Encouraging post-treatment self-help group involvement to reduce demand for continuing care services: two-year clinical and utilization outcomes

Background: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients’ health care costs in the first year after treatment, but such initially impressive effects may wane over time.

This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up.

Methods: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step-based (n = 887 patients) or cognitive-behavioral (CB, n = 887 patients) treatment programs.

The 12-step-based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs.

The 2-year follow-up assessed patients’ substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs.

substantially higher abstinence rate among patients treated in 12-step

Results: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) in contrast to CB (37.0%) programs.

Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs.

30% lower costs in the 12-step treatment programs

In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p = 0.01).

Conclusions:

• Promoting self-help group involvement appears to improve post-treatment outcomes while reducing the costs of continuing care.
• Even cost offsets that somewhat diminish over the long term can yield substantial savings.
• Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

Research; Keith Humphreys, and Rudolf H. Moos Alcoholism: Clinical and Experimental Research 2007; 31(1):64-68) - 1 This computation is in 2006 dollars, to which we converted for comparative purposes our prior findings, which had been originally reported in 1999 dollars (Humphreys and Moos, 2001).

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Rates and Correlates of Relapse Among Individuals in Remission From DSM-IV Alcohol Dependence: A 3-Year Follow-Up.

Background: There is little information on the stability of abstinent and nonabstinent remission from alcohol dependence in the general U.S. population. The aim of this study was to examine longitudinal changes in recovery status among individuals in remission from DSM-IV alcohol dependence, including rates and correlates of relapse, over a 3-year period.

Methods:This analysis is based on data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of U.S. adults aged 18 years and older originally interviewed in 2001 to 2002 and reinterviewed in 2004 to 2005. The Wave 1 NESARC identified 2,109 individuals who met the DSM-IV criteria for full remission from alcohol dependence. Of these, 1,772 were reinterviewed at Wave 2, comprising the analytic sample for this study. Recovery status at Wave 2 was examined as a function of type of remission at Wave 1, with a focus on rates of relapse, alternately defined as recurrence of any alcohol use disorder (AUD) symptoms and recurrence of DSM-IV alcohol dependence. Logistic regression models were used to estimate the odds of relapse among asymptomatic risk drinkers and low-risk drinkers relative to abstainers, adjusted for a wide range of potential confounders.

Results: By Wave 2,

• 51.0% of the Wave 1 asymptomatic risk drinkers had experienced the recurrence of AUD symptoms, compared with
• 27.2% of low-risk drinkers and
• 7.3% of abstainers.

Across all ages combined, the adjusted odds of recurrence of AUD symptoms relative to abstainers were

• 14.6 times as great for asymptomatic risk drinkers and
• 5.8 times as great for low-risk drinkers.

The proportions of individuals who had experienced the recurrence of dependence were

• 10.2%, for asymptomatic risk drinkers
• 4.0%, for low-risk drinkers and
• 2.9%,  for abstainers

The adjusted odds ratios relative to abstainers were

• 7.0 for asymptomatic risk drinkers and
• 3.0 for low-risk drinkers.

Age significantly modified the association between type of remission and relapse. Differences by type of remission were not significant for younger alcoholics, who had the highest rates of relapse.

Conclusions: Abstinence represents the most stable form of remission for most recovering alcoholics.

Study findings highlight the need for better approaches to maintaining recovery among young adults in remission from alcohol dependence, who are at particularly high risk of relapse.

Research; Deborah A. Dawson, Risë B. Goldstein, Bridget F. Grant. Rates and Correlates of Relapse Among Individuals in Remission From DSM-IV Alcohol Dependence: A 3-Year Follow-Up. Alcoholism: Clinical and Experimental Research (2007) 31 (12), 2036–2045.

Brief-TSF can assist patients cease alcohol consumption.

One-Year Outcomes among Members of a Dual-Recovery Self-Help Program.

Research Objective: Self-help is gaining increased acceptance among treatment professionals as empirical support for of its effectiveness is growing and the advent of managed care warrants the use of cost-effective modalities. Traditional “one disease-one recovery” self-help programs cannot serve adequately the needs of the dually-diagnosed.

This paper presents one-year outcome data from a longitudinal study of the effectiveness of self-help for the dually-diagnosed.

