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12‐Step Approaches for the Dually Diagnosed: Mechanisms of Change
Abstract
Existing data indicate that 12-step program involvement is associated with improved outcomes in the dually diagnosed, but there are questions concerning the magnitude and mechanisms of this effect in various dually diagnosed populations.
Publications identified in a comprehensive review of the literature pertaining to 12-step programs and patients with addictions and co-occurring psychiatric disorders were reviewed for any content relevant to understanding the process of change involving dually diagnosed patients involved with 12-step programs.
Dually diagnosed individuals attend 12-step programs at rates comparable to the nondually diagnosed, although specific diagnoses may have some effect on attendance. The benefits of 12-step attendance do not appear to be markedly different for those with psychiatric disorders. Specialized 12-step programs could have benefits for the dually diagnosed over and above those of traditional 12-step programs. Existing data suggest that nonspecific change mechanisms (self-efficacy, social support) are similar to those found in the general AA literature.
Based on existing data, the change mechanisms are broadly similar to those found in the general 12-step literature, but additional factors related to mental illness may also play a significant role. Further work is necessary to test the components of this model and to achieve a firm empirical foundation for understanding the processes of 12-step recovery in the dually diagnosed.
... Engaging in other 12-Step group activities (e.g., doing service at meetings, reading 12-Step literature, doing "step work," getting a sponsor, or calling other 12-Step group members or one's sponsor) may be a better indicator of engagement and a better predictor of abstinence than merely attending meetings. In addition, increased involvement in 12-Step meetings and activities following formal treatment may serve as an important source of support and a form of continuing care that has been shown to lead to decreased utilization of mental health and substance abuse treatment services and associated costs , 2007. Although the positive relationship between 12-Step involvement and clinical outcomes is compelling, it is not possible to infer a causal relationship from correlational findings. ...
... Individuals with concurrent psychiatric and substance use disorders (e.g., dual disorders or cooccurring disorders) often have more and greater challenges in their recovery process and poorer outcomes than individuals with only a SUD (Laudet, Magura, Vogel, & Knight, 2000). There is evidence that individuals diagnosed with substance-use and psychiatric disorders can benefit from 12-Step involvement (Bogenschutz, 2007;Bogenschutz, Geppert, & George, 2006;Magura, 2008;Timko & Sempel, 2004). It is possible, however, that attendance rates may be affected by diagnosis. ...
... For instance, individuals diagnosed with schizophrenia or schizoaffective disorder reported attending fewer 12-Step meetings than those with other cooccurring psychiatric diagnoses (Jordan, Davidson, Herman, & BootsMiller, 2002). It has also been suggested that specialized 12-Step support groups for the dually diagnosed, such as Double Trouble in Recovery (DTR) or Dual Recovery Anonymous, could be even more valuable for this population than traditional groups (Bogenschutz, 2005(Bogenschutz, , 2007Magura, 2008;Timko, 2008;Vogel, Knight, Laudet, & Magura, 1998). One aspect related to this is that individuals with dual disorders may feel more comfortable and safe discussing their dual recovery needs and their use of psychotropic medications as part of their ongoing treatment than would be true in traditional 12-Step groups (Bogenschutz, et al., 2006;Magura, Laudet, Mahmood, Rosenblum, & Knight, 2002;Vogel et al., 1998). ...
Social workers and other behavioral health professionals are likely to encounter individuals with substance use disorders in a variety of practice settings outside of specialty treatment. 12-Step mutual support programs represent readily available, no cost community-based resources for such individuals; however, practitioners are often unfamiliar with such programs. The present article provides a brief overview of 12-Step programs, the positive substance use and psychosocial outcomes associated with active 12-Step involvement, and approaches ranging from ones that can be utilized by social workers in any practice setting to those developed for specialty treatment programs to facilitate engagement in 12-Step meetings and recovery activities. The goal is to familiarize social workers with 12-Step approaches so that they are better able to make informed referrals that match clients to mutual support groups that best meet the individual's needs and maximize the likelihood of engagement and positive outcomes.
... A person with a diagnosis of an anxiety or mood disorder is twice as likely to also have a substance abuse problem (Conway, Compton, Stinson, & Grant, 2006; National Institute on Drug Abuse, 2010). While mutualsupport groups for dually diagnosed individuals do exist and have been shown to confer benefit (Bogenschutz, 2007;Rosenblum et al., 2014) they are not currently widely available, particularly on an international level. Thus, mutual support groups for addictions are the main option for people with co-occurring substance use and mental health disorders. ...
