stories: Narrative Therapy and 12-Step Programs as Partners in
Treatment. 60-minute education session presented at the American Counseling Association
2022 Conference, Atlanta, GA.
Moritz, S., Lysaker, P. H., Hofmann, S. G., & Hautzinger, M. (2018). Going meta on metacognitive
interventions. Expert Review of Neurotherapeutics,18(10), 739–741.
Moses, T. (2018). Suicide attempts among adolescents with self-reported disabilities. Child Psychi-
atry & Human Development,49(3), 420–433.
https://link.springer.com/article/10.1007/s10578-017-0761-9
Moss, H. B. (2013). The impact of alcohol on society: a brief overview. Social work in public
health,28(3-4), 175–177.
Muran, J. C., & Barber, J. P. (Eds.). (2011). The therapeutic alliance: An evidence-based guide to
practice. Guilford Press.
Metacognition and 12-Step 47
Nakken, C. (2009). The addictive personality: Understanding the addictive process and compulsive
behavior. Simon and Schuster.
National Alliance on Mental Illness. (2022). Support Groups.
https://www.nami.org/Support-Education/Support-Groups
Olney, M. F., & Emery-Flores, D. S. (2017). “I Get My Therapy From Work” Wellness Recovery Ac-
tion Plan Strategies That Support Employment Success. Rehabilitation Counseling Bulle-
tin,60(3), 175–184.
Peterson, S. & Olney, M. F. (2021). Disparities between individuals with and without psychiatric
disabilities: State vocational rehabilitation services and employment outcomes. Journal of Re-
habilitation, 87(3), 36–46.
Peterson, S., Saia, T., Maya Castellanos, A. D., & Olney, M. (2021). Promoting ethical individual-
ized plan for employment (IPE) development with the wellness recovery action plan (WRAP).
Journal of Rehabilitation 87(4), 4–11.
Pratt, C. W., Gill, K. J., Barrett, N. M., & Roberts, M. M. (2013). Psychiatric Rehabilitation.Academic
Press.
Psychiatric Rehabilitation Association. (2022). Core Principles and Values.
https://www.psychrehabassociation.org/about/core-principles-and-values
Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health ser-
vices. Journal of mental health,20(4), 392–411.
Rosenthal, D. A., Dalton, J. A., & Gervey, R. (2007). Analyzing vocational outcomes of individuals
with psychiatric disabilities who received state vocational rehabilitation services: A data min-
ing approach. International Journal of Social Psychiatry, 53(4), 357–368.
Salzer, M. S., Baron, R. C., Brusilovskiy, E., Lawer, L. J., & Mandell, D. S. (2011). Access and out-
comes for persons with psychotic and affective disorders receiving vocational rehabilitation ser-
vices. Psychiatric Services, 62(7), 796–799.
Schaller, J., & Yang, N. K. (2007). Gender, race, and depressive/mood disorders: An analyses of
state-federal rehabilitation outcomes. Journal of Applied Rehabilitation Counseling, 38(1),
32–38.
Sevak, P., & Khan, S. (2017). Psychiatric versus physical disabilities: A comparison of barriers and
facilitators to employment. Psychiatric Rehabilitation Journal, 40(2), 163–171.
Substance Abuse and Mental Health Services Administration [SAMHSA]. (2010a). Integrated
Treatment for Co-Occurring Disorders Evidence-Based Practices (EBP) KIT.
https://store.samhsa.gov/product/Integrated-Treatment-for-Co-Occurring-Disorders-Evidence-
Based-Practices-EBP-KIT/SMA08-4366
SAMHSA. (2010b). Supported Employment Evidence-Based Practices (EBP) KIT.
https://store.samhsa.gov/product/Supported-Employment-Evidence-Based-Practices-EBP-Kit/
SMA08-4364
Twamley, E., Narvaez, J., Becker, D., Bartels, S., & Jeste, D. (2008). Supported employment for
middle-aged and older people with schizophrenia. American Journal of Psychiatric Rehabilita-
tion, 11(1), 76–89. doi:10.1080/15487760701853326
Twamley, E., Vella, L., Burton, C., Becker, D., Bell, M., & Jeste, D. (2012). The efficacy of supported
employment for middle-aged and older people with schizophrenia. Schizophrenia Research,
135(1-3), 100–104. doi:10.1016/j.schres.2011.11.036
Van der Kolk, B. A. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma.
Penguin Books.
Webb, J. R., & Toussaint, L. L. (2018). Self-forgiveness as a critical factor in addiction and recovery:
A 12-step model perspective. Alcoholism Treatment Quarterly,36(1), 15–31.
48 Peterson
White, A. R. (2011). Characteristics of three consumer cohorts in vocational rehabilitation: A com-
parison of consumers with dual-diagnosis, psychiatric, or substance use related disorders. Jour-
nal of Applied Rehabilitation Counseling, 42(1), 15–24.
Zemore, S. E., Lui, C., Mericle, A., Hemberg, J., & Kaskutas, L. A. (2018). A longitudinal study of
the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups
for those with AUD. Journal of Substance Abuse Treatment,88, 18–26.
Author Note
Dr. Sonia Peterson, PhD, CRC, LPCC is an Assistant Professor and Director of the Clinical Rehabili-
tation Counseling program at San Diego State University. She earned her PhD in Rehabilitation and
a certificate in Educational Research Methodology at the University of Arizona and an MA in Reha-
bilitation Counseling from the University of Iowa. She also holds a certificate in Rehabilitation Ad-
ministration from San Diego State University.
Correspondence concerning this article should be addressed to Sonia Peterson at
slpeterson@sdsu.edu
Metacognition and 12-Step 49
