» Empirical Awakening: The New Science  on 12-step Treatment and Related  Addiction Mutual-Help Organization  Participatio...
» Substance Use Disorders: massive medical, social, and  economic burden» Mutual-help groups (MHGs) can help offset burden...
• #1 public health problem (Institute for Health                  Policy, 2011); notably youth (CASA, 2011)Public health  ...
$450     $400     $350     $300     $250                                                                                  ...
Typical Clinical Course for Substance Dependence and RecoveryAddiction     Help                 Full Sustained            ...
» SUDs: massive health, social, and economic burden» Mutual-help groups (MHGs) can offset that burden» MHGs work for many ...
» Past 40 years increase in quality and  quantity of SUD treatment in US and  developed countries» However, professional r...
» Cost-effective -free; attend as intensively, as long as desired» Focused on addiction recovery over the long haul» Widel...
 1950’s “Minnesota Model” >90% of private SUD treatment in US base tx on the 12-step  principles (Roman & Blum, 1998) A...
Substance Focused Mutual-help Groups                               Year of                                                ...
» SUDs: massive health, social, and economic burden» Mutual-help groups (MHGs) can offset that burden» MHGs work for many ...
 Emrick et al. 1993 - 107 studies. AA attendance and involvement modest  beneficial effect on drinking behavior Tonigan ...
» Attempted to examine RCTs of AA or TSF» 8 trials involving 3417 people were included.» Findings:   ˃ AA may help patient...
 Clinical concerns member-group fit with 12-step mutual-  help organizations.    1. Dual-diagnosed (DD)       Medicatio...
SettingAuthors                         Year    N      Follow-up (Months)      % Female   M Age                            ...
Any, Monthy, and Weekly AA/NA Attendance across 8 Years                                                             Follow...
Percent of Youth in Each Trajectory Outcome Group attending AA/NA at least Weekly                                         ...
Parameter                  Estimate        Standard Error    95% Confidence      Z        P                               ...
20Kelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of YouthTreatment Outcome in Rela...
Moderators: Might Age Composition of AA/NA meetings              100                  moderate participation and derived b...
» SUDs: massive health, social, and economic burden» Mutual-help groups (MHGs) can offset that burden» MHGs work for many ...
» Studies of treatment are often theory-based  (e.g, Longabaugh and Morgenstern, 2002;  Moos, 2007)» However, studies of S...
Parallels in the onset and offset of SUD      People want to use      substances for 4 main      reasons (NIDA, 2005):    ...
Parallels in the onset and offset of SUD      People want to use        People want to stop using      substances for 4 ma...
Theory                                    Key process mechanisms for…                                Substance use        ...
Theory                                    Key process mechanisms for…                               Substance use         ...
How might MHGs like AA reduce relapse risk and sustain the                                 recovery process?              ...
(15-mo) Alcohol Outcomes                                         (3-mo) AA attendance                                     ...
Aftercare (PDA)                                 effect of AA on                    Aftercare (DDD)                        ...
effect of AA on                            Aftercare (PDA)                                                                ...
32
CONCLUSIONS    ˃ Recovery benefits derived from AA differ in nature and magnitude between      more severely alcohol invol...
» SUDs: massive health, social, and economic burden» Mutual-help groups (MHGs) can offset that burden» MHGs work for many ...
HEALTH CARE COST OFFSET POTENTIAL OF MHGS (1)               CBT VS 12-STEP RESIDENTIAL TREATMENT                          ...
» The first study to examine how 12-Step participation affects  medical costs in adolescents with SUD» 4 intensive outpati...
» Avg annual medical costs for all participants  over 7 years: $3085 per person per year» 4.7% decrease in medical costs w...
» SUDs: massive health, social, and economic burden» Mutual-help groups (MHGs) can offset that burden» MHGs work for many ...
Risk             Treatment Settings          High Supportive Treatment           Low supportive Treatment   Factors       ...
Source: Kelly & Moos (2003) Dropout from 12-Step Groups: Prevalence, Predictors and Counteracting TreatmentInfluences, Jou...
» 20 patients randomly selected from outpatient tx  program for alcohol use disorder» Randomly assigned to:   ˃1: Standard...