... More broadly, while there is some research that suggests groups such as Alcoholics Anonymous (AA) can have benefits for mental health symptoms (e.g. Bogenschutz, 2007;Kelly, Stout, Magill, Tonigan, & Pagano, 2010;Timko, Cronkite, McKellar, Zemore, & Moos, 2013), the number of studies is limited and largely restricted to 12-step fellowship forms of mutual support groups (Zweben & Ashbrook, 2012). ...
Objective: SMART Recovery provides cognitive behavior therapy based mutual support groups for addictions. The aim of the present study was to explore the impact of cognitive behavior skill use and the influence of a person's social network on psychological distress. Method: Paper based surveys were mailed out to 121 SMART Recovery groups across Australia. A sample of 75 SMART Recovery group members participated. Measures of social network size and composition, psychological distress and cognitive behavior skill use were collected. Results: There are high rates of self-reported mental illness within SMART Recovery respondents. Use of behavioral skills and social network influence was significantly associated with level of psychological distress. Discussion: The current results indicate that engaging in behavioral activation and having a social network of non-drinking or non-using people is associated with lower levels of psychological distress. Given the high rates of self-reported comorbid mental illness in this population, it is important research continues to explore the role of specific cognitive behavioral therapy components and social networks on recovery within mutual support groups.
... Each of these aspects of mutual-help group participation is an indicator of proposed 12-step group mechanisms of change (Moos, 2008). Proposed active ingredients of 12-step groups, both DFGs and SFGs, are support, goal direction, and structure; abstinence-oriented norms and role models; engagement in rewarding activities; and bolstering self-efficacy and coping skills (Bogenschutz, 2007;Moos, 2008). The 12-step group behaviors and experiences associated with the intensive-referral intervention and better psychiatric and alcohol outcomes are consistent with these higher-order active ingredients. ...
... If a dual diagnosis patient is uncomfortable in a SFG, special procedures could be followed to identify and access a suitable DFG. Intensive referral could emphasize the common benefits of mutualhelp group participation, such as support, direction, and structure; abstinence-oriented role models and norms; and opportunities for rewarding activities, bolstering self-efficacy, and learning new coping skills (Bogenschutz, 2007;Moos, 2008). The funding agencies had no further role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. ...
... Despite the documented benefits associated with participation in single-focus 12-step groups (Krentzman, et al., 2010;Galanter et al., 2013), there is a growing body of research and narrative accounts suggesting that persons with mental health and substance use problems may feel stigmatized when attending single-focus groups. Such stigmatization may become especially apparent when 12-step participants discuss the severity of their psychiatric symptoms and use of prescribed medications to manage these symptoms (Bogenschutz, 2007;Jordan et al., 2002;Matusow et al., 2013;Magura et al., 2008a;Vogel et al., 1998;Vogel, 2010a). ...
Previous studies have indicated that persons with co-occurring mental health and substance use problems can benefit by attending dual-focus mutual aid groups. However, to date, a trial to test the efficacy of these groups has not been published.
This study randomly assigned 203 substance misusing clients attending a mental health or dual-diagnosis facility to either a dual-focus 12-step group (Double Trouble in Recovery; DTR) or a waiting list control group. Participants were followed for 3-6 months. The primary outcome was substance use (days used in the past 30 with saliva testing to detect under-reporting); secondary outcomes included psychiatric medication adherence, attendance at traditional (single-focus) 12-step meetings (e.g., AA/NA); and improvement in mental health and substance use problems (quality of life). Multilevel model (MLM) regression was used to analyze the nested effect of participants within 8 facilities (7 in New York City and 1 in Michigan). Regression imputation was used to adjust for drug use under-reporting.
At follow-up 79% of the subjects were interviewed. In intent to treat analysis, DTR subjects compared with control subjects used alcohol (p=.03) and any substances (p=.02) on fewer days. DTR compared with control subjects were also more likely to rate themselves as experiencing better mental health and fewer substance use problems (p=.001). There were no effects for DTR on drug use only, medication adherence or NA/AA attendance.
Findings reported in previous studies on the association between exposure to DTR and reductions in substance use were partially supported in this efficacy trial.
