Transcript Strategies for Facilitating Outpatient Attendance of AA

Empirical Awakening:
The New Science on AA
And 12-Step Treatment
and How You can Enhance
Your Patients’ Outcomes
John F. Kelly, Ph.D.
Associate Professor in Psychiatry
Harvard Medical School
Associate Director
MGH Center for Addiction Medicine
TUERK Conference, May 10th, 2011 Baltimore, MD
OVERVIEW
Why have mutual-help groups (MHG) emerged, grown, and
persisted despite efficacious professional treatments?
Effectiveness/efficacy research/Cost effectiveness
Can clinicians/programs influence MHG participation?
Professional MHG Facilitation: What to do and what to
expect
OVERVIEW
Why have mutual-help groups (MHG) emerged, grown, and
persisted despite efficacious professional treatments?
Effectiveness/efficacy research/Cost effectiveness
Can clinicians/programs influence MHG participation?
Professional MHG Facilitation: What to do and what to
expect
WHY HAVE MHGS GROWN DESPITE INCREASED
EFFICACIOUS TREATMENTS? BURDEN OF DISEASE,
TREATMENT COSTS AND STIGMA




Harmful use/SUDs pervasive confer massive burden of disease
Professional resources alone cannot
cope; stigma and cost present
further barriers to access
Addiction often has chronic course (9
yrs from 1 st tx to achieve FSR;
Dennis et al, 2005); 4-5 yrs before
risk of relapse <15%
In tacit recognition, most societies
seen increases in MHGs during past
70 yrs (Kelly & Yeterian, 2008)
WHY HAVE MHGS GROWN DESPITE EFFICACIOUS TREATMENTS?
RECOVERY MANAGEMENT AND THE CHRONIC NATURE OF
SUBSTANCE DEPENDENCE


Addiction talked as chronic but still
treated as acute condition:
 Serial episodes of self-contained
and unlinked intervention
 Implicit expectation that a
lifelong cure will occur following a
single episode of “rehab”
 Continuing care (“aftercare”) as
afterthought
Recovery management is a philosophy
of organizing addiction treatment
and recovery support services to
enhance early pre-recovery
engagement, recovery initiation,
long-term recovery
maintenance…(White, 2008).
WHY HAVE MHGS GROWN DESPITE EFFICACIOUS
TREATMENTS? MHGS & TREATMENT INTEGRATION




1950’s “Minnesota Model”
>90% of private SUD treatment in US base tx on
the 12-step principles (Roman & Blum, 1998)
About 80% of VA SUD patients are referred to 12step groups (Humphreys et al., 1997)
84% of youth are referred to AA/NA post-discharge
(Knudsen et al, 2008; Kelly et al, 2008)
Table 1. Substance Focused Mutual-help Groups
Name
Year
of
Origin
Alcoholics
Anonymous (AA)
1935
Narcotics Anonymous
(NA)
1940s
Cocaine Anonymous
(CA)
1982
Methadone
Anonymous (MA)
1990s
Approx. 100 groups
25 States; online meetings at
http://methadone-anonymous.org/chat.html
Marijuana
Anonymous (MA)
1989
Approx. 200 groups
24 States; online meetings at
www.ma-online.org
Rational Recovery
(RR)
1988
No group meetings or mutual helping;
emphasis is on individual control and
responsibility
-----------------------------------------------------
Self-Management and
Recovery Training
(S.M.A.R.T.
Recovery)
1994
Approx. 250 groups
40 States; 19 online meetings at
www.smartrecovery.org/meetings/olschedule.htm
Secular Organization
for Sobriety, a.k.a.
Save Ourselves (SOS)
1986
Approx. 480 groups
all 50 States; Online chat at
www.sossobriety.org/sos/chat.htm
Women for Sobriety
(WFS)
1976
150-300 groups
Online meetings at
http://groups.msn.com/ WomenforSobriety
Moderation
Management (MM)
1994
Approx.16 face-to-face meetings
12 States; Most meetings are online at
www.angelfire.com/trek/mmchat/;
Number of groups in U.S.
52,651
Approx. 15,000
Approx. 2000 groups
Source: Kelly & Yeterian, 2008
Location of groups in U.S.
all 50 States
all 50 States
most States; 6 online meetings at
www.ca-online.org
Table 2. Dual-Diagnosis Focused Mutual-help Groups
Name
Year of Origin
Number of
groups in U.S.
Location of groups in U.S.
Double Trouble
in Recovery
(DTR)
1989
200
Highest number of groups in
NY, GA, CA, CO, NM, FL
Dual Recovery
Anonymous
(DRA)
1989
345
Highest number of groups in
CA, OH, PA, MA
Dual Disorders
Anonymous
1982
48
28 in IL
Dual Diagnosis
Anonymous
(DDA)
56
38 in CA
Source: Kelly & Yeterian, 2008)
Table 3. Non-Substance Focused Addictive Behavior Mutual-help Groups
Name
Year of
Origin
Number of groups in U.S.
Location of groups in U.S.
Gamblers
Anonymous
(GA)
1957
Approx. 1000 chapters
all 50 States
Approx. 700 meetings
most States; Online meetings at
www.sexaa.org/online.htm; Telephone
meetings
Approx. 1320 groups
worldwide
(including in all 50 States), Online
meetings at
www.slaafws.org/online/onlinemeet.ht
ml; Regional teleconference calls
Approx. thousands of
meetings
all 50 States; Numerous online
(www.oa.org/pdf/OnlineMeetingsList.p
df) and telephone meetings
(www.oa.org/pdf/phone_mtgs.pdf)
Sex Addicts
Anonymous
(SAA)
Sex and Love
Addicts
Anonymous
(SLAA)
Overeaters
Anonymous
(OA)
1977
1976
1960
Source: Kelly & Yeterian, 2008)
WHAT GROUPS DO PATIENTS ATTEND?
Yr 1
Yr 2
Yr 3
% (n)
% (n)
% (n)
Total
Women*
Total
Women
Total
Women
Any Addiction Mutual-help
Organization
79% (188)
29% (54)
54% (129)
30% (38)
54% (127)
27% (34)
Alcoholics Anonymous (AA)
76% (180)
28% (50)
52% (123)
29% (35)
52% (123)
26% (32)
Narcotics Anonymous (NA)
7% (16)
25% (4)
3%
(6)
33% (2)
4%
(9)
33% (3)
SMART Recovery
3%
(7)
57% (4)
2%
(5)
60% (3)
1%
(3)
33% (1)
Rational Recovery (RR)
1%
(2)
50% (1)
.5%
(1)
0% (0)
.5%
(1)
100% (1)
Women for Sobriety (WFS)
2%
(4)
100% (4)
3%
(6)
100% (6)
0%
(0)
-
Other (e.g., church group)
0%
(0)
-
.5%
(1)
0% (0)
.5%
(1)
0% (0)
50% (119)
26% (31)
52% (123)
26% (32)
12-step only (e.g., AA, NA)
Non-12-step only (e.g., SMART)
74% (176)
3%
(7)
26% (46)
57% (4)
2%
(5)
60% (3)
2%
(4)
50% (2)
Source: Kelly, Stout, Zywiak et al, 2006, Alcoholism: Clinical and Experimental Research
SUMMARY
MHGs for SUDs long history
AA is similar to others – lasted longest
Many new mutual-help groups
Many widely available
MHG integration with SUD tx
OVERVIEW
Why have mutual-help groups (MHG) emerged, grown, and
persisted despite efficacious professional treatments?
Effectiveness/efficacy research/Cost effectiveness
Can clinicians/programs influence MHG participation?
Professional MHG Facilitation: What to do and what to
expect
POTENTIAL ADVANTAGES OF COMMUNITY
MUTUAL-HELP