» Results:   ˃0% clients in standard referral attended a meeting during the    target week   ˃100% clients in systematic e...
T     OS     TF     HStand alone           Integrated into an existing   Component of a treatmentIndependent therapy      ...
» Multisite randomized clinical trial of alcohol dependent  individuals   2 arms       • Aftercare (n=774)- recently fini...
» Individuals randomly assigned to TSF attended AA more frequently and had  higher rates of continuous abstinence (71% mor...
 Effects mediated by ongoing AA attendance Across txs, those who attended AA groups had better outcomes (Tonigan  et al,...
T     OS     TF     HStand alone           Integrated into an existing   Component of a treatmentIndependent therapy      ...
» Approaches to assist in involvement in AA» 169 adult alcoholic outpatients randomly assigned to  one of three treatment ...
»   Treatment varied between 3 conditions in terms of how the therapist discussed AA and how    much information about AA ...
» Participants exposed to the Directive TSF approach reported  significantly more:   ˃attendance of AA meetings   ˃more ac...
T     OS     TF     HStand alone           Integrated into an existing   Component of a treatmentIndependent therapy      ...
» Making AA Easier- manual guided - designed to help clients prepare for AA» Goal: to prepare for AA (encourage participat...
» Structure of Program:» Six, weekly, 90-minute sessions   ˃Homework assigned at the end of each session       - List of t...
» Spirituality: provides clients with range of “spirituality” definitions that do  not all require religious orientation. ...
» Abstinence:   ˃ TSF participants significantly more past 30 day alcohol     abstinence, drug abstinence, and both alcoho...
T     OS     TF     HStand alone           Integrated into an existing   Component of a treatmentIndependent therapy      ...
 Evaluation of procedures to effectively refer patients to 12-step meetings Individuals with SUDs entering a new outpati...
» At 6m, patients in intensive referral who had relatively less  previous 12-Step experience had:   ˃higher meeting attend...
» Timko et al. (2011; N=287): standard vs. intensive referral  condition» Patients in the intensive referral group were mo...
San Juan talk, empirical awakening (fri march 15 2013) - John Francis Kelly
San Juan talk, empirical awakening (fri march 15 2013) - John Francis Kelly
San Juan talk, empirical awakening (fri march 15 2013) - John Francis Kelly
San Juan talk, empirical awakening (fri march 15 2013) - John Francis Kelly
San Juan talk, empirical awakening (fri march 15 2013) - John Francis Kelly
San Juan talk, empirical awakening (fri march 15 2013) - John Francis Kelly
San Juan talk, empirical awakening (fri march 15 2013) - John Francis Kelly
San Juan talk, empirical awakening (fri march 15 2013) - John Francis Kelly
San Juan talk, empirical awakening (fri march 15 2013) - John Francis Kelly
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  • More than 400 disorders in the DSM IV AUD alone confers 36% of DALYS attributable to psychiatric disorders!!!!
  • I left some extra spaces in case you had some more articles in mind – you can send them to me and I can plug in the information
  • Some young people, particularly those who have received formal treatment, do participate in AA/NA….Dropout rate of about 40% at 1 yr almost identical to MATCH dropout, and VA multisite dropout
  • Social learning, stress and coping, and behavioral economic theories all pertain to ongoing mutual-help organization participation that can aid long term recovery…
  • Men may use AA more than women to help them buffer socially-relevant relapse risks. Women appear to benefit in similar ways, but more work is needed to understand the additional ways women derive recovery benefit from AA. The pattern of findings underscores some gender-based differences that may have broader implications for the addiction treatment and recovery field. For women between the ages of 30 and 50, a focus on finding alternative ways to cope with negative affect may yield recovery benefits, while among men in the same life-stage, a relatively greater focus on coping with high risk social situations may yield recovery related benefits.
