A professional perspective on mutual help organisations for addictions

1
A professional perspective on mutual help
organisations for addictions
Scotlands Futures Forum, Edinburgh, Scotland UK
23 March 2009

• Keith Humphreys
• Professor of Psychiatry
• Veterans Affairs and Stanford University Medical
  Centers
• Palo Alto, California USA

2
Acknowledgement

• U.S. National Institute of Alcohol Abuse and
  Alcoholism
• U.S. Department of Veterans Affairs
• Rudy Moos, Christine Timko, John Finney
• Research participants

3
Overview

• Definition of mutual help groups
• Effectiveness and Cost-effectiveness
• Mediators of Change
• So What? Implications for Designing Better
  Services

4
Characteristics Shared by All Self-Help/Mutual
Aid Groups

• Members share some problem or status that results
  in suffering/distress
• Groups are organized and facilitated by members
  themselves
• Experiential knowledge is the basis of expertise
• All members are both helpers and helpees
• No fees are charged, save pass the hat
  contributions

5
Characteristics of Only Some Self-Help/Mutual Aid
Groups

• A codified world view/program for change
• Residential setting
• Internet presence
• Connection to a larger organization
• Political Advocacy

6
Lifetime and past 12 months participation in
self-help groups, 1995
7
Help-seeking visits in U.S. for psychiatric and
substance abuse problems by sector
8
Alcohol and drug-related self-help/mutual aid
organizations (12 step in red)

• Estimated Number of Groups Worldwide
• Alcoholics Anonymous 95,000
• Al-Anon 32,000
• Narcotics Anonymous 21,000
• Cocaine Anonymous 2,000
• Adult Children of Alcoholics 1,500
• LifeRing/Secular Organization for Sobriety
  1,200
• Marijuana Anonymous 1,000
• Women for Sobriety 350
• SMART Recovery 300
• Moderation Management 50
• Source White and Madara (1998). Self-help
  sourcebook. Denville, NJ American Self-help
  clearinghouse and Humphreys, K. (2004) Circles of
  Recovery.

9
12-step groups have established themselves in the
once-impenetrable Middle East
Note NA is for all drugs not just narcotics
10
(No Transcript)
11
Selected data on clinical and cost-effectiveness
of 12-step mutual help organizations
12
Clinical trial of Oxford House

• Oxford House is a 12-step influenced,
  peer-managed residential setting
• 150 Patients randomized after inpatient treatment
  to Oxford House or TAU
• 77 African American 62 Female
• Follow-ups every 6 months for 2 years, 90 of
  subjects re-contacted

13
At 24-months, Oxford House (OH) produced 1.5 to 2
times better outcomes
Jason et al. (2006). Communal housing settings
enhance substance abuse recovery. American J
Public Health, 96, 1727-1729.
14
Veterans Affairs RCT on AA/NA referral for
outpatients

• 345 VA outpatients randomized to standard or
  intensive 12-step group referral
• 81.4 FU at 6 months
• Higher rates of 12-step involvement in intensive
  condition
• Over 60 greater improvement in ASI alcohol and
  drug composite scores in intensive referral
  condition

Source Timko, C. (2006). Intensive referral to
12-step self-help groups and 6-month substance
use disorder outcomes. Addiction, 101, 678-688.
15
Study of cost consequences
16
Comparable baseline demographic and alcohol use
characteristics of 201 alcoholic individuals who
initially chose AA or outpatient treatment

• Total sample AA Outpatient
• Characteristic (n201) (n135) (n66)
• Caucasian Race 86.6 88.9 81.8
• Female 49.3 54.1 39.4
• Married 25.9 23.7 30.3
• Employed 52.2 48.1 60.6
• Mean Mean Mean
• Age (years) 35.3 34.7 36.4
• ETOH (oz) 11.5 12.3 10.0
• ADS Score 10.1 10.9 8.6
• Days intox 11.7 11.9 11.4

17
Total alcohol-related health care costs over
three years by comparable alcoholic individuals
who initially chose Alcoholics Anonymous or
professional outpatient treatment

• AA group Outpatient group
• (n135) (n66) F
• mean SD mean SD (df1,199)
• Per person costs
• Year 1 1,115 2,386 3,129 4,355
• Years 2 and 3 1,136 4,062 948 2,852
• Total 2,251 5,075 4,077 5, 371 5.52
• Note plt.05

18
Alcohol-related outcomes of individuals initially
selecting AA or outpatient treatment (OP)
19
Replication of cost offset findings in Department
of Veterans Affairs Sample

• Source This study appeared in Alcoholism
  Clinical and Experimental Research, 25, 711-716.

20
Design

• Follow-up study of over 1700 patients receiving
  one of two types of care
• 5 programs were based on 12-step principles and
  placed heavy emphasis on self-help activities
• 5 programs were based on cognitive-behavioral
  principles and placed little emphasis on
  self-help activities

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Participants

• N 1,774
• Sex 100 Male
• Race 49 Caucasian, 46 African-American
• SES 100 low-income
• Age 42.9 Years (Sd 9.8)
• Dx 16 Drug, 46 Alc, 38 Both

22
Self-help group participation at 1-year follow-up
was higher after self-help oriented treatment

• 36 of 12-step program patients had a sponsor,
  over double the rate of cognitive-behavioral
  program patients
• 60 of 12-step program patients were attending
  self-help groups, compared with slightly less
  than half of cognitive-behavioral program patients