... [9][10][11][12] Despite the documented benefits of single-focus 12-step groups such as AA and Narcotics Anonymous (NA), there is a small but growing body of research and narrative accounts suggesting that single-focus 12-step groups may be underutilized by persons with dual disorders and that dually diagnosed persons may feel stigmatized when attending singlefocus groups, for example, by not being able to discuss their mental illness or issues such as challenges in adhering to psychiatric medication regimens. [13][14][15][16][17] Moreover, while studies evaluating 12-step groups for persons with co-occurring disorders have reported benefits associated with 12-step participation, 18,19 clinicians are less likely to refer their dually diagnosed patients to mutual aid groups as compared with their singly diagnosed patients, that is, those with substance use disorders only. 9,20,21 Double Trouble in Recovery (DTR) Double Trouble in Recovery (DTR) is a mutual aid program adapted from the 12 steps of AA. ...
Mutual aid fellowships have been shown to improve outcomes for those with co-occurring substance use and mental illness disorders. Processes associated with usefulness include helper therapy (the assumption of a helping role to foster commitment) and reciprocal learning (the sharing of problems and solutions among members). The present qualitative investigation used focus groups comprised a subset of participants in Double Trouble in Recovery (DTR), a 12-step mutual aid group for those with co-occurring disorders, to gather their subjective perceptions of the groups. Participants emphasized that in linking them to others with similar problems, the DTR groups played a vital emotional role in their lives and provided a needed venue for information sharing that might have been otherwise unavailable.
... If a dually diagnosed patient is too uncomfortable in a MHG, specialized approaches (Raj & Sheehan 2001) may be necessary to help him or her manage social anxiety symptoms to ease the distress of MHG participation and facilitate its benefits. As part of these approaches, treatment providers may emphasize the rewards of MHG participation accrued over time, such as support from peers, guidance from role models, increased self-efficacy, and new coping skills (Bogenschutz 2007;Moos 2008). ...
... For example, Laudet [23] found that drugs and alcohol may be used as a coping strategy by those with addictions to suppress negative experiences and feelings; thus, whilst achieving sobriety may be desired, the demands and requirements of a new lifestyle without the crutch of alcohol or drugs will also inevitably be associated with anxiety. There is a large evidence base for the value of self-help interventions, such as Double Trouble in Recovery and 12-Step Approaches, where people share their experiences and coping strategies, gain strength and hope, and to help each other through the recovery process [5,7,16,25,35]. Peer facilitators who are in an advanced stage of recovery have been identified as being of particular value in serving as a role model for those at an early stage in their recovery [25]. However, little is known about the meaning of recovery (beyond abstinence and symptom relief) to those with dual diagnosis. ...
The ‘recovery approach’ to the management of severe mental health problems has become a guiding vision of service provision amongst many practitioners, researchers, and policy makers as well as service users.
This qualitative pilot study explored the meaning of ‘recovery’ with users of three specialist mental health services (eating disorders, dual diagnosis, and forensic) in 18 semi-structured interviews.
The relevance of themes identified in mainstream recovery literature was confirmed; however, the interpretation and relative weight of these themes appeared to be affected by factors that were specific to the diagnosis and treatment context. ‘Clinical’ recovery themes were also seen as important, as were aspects of care that reflect core human values, such as kindness.
... Patients in these treatment environments participated more intensively in treatment, were more satisfied with the program, and improved more during treatment on such proximal outcomes as self-efficacy and coping skills. With respect to further research, information about the probable mechanisms of change in SUD treatment (Bogenschutz, 2007;Moos, 2007) can guide researchers in their quest to identify the most effective ingredients of SUD treatment for both DD and SUD patients. DD and non-DD (SUD) patients' status on intake values of proximal and substance use and psychiatric distal outcomes DD and non-DD (SUD) patients' status on perceptions of treatment and proximal outcomes at discharge DD and non-DD (SUD) patients' 1-and 5-year substance use and psychiatric outcomes ...
Few studies have investigated whether dually diagnosed patients with co-occurring substance use and psychiatric disorders (DD) respond as well to substance use disorder (SUD) treatments as patients with SUD do. Here we assessed whether male veteran DD and SUD patients with alcohol dependence diagnoses differed in the process and outcomes of residential SUD treatment. The main findings showed that (a) DD patients did not perceive SUD programs as positively as patients with SUD did and had worse proximal outcomes at discharge from treatment; (b) DD patients did as well as SUD patients on 1- and 5-year substance use outcomes but had worse psychiatric outcomes; and (c) patients who perceived treatment more positively and had better outcomes at discharge had better longer term outcomes. Thus, residential SUD programs are relatively effective in reducing DD patients' substance use problems; however, they are less successful in engaging DD patients in treatment and addressing their psychiatric problems.