Cost-effective -free; attend as intensively, as long as desired

AA/NA focused on addiction recovery over the long haul

Widely available, easily accessible, flexible

Access to fellowship/broad support network

Entry threshold (no paperwork, insurance); anonymous (stigma)

Adaptive community based system that is responsive to
undulating relapse risk (Kelly et al, 2009)
12-STEP RESEARCH- RECENT HISTORY


Given public health significance,
Institute of Medicine (IOM, 1990)
called for AA research.
state of science summarized and
further research opportunities
outlined (McCrady and Miller,
1993)
Number of Publications on AA
and NA
1960-2010
450
400
350
300

Past 20 yrs significant increase in
scientific interest and rigor
focused on AA.
250
200
150
100
50
0
1960-70
1971-80
1981-90
1991-00
2001-10
EVIDENCE OF BENEFIT - META
ANALYSES OF AA

4 meta-analytic reviews

Emrick et al. 1993

Tonigan et al, 1996

Kownacki et al. 1999

Ferri, Amato, & Davoli, 2006
FINDINGS FROM META-ANALYSES
 Emrick et al. 1993 - 107 studies. AA attendance and
involvement modest beneficial effect on drinking
behavior
 Tonigan et al., 1996 - 74 studies. Examined
moderators of effectiveness (i.e. outpatient vs.
inpatient; study quality)
 Studies generally, were “methodological poor” and
underpowered
FERRI, AMATO, DAVOLI, 2006 (COCHRANE
REVIEW)

Attempted to examine RCTs of AA or TSF

8 trials involving 3417 people were included.

Findings:
 AA may help patients to accept treatment and keep patients
in treatment more than alternative treatments
 AA had similar retention rates
 3 studies compared AA combined with other interventions
against other treatments and found few differences in the
amount of drinks and percentage of drinking days
 AA found to be as effective as other comparison professionallydelivered interventions
META-ANALYSES (CONTINUED)





Kownacki & Shadish, 1999 – 21 studies;
examined controlled trials only
Randomization confounded with coerced
status (justice system required)
Coerced individuals fared worse than
individuals in other treatment or no
treatment
Coerced individuals may have better
outcomes if coerced into other kinds of
treatment
Found support for 12-step-based tx and noncoerced AA attendance
RESULTS AND LIMITATIONS
 Results
from hundreds of studies reveal AA
confers a consistent moderate beneficial effect
 Results
from RCTs of AA itself, reveal mixed
findings depending on whether individuals
were coerced/mandated to attend AA meetings
or not
 Most
attended following treatment –difficult to
discern unique effects of AA…
UNIQUE EFFECTS: NATURALISTIC STUDY (TIMKO ET AL,
2000)

8 yr study of unique effects of AA on
drinking outcomes (N=466 previously
untreated “problem drinkers”

Compared 4 groups self-selecting:
1.
2.
3.
4.
no treatment (n=78)
AA only (n=66)
professional treatment only (n=74)
professional treatment + AA (n=248)
LONG-TERM PROSPECTIVE STUDY
RESULTS




Formal tx or AA only had better outcomes than untreated
sample at all waves
AA-only more abstinence & less drinking/problems than
professional tx
AA-only cohort equivalent on drinking, functioning and
coping outcomes at 1-, 3- and 8-year follow-up compared to
professional tx + AA
Those choosing AA only, fare better than untreated, as well
as those choose professional tx
EFFECTIVENESS STUDIES – I.
MULTISITE VA STUDY



Large-scale prospective, multisite, comparing 12step, cognitive-behavioral and eclectic (N=3,698)
Patients treated in 12-step programs more likely
to be abstinent at 1 year follow-up (45% vs. 36%)
Patient involvement in 12-step mutual-help
groups associated with better outcomes
irrespective of initial treatment
EFFECTIVENESS STUDIES – II. DRUG ABUSE
TREATMENT OUTCOME STUDY (DATOS)



N= 927 cocaine dependent patients
enrolled in outpatient, residential, and
short-term inpatient.
At least twice weekly AA/NA attendance
reduced likelihood of relapse
others have also found evidence for benfits
of AA/NA attendance (e.g. Morgenstern et
al., 1997; Fiorentine et al., 2000; Miller et
al., 1997).
EFFECTIVENESS STUDIES – III




Multi-site, outpatient study (N= 2,029; Miller,
Ninonuevo et al., 1997)
Pre-, during, and post-treatment variables
Most powerful predictors -post-treatment variables
 12-step mutual-help attendance
 involvement in a continuing care program
Post-treatment AA attendance in first year uniquely
accounted for 14% of outcome variance
EFFECT OF HELP-SEEKING (TX, 12-STEP, AND
TX + 12-STEP) ON RECOVERY (DAWSON ET AL,
2006)

NESARC (N= 4,422, with alcohol dependence)

Only a quarter of sample sought any kind of help


More severe individuals more likely to seek help
and more likely to achieve recovery
Those participating in tx + 12-step had more
than twice rate of recovery compared to those
receiving tx alone
SPECIAL
POPULATIONS
FOR WHOM ARE MUTUAL-HELP GROUPS
PARTICULARLY HELPFUL / NOT HELPFUL?