Subjects are members of Double Trouble in Recovery (DTR), a 12-step self-help program designed to meet the special needs of those diagnosed with both a mental health disorder and a chemical addiction.Study.

Design: The study uses a 12-month prospective longitudinal design with follow-ups at 12 and 24 months after baseline. Subjects (N = 310) were recruited at 25 DTR meeting sites throughout New York City. Semi-structured instruments assess history and current status of mental health and substance abuse, treatment in both areas, and self help participation (DTR as well as traditional 12-step groups such as AA and NA).

Population Studied: Community-based individuals dually-diagnosed with a mental health disorder and substance abuse.

Principal Findings: S’s are mostly members of underserved minority groups with long histories of substance abuse and mental health disorders.

Most S’s attend outpatient treatment (for drug use, mental health or dual-diagnosis - 77%) and take psychotropic medications (87%).

At the 12 months follow-up,

• 76% were still attending DTR;
• 68% were also attending AA or NA.

Mean number of symptoms S’s. experienced in the past year decreased significantly;

• two-thirds (69%) of S’s reported that their mental health was “better” in the past month than it was at baseline.
• One-third (29%) reported substance use in the past year, compared to 42% at baseline (p = .002).

Substance use (less) was significantly associated with DTR attendance:

• Total time abstinent was related to lifetime length of DTR attendance (r = .25, p = .002) and
• past year substance use was related to number of months of DTR attendance in the past year (r = -.17, p = .02).

Conclusions: For dually-diagnosed individuals, continued participation in dual recovery self-help groups plays a significant role in the recovery process, particularly in the area of substance use.

Implications for Policy, Delivery or Practice: Participation in dual-recovery self-help groups, both during and after formal treatment, should be encouraged as part of an integrated lifelong recovery plan for dually-diagnosed individuals.

Research; One-Year Outcomes among Members of a Dual-Recovery Self-Help Program. Laudet A, Magura S, Vogel H, Knight E, Staines G; Abstr Acad Health Serv Res Health Policy Meet. 2000; 17.

More at; Double Trouble in Recovery

See also;

• 12-Step Treatment More Effective than Alternative
• AA and Treatment Work Better Together
• Subscribe to Twelve Step Facilitation by e-Mail

Dual Diagnosis; Counseling the Mentally Ill Substance Abuser by Katie Evans, J. Michael Sullivan Read more about this title…

Motivational Enhancement Therapy (MET) is a systematic intervention approach for evoking change in problem drinkers.

It is based on principles of motivational psychology and is designed to produce rapid, internally motivated change. This treatment employs motivational strategies to mobilize the client’s own change resources.

MET consists of four carefully planned and individualized treatment sessions.

The first two focus on structured feedback from the initial assessment, future plans, and motivation for change,

The final two sessions at the midpoint and end of treatment provide opportunities for the therapist to reinforce progress, encourage reassessment, and provide an objective perspective on the process of change.

The counselor seeks to develop a discrepancy in the client’s perceptions between current behavior and significant personal goal; emphasis is placed on eliciting from clients self-motivational statements of desire for and commitment to change.

The working assumption is that intrinsic motivation is a necessary and often sufficient factor in instigating change.

See also;

• Address the drinking problem directly
• Alcohol & Medication Interactions
• Alcoholic Family Roles
• Brief-TSF is designed to as adjunctive therapy for anti-craving medication.

Drug and Alcohol Abuse: A Clinical Guide to Diagnosis and Treatment by Marc A. Schuckit Read more about this title…

Twelve Step Facilitation Therapy facilitates patients’ active participation in the fellowship of Alcoholics Anonymous.

TSF regards such active involvement as the primary factor responsible for sustained sobriety (recovery) and therefore as the desired outcome of participation in this treatment program.

This therapy is grounded in the concept of alcoholism as a spiritual and medical disease.

TSF consists of a brief, structured, and manual-driven approach to facilitating early recovery from alcohol abuse/alcoholism and other drug abuse/addiction.

It is intended to be implemented on an individual basis in 12 to 15 sessions and is based in behavioral, spiritual, and cognitive principles that form the core of 12-step fellowships such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).

It is suitable for problem drinkers and other drug users and for those who are alcohol or other drug dependent.

• TSF is only used by specialist alcoholism therapists.
• BriefTSF is used by generalist healthcare workers.

