10/29/2015. Clinical Implications and Applications of the Research on Twelve-Step Facilitation and mutual-help organizations

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1 Clinical Implications and Applications of the Research on Twelve-Step Facilitation and mutual-help organizations John F. Kelly, Ph.D. Elizabeth R. Spallin Associate Professor in Psychiatry Harvard Medical School Director Recovery Research Institute Program Director Addiction Recovery Management Service Associate Director MGH Center for Addiction Medicine Breakout Session MARRCH Conference St. Paul, MN, October Treating addiction with spirituality? Three years ago when my head doctor, Silkworth, began to tell me of the idea of helping drunks by spirituality, I thought it was crackpot stuff, but I ve changed my mind. One day this bunch of ex-drunks of yours is going to fill Madison Square Garden (1937) Alcoholics Anonymous, 1952, p.136 1

2 T S F O T H TSF Delivery Modes Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular appendage linkage component In past 25 years, AA research has gone from contemporaneous correlational research to rigorous RCTs and (3-mo) AA attendance (15-mo) Alcohol Outcomes (PDA or DDD) Baseline (BL) Covariates Age Race Sex Marital Status Employment Status Prior Alcohol Treatment MATCH Treatment group MATCH study site and lagged moderated multiple mediation studies to elucidate its impact and MOBCs Alcohol Outcomes (PDA/DDD) (BL) Self-efficacy Negative Affect (BL) Self-efficacy Positive Social (BL) Religious/Spiritual Practices (BL) Depression (BL) Social Network pro-abstinence (BL) Social Network pro-drinking (9-mo) Self-efficacy Negative Affect (9-mo) Self-efficacy Positive Social (9-mo) Religious/Spiritual Practices (9-mo) Depression (9-mo) Social Network pro-abstinence (9-mo) Social Network pro-drinking Source: Kelly, Hoeppner, Stout, Pagano (2012), Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2): T S F O T H TSF Delivery Modes Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular appendage linkage component 2

3 % Participants % Participants 10/29/2015 TSF often produces significantly better outcomes relative to active comparison conditions (e.g., CBT) Although TSF is not AA, it s beneficial effect is explained by AA involvement post-treatment. Also, state of the art instrumental variables analyses, as well as propensity score matching (Ye and Kaskutas, 2013) that help to remove selfselection biases, indicate AA has a causal impact on enhancing abstinence and remission rates. Linkage to AA can lead to much higher rates of full sustained remission TSF treatment can lead to (Project MATCH, 1997) much higher rates of full sustained remission Continuous Abstinence Rates during year following treatment (4-15 Months) Continuous Abstinence Rates past 90 days- 3 Years TSF TSF CBT CBT MET MET 10 Treamtment Condition 10 Treamtment Condition 3

4 HEALTH CARE COST OFFSET CBT VS 12-STEP RESIDENTIAL TREATMENT $20,000 $18,000 $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 $17,864 $12,129 $5,735 CBT $9,840 $7,400 $2,440 TSF Compared to CBT-treated patients, 12-step treated patients more likely to be abstinent, at a $8,000 lower cost per pt over 2 yrs ($10M total savings) Year 1 Year 2 Total Also, higher remission rates, means decreased disease and deaths, increased quality of life for sufferers and their families 4

5 Does AA cause better outcomes or is AA participation an outcome of better prognosis? Using accepted scientific standards (Bradford Hill criteria) and the most rigorous scientific methods (i.e., RCTs, instrumental variables analysis, PS matching), evidence indicates causal therapeutic benefit of AA The one exception is specificity (e.g., other interventions could also cause these benefits) But given AA is available free of charge in practically every US community and that an intervention s Impact is a product of = reach x effectiveness (Glasgow et al, 2003), AA can be considered a clinical and public health ally in ameliorating the prodigious burden of disease attributable to alcohol addiction Substance Use and Problem Onset and Offset Epidemiologist s Illusion vs. Clinician s Illusion National Survey on Drug Use and Health (NSDUH) Age Groups 100 Severity Category No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence NSDUH and Dennis & Scott For more severely addicted individuals course of SUD and achievement of stable recovery can take a long time Addiction Onset Help Seeking Full Sustained Remission (1 year abstinent) Relapse Risk drops below 15% 4-5 years 8 years 5 years Selfinitiated cessation Opportunity attempts for earlier detection through screening in nonspecialty settings like primary care/ed 4-5 Treatment episodes/ mutualhelp Continuing care/ mutualhelp 60% of individuals with addiction will achieve full sustained remission (White, 2013) 5

