Twelve Step Fellowships: Potential Options and Barriers

1. Twelve Step Fellowships: Potential Options and Barriers Ed Day

2. AIMS • Why community mutual-help? • Why 12-step group participation? • Can we enhance the link from professional treatment to 12-step group participation? • What are the potential barriers to 12-step facilitation? • What can we do to overcome these barriers?

3. Potential Advantages of Community Mutual-Help • Low entry threshold (no paperwork) & anonymous (stigma) • Provide access at high risk times when professional services not available • Cost-effective: free; attend as intensively & as long as desired • Adaptive system responsive to variable relapse risk

4. RCTs: Results and Limitations Meta-analysis of hundreds of studies show AA confers a consistent moderate beneficial effect Results from RCTs of AA show mixed findings depending on whether individuals were coerced/mandated to attend AA meetings or not Difficult to work out unique effects of AA – most studies follow professional treatment

5. 27+ weeks of treatment or AA in the 1st year after seeking help had better 16-year alcohol-related outcomes • AA involvement after year 1 also associated with better 16-year outcomes • Treatment after year 1 not associated with better 16-year outcomes Duration of AA Duration of treatment

6. RESULTS: AA helps people to recover through 1. common process mechanisms [ self-efficacy, coping skills & motivation] 2. facilitating social network changes

7. OUTPATIENT GROUP: Adaptive social network changes social abstinence self-efficacy AFTERCARE GROUP: Adaptive social network changes  social abstinence self-efficacy + spirituality & religiosity negative affect “While AA facilitates recovery by mobilizing several processes simultaneously, it is changes in social factors which appear to be of primary importance”

8. SUMMARY • AA and NA participation is associated with • likelihood of abstinence, often for prolonged periods (Moos 2006) • improved psychosocial functioning • greater levels of self-efficacy • Increased involvement in 12-Step meetings and activities following treatment leads to use of treatment services and costs (Humphreys & Moos, 2001, 2007) • Small amounts of participation may abstinence, higher “doses” may be needed to reduce the likelihood of relapse • Engaging in other 12-Step group activities may be a better predictor of abstinence than merely attending meetings • Starting TSG participation while in treatment associated with better outcomes

9. CLASSIC 12 STEP FACILITATION MODIFIED 12 STEP FACILTATION MOTIVATIONAL OR DIRECTIVE BRIEFER INTERVENTIONS +/- PEERS

10. Twelve Step Facilitation (TSF) • About 12 sessions • Individual or group • Facilitated by drug counsellor/therapist • 3 goals: • Facilitate ‘acceptance’ • Facilitate ‘surrender’ • Facilitate active involvement in 12-Step meetings and related activities

11. Project MATCH- Findings • TSF v MET v CBT • Similar on continuous outcomes (PDA/DDD) • TSF attended AA more frequently and had 71% more continuous abstinence 1yr and 3yrs after treatment • 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 / CBT

12. Making Alcoholics Anonymous EZ (MAAEZ)

13. 2 12-Step oriented programs: residential + OP • 508 participants • Drug and Alcohol dependence • OFF/ON design • More clients in ON condition reported past 30 day abstinence from alcohol/drugs at 12 months • Odds of abstinence increased significantly with each additional MAAEZ session attended • More effective if more prior TSG exposure, severe psychiatric symptoms, or atheist/agnostic

14. All clients received treatment that included: • 12 sessions • Focus on problem-solving, drink refusal, relaxation • Recommendation to attend AA meetings • 1: Directive approach • Client signed contract describing goals to attend AA meetings • Client encouraged to keep journal • Reading material about AA provided • Client informed about skills to use during meetings and about using a sponsor • 38% material about AA • 2: Motivational enhancement approach • Elicit client feelings and attitudes about AA • Therapist describes positive aspects of AA, but up to the client how involved to be • Therapist assists the client in making a decision in favourof AA • 20% material about AA • 3: CBT treatment as usual • Therapist briefly inquires about AA and encourages client to attend • 8% material about AA

15. Participants exposed to the Directive TSF approach reported significantly more: • attendance of AA meetings • more active involvement in AA • higher percent days abstinent in comparison to the treatment as usual group • Evidence suggests AA involvement partially mediated the effects of the directive approach

18. Control group: • No-referral intervention (NI): Patient provided with a list of meetings • Intervention groups: • Doctor-referral intervention (DI): talk to patient about 12-step meetings • Peer-referral intervention (PI): talk to patient about 12-step meetings and share personal experiences with 12-step groups • Active linkages produced higher attendance rates 88% vs 73% • Those attending during treatment more likely to attend afterwards 59% vs 20% • Significant differences in post-discharge attendance rates PI 64%, DI 48%, NI 33%

19. 88% rated knowledge level about AA/NA as average or above average (33% rated it as high or very high) • 33% had attended either an AA/NA meeting • 46% likely to recommend TSG meetings to their clients • Nursing staff more likely to have a positive attitude • Significant association between the level of reported spirituality and the likelihood of recommending AA/NA • 11% estimated to attend AA/ NA (range = 0–100%)