See also;

• 12-Step Treatment More Effective than Alternative
• AA Offers Recovery Not Religion
• Brief-TSF can assist patients cease alcohol consumption.
• Subscribe to Twelve Step Facilitation by e-Mail

The 1956 General Service Conference of A.A. adopted unanimously the following statement of “A.A.’s Public Information

Policy”: In all public relationships, A.A.’s sole objective is to help the still suffering alcoholic. Always mindful of the importance of personal anonymity, we believe this can be done by making known to him, and to those who may be interested in his problem, our own experience as individuals and as a fellowship in learning to live without alcohol. We believe that our experience should be made available freely to all who express sincere interest.

We believe further that all our efforts in this field should always reflect our gratitude for the gift of sobriety and our awareness that many outside A.A. are equally concerned with the serious problem of alcoholism.

This statement reflects a longstanding A.A. tradition of not seeking publicity for promotional purposes, but of always being willing to cooperate with representatives of all media who seek information about the recovery program or about the structure of the Fellowship. Thousands of inquiries of this type are handled each year at the General Service Office (475 Riverside Drive, New York, NY 10115; mail address: Box 459, Grand Central Station, New York, NY 10163; telephone: 2128703400; www.aa.org). Many countries have local website’s that can be accessed from this main site.

Information and public relations matters affecting the Fellowship of A.A. as a whole are the concern of the Public Information Committee and the Committee on Cooperation with the Professional Community/Treatment Facilities of the General Service Board of Alcoholics Anonymous.

Reporters are welcome at A.A. open meetings, dinners, regional gettogethers, or similar gatherings of recovered alcoholics.

The only restriction is a request not to disclose the name of any A.A. member. (For obvious reasons, photographs cannot be taken at A.A. meetings.)

Note: In many areas, A.A. members have established committees on public information and cooperation with the professional community, to assist local media in obtaining accurate information about the Fellowship. Background material on A.A. may also be obtained upon request from these groups.

A.A. FACT FILE; PREPARED BY GENERAL SERVICE OFFICE OF ALCOHOLICS ANONYMOUS

Mutuality is a feature of many ’self-help groups’ for people with mental health and/or substance misuse needs.

These groups are diverse in terms of membership, aims, organisation and resources.

Collectively, in terms of the pathways for seeking help, support, social capital or simply validation as people, mutual aid groups figure at some time in the life story of many psychiatric and/or substance misuse patients.

From the viewpoint of clinical services, relations with such groups range from formal collaboration, through incidental shared care, via indifference, to incomprehension, suspicion, or even hostility.

How should mental health and substance misuse clinicians relate to this informal care sector, in practice?

Aims: To synthesise knowledge about three aspects of the relationship between psychiatric/substance misuse services and mutual aid groups:

• profile groups’ engagement of people with mental health and/or substance misuse needs at all stages of vulnerability, illness or recovery;
• characterise patterns of health benefit or harm to patients, where such outcome evidence exists;
• identify features of mutual aid groups that distinguish them from clinical services.

Method: A search of both published and unpublished literature with a focus on reports of psychiatric and substance misuse referral routes and outcomes, compiled for meta-synthesis.

Results: Negative outcomes were found occasionally, but in general mutual aid group membership was repeatedly associated with positive benefits.

Conclusions: Greater awareness of this resource for mental health and substance misuse fields could enhance practice.

Mutual aid groups in psychiatry and substance misuse. Alex Baldacchino;  Woody Caan; Carol Munn-Giddings. Mental Health and Substance Use: dual diagnosis, Volume 1, Issue 2 June 2008 , pages 104 - 117

See also;

• 12-Step Treatment More Effective than Alternative
• AA Offers Recovery Not Religion
• Brief-TSF can assist patients cease alcohol consumption.
• Subscribe to Twelve Step Facilitation by e-Mail

CONTRAST TO OTHER COUNSELING APPROACHES

Most Similar Counseling Approaches

TSF has its roots in the Minnesota Model first described by Daniel J. Anderson and as implemented in most AA-oriented treatment programs (e.g.,the Hazelden Foundation, the Betty Ford Foundation, the Sierra Tuscan Center, and others). These models assume addiction can be arrested but not cured, ascribe to the AA/NA philosophy as described in AA/NA literature that relies heavily on a combination of spirituality and pragmatism, and advocate peer support as the primary means for achieving sustained sobriety.