Purpose
Dual Diagnosis Anonymous (DDA) is a peer-led programme developed in the USA, which aims to address mental and addictive disorders in an integrated manner. This study is part of a mixed-methods evaluation of the first DDA pilot in the UK, and the purpose of this study is to explore the impact and mechanism of change of the programme through the perspective of DDA attendees, facilitators and the funding commissioners.
Design/methodology/approach
Six DDA members were interviewed three times over a period of 12 months, the facilitators were interviewed twice and the commissioner was interviewed once. The qualitative longitudinal data were analysed using a trajectory thematic analysis.
Findings
DDA attendance was perceived to have had a positive impact on five main areas: acceptance of self, of others and from others; social functioning; self-development; recovery progression; and feeling of hope. The possibility of addressing both mental health and addiction at the same time was a key factor in the recovery process. The facilitators observed that DDA had contributed to
Background:
Depression may contribute to increased drinking in individuals with alcohol use disorder. Although Alcoholics Anonymous (AA) attendance predicts drinking reductions, there is conflicting information regarding the intermediary role played by reductions in depression.
Objectives:
We explored whether AA attendance reduces depressive symptoms, the degree to which improvement in depression results in reductions in drinking, and in which subgroups these effects occur.
Methods:
253 early AA affiliates (63% male) were recruited and assessed at baseline 3, 6, 9, 12, 18, and 24 months. Depression was measured using the Beck Depression Inventory (BDI) and was administered at baseline 3, 6, 12, 18, and 24 months. AA attendance and alcohol use outcomes were obtained with the Form 90. Mediation analyses were performed at early (3, 6, and 9 months) and late (12, 18, and 24 months) follow-up to investigate the degree to which reductions in depression mediated the effect of AA attendance on drinking, controlling for concurrent drinking. In addition, a series of moderated mediation analyses were performed using baseline depression severity as a moderator.
Results:
At early follow-up, reductions in depression (6 months) mediated the effects of AA attendance (3 months) on later drinking (drinks per drinking day) (9 months) (b = -0.02, boot CI [-0.055, -0.0004]), controlling for drinking at 6 months. Baseline depression severity did not moderate the degree to which BDI mediated the effects of AA attendance on alcohol use (ps > .05).
Conclusion:
These findings provide further evidence that depression reduction is a mechanism by which AA attendance leads to reductions in alcohol use. Improving depression may help reduce alcohol use in individuals with AUD, and AA attendance may be an effective way to achieve that goal.
Addictive behaviors have the potential to disrupt the life of the individual who possesses the addiction; however, these behaviors also tend to produce a negative and cascading effect on everyone who may come into contact with the individual. More specifically, not only does an addiction produce misery for the addicted, it also creates misery for those who care for the individual, those who depend on the individual, and those who may be victims of the addicted individual’s impaired judgment and behavior. As the foregoing suggests, addictive behaviors constitute a serious issue in mental health. For many addicts, their problems are chronic and complex; therefore, they have been long standing enough to produce a variety of related problems in a variety of contexts.
IntroductionStress Coping and Self-Medication ModelsTreatment in the Community12-Step ApproachesCognitive and Behavioral TherapiesConclusions
AcknowledgmentReferences
This article gives an overview of the development of mutual-help groups for addictive disorders, mental health disorders, and co-occurring disorders. It highlights the history and current status of each type of group, discusses some alternatives to 12-step programs, and describes current challenges and dilemmas. It reports on the limited research on groups for co-occurring disorders and highlights the research in the other areas. It also reviews some of the interventions designed to facilitate the use of mutual-help groups, including groups for individuals with severe mental illness.
Purpose
– The purpose of this paper is to investigate research in the field of addictions utilising CBT and 12 step fellowship methods and to create an evidence base for an integrated treatment method utilising both approaches.
Design/methodology/approach
– Research on CBT and 12 step fellowships and their current applications in addiction treatment are presented. Models of severe mental illness are referenced and the use of directive and guided referrals are used as a basis to build the paper's hypothesis. A mode of action how the treatments may work together is presented.