  • TSF implemented in various ways:
  • TSF implemented in various ways:
  • TSF implemented in various ways:
  • TSF implemented in various ways:
  • San Juan talk, empirical awakening (fri march 15 2013) - John Francis Kelly

    1. 1. » Empirical Awakening: The New Science on 12-step Treatment and Related Addiction Mutual-Help Organization Participation John F. Kelly, Ph.D. President Elect, Society of Addiction Psychology, American Psychological Association Associate Professor in Psychiatry Harvard Medical School Program Director Addiction Recovery Management Service Associate Director MGH Center for Addiction MedicineAwakening to the New Science of Mutual Help for Drug Addiction Recovery San Juan, Puerto Rico, March 15th, 2013
    2. 2. » Substance Use Disorders: massive medical, social, and economic burden» Mutual-help groups (MHGs) can help offset burden» MHGs work for many different types of individuals and produce additional benefit over and above formal treatment» MHGs work through mechanisms similar to those operating in formal treatment» MHGs can reduce costs by reducing patients’ reliance on professional services without any detriment to outcomes, and may even enhance outcomes» Empirically-supported clinical interventions can increase patients’ participation in MHGs and enhance treatment outcomes
    3. 3. • #1 public health problem (Institute for Health Policy, 2011); notably youth (CASA, 2011)Public health • Of all DALYs lost due to all psychiatric conditions, alcohol use disorder alone = 36% • $425 billion in US each year (lost productivity, criminal justice, medical costs) Economic • Excessive alcohol consumption costs society $2 per drink • SUD leading cause of mortality -alcohol leading risk factor among males 15-59 yrs worldwide Mortality • Opiate overdose – leading cause of accidental death nationwide • Onset of long-term problems occur during adolescence/young adulthood Prevention • 90% adults with dependence start using before age 18 • 50% of adults start using before age 15
    4. 4. $450 $400 $350 $300 $250 Economic cost (in billions) $200 $150 $100 $50 $0 Alcohol/drugs Heart disease Alcohol Drugs Diabetes Smoking ObesitySource: Bouchery, Harwood, Sacks, Simon, & Brewer (2011); US Department of Justice (2011)
    5. 5. Typical Clinical Course for Substance Dependence and RecoveryAddiction Help Full Sustained Relapse Risk Remission drops below Onset Seeking 15% 4-5 years 8 years 5 years Self- 4-5 Treatment Continuing initiated episodes/ care/ cessation mutual- mutual- attempts help help
    6. 6. » SUDs: massive health, social, and economic burden» Mutual-help groups (MHGs) can offset that burden» MHGs work for many different types of individuals over and above formal treatment» MHGs work through mechanisms similar to those operating in formal treatment» MHGs can reduce costs by reducing patients’ reliance on professional services without any detriment to outcomes, and may even enhance outcomes» Empirically-supported clinical interventions increase patients’ participation in MHGs and enhance treatment outcomes
    7. 7. » Past 40 years increase in quality and quantity of SUD treatment in US and developed countries» However, professional resources alone cannot cope; stigma and cost present further barriers to access» Addiction often has chronic course (8 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)
    8. 8. » Cost-effective -free; attend as intensively, as long as desired» 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
    9. 9.  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 12-step groups (Humphreys et al., 1997) 84% of youth are referred to AA/NA post-discharge (Knudsen et al, 2008; Kelly et al, 2008)
