Transcript Self-Management and Recovery Training

Self-Management and Recovery Training:
Program Approach, Principles, and Mechanisms for
Change
Justin R. Watts PhD. NCC
Assistant Professor
University of North Texas
Department of Disability and Addiction Rehabilitation
Deirdre O’Sullivan PhD. CRC
Associate Professor
The Pennsylvania State University
Educational Psychology, Counseling, and Special Education
4th Annual Recovery Conference
Program Objectives
 Overview of peer support groups and mechanisms that
support recovery
 Discussion of SMART Recovery model
 Discuss developing research related to SMART Recovery
Issues Related to Treatment
 22.7 million individuals needed treatment for drug or
alcohol use in 2013 1
 2.5 Million (9%) received treatment at a specialty facility
 Barriers to Treatment
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Cost
No health insurance
Transportation
Employer and community stigma
Lack of education regarding treatment options
Peer Support Groups
 Most widely utilized form of treatment 1
 Supplemental and free option
 Those who attend demonstrate higher rates of remission
 Reduced involvement, less likelihood of abstinence
 Relapse Rate in the US is estimated to be 60% 2, suggesting a
need for continued support post-treatment
Peer Support (Mechanisms for Change)
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Social Support 2, 3
Structure
Strategies to cope with cravings
Alternative activities
Opportunity to establish recovery goals
Learning
 New behaviors and attitudes which promote sobriety
 Self-efficacy
Peer Support Groups
 12-Step (Alcoholics Anonymous, Narcotics Anonymous) are the
most widely utilized models
 Consistently, positively, significantly associated with abstinence 4
 The large body of research related to 12-step has likely
overshadowed research on alternative programs 5
 Most of the mechanisms credited to promoting change are not
unique to one program
 Recovery occurs via many pathways
 Individuals are unique with distinct needs, strengths, preferences, goals,
culture and backgrounds, including trauma experiences that affect and
determine their pathway(s) to recovery 6
12-Step (Alcoholics Anonymous)
SMART Recovery
Peer led
Facilitator led
Free, widely available
Free, less widely available, online option
Sponsors utilized
Does not use sponsor model
Utilizes 12-Steps
Utilizes CBT, REBT, MI
Disease Model
Free will model (self-empowerment)
Recovery and membership generally life-long
commitment
Members are invited to stay involved after
gaining independence from addiction
Recovery occurs through surrender to higher
power, working the 12-steps
Recovery occurs through, building and
maintaining motivation coping with urges
managing thoughts, feelings and behaviors
living a balanced life
Methods
 Participants were self-selected adult participants
affiliated with SMART Recovery (facilitators included)
 Phase 1 = participants who were affiliated > 3 months
 Phase 2 = participants who were affiliated < 3 months
 Overall response rates 54% - 74%
 Descriptive data was gathered related to health, SUD
history, demographics, motivations for attending
SMART Recovery meetings
Demographic Characteristics of Established SMART Recovery
Members (n = 81)
Age
18-72 years (M=49.7: SD = 13)
Gender
Male
66.7%
Female
33.3%
Ethnicity
White
90.1%
Hispanic
3.7%
Asian American/PI
2.5%
African American
1.2%
Other
2.5%
Education
Bachelor’s
37%
Graduate Degree
29.6%
Some College
17.3%
Associate’s
8.6%
High school degree
4.9%
Some high school
2.5%
Demographic Characteristics of Established SMART Recovery Members (n
= 81)
Employment Status
Unemployed
37%
Employed
63%
Full Time
36.7%
Part Time
63.3%
Marital Status
Married/Partnered
43.2%
Single
34.6%
Divorced
18.5%
Separated
3.7%
Disability Status
Without
35%
With
65%
Psychiatric
51%
Physical
40%
Both
9%
SMART members’ ranking of the top 3 factors facilitating recovery
Established members’ reasons for attending SMART Recovery
1. Alignment with SMART Recovery program’s philosophy, principles, and
format.
2. Difficulties with surrendering to a higher power, and the adoption of a
powerlessness identity.
3. Attending both 12-step meetings and SMART Recovery meetings.
4. Outlier responses
Alignment with SMART Program Philosophy
 Thirty-three participants (51.6%) stated the benefit of connecting with
SMART Recovery philosophy, principles, and format as compared to 12step models
 The cognitive-behavioral approach utilized is a foundational appeal for
many members
 This essence was captured in one participant who stated, “I’ve had good
results with [cognitive behavioral therapy]. I sometimes see the rituals of
12 step programs as obstacles”
 “What attracted me to SMART were the trained facilitators and the
conversation - I feel much more supportive using reason - makes a lot
more sense to me then (sic) 12 steps which you have to rely on an addict
to help you through”
Difficulty surrendering to a higher power: powerlessness identity
 Seventeen participants (26.6%) reported switching as a result of viewing
the low utility for a higher power and an aversion to adopt a
powerlessness identity.