6 What does this chronic clinical course suggest? Recovery Capital: Achievement of sustained recovery from alcohol or other drug use disorders is not just a function of medical stabilization (e.g. detox) or addressing shortterm deficits and psychopathology, but also by building and successfully mobilizing personal, social, and environmental resources that can be brought to bear on maintaining remission and long-term recovery. Recovery Support Services Mutual help organizations Recovery supports in educational settings Peer-based recovery support services Recovery Recovery community centers Clinical models of long-term recovery management Sober living environments Do we have good Theories of Remission and Recovery? Studies of treatment are often theory-based (e.g, Longabaugh and Morgenstern, 2002; Moos, 2007) However, studies of SUD recovery are very seldom theory-based But, there are empirically supported theories that help explain the onset of substance use and SUD These same theories may be useful in helping explain SUD remission and recovery 6

7 Parallels in the onset and offset of SUD People want to use substances for 4 main reasons (NIDA, 2005): To feel good To feel better To do better Because others are doing it Parallels in the onset and offset of SUD People want to use substances for 4 main reasons (NIDA, 2005): To feel good To feel better To do better Because others are doing it People want to stop using substances and recover for the same 4 main reasons: To feel good To feel better To do better Because others are doing it Theory Key process mechanisms for Social Control Social Learning Stress and coping Behavioral economics Substance use Lack of strong bonds with family, friends, work, religion, other aspects traditional society Modeling and observation and imitation of substance use, social reinforcement for and expectations of positive consequences from use; positive norms for use life stressors (e.g., social/work/financial problems, phys/sex abuse) lead to substance use especially those lacking coping and avoid problems; substance use form of avoidance coping, selfmedication Lack of alternative rewards provided by activities other than substance use Recovery Goal-direction, structure and monitoring, shaping behavior to adaptive social bonds Social network composed of individuals who espouse abstinence, reinforce negative expectations about effects of substances, provide models of effective sober living Effective coping enhances self-confidence and self-esteem Effective access to alternative, competing, rewards through involvement in educational, work, religious, social/recreational pursuits Source: Moos, RH (2011) Processes the promote recovery from addictive disorders. 7

8 Addiction Recovery Mutual aid organizations Theory Key process mechanisms for Social Control Social Learning Substance use Recovery Lack of strong bonds with family, Goal-direction, structure and monitoring, friends, work, religion, other aspects shaping behavior to adaptive social bonds traditional society Modeling and observation and imitation of substance use, social reinforcement for and expectations of positive consequences from use; positive norms for use Social network composed of individuals who espouse abstinence, reinforce negative expectations about effects of substances, provide models of effective sober living Stress and coping Behavioral economics life stressors (e.g., social/work/financial problems, phys/sex abuse) lead to substance use especially those lacking coping and avoid problems; substance use form of avoidance coping, selfmedication Lack of alternative rewards provided by activities other than substance use Effective coping enhances self-confidence and self-esteem Effective access to alternative, competing, rewards through involvement in educational, work, religious, social/recreational pursuits Source: Moos, RH (2011) Processes the promote recovery from addictive disorders. So, how might mutual help organizations reduce relapse risk and aid recovery? 23 Cue Induced Stress Induced RELAPSE Social Alcohol Induced Psych Bio-Neuro AA Kelly, JF Yeterian, JD In: McCrady and Epstein Addictions: A comprehensive Guidebook, Oxford University Press (2013) How might MHOs reduce relapse risk and aid recovery? 24 Cue Induced CUES: -MHOs reduces relapse risks via social network changes that may reduce exposure to triggers and increase active coping and social ASE; MHOs may also reduce craving and Stress Induced impulsivity; RELAPSE STRESS: MHOs helps reduce stress induced relapse possibly via increased coping Social skills and spiritual framework and boosting negative Psych affect ASE, particularly among women Alcohol Induced Bio-Neuro ALCOHOL: MHOs may reduce alcohol induced relapse via reducing cravings, strong emphasis on abstinence (preventing priming dose exposure); boosting social and negative affect ASE AA Kelly, JF Yeterian, JD In: McCrady and Epstein Addictions: A comprehensive Guidebook, Oxford University Press (2013) 8