Findings
– Findings indicate that guided treatment approaches for dual diagnosis are more likely to lead to long term therapeutic gains. Discussion involves the practical implications of this treatment and its ability to create a synergistic approach.
Practical implications
– Implications include the potential for streamlined treatment approaches which have the potential to increase treatment adherence and outcomes. Implications, such as the joint use of social reinforcement techniques between 12 step fellowship approaches and CBT, are also discussed.
Originality/value
– There is no previous research on the application of CBT and 12 step treatment modalities working together in a structured manner. Previous work has focussed primarily on severe mental illness. The current paper aims to provide an approach to treatment which utilises several modes of treatment to create more robust treatments for people suffering from dual diagnoses.
Objective:
People with severe mental illness and a co-occurring substance use disorder (co-occurring disorders) who live in urban areas experience high rates of incarceration. This study examined sociodemographic, clinical, economic, and community integration factors as predictors of incarceration among people with co-occurring disorders.
Methods:
This secondary analysis used data from a randomized controlled trial of assertive community treatment versus standard case management. In the parent study, researchers interviewed 198 people with co-occurring disorders from two urban mental health centers in Connecticut at baseline and every six months for three years. Researchers tracked incarceration, clinical engagement and status, employment, living situation, social relationships, and substance use. The study reported here used bivariate analyses and logistic regression analyses to compare individuals who were incarcerated during the study period with those who were not.
Results:
The overall incarceration rate was 38% during the study period. In multivariate analyses, prior incarceration predicted incarceration during the study period (odds ratio [OR]=3.26). Two factors were associated with a reduced likelihood of incarceration: friendships with individuals who did not use substances (OR=.19) and substance use treatment engagement (OR=.60).
Conclusions:
Positive social relationships and engagement in substance use treatment are promising service and policy targets to prevent incarceration in this high-risk population.
Converging evidence from epidemiologic and treatment studies indicate that anxiety disorders and substance use disorders commonly co-occur, and the interaction is multifaceted and variable. Epidemiological studies and investigations within clinical substance abuse populations have found an association between anxiety disorders and substance use disorders. Specific anxiety disorders including generalized anxiety disorder, panic disorder, and post traumatic stress disorder have all been associated with substance use. The association with obsessive-compulsive disorder is less robust, and some research has found a negative association. The risk of nicotine dependence is significantly higher among individuals with an anxiety disorder, and conversely, smoking has been found to be associated with trait anxiety and anxiety disorders. A review of the current literature and the relationship between specific anxiety disorders and alcohol and substance use disorders is discussed in detail. This article, written for social workers in a variety of practice settings, reviews the prevalence, diagnostic, and treatment issues at the interface of substance use disorders and anxiety disorders.
Most people with alcohol and other drug (AOD) use disorders suffer from co-occurring disorders (CODs), including mental health and medical problems, which complicate treatment and may contribute to poorer outcomes. However, care for the patients' AOD, mental health, and medical problems primarily is provided in separate treatment systems, and integrated care addressing all of a patient's CODs in a coordinated fashion is the exception in most settings. A variety of barriers impede further integration of care for patients with CODs. These include differences in education and training of providers in the different fields, organizational factors, existing financing mechanisms, and the stigma still often associated with AOD use disorders and CODs. However, many programs are recognizing the disadvantages of separate treatment systems and are attempting to increase integrative approaches. Although few studies have been done in this field, findings suggest that patients receiving integrated treatment may have improved outcomes. However, the optimal degree of integration to ensure that patients with all types and degrees of severity of CODs receive appropriate care still remains to be determined, and barriers to the implementation of integrative models, such as one proposed by the Institute of Medicine, remain.
Alcoholics Anonymous (AA) and other 12-step programs represent an affordable and widely accessible community-based resource for the estimated 18 million Americans with alcohol-related disorders. While substantiating information regarding 12-step programs remains challenging due to their autonomous structure and emphasis on anonymity, an ever increasing body of research provides a wealth of data regarding AA's efficacy, mechanisms of change, and viability for various special populations. This review presents key empirical findings from 2002 to 2007 in these areas, as well as proposes recommendations for future research.
Homeless individuals with co-occurring disorders (CODs) of severe mental illness and substance use disorder are one of the
most vulnerable populations. This article provides practitioners with a framework and strategies for helping this client population.