    10. 10. Substance Focused Mutual-help Groups Year of Evidence base* Name Location of groups in U.S. Origin Number of groups in U.S. (0-3) Alcoholics Anonymous 52,651 all 50 States 1, 2, 3 (AA) 1935 Narcotics Anonymous Approx. 15,000 all 50 States 1, 2 (NA) 1940s Cocaine Anonymous Approx. 2000 groups most States; 6 online meetings at 0 (CA) 1982 www.ca-online.org Methadone Anonymous 25 States; online meetings at Approx. 100 groups 1, 2 (MA) 1990s http://methadone-anonymous.org/chat.html Marijuana Anonymous 24 States; online meetings at Approx. 200 groups 0 (MA) 1989 www.ma-online.org No group meetings or mutual 1988 helping; emphasis is on Rational Recovery (RR) ----------------------------------------------------- 1, 2 individual control and responsibility Self-Management and 40 States; 19 online meetings at Recovery Training 1994 Approx. 250 groups www.smartrecovery.org/meetings/olschedule 1, 3 (S.M.A.R.T. Recovery) .htmSecular Organization for all 50 States; Online chat at Sobriety, a.k.a. Save 1986 Approx. 480 groups 1 www.sossobriety.org/sos/chat.htm Ourselves (SOS) Women for Sobriety Online meetings at 150-300 groups 1 (WFS) 1976 http://groups.msn.com/ WomenforSobrietyModeration Management Approx.16 face-to-face 12 States; Most meetings are online at 1 (MM) 1994 meetings www.angelfire.com/trek/mmchat/;*0= None 1=Descriptive studies only 2 = Observational (correlational, longitudinal) 3= Experimental (random assignment, controlled).Source: Kelly & Yeterian, 2008
    11. 11. » SUDs: massive health, social, and economic burden» Mutual-help groups (MHGs) can offset that burden» MHGs work for many different types of individuals over and above formal treatment» MHGs work through mechanisms similar to those operating in formal treatment» MHGs can reduce costs by reducing patients’ reliance on professional services without any detriment to outcomes, and may even enhance outcomes» Empirically-supported clinical interventions increase patients’ participation in MHGs and enhance treatment outcomes
    12. 12.  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 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 notreatment - Coerced individuals may have better outcomes if coerced into other kindsof treatment - Found support for 12-step-based tx and non-coerced AA attendance
    13. 13. » 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 ˃ Peer-led AA participation found to be as effective as other comparison professionally-delivered interventions to which it was compared (e.g., CBT)
    14. 14.  Clinical concerns member-group fit with 12-step mutual- help organizations.  1. Dual-diagnosed (DD)  Medications  Clinical syndromes vs. “not working the program”  2. Non-religious people  Barriers to 12-step  3. Women  “Powerlessness”  4. Young People  Developmental barriers
    15. 15. SettingAuthors Year N Follow-up (Months) % Female M Age (No. of sites)Alford, Koehler, Leonard 1991 157 6, 12, 24 38% 16 Inpatient (1)Brown 1993 140 12 42% 16 Inpatient (2)Kennedy & Minami 1993 91 12 23% 16.5 Inpatient (1)Hsieh, Hoffman, Hollister 1998 2,317 6, 12 35% 17-19 Inpatient (24)Kelly, Myers, Brown 2000 99 6 60% 16 Inpatient (2)Kelly, Myers, Brown 2002 74 6 62% 16 Inpatient (2)Mason and Luckey 2003 95 3, 12 32% 22 Inpatient (2) 2004 810 12 30% 16 Residential (8),STI (6),Grella, Joshi, Hser Outpatient (9)Kelly, Myers, Brown 2005 74 6 62% 16 Inpatient (2)Kelly, Brown et al 2008 160 6, 12, 24, 48, 72, 96 34% 13-18 Inpatient (2)Chi, Kaskutas, Sterling et al 2009 419 6, 12, 36 34% 13-18 Intensive outpatient (4)Kelly, Dow, Yeterian 2010 127 3, 6 24% 16.7 Outpatient (1)Chi, Sterling, Campbell, 2012 419 12, 36, 60, 72, 84 34% 13-18 Intensive outpatient(4)WeisnerKelly and Urbanoski 2012 127 3, 6, 12 24% 16.7 Outpatient (1)Kelly, Stout, Slaymaker 2012 303 1, 3, 6, 12 27% 20 Residential (1)
    16. 16. Any, Monthy, and Weekly AA/NA Attendance across 8 Years Following Inpatient Treatment 100% 90% 80% % Attending AA/NA 70% Any 60% Monthly 50% Weekly 40% 30% 20% 10% 0% 0-6m 6m-1yr 1-2yr 2-4yr 4-6yr 6-8yr Follow-UpSource: Kelly, J.F., Brown, S. A., Abrantes, A., Kahler, C. H., & Myers, M. (2008) Social Recovery Model: An 8-year Investigation of adolescent 12-step group participation following inpatient treatment. Alcoholism:Clinical and Experimental Research.
    17. 17. Percent of Youth in Each Trajectory Outcome Group attending AA/NA at least Weekly across 8 Years 100% Attending AA/NA weekly 90 80 70 Abstainers 60 Infrequent User 50 worse with time 40 Frequent User 30 20 10 0 6m 12m 24m 48m 72m 96m Time
    18. 18. Parameter Estimate Standard Error 95% Confidence Z P Limits 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 covariateKelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of Youth Treatment Outcome inRelation to 12-step Group Involvement. Alcoholism: Clinical and Experimental Research, 2008, 32, 8 1468-1478.