Clinical concerns member-group fit with
12-step mutual-help organizations.

1. Dual-diagnosed (DD) ?

2. Non-religious people?

3. Women?

4. Young People?
PSYCHIATRIC COMORBIDITY I.



SUDs frequently co-occur
with psychiatric illnesses
Concerns about membergroup fit of co-morbid with
typical 12-step groups
Barriers –
Putative opposition to
medications
 Clinical syndromes vs. “not
working the program”

PSYCHIATRIC COMORBIDITY II.



Rychtarik, et al. (2000;N= 277 ) - 86% of sampled
AA members believed medications intended to
reduce relapse risk (e.g. naltrexone, disulfiram)
was good idea/might be a good idea.
29% pressured to stop medications of one kind or
another
Individuals with AUDs hold generally negative
views toward any medications (Tonigan & Kelly,
2004)
PSYCHIATRIC COMORBIDITY III.



Meissen et al., (1999; N=125) AA contact persons - 93
% believed dual-diagnosed should continue
medication.
54% believed participation in specific dual diagnosis
group more desirable
Such groups scarce but growing (e.g. Double Trouble
in Recovery; Dual Recovery Anonymous)
PSYCHIATRIC COMORBIDITY IV. EVIDENCE
OF EFFECTIVENESS – TRADITIONAL 12-STEP
Ouimette et al.
(2001) Veterans
with PSTD
attend and
benefit as much
as non DD
Bogunschutz et
al. (2000); DD
patients attended
at comparable
rates to non DD,
except psychotic
patients
Tommassen
(1998); Jordan et
al. (2002); all DD
except psychotic
spectrum
attended at
comparable rates
as non DD
Noordsy et al.
(1996) no
beneficial effects
for psychotic
cohort
involvement in
12-step mutualhelp
Kelly et al. (2003)
DD patients with
MDD do not
become as
socially involved
in 12-step groups
and derive
progressively less
benefit over 2 yr
follow-up
RELATIONSHIP BETWEEN 12-STEP
INVOLVEMENT AND SUBSTANCE USE OUTCOME
FOR
SUD-ONLY VS. SUD-MDD PATIENTS
0.6
Probability of Abstinence
0.55
0.5
0.45
0.4
0.35
SUD-ONLY
0.3
SUD-MDD
0.25
-2
-1
0
1
12-Step Affiliation
(Standard Deviations)
2
Source: Kelly et al., (2003) Comorbid Major Depression in Patients with Substance Use Disorders: Effects on 12-Step
mutual-help Participation and Substance use outcomes. Addiction, 98, 499-508
RELATIONSHIP BETWEEN 12-STEP
INVOLVEMENT AND SUBSTANCE USE OUTCOME
FOR
SUD-ONLY VS. SUD-MDD PATIENTS
0.43
0.41
Probability of Remission
0.39
0.37
0.35
0.33
0.31
SUD-ONLY
0.29
SUD-MDD
0.27
0.25
-2
Source: Kelly et al., (2003)
-1
0
1
12-Step Affiliation
(Standard Deviations)
2
PSYCHIATRIC COMORBIDITY V.
EFFECTIVENESS – DD SPECIFIC GROUPS
 mutual-help groups specifically designed for
comorbidity have emerged and may be a better fit
for severely impaired….
PSYCHIATRIC COMORBIDITY VI.
EFFECTIVENESS – DD SPECIFIC GROUPS

Magura et al. (2002; N=240) attendance at DRA
meetings

Better medication compliance

Less hospitalization
PSYCHIATRIC COMORBIDITY VII.
EFFECTIVENESS – DD SPECIFIC
GROUPS



RCT - REBT tx with a 12-step tx for
severe DD (Penn & Brooks, 2000).
REBT - lower ratings on need for
psychiatric tx & fewer needed inpatient
tx at follow-up
12-step patients better alcohol outcomes,
bigger decrease in need for alcohol tx at
12-months, and less drug use at 3-month
COMORBIDITY SUMMARY
SHOULD DD PATIENTS BE REFERRED TO
AA/NA?

Attendance rates may be similar and many
may benefit (e.g. PTSD)

More severely impaired (e.g., psychosis)
may have more difficulty

Attendance rates may be similar but comorbid may require additional/more specific
support and/or greater facilitation (e.g.
severe MDD)
RELIGIOUSNESS & 12-STEP
MUTUAL-HELP

Concerns about quasi-religious concepts

Implications for non-religious individuals


Referral to 12-step organizations should
take into account religious background.
Practice guidelines of APA, recommend
clinicians refrain from referring
nonreligious people to 12-step.
RELIGIOUSNESS & 12-STEP
MUTUAL-HELP




Winzelberg & Humphreys, (1999; N=3,018
male veterans)
“Belief in God” did not relate to attendance
People lower in recent religious practices
attended less frequently
Degree of religiosity did not affect salutary
relationship between AA/NA and substance use
outcomes at 1 and 3yrs (Kelly, Stout et al, 2006;
Winzelberg et al, 1999)
RELIGIOUSNESS & 12-STEP MUTUAL-HELP


Project MATCH - religiousness did not interact
with txs (Connors et al.2001)
Brown, et al (2001; N= 153) – no relationship
between religious involvement and frequency of
12-step attendance.
RELIGIOSITY SUMMARY &
RECOMMENDATIONS:
 Should non-religious patients be
referred to 12-Step mutual-help groups?