20. Wall, Sondhi & Day (EAR, In press) • 57 % rated knowledge of TSGs as intermediate, with equal numbers rating it as either high or low (16%) • Mean objective knowledge score = 8/14 • 41% had attended either an AA/NA meeting • 80% referred at least some of their clients to a TSG meeting • 30% estimated to attend AA/ NA (range = 0–100%) • No difference between the two time periods in • % participants who had ever attended a TSG (38% vs. 41%) • level of knowledge about TSGs (37% ‘high’ or ‘very high’ in 2003 vs. 24% in 2012) •  ‘positive’/‘very positive’ attitude to TSGs 42% vs. 77%

21. The Opiate Conundrum • Is NA as effective as AA? • Will this work in a UK context • Is opiate dependence different? • How does OST impact on this situation?

24. 1. KEY 12-STEP COMPONENTS • ‘Religious’ nature of TSGs (particularly for non-Christians or atheists) • Dependence is a disease, powerlessnessor the removal of personal responsibility • TSGs focus ‘narrowly’ on the 12 Steps, excluding other ways of helping “Clients don’t buy into the ‘no choice’ approach to addiction. Some don’t like the disease model, and feel that it is the wrong mindset” [3.20] • Possibility of becoming dependent on TSGs “It is not a recovery model as you are always an addict and you always have a disease. People don’t want to associate with their past life. They don’t like the idea that once an addict, always an addict. They want to move on” [4.26]

25. 1. KEY 12-STEP COMPONENTS 1a. Lack of information about TSGs or ‘stereotyped’ views “Clients are influenced by rumours that you have to believe in God, that people sit around saying prayers, and that after the group everyone uses drugs together” [1.6] • TSGs were thought to • have a ‘bad reputation’ • be strict • prohibit smoking tobacco • Belief that you have to share your intimate thoughts and feelings • Attending a meeting was perceived as stigmatizing “There is a fear of seeing people that they know because they want their addiction to be confidential” [4.35]

26. 2. NOT SUITABLE FOR ANY GROUP-BASED INTERVENTION 2a. The client is not ‘ready’ or lacks motivation • ‘Pre-contemplative stage’ is too early in the recovery journey • Clients perceive their problem to be not as bad as others “They lack of insight into the problem, and they don’t feel they need intervention. It is a personal choice and they have opted out” [4.34] “Some don’t want to give up. They don’t have enough motivation because they have been forced to attend by the criminal justice system” [3.19] • Control drug use rather than abstain, or would attend TSG meeting intoxicated • Some had stopped using illicit drugs since starting prescription medication “They want to put drug use behind them completely. It’s their past and they want to close that chapter” [2.15]

27. 2. NOT SUITABLE FOR ANY GROUP-BASED INTERVENTION 2b. General or non-TSG specific factors • Dislike or fear of a group setting in general – prefer one-to-one encounters • Groups are frightening, intimidating, challenging, intense, anxiety-provoking, judgemental, and potentially rejecting “The idea of opening up in front of others. People may feel vulnerable as this is intrusive if they don’t want to speak in front of others” [1.7] “It gets too deep for some people too early. It can become frightening” [1.11] • Physical contact (shaking hands or hugging) felt to be unavoidable and unpleasant • Fear of a hierarchy or cliques that would exclude the newcomer • Meetings could be boring, repetitive and ‘church-like’ • Practical difficulties - meetings were too far away, sited in inappropriate or inaccessible locations, and had limited ‘opening times’

28. 2. NOT SUITABLE FOR ANY GROUP-BASED INTERVENTION 2c. Risk to the client or others • Risk that client may present to others “It may put others at risk if they are very chaotic, have a criminal record, or are violent. The group may trigger aggression” [4.27] • Physical or emotional harm to the client from TSG members “Clients with very traumatic childhood experiences or a currently chaotic lifestyle would not be suitable. They may be at risk when sharing or opening themselves up to things they can’t cope with that are present in their lifestyle, such as a history of sexual abuse” [2.14] • Risk of lapse or relapse to substance use

29. 3. CONTRAST WITH PROFESSIONAL TREATMENT • TSGs do not tackle issues that clients bring to treatment services • Liaison with other professionals (e.g. probation, courts, or social workers) • Prescription to manage the symptoms of physical dependence • Health advice, referral for treatment for blood borne viruses “12 step group members are not medically trained and can’t provide treatment, mental health assessment, detoxification or physical health assessment” [5.92] • More comfortable opening up to professionals rather than peers • Clients concerned that they would know people attending the groups

30. The Key Elements of Facilitation • Which of the various beneficial elements should a worker promote? • Should you offer direction, motivational enhancement or both? • How do you involve peers most effectively?

31. NEXT STEPS?