Four components emerged from a literature review: (1) ensuring an effective transition for individuals with CODs from an institution
(such as a hospital, foster care, prison, or residential program) into the community, a particularly important component for
clients who were previously homeless, impoverished, or at risk of homelessness; (2) increasing the resources of homeless individuals
with CODs by helping them apply for government entitlements or supported employment (3) linking homeless individuals to supportive
housing, including housing first options as opposed to only treatment first options, and being flexible in meeting their housing
needs; and (4) engaging homeless individuals in COD treatment, incorporating modified assertive community treatment, motivational
interviewing, cognitive–behavioral therapy, contingency management, and COD specialized self-help groups.
They're fast, cheap, and promise amazing results-no wonder more people seek mental health advice from self-help books and sites rather than seeking therapy. Complicating this picture: many resources are inappropriate, ineffective, even dangerous. For the clinicians who would gladly recommend self-help for their clients, the challenge is finding reliable, evidence-based sources of help among the vast quantities available. Self-Help in Mental Health: A Critical Review guides readers through this plethora of materials, organizing it into useful order, evaluating popular approaches and trends, and recommending clinically valid, science-based resources for specific clinical and sub-clinical problems. Its authors explain how and why such methods work, offering innovative uses for self-help in prevention and promotion, therapy and rehabilitation, including strengthening therapeutic gains (akin to homework in cognitive-behavioral therapy) and encouraging self-reliance. While some may be tempted to write-off all self-help as quackery or therapy-lite, Harwood and L'Abate recognize the potential the self-help movement holds for countering the stigma associated with mental health treatments. Further, self-help resources represent a viable means of reaching under-served populations, and, for some individuals, they are preferable to conventional therapy. Included in the coverage: Recommendations for books, web sites, organizations, support groups, hotlines, and audio-visual materials Depression, anxiety, eating disorders, addictions, and other conditions. Guidelines for evaluating self-help and guided self-support materials. Strategies for integrating self-help with traditional modes of therapy. Assessment tools for determining client appropriateness for self-help. New directions in theories of self-help and self-change. Contraindications for self-help approaches. Concise and comprehensive, Self-Help in Mental Health is timely reading that will enhance the work of psychotherapists and family and couples therapists, as well as researchers in clinical psychology, psychiatry, and other mental health fields. © Springer Science+Business Media, LLC 2010 All rights reserved.
Recovery is a new way of life for many patients; a life without substances to alter their moods but with a major change improving the physical, psychological, and emotional stability with improved overall health outcomes. The Twelve Steps of the Alcoholics Anonymous (AA) are the foundation of the AA, describing both the necessary actions and the spiritual basis for the recovery program of the AA. The Twelve Steps of the AA provide a structure for which a patient with alcoholism may turn for an answer to their problem of alcohol use, abuse, or dependence.
This article provides some commentary on six brief presentations on treatment processes and mediators of substance use disorder (SUD) treatment effects that were made at the 2005 Research Society on Alcoholism Satellite Preconference on "The Search for Mechanisms of Change in Evidence-Based Behavioral Treatments." Methods: Six presentations are discussed.
The foci of the presentations ranged from the linkages of intermediate outcomes of cognitive-behavioral and 12-step treatment (e.g., spirituality) to posttreatment substance use to the relationship between treatment completion of brief motivational interviewing and treatment outcome. None of the six presentations met all or even most of the criteria for analyses of mediation of intervention effects outlined by Kazdin and Nock. In fact, some did not examine mediation at all. However, the presentations were valuable in illustrating that important new knowledge can be gained from addressing SUD treatment processes and mechanisms of treatment change.
Given the paucity of extant research on mediation of SUD treatment effects, correlational explorations of treatment processes and treatment mediators are useful at this point, even though most mediational analyses do not meet many of the criteria listed by Kazdin and Nock. More attention should be devoted to assessing mediators before the assessment of outcome variables (e.g., during treatment) in order to address temporal precedence. Only after reasonable evidence has accrued regarding statistical mediation (expected associations, temporal precedence, reduction in treatment effects when putative mediator is controlled) does it make sense to mount expensive studies with experimental designs to examine causal mediation effects.