One participant reported:
“I am not a 12 stepper and I don't believe that a “higher power” has any
utility for me. If there is a God, it does not intervene in human affairs.
Admitting that you are powerless against addiction, and need divine
intervention to overcome that addiction is not a constructive mindset”
Attending both 12 step and SMART meetings
 Twelve participants (18.8%) maintained membership in both
SMART Recovery and traditional 12-step communities
 One participant reported that he/she is, “Currently doing both.
With a ‘home group’ for SMART recovery and a separate one for
[Alcoholics Anonymous]”
 Another participant reported, “I haven’t switched. I find
different perspectives valuable”
SMART Recovery facilitators’ ranking of the top three program goals that
help members with their recovery
Rank ordering of recovery goals findings: Overview
Top 3 recovery goals for facilitators:
• Abstinence
• Correcting irrational beliefs/behaviors
• Learning to cope with urges
Top 3 recovery goals for members:
• Changing thoughts and behaviors
• Feeling better about self
• Connecting past events to current use/abuse
Reasons for becoming a facilitator
 Four overarching categories emerged from analyzing
the participants’ (n = 38) responses regarding
reasons for becoming a SMART Recovery facilitator.
 To give back by helping others
 Personal benefit for their own recovery
 Accidental Facilitator
 To provide an alternative recovery group
Facilitator Preparation
 3 overarching categories emerged from analyzing the
participants’ (n = 35) responses to what prepared
them to be a SMART Recovery facilitator
 SMART Recovery training materials and resources
 Additional resources outside of SMART Recovery
materials
 Formal training and education
Refusal Self Efficacy
• Strong and reliable predictor of long-term recovery outcomes
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–
–
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reduced drinking/using
more days abstinent
longer affiliation with peer support groups
transition to stable recovery
• Research supports Self Efficacy as a reliable construct that is significantly related
to changing health related behaviors including drinking/drug use
• SMART Recovery asked that we not explicitly inquire about abstinence; RSE is a
known predictor of abstinence
• We didn’t want participants to be prompted to feel guilty if lapsed, or if they
were taking prescribed pain or mood altering medications due to
injury/disability, or psychiatric conditions
Instrument and Variables
 Brief Situational Confidence Questionnaire
 10 items rate from 0 to 100
 Respond to emotional and situation triggers, such as
feeling depressed, wanting to celebrate with friends, etc.
 Strong psychometrics
 BSCQ has a cut off score: 45+ indicates lower risk for
relapse
 New (affiliated < 3 months) vs Established membership
(affiliated for 3 months or more)
 Low, (less than moderate, frequent attenders)
Results
 Established members reported significantly higher refusal self
efficacy compared to new members
 Established (M = 57.58) New (M = 39.20), p = .006
 New members reported BSCQ scores that are indicative of relapse
vulnerability
 Frequent attenders reported significantly higher refusal self efficacy
compared to infrequent attenders
 10+ meetings/month (M = 83.2) Fewer than 4 meetings/month
(M = 70.58), p = .03
 No differences among moderate attenders and other groups, but
medium effects indicating meaningfully higher scores as meeting
attendance increases
Discussion
 Longer affiliation and more frequent attendance
improves refusal self efficacy
 Essential for those in early recovery
 Encourage clients to affiliate with appropriate peer
support group for at least 3 months, and attend
meetings frequently
 Online meetings can supplement in-person meetings
(accessibility)
 Facilitators can help clients to find other supports as
well (counseling, other forms of treatment, role
models)
Early
Recovery
Middle
Recovery
Late
Recovery
• Initiation of abstinence – 3mos (2-3 years) 7,8
• Heavy focus on abstinence; highest risk for
relapse, instability
• 3 months- several years (for some indefinite)
• More stability, confidence related to
abstinence, reduced focus on abstinence
more focus on relapse prevention and reprioritizing work and relationships. Relapse
less likely but still possible
• Several years
• Less emphasis on abstinence and relapse
prevention, more attention on individual
growth. Focus on work and relationships,
individual growth, meaning.
Recovery Capital
 Supports which promote recovery over time
 Social support, self-efficacy, self-esteem, peer support affiliation,
professional treatment, adaptive coping strategies are significantly
related to recovery 8, 9, 10
 Recovery capital has been shown to increase quality of life by 22%
for those in recovery
 Essential to understand the supports and interventions appropriate
and necessary at each stage
 Presumably, more “recovery capital” translates into higher quality
of life, which should result in a reduced risk for relapse
 progression to more advanced stages of recovery
Instruments and Variables
 Flourishing Scale 11
 self perceived life success and satisfaction on several domains including
relationships, daily activities, and optimism about the future.