Little evidence to suggest not
Educate about “spirituality” vs. “religion” and socially
mediated benefits (e.g., Litt et al, 2009; Kelly et al, 2011)
50% of original membership atheist/agnostic (AA, 2001)
WOMEN AND MUTUAL-HELP I




Women make up about one-third of tx & AA
population
Concern over fit of women in 12-step
organizations
Emphasis on “powerlessness”
Minority status of women in 12-step groups. women-specific issues more difficult to discuss.
WOMEN AND MUTUAL-HELP II
Project MATCH (Del Boca, et al, 2001).
no gender x tx interaction found – women benefited as
much as men in TSF as in other txs
Women actually attended as much as (for outpts) or
more (in aftercare) and became more involved in AA
Women attended as often as men; gender did not
moderate effects among outpts (Kelly, Stout et al, 2006)
WOMEN AND MUTUAL-HELP III
Women appear to attend and benefit as
much as men (and get more involved)
Unclear whether women-only meetings
(common in AA) benefit women more
Unclear whether other women-specific
organizations (Women for Sobriety) may
improve outcomes for women
YOUNG PEOPLE AND AA/NA?
SUBSTANCE USE AND PROBLEM ONSET AND OFFSET
NSDUH Age Groups
100
Severity Category
90
80
No Alcohol or Drug Use
70
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
0
Dependence
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
NSDUH and Dennis & Scott
PREVALENCE OF DSM-IV ALCOHOL
DEPENDENCE ACROSS THE LIFESPAN
Source: Grant, Dawson et al, 2004
% USING PRIOR TO AGE 15
35%
30%
25%
20%
% using
Alcohol use
Marijuana
Cocaine
15%
Hallucinogens
10%
5%
0%
1934-1944
1945-1955
1956-1960
1961-1965
1966-1970
1971-1975
1976-1980
Adapted from: Johnson and Gerstein (1998) Am Jnl Public Health, 88, 1, 27-33
1981-1985
1986-1990
IN THEORY…

AA/NA possess certain elements that make them
attractive as adjunct to formal treatment:





Accessible, Flexible, Adaptive: Meetings held several
times a day; pts can self-select; “on demand”- provide
degree flexibility seldom available professionally
Low threshold entry: no paperwork, anonymous
Recovery-Specific Experience/Support: Members
serve as role models - share sobriety experience and
advice
Foster Continuing Risk Appraisal: Provides continued
reminders of past negative experiences & exposure to
testimonials & modeling of successful sobriety
Cost-effective: AA and NA groups can also be attended
free of charge for as long as individuals desire-decrease
reliance on formal services
WHAT ABOUT YOUTH?
POTENTIAL DEVELOPMENTAL BARRIERS:

Youth-adult differences:

Recovery Specific:



Life-Context Specific:



Younger age relative to AA/NA members mismatch with lifecontext factors (e.g., marriage, children, employment problems)
/safety issues
Dependence on parents for transportation/financial support
12-step Specific:


Addiction severity (withdrawal/consequences)
Problem recognition/motivation for abstinence
Potential discomfort with spiritual/”religious”
May signify poor fit with 12-step fellowships’ emphases on
complete abstinence and spiritual growth
RESULTS: RATES OF ATTENDANCE
Any, Monthy, and Weekly AA/NA Attendance across 8 Years
Following Inpatient Treatment
100%
90%
% Attending AA/NA
80%
70%
Any
60%
Monthly
50%
Weekly
40%
30%
20%
10%
0%
0-6m
6m-1yr
1-2yr
2-4yr
Follow-Up
4-6yr
6-8yr
Percent of Youth in Each Trajectory Outcome Group attending AA/NA at least Weekly
across 8 Years
% Attending AA/NA weekly
100
90
80
70
Abstainers
60
Infrequent User
50
worse with time
40
Frequent User
30
20
10
0
6m
12m
24m
48m
Time
72m
96m
LAGGED GEE MODEL OF YOUTH TREATMENT OUTCOME OVER 8
YEARS IN RELATION TO AA/NA ATTENDANCE IN THE FIRST 6
MONTHS POST-TREATMENT
Parameter
Estimate
Standard
Error
95% Confidence Limits
Z
P
Intercept
51.5854
10.9072
30.2077
72.9631
4.73
<.0001
Time
1.0041
1.6354
-2.2012
4.2094
0.61
0.5392
Gender
-11.0712
4.1317
-19.1692
-2.9733
-2.68
0.0074
PDA 6m
0.3156
0.0681
0.1821
0.4491
4.63
<.0001
Pre-treatment PDA
-0.0987
0.0860
-0.2673
0.0700
-1.15
0.2514
Moderate use
-2.6835
1.5748
-5.7702
0.4031
-1.70
0.0884
Formal Treatment 6m
-0.4683
4.6025
-9.4889
8.5524
-0.10
0.9190
Aftercare1 6m
0.7602
0.8735
-0.9519
2.4724
0.87
0.3841
AA/NA 6m
0.5079
0.1213
0.2702
0.7455
4.19
<.0001
Time x AA/NA 6m
-0.1158
0.0316
-0.1777
-0.0540
-3.67
0.0002
1. Square root transformed N = 150
Kelly, Brown, Abrantes, Kahler, & Myers (2008): Alcoholism: Clinical Experimental Research, 32, 8 1468-1478.
LAGGED GEE MODEL OF YOUTH TREATMENT OUTCOME IN
RELATION TO AA/NA ATTENDANCE OVER 8 YEARS
Parameter
Estimate
Standard Error
95% Confidence
Limits
Z
P
Intercept
37.3071
6.9601
23.6656
50.9486
5.36
<.0001
Time
1.4424
0.8693
-0.2614
3.1462
1.66
0.0971
Gender
-9.3380
2.6605
-14.5526
-4.1234
-3.51
0.0004
Pre-treatment PDA
-0.0811
0.0490
-0.1772
0.0150
-1.65
0.0980
Moderate use
-1.8816
0.9646
-3.7722
0.0090
-1.95
0.0511
Aftercare1 6m
0.4349
0.5158
-0.5761
1.4460
0.84
0.3991
Formal Treatment2
5.5669
3.2856
-0.8727
12.0065
1.69
0.0902
AA/NA2
1.9517
0.4512
1.0674
2.8360
4.33
<.0001
PDA2
0.5030
0.0371
0.4304
0.5757
13.56
<.0001
1= Sq root transformed; 2= Time varying covariate
Kelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of Youth Treatment Outcome in
Relation to 12-step Group Involvement. Alcoholism: Clinical and Experimental Research, 2008, 32, 8 1468-1478.
61
Kelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of Youth
Treatment Outcome in Relation to 12-step Group Involvement. Alcoholism: Clinical and Experimental
Research, 2008, 32, 8 1468-1478.
Treatment Intake (0M)
1-3M Follow-up
ABSTINENCEFOCUSED COPING
0M
4-6M Followup
ABSTINENCEFOCUSED COPING
3M
.33**
.17*
SELF-EFFICACY
0M
-.12
.14†
.15
MOTIVATION FOR
ABSTINENCE 0M
-.11
12-STEP
ATTENDANCE
†
SELF-EFFICACY 3M
-.21**
.18*
.12
.17*
.21*
.26**
SUBSTANCE USE
PROBLEM SEVERITY
***p<.001 **p<.01 *p< .05 †p<.10
.11
.40**
.22**
DAYS ABSTINENT
OM
DAYS ABSTINENT
4-6M
MOTIVATION FOR
ABSTINENCE 3M
AFTERCARE
ATTENDANCE
N=99
Kelly, Myers, Brown (2000) Psychology of Addictive Behaviors
MOTIVATION FOR
ABSTINENCE 0M
.15
†
.26*
.22**
12-STEP
ATTENDANCE
SUBSTANCE USE
PROBLEM SEVERITY
.18*
DAYS ABSTINENT
OM
***p<.001 **p<.01 *p< .05 †p<.10
.21*
MOTIVATION FOR
ABSTINENCE 3M
.46***
DAYS ABSTINENT
3-6M
.12
.07
AFTERCARE
ATTENDANCE
N=99
Kelly, Myers, Brown (2000) Psychology of Addictive Behaviors
.20*
What do you like best about AA/NA meetings? (6m follow-up; n=53)
Response Domain
Domain Description
Example
Universality
Not feeling alone; a sense of
belonging
“To know I am not the
only one with this
problem”
17
1
Positive
Attention/Encourage
ment (Support)
Getting support from others –
that other members care
about them
“They always care what I
have to say”
17
1
Instillation of hope
Recovery is possible; feeling
better; seeing/
hearing others who have
recovered; feeling inspired
“Hearing stories of how
other people got
through”
14
3
None/negative
Items placed in this category
pertain to generally
negative responses like
“nothing”
“Nothing”
10
4
Catharsis
A place to talk, express
feelings, thoughts etc.
“Get my feelings out”
7
5
Imparting of information/
Interpersonal learning
Learning skills, getting
information and advice
from others
“Principles for everyday
life”
4
6
AA-specific
Content/Philosophy
AA content-specifics, such as
working the 12 steps,
spirituality, having an AA
sponsor, using AA
philosophy/slogans
“One day at a time
philosophy”
4
6
Other
Providing structure, group
cohesion, insight,
cognitive restructuring
“Something to do to stay
busy”
1
8
Source: Kelly, Rodolico & Myers (in press) Journal of Substance Abuse
Frequency
Rank
RELATION BETWEEN AGE COMPOSITION OF ATTENDED MEETINGS
AND PERCENT DAYS ABSTINENT FOR ADOLESCENTS
100
95
90
85
80
75
70
65
60
55
Days Abstinent (3m)
50
Days Abstinent (6m)
All adults
Mostly adults
Even mix
Mostly teens
All teens
Kelly, Myers & Brown, (2005) Journal of Child and Adolescent Substance Abuse
90%
80%
70%
PDA
60%
50%
40%
48.2%
57.4%
84.0%
30%
No attendance
< 1 meeting/week
> 1 meeting/week
12-step attendance
68
Can 12-step Group Participation Potentiate and Extend the benefits of Adolescent
Addiction Treatment (Kelly et al, 2010), Drug and Alcohol Dependence
WITHIN-PERSON CHANGE IN PDA FOR DISCRETE SUB-GROUPS
OF AA/NA ATTENDEES FOLLOWING OUTPATIENT SUD
TREATMENT (N=111)
90
12-step attendance after
admission:
80
70
60
50
None (n=61)
40
Inconsistent (n=43)
Weekly (n=7)
30
20
10
0
Admission 3 months 6 months 12 months
FOR WHOM ARE MUTUAL-HELP GROUPS
PARTICULARLY HELPFUL / NOT HELPFUL?

Clinical concerns member-group fit with 12-step mutual-help
organizations.