Posttraumatic stress disorder (PTSD) and alcohol use disorders are frequently comorbid conditions (Stewart, 1996). Alcohol use may serve a “negatively-reinforcing” function among traumatized individuals with PTSD (Stewart, 1996; Stewart, Conrod, Pihl, & Dongier, 1999a; Stewart, Pihl, Conrod, & Dongier, 1998). As such, the heavy drinking behavior of those with PTSD should be relatively situation-specific (i.e., more frequent in “negative” discriminative contexts than in other types of contexts). To test this “situational-specificity” hypothesis, a lifetime measure of trauma exposure (Everstine & Everstine, 1993), the PTSD Symptom Self-Report Scale (Foa, Riggs, Dancu, & Rothbaum, 1993), and the 42-item Inventory of Drinking Situations (Annis, Graham, & Davis, 1987) were administered to a community-recruited sample of 294 adult women substance abusers. PTSD symptoms were significantly positively correlated with frequency of heavy drinking in negative situations, but unrelated to frequency of heavy drinking in positive and temptation situations. At the level of specific drinking situations, PTSD symptoms were significantly positively correlated with frequency of heavy drinking in the negative situations of Unpleasant Emotions, Physical Discomfort, and Conflict with Others. PTSD symptoms were unrelated to frequency of heavy drinking in the positive situations of Pleasant Times with Others and Social Pressure to Drink, or in the temptation situations of Testing Personal Control and Urges and Temptations. Additionally, PTSD symptoms were significantly negatively correlated with frequency of heavy drinking in positive situations involving Pleasant Emotions. Anxiety sensitivity (fear of anxiety-related sensations; Peterson & Reiss, 1992), but not Neuroticism (tendency to experience negative affect; Costa & McCrae, 1992), mediated the observed associations between PTSD symptoms and situation-specific heavy drinking in negative contexts in general, and Conflict with Others and Physical Discomfort situations in particular. Implications for designing potentially more effective interventions for women with comorbid PTSD-alcohol use disorders are discussed.
Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a multisite collaborative project designed to evaluate patient-treatment interactions in alcoholism treatment. To evaluate whether major threats to the internal validity of the independent (treatment) variable in Project MATCH could be ruled out, we investigated several aspects of treatment integrity and discriminability. In this study, 1,726 alcohol-dependent participants at 10 sites were randomized to 3 treatments: cognitive-behavioral treatment (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF). Participants received treatment either as outpatients or as aftercare following a more intensive inpatient or day hospital treatment. For both the outpatient and aftercare arms of the study, treatments were discriminable in that therapists implemented each of the treatments according to manual guidelines and rarely used techniques associated with comparison approaches. Participants received a high level of exposure to their study treatments, and the intended contrast in treatment dose between MET and the 2 more intensive treatments (CBT and TSF) was obtained. Alcoholics Anonymous involvement was significantly higher for participants assigned to TSF versus MET or CBT, whereas the treatments did not differ in utilization of other nonstudy treatments. Nonspecific aspects of treatment such as therapist skillfulness and level of the therapeutic alliance were comparable across treatment conditions.
Recovery from substance abuse and mental health disorders (dual-diagnosis) requires time, hard work and a broad array of coping skills. Empirical evidence has demonstrated the buffering role of social support in stressful situations. This paper investigates the associations among social support (including dual-recovery mutual aid), recovery status and personal well-being in dually-diagnosed individuals (N = 310) using cross-sectional self-report data. Persons with higher levels of support and greater participation in dual-recovery mutual aid reported less substance use and mental health distress and higher levels of well-being. Participation in mutual aid was indirectly associated with recovery through perceived levels of support. The association between mutual aid and recovery held for dual-recovery groups but not for traditional, single-focus self-help groups. The important role of specialized mutual aid groups in the dual recovery process is discussed.
The authors examined the associations between attendance at self-help meetings, adherence to psychiatric medication regimens, and mental health outcomes among members of a 12-step self-help organization specifically designed for persons with both chronic mental illness and a substance use disorder.
A sample of members of Double Trouble in Recovery (DTR) was interviewed at baseline and one year later. Correlates of adherence to psychiatric medication regimens at the follow-up interview were identified for 240 attendees who had received a prescription for a psychiatric medication.
Consistent attendance at DTR meetings was associated with better adherence to medication regimens after baseline variables that were independently associated with adherence were controlled for. Three baseline variables were associated with adherence: living in supported housing, having fewer stressful life events, and having a lower severity of psychiatric symptoms. In addition, better adherence was associated with a lower severity of symptoms at one year and no psychiatric hospitalization during the follow-up period.