    19. 19. 20Kelly JF, Brown SA, Abrantes, A. et al. Social Recovery Model: An 8-Year Investigation of YouthTreatment Outcome in Relation to 12-step Group Involvement. Alcoholism: Clinical and ExperimentalResearch, 2008, 32, 8 1468-1478.
    20. 20. Moderators: Might Age Composition of AA/NA meetings 100 moderate participation and derived benefits? 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 teensKelly JF, Myers, MG Brown SA (2005). The effect of age composition of 12-step meetings on adolescent attendance and outcomesJournal of Child and Adolescent Chemical Dependency.
    21. 21. » SUDs: massive health, social, and economic burden» Mutual-help groups (MHGs) can offset that burden» MHGs work for many different types of individuals over and above formal treatment» MHGs work through mechanisms similar to those operating in formal treatment» MHGs can reduce costs by reducing patients’ reliance on professional services without any detriment to outcomes, and may even enhance outcomes» Empirically-supported clinical interventions increase patients’ participation in MHGs and enhance treatment outcomes
    22. 22. » Studies of treatment are often theory-based (e.g, Longabaugh and Morgenstern, 2002; Moos, 2007)» However, studies of SUD remission and 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…
    23. 23. 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
    24. 24. Parallels in the onset and offset of SUD People want to use People want to stop using substances for 4 main substances and recover for reasons (NIDA, 2005): the same 4 main reasons: To feel good To feel good To feel better To feel better To do better To do better Because others are Because others are doing it doing it
    25. 25. Theory Key process mechanisms for… Substance use Recovery Social Lack of strong bonds with family, Goal-direction, structure and monitoring, Control friends, work, religion, other aspects shaping behavior to adaptive social bonds traditional society Social Modeling and observation and Social network composed of individuals Learning imitation of substance use, social who espouse abstinence, reinforce negative reinforcement for and expectations expectations about effects of substances, of positive consequences from use; provide models of effective sober living positive norms for use Stress and life stressors (e.g., Effective coping enhances self-confidence coping social/work/financial problems, and self-esteem phys/sex abuse) lead to substance use especially those lacking coping and avoid problems; substance use form of avoidance coping, self- medication Behavioral Lack of alternative rewards provided Effective access to alternative, competing, economics by activities other than substance rewards through involvement in use educational, work, religious, social/recreational pursuitsSource: Moos, RH (2011) Processes the promote recovery from addictive disorders.
    26. 26. Theory Key process mechanisms for… Substance use Recovery Social Lack of strong bonds with family, Goal-direction, structure and monitoring, Control friends, work, religion, other aspects shaping behavior to adaptive social bonds traditional society Social Modeling and observation and Social network composed of individuals Learning imitation of substance use, social who espouse abstinence, reinforce negative reinforcement for and expectations expectations about effects of substances, of positive consequences from use; provide models of effective sober living positive norms for use Stress and life stressors (e.g., Effective coping enhances self-confidence coping social/work/financial problems, and self-esteem phys/sex abuse) lead to substance use especially those lacking coping and avoid problems; substance use form of avoidance coping, self- medication Behavioral Lack of alternative rewards provided Effective access to alternative, competing, economics by activities other than substance rewards through involvement in use educational, work, religious, social/recreational pursuitsSource: Moos, RH (2011) Processes the promote recovery from addictive disorders.
    27. 27. How might MHGs like AA reduce relapse risk and sustain the recovery process? Cue Induced Stress Induced RELAPSE Drug Induced AA-related social network changes may help avoid cues, reduce and tolerate distress, and maintain abstinence minimizing drug-induced relapse risks AAKelly JF, Yeterian, JD, (In 28 press). Mutual help groups. In McCrady and Epstein. Comprehensive Textbook on Substance Abuse.