1. Dual-diagnosed (DD)?- less severe/non-psychotic benefit as much;
more severe DD specific groups better

2. Non-spiritual/religious people?- less likely to attend but benefit as
much

3. Women? – more involved than men, benefit as much

4. Young People? – more severe participate; benefit as much as adults

In general, other factors (e.g., percieved severity; Finney and Moos, 1995)
may override other participation barriers
Cost Effectiveness
COST-EFFECTIVENESS (1) (HUMPHREYS & MOOS, 2001)
90%
80%
70%
60%
50%
CBT
TSF
40%
30%
20%
10%
0%
Abstinent
No SA-related problems No psychological problems No psychiatric problems
COST-EFFECTIVENESS (2) (HUMPHREYS & MOOS, 2001)
18.0
16.0
14.0
12.0
10.0
CBT
TSF
8.0
6.0
4.0
2.0
0.0
12-step attendance
Inpatient days
Outpatient visits
COST-EFFECTIVENESS (3) (HUMPHREYS & MOOS, 2001)
Cost per patient over 1 year *
CBT
Resulted in
$4,729
greater costs
per patient
with sig.
worse
outcomes
Cost per patient over 1 year *
$12,129.00
$7,400.00
CBT
TSF
COST-EFFECTIVENESS II (1) (HUMPHREYS & MOOS,
2007; 2YR FOLLOW-UP
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
CBT
TSF
30.0%
20.0%
10.0%
0.0%
Abstinent
No SA-related
problems
No psychological
problems
No psychiatric
problems
COST-EFFECTIVENESS II (2) (HUMPHREYS &
MOOS, 2007; 2YR FOLLOW-UP
12.0
10.0
8.0
CBT
6.0
TSF
4.0
2.0
0.0
12-step attendance
Inpatient days
Outpatient visits
COST-EFFECTIVENESS II (3) (HUMPHREYS &
MOOS, 2007; 2YR FOLLOW-UP
CBT Resulted in
$3,295 greater
costs per patient
with sig. worse
outcomes in Yr
2 Follow up
Cost per patient over 1-2 year
Cost per patient
$5,735.00
$2,440.00
CBT
TSF
How and why does AA/NA help?
How might MHGs like AA reduce relapse risk and aid the recovery process?
Cue Induced
RELAPSE
Stress Induced
Drug Induced
AA-related social network
changes may help avoid cues,
reduce and tolerate distress, and
maintain abstinence minimizing
drug-induced relapse risks
AA
79
Conceptualization of How AA May Reduce Relapse
Risk: Cognitive Behavioral Relapse Prevention
Model
Coping
Response
High Risk
Situation
Decreased
probability
of relapse
Self-efficacy
AA
No coping
response
Decreased
self -efficacy
Positive
Outcome
Expectancies
for initial use
of the
substance
Adapted from: Marlatt & Gordon, 1985
Initial use
of
substance
Abstinence
violation
effect:
Dissonance
conflict and
self attribution
(guilt
loss control)
Increased
probability
of relapse
HOW DO MUTUAL-HELP GROUPS ENHANCE
OUTCOMES? POSSIBLE MECHANISMS
Social
network
changes
(reduction of
cue
exposure)
Paths to Relapse…
Druginduced
AA
Cueinduced
Stressinduced
Temporally Lagged Controlled A-B-C Mediational Model
B: THEORETICAL
MEDIATOR
A: AA/NA
CONTROL VARIABLES
C: OUTCOMES
FIGURE 2A. AA ATTENDANCE AND THE % CHANGE IN BOTH PROABSTINENT AND PRO-DRINKING NETWORK TIES FROM
TREATMENT INTAKE TO THE 9-M (OP SAMPLE)
Source: Kelly et al, 2011, Drug and Alcohol Dependence
FIGURE 2B. AA ATTENDANCE AND THE % CHANGE IN BOTH PROABSTINENT AND PRO-DRINKING NETWORK TIES FROM
TREATMENT INTAKE TO THE 9-M (AC SAMPLE)
Source: Kelly et al, 2011, Drug and Alcohol Dependence
(15-mo) Alcohol Outcomes
(PDA or DDD)
(3-mo) AA attendance
Baseline (BL) Covariates
Age
Race
Sex
Marital Status
Employment Status
Prior Alcohol Treatment
MATCH Treatment group
MATCH study site
Alcohol Outcomes (PDA/DDD)
(BL) Self-efficacy
Negative Affect
(9-mo) Self-efficacy
Negative Affect
(BL) Self-efficacy
Positive Social
(9-mo) Self-efficacy
Positive Social
(BL) Religious/Spiritual
Practices
(9-mo) Religious/Spiritual
Practices
(BL) Depression
(9-mo) Depression
(BL) Social Network
“pro-abstinence”
(9-mo) Social Network
“pro-abstinence”
(BL) Social Network
“pro-drinking”
(9-mo) Social Network
pro-drinking”
Source: Kelly, Hoeppner, Stout, Pagano (2011)
SUMMARY
Studies increased in methodological rigor past 15 yrs
Evidence from both efficacy & effectiveness studies reveals consistent benefits of
involvement
AA/NA highly cost-effective reduce health care costs while enhancing treatment outcomes
AA/NA seems to work by mobilizing similar processes of change as formal intervention
but over long periods - strength may lie in its ability to provide free, long-term, easy
access and exposure to recovery-related common therapeutic elements
Empirical support for use as adjunct to formal care(e.g. American Psychiatric Association,
2006; SAMHSA/Department of Veterans Healthcare, 2005)
OVERVIEW
Why have mutual-help groups (MHG) emerged, grown, and persisted
despite efficacious professional treatments?
Why refer patients to AA/MHGs?
Effectiveness/efficacy research/Cost effectiveness
Can clinicians/programs influence MHG participation?
Professional MHG Facilitation: What to do and what to expect
DOES FACILITATION DURING TX
AFFECT RISK FOR DROPOUT?
Risk
Factors
0
1
2
3
4
5
6-7
Treatment Settings
Combined
n
261
548
582
512
381
150
78
Dropout Rate
30 % (77)
30 % (163)
38 % (221)
43 % (218)
51 % (193)
54 % (81)
65 % (51)
High Supportive Treatment
milieu
n
151
274
269
176
119
36
16
Dropout Rate
30 % (45)
29 % (79)
38 %(103)
40 % (70)
42 % (50)
47 % (17)
50 % (8)
Low supportive Treatment
milieu
n
110
274
313
336
262
114
62
Dropout Rate
29 % (32)
31% (84)
38 % (118)
44% (148)
55% (143)
56% (64)
70% (43)
•Dropout rate = 40%
•AA dropouts had 3x higher odds of relapse to alcohol/drug use
FACILITATION BY DROPOUT-RISK
INTERACTION
Source: Kelly & Moos (2003) Dropout from 12-Step Groups: Prevalence, Predictors and Counteracting Treatment
Influences, Journal of Substance Abuse Treatment,24, 241-250
OVERVIEW
Why have mutual-help groups (MHG) emerged, grown, and persisted
despite efficacious professional treatments?
Why refer patients to AA/MHGs?
Effectiveness/efficacy research/Cost effectiveness
Can clinicians/programs influence MHG participation?
Professional MHG Facilitation: What to do and what to expect
T
S
F
O
T
H
TSF DELIVERY MODES
Stand alone
Independent therapy
As Modular appendage
linkage component
Integrated into an existing
therapy
Component of a treatment
package (e.g., an
additional group)
PRECURSOR TO CURRENT TSF RESEARCH
(SISSON AND MALAMS, 1981)
 20
patients randomly selected from outpatient
tx program for alcohol use disorder
 Randomly assigned to:

1: Standard referral


given information about AA including time, date, location of
meetings, encouraged to attend meetings
2: Systematic encouragement and community access

In addition to standard procedure, clients had phone conversation
with AA member during a session - client and AA member met
before first meeting, member provided client with ride; client also
received a reminder phone call from the member
PRECURSOR TO CURRENT 12-STEP
FACILITATION RESEARCH
 Results:

0% clients in standard referral attended a meeting
during the target week

100% clients in systematic encouragement and
community access group attended meeting during target
week

Mean AA meeting attendance rate for 4 week period:

0 for standard referral group vs 2.3 for systematic
encouragement group
T
S
F
O
T
H
TSF DELIVERY MODES
Stand alone
Independent therapy
As Modular add-on
linkage component
Integrated into an existing
therapy
Component of a treatment
package (e.g., an
additional group)
PROJECT MATCH
 Multisite
randomized clinical trial of alcohol
dependent individuals

2 arms
Aftercare (n=774)- recently finished inpatient treatment
 Outpatient (n=952)


3 conditions, all with ultimate goal of abstinence



Twelve Step Facilitation

Therapist took firm stance against any drinking

Therapist assisted in building skill set to maintain abstinence

Therapist aimed to build clients motivation to accept abstinence
as objective
Cognitive Behavioral Therapy
Motivational Enhancement Therapy
PROJECT MATCH- FINDINGS
 Individuals
randomly assigned to TSF
attended AA more frequently and had
higher rates of continuous abstinence (71%
more) 1yr following tx (TSF=24%,
CBT=15%, MET=14%)
 than those assigned to CBT or MET; similar
on continuous outcomes (PDA/DDD)
 Social support for drinking

3 yrs post treatment, clients whose social networks were
more supportive of drinking prior to treatment had
higher abstinence and lower drinks per drinking day in
TSF than in MET (clients in CBT did not show a
significant advantage over those in MET)
I. PROJECT MATCH- RESULTS



Effects mediated by ongoing AA attendance
Across txs, those who attended AA groups had better outcomes
(Tonigan et al, 2002)
AA valuable adjunct to SUD treatment - even when not formally
emphasized
RECENT RCTS - II. COCAINE
COLLABORATIVE STUDY



Controlled trial for cocaine patients (N=487)
Compared 3 theoretically distinct treatments for
cocaine dependence (Cognitive, SupportiveExpressive; 12-step drug counseling)
12-step drug counseling had superior outcomes at
1 year and were attending more 12-step meetings
(Crits-Christoph et al, 1999)
CHANGING NETWORK SUPPORT FOR DRINKING (LITT ET AL., 2009)

Network Support Project -to determine if tx can
change social networks to ones supportive of sobriety

Alcohol dependent individuals (N=210) randomly
assigned to 1 of 3 txs:

Network Support (NS)


Network Support +Contingency Management (NS+CM)


Meant to help patients change social network to include people in support
of abstinence; based on TSF treatment created for Project MATCH; 6 core
sessions+ 6 elective sessions
Same network support as described above, plus drawings from a “fishbowl”
if soc. network enhancing tasks completed (eg. AA meeting, having coffee
with a sober friend)
Case Management (CaseM, control condition)

Based on intervention used in Marijuana Treatment Project; therapist and
participant worked together to indentify barriers to abstinence and develop
goals and identify resources to be used to aid in achieving abstinence
CHANGING NETWORK SUPPORT FOR
DRINKING FINDINGS
 Results
indicated NS did best; NS+CM did
worse than NS alone, but better than CaseM
 Participants

20% more days abstinent than those in other
conditions at 2 year follow-up


in NS condition:
NS: 80%, NS+CM: 60%, CaseM: 60%
greater increases in social network support for
abstinence, AA attendance and AA involvement than
those in other conditions at 15 month follow-up
CHANGING NETWORK SUPPORT FOR DRINKING- FINDINGS
AFTERCARE TREATMENTS AND CLIENT
CHARACTERISTICS (BROWN ET AL, 2004)

Sample of adults randomly assigned to one of two
aftercare treatment conditions:

Structured Relapse Prevention (RP, N=61)


10 weekly group sessions, manualized program including an
individual treatment plan focusing on triggers, coping
methods and initiating change
12-Step Facilitation (TSF, N=72)
10 weekly group sessions based on Project MATCH manual
 Session included discussions of AA reading material and AA
involvement


Patient characteristics matched to treatment: age,
gender, substance abuse profile, and psychological
Brown et al
status
AFTERCARE TREATMENTS AND CLIENT
CHARACTERISTICS- FINDINGS
 Substance

use profile
TSF associated with significantly better alcohol
and drug use outcomes than RP for those with a
multiple substance use profile
 Gender

TSF significantly better alcohol use outcomes than
RP for women
 Psychological

distress
TSF associated with prolonged post treatment
abstinence in comparison to RP for those with high
levels of psychological distress
T
S
F
O
T
H
TSF DELIVERY MODES
Stand alone
Independent therapy
As Modular add-on
linkage component
Integrated into an existing
therapy
Component of a treatment
package (e.g., an
additional group)
STRATEGIES FOR FACILITATING OUTPATIENT
ATTENDANCE OF AA (WALLITZER ET AL, 2008)

Approaches to assist in involvement in AA
 169
adult alcoholic outpatients randomly
assigned to one of three treatment
conditions
 All
clients received treatment that included:
12 sessions
 Focus on problem-solving, drink refusal, relaxation
 Recommendation to attend AA meetings

STRATEGIES FOR FACILITATING
OUTPATIENT ATTENDANCE OF AA

Treatment varied between 3 conditions in terms of how the therapist
discussed AA and how much information about AA was shared

Condition 1: Directive approach







Condition 2: motivational enhancement approach (more client centered)





Therapist directed
Client signed contract describing goals to attend AA meetings
Therapist encouraged client to keep a journal about meetings
Reading material about AA provided to client
Therapist informs client about skills to use during meetings and about using a sponsor
38% total material covered in sessions was about AA
Therapist obtains clients feelings and attitudes about AA
Therapist describes positive aspects of AA, but states that it is up to the client how much
they will be involved
Therapist intends to assist the client in making a decision in favor of AA
20% total material covered in sessions about AA
Condition 3: CBT treatment as usual, no special emphasis on AA


Throughout treatment, therapist briefly inquires about AA and encourages client to
attend AA
8% total material covered in sessions about AA
Walitzer, Dermen & Barrick, 2009
STRATEGIES FOR FACILITATING
OUTPATIENT ATTENDANCE OF AAFINDINGS
Participants exposed to the Directive TSF approach
reported significantly more:
 attendance of AA meetings
 more active involvement in AA
 higher percent days abstinent in comparison to the
treatment as usual group
 Evidence suggests AA involvement partially mediated
the effects of the directive approach