9 Empirically-supported MOBCs through which AA confers benefit Social network Spirituality Social Abstinence selfefficacy Coping skills Recovery motivation Impulsivity Negative Affect Abstinence selfefficacy Craving Psychologica l Well-being Recovery motivation The importance of re-motivation and prioritization Re-motivation Like all chronic illnesses, critically important to remaining in remission is the notion of a clear recognition and acceptance that one has the illness, and that one is susceptible to relapse/reinstatement of the disorder over the longterm One of the therapeutic functions of AA is that meetings and social interactions with recovering persons facilitates constant re-exposure to aversive memories of past addictive behaviors (through hearing recounting of personal case histories) which can lie dormant, be suppressed, or naturally decay over time Re-exposure to aversive memories coupled with evident observable success and positive attributes of other people in long-term recovery, leads to ongoing re-appraisals through a process of implicit decisional balance, that favors continued adherence and recovery 9

10 Implications of the research? Helping individuals with SUD make extensive use of MHOs through referral and linkages will improve outcomes, particularly remission MHO participation reduces health care costs while enhancing remission MHOs work through mechanisms that are similar (but not identical) to those operating in formal treatment MHOs can engage people in a social network; the bonds formed in which can help engage and sustain people in remission over time MHO participation can be clinically influenced So, what are some of the proven ways to get individuals involved in MHOs and thereby improve outcomes and reduce health costs? Risk Factors Can what we do during treatment influence subsequent dropout risk? Treatment Settings Combined High Supportive Treatment milieu Low supportive Treatment milieu n Dropout Rate n Dropout Rate n Dropout Rate % (77) % (45) % (32) % (163) % (79) % (84) % (221) %(103) % (118) % (218) % (70) % (148) % (193) % (50) % (143) % (81) % (17) % (64) % (51) % (8) 62 70% (43) Dropout rate = 40% AA dropouts had 3x higher odds of relapse to alcohol/drug use Source: Kelly & Moos (2003) Dropout from 12-Step Groups: Prevalence, Predictors and Counteracting Treatment Influences, Journal of Substance Abuse Treatment,24, 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,

11 Precursor to current TSF research (Sisson and Mallams, 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 Results: Precursor to current 12-Step facilitation research 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 Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular add-on linkage component 11

12 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 Cognitive Behavioral Therapy - Therapist assisted in building skill set to maintain abstinence Motivational Enhancement Therapy - Therapist aimed to build clients motivation to accept abstinence as objective TSF (MATCH, 1997) Core Topics Acceptance (step 1) Surrender (steps 2-3) Getting active (readings, meetings, getting a sponsor, using the telephone, speaking at meetings) Elective Topics Genogram Being enabled People, places, things HALT Steps 4-5 Sober Living Nowinski, Baker, Carroll (1993) Twelve Step Facilitation Therapy Manual, NIAAA Project MATCH- Results (1) 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) 12

13 % Participants % Participants 10/29/2015 Linkage to MHO like AA can lead to much higher rates of full sustained remission (Project MATCH, 1997) TSF treatment can lead to much higher rates of full sustained remission Continuous Abstinence Rates during year following treatment (4-15 Months) Continuous Abstinence Rates past 90 days- 3 Years TSF TSF CBT CBT MET MET 10 Treamtment Condition 10 Treamtment Condition 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) 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 Network Support +Contingency Management (NS+CM) 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 Network Support: Higher PDA More total abstinent Lower consequenc es Lower DDD 13