 Strong psychometrics (α = .85)
 BSCQ
 Self-Stigma and Mental Illness Scale 12
 Internalized stigma from public stereotypes of having mental illness (substance
dependence)
 Strong psychometrics (α = .94)
 Relapse history (number of prior relapses)
 No prior relapses, few (1-4), multiple (5+)
 Participation (n = 80) in peer support meetings
Findings
• Quality of life was significantly correlated with self-concept
and abstinence self-efficacy
• Significant negative correlation was detected between
abstinence self-efficacy and self-stigma (r = -.34, p < .01)
• Significant positive correlation was detected between
abstinence self-efficacy and quality of life (r = .44, p < .01).
• Significant negative correlation between self-stigma and
quality of life (r = -.52, p < .01).
• Full model with relapse history (step one), abstinence selfefficacy, and self-stigma (step 2) significantly explained
variance in quality of life
– p < .001, R2 = .363, R2adj = .337. Abstinence self-efficacy and self
stigma explained an additional 28.7% to 31.3% of the variance in
quality of life.
Discussion
 Abstinence self-efficacy and self-concept are significantly related to quality
of life in expected directions.
 Negative significant relationship between self-stigma and abstinence selfefficacy
 more internalized negative self-concept is related to a low refusal efficacy
 Focus on self-stigma and self-concept is recommended for enhancement
of refusal self-efficacy which translates to reduced relapses, better
trajectory through the recovery stages
• Enhancing self-efficacy is an explicit goal of SMART Recovery prior
research shows that affiliation and frequency of meeting attendance
increases self-efficacy, this is also the case in other programs
• Enhancing self-concept and reducing self stigma are important in recovery
as people learn to disavow the public’s perception of someone who
struggles with addiction, and adopt a positive self-image
• Peer support meetings are not known to focus on self-stigma as a primary
meeting goal but perhaps a more deliberate inclusion in meetings would
enhance progress through the recovery stages.
• Relapse history did explain a small amount of quality of life when entered
alone (5%)
Selected References
1 U.S.
Department of Health and Human Services Substance Abuse and Mental Health Services Administration (2014). Substance Use and Mental Health
Estimates from the 2013 National Survey on Drug Use and Health. www.samhsa.gov
2
National Institute on Drug Abuse (2013). Relapse rates for drug addiction are similar to those of other well-characterized chronic illnesses. Retrieved from
https://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction-basics
3
Bond, J., Kaskutas, L., & Weisner, C. (2003). The persistent influence of social networks and alcoholics anonymous on abstinence. Journal of Studies on
Alcohol, 62, 579-588
4
Gossop, M., Stewart, D., & Marsden, J. (2008). Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and
substance use outcomes after residential treatment for drug dependence: A 5-year follow-up study. Addiction, 103, 119-125.
5
O’Sullivan, Blum, Watts, Bates (2015) SMART Recovery: Continuing care considerations for rehabilitation counselors. Rehabilitation Counseling Bulletin,
58(4)
6 National Association of
Addiction Professionals (2016). Recovery to practice definitions. Retrieved from: http://www.naadac.org/recovery-definitions
7National
Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A research-based guide (3rd ed.). Retrieved from
http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment
8 Laudet,
A., Morgen, K., White, W. (2006). The role of social supports, spirituality, religiousness, life meaning and affiliation with 12-step fellowships in quality
of life satisfaction among individuals in recovery from alcohol and drug use. Alcoholism Treatment Quarterly, 24(1&2): 33–74.
9
Kelly, J. F., Magill, M., & Stout, R. L. (2009). How do people recover from alcohol dependence? A systematic review of the research on mechanisms of
behavior change in Alcoholics Anonymous. Addiction Research & Theory, 17, 236-259.
10
Fiorentine, R., Anglin, M. D. (1996). More is better: counseling participation and the effectiveness of outpatient drug treatment. The Journal of Substance
Abuse Treatment, 13, 341–348.
11 Diener,
E., Wirtz, D., Tov, W., Kim-Prieto, C., Choi, D., Oishi, S., & Biswas-Diener, R. (2010). New well-being measures: Short scales to assess quality of life
and positive and negative feelings. Social Indicators Research, 97(2), 143-156.
12
Corrigan, P. W., Watson, A. C., & Barr, L. (2006). The self-stigma of mental illness: Implications for self-esteem and self-efficacy. Journal of Social and Clinical
Psychology, 25(8), 875-884.
Thank
You.
Justin R. Watts PhD. NCC
[email protected]