23
1-Year Treatment Costs, Inpatient Days and
Outpatient visits
Note All differences significant at p lt.001
24
1-Year Clinical Outcomes ()
Note Abstinence higher in 12-step, plt .001
25
2-year follow-up of same sample

• 50 to 100 higher self-help group involvement
  measures favoring 12-step
• Abstinence difference increased 49.5 in 12-step
  versus 37.0 in CB
• A further 2,440 health care cost reduction
  (total for two years 8,175 in 2006USD)

26
What mediates these benefits?
27
B mediates the relationship between A and C
Agtgtgtgtgtgtgtgtgt?Bgtgtgtgtgtgtgtgt?C
28
Structural equation modeling results from over
2,000 patients assessed at intake, 1-year, 2-year
Active Coping
Motivation to change
Self-Help Group Involvement
Reduced Substance Use
General Friendship Quality
Friends Support For Abstinence
Note All paths significant at plt.05. Goodness
of Fit Index .950.
29
Partial mediators of 12-step groups effect on
substance use identified in research

• Increased self-efficacy
• Strengthened commitment to abstinence
• More active coping
• Enhanced social support
• Greater spiritual and altruistic behavior
• Replacement of substance-using friends with
  abstinent friends

30
12-step vs. non-12 step based friendship networks
of 1,932 treated SUD patients
Source Humphreys, K., Noke, J. (1997). The
influence of posttreatment mutual help group
participation on the friendship networks of
substance abuse patients. American J of
Community Psychology, 25, 1-16.
31
So what?Clinical implications
32
12-step group involvement of 2,045
substance-dependent veterans after 12-step or
cognitive-behavioral treatment
100
75
66
60
58
48

48
45
50
36
Cog Beh
25
18
12-Step
0
attended meetings
had sponsor
read 12-step
had a friend who
literature
Attends AA/NA
12-step self-help group involvement
Note Involvement was measured one year after
discharge by patient reports of activities in the
past 3 months. Data in this table were drawn
from Humphreys et al. (1999), Alcoholism
Clinical and Experimental Research, 23, 558-563.
33
Abstinence from illicit drugs and alcohol as a
function of self-help involvement and treatment
type in 3,018 patients Self-help
group Involvement Proportional
-1SD 1SD Difference Treatment
Orientation 12-step 19 75 14.0 Non-12-s
tep 25 65 12.6
34
How can referrals to self-help groups be more
effective?
Sample 20 alcohol outpatients Design Outpatient
s randomly assigned to standard 12-step
self-help group referral (list of meetings and
therapist encouragement to attend) or intensive
referral (in-session phone call to active
12-step group member) Results Attendance rate
after intensive referral 100 Attendance rate
after standard referral 0 Source Sisson,
P.W., Mallams, J.H. (1981). The use of
systematic encouragement and community access
procedures to increase attendance at AA meetings.
Am J Drug Alc Abuse, 8, 371-376.
35
Self-help referral can be beneficial in
non-specialty settings

• Control BI BIPeer
• 6-month abstinence 36 51 64
• TX/AA Initiation 9 15 49

Source Study by Rick Blondell, M.D. of 140
patients hospitalized For alcohol-related
injuries, J Fam Practice, 50
36
Implications of mediational results for clinicians

• Promoting involvement as important as promoting
  attendance
• May help to focus treatment on mediators even for
  non-12-step involved patients
• Help anticipate and reinforce mediational changes
  likely to occur in self-help groups

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Conclusions

• 12-step group participation significantly reduces
  drug and alcohol use.
• 12-step group involvement reduces surplus health
  care utilization.
• Benefits of 12-step groups mediated both by
  psychological and social changes.
• Applying these findings in treatment settings
  should improve outcomes and reduce costs.

38
Collaboration and competition between self-help
groups and professionals

• Keith Humphreys
• Veterans Affairs and Stanford University School
  of Medicine

39
Bases of collaboration

• Shared commitment to a stigmatized activity
• Overlap of some goals, e.g., recovery
• Shared value orientation
• Overlap of personnel

40
Self-reported global attitudes are positive in
German, U.S. and Canadian studies

• Items w/95-99 endorsement
• Self-help groups are an important resource
• Professionals and self-help groups should work
  together to help people in need
• As a self-helper/professional, I want to
  collaborate with self-helpers/professionals

41
We love humanity in general, but we dont much
like anyone in particular

• The code of the Minnesota Liberal, as described
  by Garrison Keillor

42
Beneath apple pie sentiments

• Fear of lost legitimacy, status and income
• Different conceptions of collaboration
• Different norms, values and language
• Lack of faith in the other fellow

43
Project MESH A Collaboration that Worked

• Form self-help promoting coalitions
• Give them money and staff support
• Ask them to use media and education to expand
  self-help groups
• Ask them to emphasize people of color and
  Spanish-language speakers
• Get out of their way

44
Coalition work

• Adopted get a grip motto
• Designed bus posters with tear offs
• Recorded public service announcements
• About 20 Espanol, 80 English
• No direct appeals to physicians
• Los Angeles modifications

45
Example poster with tear off
46
Example poster with tear off
47
Number of visits to self-help groups in Oakland
and Los Angeles in 3 months of MESH Project vs.
in same 3 months of prior year
48
Why did the collaboration in Project MESH work?

• Independent bases of authority and legitimacy
• Independent resources
• Shared commitment to self-help groups
• Socially skilled group leaders and project
  facilitator
• Shared commitment to an outcome rather than a
  process