14 T S F O T H TSF Delivery Modes Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular add-on linkage component 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 - 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 Condition 2: motivational enhancement approach (more client centered) - 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,

15 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 Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular add-on linkage component 15

16 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) MAAEZ intervention is conducted in a group format to help prepare for group dynamic of AA Facilitator goal: to inform clients about AA and facilitate group interaction 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 of Program: Six, 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. 16

17 MAAEZ Intervention- Results 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- Results T S F O T H TSF Delivery Modes Stand alone Independent therapy Integrated into an existing therapy Component of a treatment package (e.g., an additional group) As Modular add-on linkage component 17

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19 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 Effectiveness of Clinician Referrals to AA- Results 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 19

20 Effectiveness of Clinician Referrals to AA- AA Participation Findings Timko 2007 Effectiveness of Clinician Referrals to AA- Abstinence Outcome Findings Psychiatric Comorbidity TSF Linkage: Efficacy Intensive 12-step referral (Timko et al, 2011) Timko et al. (2011; N=287): standard vs. intensive referral condition Patients in the intensive referral group were more likely to attend and be involved in dual-focused mutual-help groups (DFGs) and substancefocused mutual-help groups (SFGs), and had less drug use and better psychiatric outcomes at follow-up Only 23% of patients in the intensive-referral group attended a DFG meeting during the sixmonth follow-up period, while 85% attended a SFG 20

21 FOR WHOM ARE MUTUAL-HELP GROUPS PARTICULARLY HELPFUL / NOT HELPFUL? 4 major clinical concerns regarding member-group fit with 12-step mutualhelp 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) 21

22 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 over 4 yrs (sample was small N=18) 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 22

23 Probability of Remission Probability of Abstinence 10/29/2015 RELATIONSHIP BETWEEN 12-STEP INVOLVEMENT AND SUBSTANCE USE OUTCOME FOR SUD-ONLY VS. SUD-MDD PATIENTS Step Affiliation (Standard Deviations) SUD-ONLY SUD-MDD 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, RELATIONSHIP BETWEEN 12-STEP INVOLVEMENT AND SUBSTANCE USE OUTCOME FOR SUD-ONLY VS. SUD-MDD PATIENTS SUD-ONLY SUD-MDD Step Affiliation (Standard Deviations) Source: Kelly et al., (2003) INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC COMORBIDITIES Psychiatric problems (e.g., psychotic spectrum illness) and/or degrees of impairment (severe major depression) that affect interpersonal functioning and social skills may reduce degrees of derived substance-focused MHO benefit mutual-help groups specifically designed for comorbidity have emerged and may be a better fit for severely impaired. 23

24 TIMKO ET AL SOCIAL ANXIETY RESULTS (N=304) MHO participation across all patients was high MHO participation no different among those with and without clinically significant social anxiety Benefits were similar, except those with higher social anxiety benefitted more from greater 12-step MHO participation 24

25 DUAL-DIAGNOSIS VS SUD-ONLY ATTENDANCE AND INVOLVEMENT SAME ACROSS DD AND SUD ONLY PATIENT GROUPS 12-Step Attendance Active 12-Step Involvement % Days Attending a Meeting Involvement Activities Follow-Up Follow-Up Dual Diagnosis SUD-Only DD PATIENTS HAD POORER OUTCOMES OVERALL BUT MODERATED BY 12-STEP PARTICIPATION 12-Step Attendance Active 12-Step Involvement Percent Days Abstinent (PDA) Time (Months) 6 12 Time (Months) Dual Diagnosis, Low Attendance/Involvement Dual Diagnosis, High Attendance/Involvement SUD-Only, Low Attendance/Involvement SUD-Only, High Attendance/Involvement DTR vs waitlist control. DTR participation associated with better alcohol/drug and psychiatric symptom/funx outcomes compared to controls 25