Most Dissimilar Counseling Approaches

Any approach that advocates controlled use of alcohol or other drugs (as compared with abstinence) is fundamentally dissimilar to TSF with respect to basic treatment goals. Cognitive-behavioural approaches that are based on the idea that problem drinking and other drug use stem primarily from inadequate stress management skills and that aim to enhance problem solving and coping skills differ from TSF with respect to the assumption of peer support as fundamental to recovery. TSF also assumes that alcoholism and other drug addiction are primary diagnoses and not symptoms of another diagnosis (e.g., depression, antisocial personality).

Reduction in heavy drinking as a treatment outcome in alcohol dependence.

This article, published in a prestigious journal, suggests that controlled drinking should return to the public health arena. This, even though this policy has been dismissed, about 2 decades ago, as being unworkable and dangerous to the individuals, their families and society as a whole.

Alcoholics who have tried controlled drinking will attest to the futility of such a policy and goal.

Reduction in heavy drinking for ‘problem drinkers’ is a viable goal but not for alcoholics.

The only valuable suggestion made in the article is the final one

“outcomes be individualized to patients’ goals”.

There is no clinical benefit in trying to get an alcoholic to control their drinking.

Abstract; In the field of clinical alcohol disorders treatment in North America, abstinence continues to be largely viewed as the optimal treatment goal; however, there is a growing awareness of limitations when abstinence is considered the only successful outcome.

Although this issue has been discussed in research settings, new studies on the public health significance of heavy drinking (defined as five or more standard drinks per drinking day in men, and four or more standard drinks per drinking day in women) in the past 10 years suggest that clinical providers should consider the value of alternative outcomes besides abstinence.

A focus on abstinence as the primary outcome fails to capture the impact of treatment on reduction in the pattern and in the frequency of alcohol consumption.

In addition, evaluating reduction in drinking as “positive” has value for patients as an indicator of clinical progress. Measurement of continuous variables, such as the quantity and the frequency of alcohol consumption, has provided a clearer understanding of the scope of alcohol-related morbidity and mortality at the societal level, and of the relationship between individual patient characteristics and the naturalistic course of alcohol use, abuse, and dependence.

A review of these characteristics suggests that there are clinical benefits associated with reducing heavy drinking in alcohol-dependent patients.

Given the significant public health consequences associated with heavy drinking and the benefits associated with its reduction, it is proposed that researchers, public health professionals, and clinicians consider using reduction in heavy drinking as a meaningful clinical indicator of treatment response, and that outcomes be individualized to patients’ goals and readiness to change.

Research report; David R. Gastfriend, James C. Garbutt, Helen M. Pettinati and Robert F. Forman. Reduction in heavy drinking as a treatment outcome in alcohol dependence. Journal of Substance Abuse Treatment. Volume 33, Issue 1, July 2007, Pages 71-80

Alcoholics Anonymous is self-help, not treatment

Alcoholics Anonymous is not really a treatment for alcoholism but a community resource for those wishing to stop drinking. Uncontrolled studies of AA have shown that people who affiliate with AA tend to stop drinking and find that their lives improve in many respects (Emrick et al. 1993).

However, evaluating AA alongside professionally delivered interventions presents problems and perhaps should not be done.

AA, the original 12 Step program, is not a fixed form of “treatment” and people are free to participate in different ways. Some go a few times and then drop out. Others go more often, but do not actively participate in meetings or “work the program.”

It is possible that both dropouts and passive participants gain some benefit from the AA experience, but this has not been adequately researched. Only a minority of those ever exposed to AA seem to become full, active members over a long period and consistently “work” all the steps.

There is evidence that certain types of people may be more likely to fully affiliate with AA than others (Ogborne and Glaser, 1981; Emrick et al., 1993), but more research is needed and some studies may no longer be relevant given the current range and diversity of AA groups. However, it seems likely that AA would appeal to those who have experienced serious alcohol-related problems and who can accept the need for abstinence and the term “alcoholic”.

When professionals refer clients to AA, as adjunctive therapy, on the assumption that they will benefit from such referrals, it is reasonable to ask about the outcomes of these referrals and to compare these outcomes with those achieved by other means.

Project MATCH (1997) included a 12-step facilitation intervention and results showed that those who were encouraged to go to AA did as well as those provided with other interventions.