STRATEGIES FOR FACILITATING AA ATTENDANCE DURING OUTPATIENT TREATMENT
Strategies for Facilitating AA Attendance during Outpatient Treatment
T
S
F
O
T
H
TSF DELIVERY MODES
Stand alone
Independent therapy
As Modular add-on
linkage component
Integrated into an existing
therapy
Component of a treatment
package (e.g., an
additional group)
MAAEZ INTERVENTION (KASKUTAS ET AL,
2009)

Making AA Easier- manual guided - designed to help clients
prepare for AA

Goal: to prepare for AA (encourage participation in AA, minimize
resistance to AA, and educate about AA)


Facilitator goal: to inform clients about AA and facilitate group
interaction


MAAEZ intervention is conducted in a group format to help prepare for
group dynamic of AA
Facilitator recommended to be an active member of AA, NA, or CA
Discussion format: MAAEZ allows and encourages feedback
(referred to as “cross-talk” in MAAEZ), unlike AA which does not
allow feedback
MAAEZ INTERVENTION- DESIGN
 Structure
 Six,

of Program:
weekly, 90-minute sessions
Homework assigned at the end of each session
List of texts for reading assignments provided in
manual
 List of articles that discuss effectiveness of AA
provided in manual
 Each homework assignment includes going to at least
one AA meeting in the 7 days following that session,
making connections with other people in AA, and
completing reading assignments

MAAEZ -4 CORE COMPONENTS/SESSIONS




Spirituality: provides clients with range of “spirituality”
definitions that do not all require religious orientation. The
homework assignment after that session is to talk to someone
longer sober, after a meeting.
Principles Not Personalities: deals with AA myths, types of
meetings/etiquette. Homework- ask someone for phone number
and speak on the phone before next session.
Sponsorship: explains function of AA sponsor, offers guidelines
for picking someone, and includes role-playing to practice asking
for a sponsor and overcoming a rejection. Homework that week is
to get a temporary sponsor.
Living Sober, tools for staying sober are tackled: relapse
triggers, service, and avoiding “slippery” people, places, and
things. Homework for this session is to socialize with someone in
AA who has more sobriety.
MAAEZ INTERVENTION- FINDINGS

Abstinence:



TSF participants significantly more past 30 day alcohol
abstinence, drug abstinence, and both alcohol and drug
abstinence at 12 month time period
Increased odds of continuous abstinence in general and for
each additional MAAEZ session attended
Prior AA Exposure:

MAAEZ found to be more effective in participants with AA
previous experience (differs from outcomes found in Project
MATCH), possibly because MAAEZ gives clients new
perspective of AA
Kaskutas et al 2009
MAAEZ INTERVENTION- FINDINGS
T
S
F
O
T
H
TSF DELIVERY MODES
Stand alone
Independent therapy
As Modular add-on
linkage component
Integrated into an existing
therapy
Component of a treatment
package (e.g., an
additional group)
EFFECTIVENESS OF CLINICIAN REFERRALS
TO AA (TIMKO ET AL 2006; 2007)


Evaluation of procedures to effectively refer patients to 12-step
meetings
Individuals with SUDs entering a new outpatient treatment
program randomly assigned to a treatment condition and provided
self reports on meeting attendance and substance use

Condition 1: standard referral


Patients given locations and schedules of meetings and encouraged to attend
Condition 2: intensive referral

Patients give locations and schedules of meetings, with the meetings preferred
by previous clients indicated

Therapist reviews a handout about program including introduction to 12-step
philosophy and common concerns

Therapist arranged a meeting with a current member and client had a phone
conversation with this member during a session

Therapist and client agreed on which meetings client will attend and client kept
a journal of meetings attended and experiences
EFFECTIVENESS OF CLINICIAN REFERRALS TO
AA- FINDINGS
 At
6m, patients in intensive referral who had
relatively less previous 12-Step experience had:
higher meeting attendance
 better substance use outcomes

 At
both the 6 and 12 month follow up, patients
in intensive referral:
more likely to attend at least one meeting per week
 had higher rates of attendance and had higher rates of
abstinence

EFFECTIVENESS OF CLINICIAN REFERRALS
TO AA- AA PARTICIPATION FINDINGS
Timko 2007
EFFECTIVENESS OF CLINICIAN REFERRALS
TO AA- ABSTINENCE OUTCOME FINDINGS
MET FOR 12 STEP INVOLVEMENT
(KAHLER ET AL, 2006)
Patients undergoing inpatient treatment assigned to
one of two treatment conditions:
• Brief Advice (BA)
• 5 minute individual session, therapist stresses gravity of the
problem with alcohol, importance of abstinence and benefits of AA
• Motivational Enhancement for 12-step involvement (ME-12)
• 60 minute individual session with focus on abstinence;
participant asked to discuss goals and positive and negative
aspects of use
• Information about AA provided included obtaining a sponsor;
participants asked to discuss ways to maximize the benefits of AA
• Participant set goal for AA attendance
Kahler
MET FOR 12 STEP INVOLVEMENTFINDINGS
MET-12 did not increase patient
involvement in AA or benefit alcohol use
outcomes
However, interaction effects indicate that
treatment success was moderated by the
patient’s prior experience with AA:
• ME-12 more effective for patients with less AA
experience- higher AA involvement and better alcohol
use outcomes
• BA more effective for patients with more AA experience
MET for 12 Step Involvement- Findings
MET FOR 12 STEP INVOLVEMENTFINDINGS
COMBINING AA/NA WITH TREATMENT SUMMARY
Evidence indicates MHG participation, such as AA and NA, strongly
associated with higher abstinence rates, and other recovery-related
indices
Likelihood of AA/NA or other MHG participation CAN be clinically
influenced
A number of empirically supported treatments are available that
can be incorporated at the practitioner or program-level (see
SAMHSA NREPP or APA Division 12 (Clinical Psychology)
Employing TSF strategies are likely to enhance treatment
outcomes, reduce health care costs, and extend the benefits
of formal care (Kaskutas, 2009; Kelly & Yeterian, 2011)
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