26 TSF (Peer-linkage) increased 12-step participation, and led to better outcomes; but most attended single-focused 12- step groups (only 23% attended DD groups). Authors recommend maximizing exposure to TSF for severely ill DD patients TSF (manualized nonpeer linkage) increased 12-step participation, but not outcomes; but greater TSF exposure (more sessions) associated linearly with better outcomes and greater 12-step participation. Authors recommend maximizing exposure to TSF for severely ill DD patients CO-MORBIDITY SUMMARY SHOULD DD PATIENTS BE REFERRED TO AA/NA? Attendance rates may be similar and many may benefit (e.g. PTSD) More severely socially-impaired (e.g., psychosis; severe major depression) may have more difficulty benefitting Attendance rates may be similar but co-morbid may require additional/more specific support and/or greater facilitation (e.g. severe MDD) Clinical strategies can enhance SF and DF MHO participation for DD patients; peer linkage may enhance outcomes. Dual focused MHOs such as DTR, when available, may provide a source of ongoing support and help for this with more severe psychiatric impairment 26

27 RELIGIOUSNESS & SPIRITUALITY AND 12- STEP MHOS 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 if non-religious attend, degree of religiosity does not affect derived benefits from AA/NA on outcomes at 1 and 3yrs (Kelly, Stout et al, 2006; Winzelberg et al, 1999) 27

28 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 12-STEP MHOS? 28

29 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 29

30 YOUNG PEOPLE AND AA/NA? 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: Addiction severity (withdrawal/consequences) Problem recognition/motivation for abstinence 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: Potential discomfort with spiritual/ religious May signify poor fit with 12-step fellowships emphases on complete abstinence and spiritual growth 30

31 % Attending AA/NA weekly % Attending AA/NA 10/29/2015 RESULTS: RATES OF ATTENDANCE Any, Monthy, and Weekly AA/NA Attendance across 8 Years Following Inpatient Treatment 100% 90% 80% 70% 60% 50% Any Monthly Weekly 40% 30% 20% 10% 0% 0-6m 6m-1yr 1-2yr 2-4yr 4-6yr 6-8yr Follow-Up Percent of Youth in Each Trajectory Outcome Group attending AA/NA at least Weekly across 8 Years Abstainers Infrequent User worse with time Frequent User m 12m 24m 48m 72m 96m Time 31

32 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 <.0001 Time Gender PDA 6m <.0001 Pre-treatment PDA Moderate use Formal Treatment 6m Aftercare 1 6m AA/NA 6m <.0001 Time x AA/NA 6m Square root transformed N = 150 Kelly, Brown, Abrantes, Kahler, & Myers (2008): Alcoholism: Clinical Experimental Research, 32, 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 <.0001 Time Gender Pre-treatment PDA Moderate use Aftercare 1 6m Formal Treatment AA/NA <.0001 PDA < = 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,

33 PDA 10/29/ % 80% 70% 60% 50% 40% 30% 48.2% 57.4% 84.0% No attendance < 1 meeting/week > 1 meeting/week 12-step attendance 97 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) Admission 3 months 6 months 12 months 12-step attendance after admission: None (n=61) Inconsistent (n=43) Weekly (n=7) Kelly JF, Urbanoski, K. (2012) Youth recovery contexts. Alcoholism: Clinical and Experimental Research YOUTH-SPECIFIC AA/NA OUTCOMES KNOWLEDGE: Follow-up Setting Authors Year N % Female M Age (Months) (No. of sites) , 12, 24 38% 16 Inpatient (1) Alford, Koehler, Leonard % 16 Inpatient (2) Brown % 16.5 Inpatient (1) Kennedy & Minami ,317 6, 12 35% Inpatient (24) Hsieh, Hoffman, Hollister % 16 Inpatient (2) Kelly, Myers, Brown % 16 Inpatient (2) Kelly, Myers, Brown , 12 32% 22 Inpatient (2) Mason and Luckey % 16 Residential (8),STI Grella, Joshi, Hser (6), Outpatient (9) % 16 Inpatient (2) Kelly, Myers, Brown , 12, 24, 48, 72, 96 34% Inpatient (2) Kelly, Brown et al Chi, Kaskutas, Sterling et , 12, 36 34% Intensive outpatient al (4) , 6 24% 16.7 Outpatient (1) Kelly, Dow, Yeterian Chi, Sterling, Campbell, , 36, 60, 72, 84 34% Intensive Weisner outpatient(4) , 6, 12 24% 16.7 Outpatient (1) Kelly and Urbanoski , 3, 6, 12 27% 20 Residential (1) Kelly, Stout, Slaymaker 33