    28. 28. (15-mo) Alcohol Outcomes (3-mo) AA attendance (PDA or DDD) 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 (9-mo) Self-efficacy Negative Affect Negative Affect (BL) Self-efficacy (9-mo) Self-efficacy Positive Social Positive Social (BL) Religious/Spiritual (9-mo) Religious/Spiritual Practices Practices (BL) Depression (9-mo) Depression (BL) Social Network (9-mo) Social Network “pro-abstinence” “pro-abstinence” (BL) Social Network (9-mo) Social Network “pro-drinking” pro-drinking”Source: Kelly, Hoeppner, Stout, Pagano (2012) , Determining the relative importance of the mechanisms of behavior change within AlcoholicsAnonymous: A multiple mediator analysis. Addiction 107(2):289-99
    29. 29. Aftercare (PDA) effect of AA on Aftercare (DDD) Self-efficacy alcohol use for (NA) Depression AC was explained 5% 3% by social factors but also by S/R Self-efficacy and through SocNet: pro-drk. (NA) SocNet: pro-drk. 16% 24% negative affect SocNet: 20% Spirit/Relig 23% (DDD only) pro-abst. 11% Depression SocNet: pro- 11% abst. Self-efficacy 16% Self-efficacy (Soc) (Soc) Spirit/Relig 21% 34% 21% Majority of effect Outpatient (PDA) of AA on alcohol Outpatient (DDD) Self-efficacy Self-efficacy Depression use for OP was (NA) Depression (NA) 2% Spirit/Relig 6% explained by 1% 5% 1% social factors Spirit/Relig 9% SocNet: pro-drk. 29% SocNet: pro-drk. Self-efficacy 33% (Soc) 27% Self-efficacy SocNet: pro- (Soc) SocNet: pro- abst. 39% abst. 17% 31%Source: Kelly, Hoeppner, Stout, Pagano (2012) , Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: 30A multiple mediator analysis. Addiction 107(2):289-99
    30. 30. effect of AA on Aftercare (PDA) Aftercare (DDD) alcohol use for Self-efficacy (NA) Depression AC was explained 5% 3% by social factors but also by S/R Self-efficacy and through SocNet: pro-drk. (NA) 16% SocNet: pro-drk. negative affect 20% 24% SocNet: Spirit/Relig (DDD only) pro-abst. 23% 11% Depression SocNet: pro- 11% abst. Self-efficacy 16% Self-efficacy (Soc) (Soc) Spirit/Relig 21% 34% 21% Majority of effect Outpatient (PDA) of AA on alcohol Outpatient (DDD) Self-efficacy Depression use for OP was Self-efficacy (NA) Depression (NA) 2% Spirit/Relig 1% 6% explained by 1% 5% social factors Spirit/Relig 9% SocNet: pro-drk. 29% SocNet: pro-drk. Self-efficacy 33% (Soc) 27% Self-efficacy SocNet: pro- (Soc) SocNet: pro- abst. 39% abst. 17% 31% 31Source: 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):289-99
    31. 31. 32
    32. 32. CONCLUSIONS ˃ Recovery benefits derived from AA differ in nature and magnitude between more severely alcohol involved/impaired and less severely alcohol involved/impaired; and between men and women ˃ These differences reflect differing needs based on recovery challenges related to differing symptom profiles, degree of subjective suffering and perceived severity/threat, recovery challenges, and gender-based social roles & drinking contexts ˃ Similar to psychotherapy literature (Bohart & Tollman, 1999) rather than thinking about how AA or similar organizations work, better to think how individuals use or make these organizations work for them – to meet their most urgent needs at any given phase of recovery
    33. 33. » SUDs: massive health, social, and economic burden» Mutual-help groups (MHGs) can offset that burden» MHGs work for many different types of individuals over and above formal treatment» MHGs work through mechanisms similar to those operating in formal treatment» MHGs can reduce costs by reducing patients’ reliance on professional services without any detriment to outcomes, and may even enhance outcomes» Empirically-supported clinical interventions increase patients’ participation in MHGs and enhance treatment outcomes
    34. 34. HEALTH CARE COST OFFSET POTENTIAL OF MHGS (1) CBT VS 12-STEP RESIDENTIAL TREATMENT Cost per patient over 1 year * Cost per patient over 1 year *CBT Resultedin $4,729 $12,129.00greater costs $7,400.00per patient withsig. worseoutcomes CBT TSF Compared to CBT- treated Cost per patient over 1-2 year patients, 12-stepCBT Resulted in treated patients Cost per patient$3,295 greater more likely to be incosts per patient $5,735.00 recovery, at awith sig. worse $8,000 lower costoutcomes in Yr 2 per pt over 2 yrs $2,440.00Follow up (about $15M for entire sample) CBT TSFSource: Humphreys & Moos (2001; 2007) Alcoholism: Clinical Experimental Research