34 RELATION BETWEEN AGE COMPOSITION OF ATTENDED MEETINGS AND PERCENT DAYS ABSTINENT FOR ADOLESCENTS 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 34

35 FOR WHOM ARE MUTUAL-HELP GROUPS PARTICULARLY HELPFUL / NOT HELPFUL? Clinical concerns member-group fit with 12-step mutualhelp organizations. 1. Dual-diagnosed (DD)?- less severe/non-psychotic benefit as much; more severe DD specific groups better (e.g., DTR); encourage SF and DF participation; peer linkage 2. Non-spiritual/religious people?- less likely to attend but benefit as much; may need TSF priming on spirituality vs. religion 3. Women? more involved than men, benefit as much 4. Young People? more severe participate; benefit as much as adults; young people s meetings may be helpful for engagement but less beneficial for long-term recovery 35

36 Mismatch The proportion of 12-step attendance that was theoretically mismatched For a patient with a primary drug use disorder: Degree of Mismatch = # of AA meetings (# of AA meetings + # of NA meetings) Degree of Mismatch Among primary drug patients, the proportion of meetings attended that were AA ranged from an average of % No effect of mismatch on future attendance or involvement Among primary drug patients does greater mismatch in the first 3 months post-treatment result in lowered rates of attendance and involvement at 6 months? 36

37 Among primary drug patients does greater mismatch during the first 3 months posttreatment result in less recovery benefit? No effect of fellowship mismatch on percent days abstinent over the follow-up period (controlling for attendance/involvement) Conclusions Implications of TSF and MHO research are that systematic encouragement and linkage should be the norm and included in treatment packages to enhance recovery outcomes and reduce health care costs A number of specific proven strategies can be employed to facilitate engagement but general principles are: Prescribe and recommend attendance Spend time during sessions discussing reactions to meetings/barriers etc. Ask patients to keep a journal of their reactions for discussion Link patients whenever possible to other MHO members to ease engagement Clinical professionals can make a big (maybe THE) difference in getting 12-step naïve individuals to try AA/NA who have never been Although, nearly all research has been conducted on 12-step MHOs, researchinformed extrapolation would suggest that because all MHOs operate in group format and possess similar therapeutic dynamics, similar clinical linkage procedures to other MHOs may produce similar benefits, when other MHOs are available and clients are adamant about not wanting 12-step. Acknowledgements Colleagues Eden Evins, MD Bettina Hoeppner, PhD Brandon Bergman, PhD Post-Doc Fellows Allison Labbe, PhD Karen Urbanoski, PhD Corrie Vilsaint, PhD Interns David Eddie, MS Staff Julie Cristello, BA Sarah Dow, BS Nilo Fallah-Sohy, BS Claire Greene, MPH Veselina Hristova, MSW Nate Kelly, BA Julie Sloane, BA Jessica Kim, NP Erin Newman, LICSW Cristi O Connor, MHS Jonathan Watson, MA Julie Yeterian, MA Sources of Funding National Institute of Alcohol Abuse and Alcoholism/R21AA A1 National Institute of Mental Health/1R21MH A1 Recovery Research Institute, Private Donations National Institute of Alcohol Abuse and Alcoholism/R01AA A1 National Institute of Alcohol Abuse and Alcoholism/R01AA A1S1 Canadian Institute of Health Research/MOP National Institute of Alcohol Abuse and Alcoholism/K24AA Conflict of Interest None declared 37