    35. 35. » The first study to examine how 12-Step participation affects medical costs in adolescents with SUD» 4 intensive outpatient programs» N = 403 adolescents, age 13-18  66% male; mean age 16.1; 49% White  Comorbid ADHD: 17%, depression: 36%» Follow-up: 6 months, 1, 3, 5, and 7 years» Difference-in-difference model was used Source: Mundt, Parthasarathy, Chi, Sterling, Campbell (2012)
    36. 36. » Avg annual medical costs for all participants over 7 years: $3085 per person per year» 4.7% decrease in medical costs with each additional 12-step meeting attended = $145 annual savings per 12-step meetings attendedSource: Mundt, Parthasarathy, Chi, Sterling, Campbell (2012)
    37. 37. » SUDs: massive health, social, and economic burden» Mutual-help groups (MHGs) can offset that burden» MHGs work for many different types of individuals over and above formal treatment» MHGs work through mechanisms similar to those operating in formal treatment» MHGs can reduce costs by reducing patients’ reliance on professional services without any detriment to outcomes, and may even enhance outcomes» Empirically-supported clinical interventions increase patients’ participation in MHGs and enhance treatment outcomes
    38. 38. Risk Treatment Settings High Supportive Treatment Low supportive Treatment Factors Combined milieu milieu n Dropout Rate n Dropout Rate n Dropout Rate 0 261 30 % (77) 151 30 % (45) 110 29 % (32) 1 548 30 % (163) 274 29 % (79) 274 31% (84) 2 582 38 % (221) 269 38 %(103) 313 38 % (118) 3 512 43 % (218) 176 40 % (70) 336 44% (148) 4 381 51 % (193) 119 42 % (50) 262 55% (143) 5 150 54 % (81) 36 47 % (17) 114 56% (64) 6-7 78 65 % (51) 16 50 % (8) 62 70% (43) •Dropout rate = 40% •AA dropouts had 3x higher odds of relapse to alcohol/drug useSource: Kelly & Moos (2003) Dropout from 12-Step Groups: Prevalence, Predictors and Counteracting TreatmentInfluences, Journal of Substance Abuse Treatment,24, 241-250
    39. 39. Source: Kelly & Moos (2003) Dropout from 12-Step Groups: Prevalence, Predictors and Counteracting TreatmentInfluences, Journal of Substance Abuse Treatment,24, 241-250
    40. 40. » 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
    41. 41. » 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
    42. 42. T OS TF HStand alone Integrated into an existing Component of a treatmentIndependent therapy therapy package (e.g., an additional group)As Modular add-onlinkage component
    43. 43. » 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
    44. 44. » 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)
    45. 45.  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
    46. 46. T OS TF HStand alone Integrated into an existing Component of a treatmentIndependent therapy therapy package (e.g., an additional group)As Modular add-onlinkage component
    47. 47. » 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
    48. 48. » 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, 2009
    49. 49. » 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 motivational and treatment as usual groups» Evidence suggests AA involvement partially mediated the effects of the directive approach
    50. 50. T OS TF HStand alone Integrated into an existing Component of a treatmentIndependent therapy therapy package (e.g., an additional group)As Modular add-onlinkage component
    51. 51. » 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
    52. 52. » 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
    53. 53. » 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.
    54. 54. » 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
    55. 55. T OS TF HStand alone Integrated into an existing Component of a treatmentIndependent therapy therapy package (e.g., an additional group)As Modular add-onlinkage component
    56. 56.  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
    57. 57. » 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
    58. 58. » 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 substance-focused 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 six-month follow-up period, while 85% attended a SFG

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