Treatment programs and clinicians should encourage patients who have both mental illness and a substance use disorder to participate in dual-focus self-help groups that encourage the responsible use of effective psychiatric medication, particularly after discharge to community living. Clinicians also should be sensitive to stressful life events and discuss with patients how such events might affect their motivation or ability to continue taking medication.
Although research on the effectiveness of 12-step group participation has been increasing, there has been little examination of the processes by which such participation leads to positive outcomes. Two kinds of factors have been proposed as mediating between 12-step group affiliation and outcomes for members, common process factors that have been identified in a range of behavioral treatments and factors that are relatively unique to the 12-step model. The study tested the hypotheses that two common process factors (internal locus of control and sociability) and two unique factors (spirituality and installation of hope) mediate the effects of 12-step group affiliation on drug/alcohol abstinence and health promoting behavior. The study respondents were members of a dual focus 12-step-based fellowship, Double Trouble in Recovery (DTR), designed to address issues of both substance use and mental health. Members of 24 DTR groups in New York City were recruited and followed-up for 1 year. The degree of 12-step group affiliation during the study period was associated with more positive outcomes at follow-up. Internal locus of control and sociability mediated the effects of 12-step group affiliation on both outcomes, whereas spirituality and hope acted as mediators only for health promoting behavior. Understanding that the therapeutic factors inherent in 12-step are not mysterious, but appear to capitalize on well-documented social learning principles, may increase the acceptance of 12-step programs among addiction and mental health professionals.
Twelve-step groups (12SG), a useful recovery resource, are underutilized by dually-diagnosed persons. There has been little empirical research in this area. This study followed members of a dual-focus 12-step-based fellowship (N = 277) over one year to gain a greater understanding of participation in both specialized dual focus and traditional 12SG among dually-diagnosed persons, including reasons for attending, perceived benefits of and obstacles to affiliation, and predictors of affiliation. Findings indicate that dually-diagnosed persons do engage in both types of fellowships; patterns of engagement differed across fellowships, suggesting different comfort levels. Both types of fellowships were used to deal with addiction. Greater difficulty with substance use at baseline was associated with greater likelihood of attending 12SG at follow-up; the reverse was true for self-reported substance use at baseline. Findings are discussed in light of existing literature and clinical implications are suggested.
This study examined participation in 12-step programs and attitudes toward 12-step meetings in an outpatient sample of 81 severely mentally ill patients with comorbid substance use disorders. The study found that dual diagnosis patients attended 12-step programs at rates comparable to those reported for patients in primary addiction treatment settings. Diagnosis and attitudes toward 12-step meetings each had independent effects on 12-step participation. The difficulties that some dual diagnosis patients report experiencing at 12-step meetings may need to be addressed to maximize 12-step attendance and potential to benefit from 12-step programs.
Male substance abuse patients with posttraumatic stress disorder (PTSD) (SA-PTSD; N = 140) were compared to patients with only substance use disorders (SA-only; N = 1,262), and those with other Axis I diagnoses (SA-PSY; N = 228) on changes during substance abuse treatment. Diagnoses were determined by chart review, and patients completed questionnaires assessing coping, cognitions, and psychological distress. Although SA-PTSD patients improved on outcomes during treatment, they showed less benefit relative to SA-only patients. At discharge, SA-PTSD patients reported less use of effective coping styles, and endorsed more positive beliefs about substance use than SA-only patients. They had more psychological distress than SA-only and SA-PSY patients. More counseling sessions devoted to substance abuse and family problems, and increased involvement in 12-step activities partially counteracted the negative effects of having a PTSD diagnosis on several outcomes. SA-PTSD patients reported fewer psychological symptoms at discharge in programs that were high in support and order/organization.
A bstract A im s. To study prospectively the type and extent of aftercare sought by patients following their admission for alcohol and other substance abuse treatment as a function of psychiatric co-morbidity . D esign. Prospective cohort study with follow-up after 16 months . Setting and participants. A nationwide sample of alcoholics discharged from inpatient treatment ( N = 351) in Iceland . M easurem ents. The Diagnostic Interview Schedule was used to assign psychiatric diagnoses at the time of index admission. A questionnaire on the type and number of aftercare attendances was mailed to all participants to obtain information about aftercare . Findings. A combination of attendance at Alcoholics Anonymous (AA) and professional care was the most common aftercare (49%); while only 8% received no aftercare whatsoever. The mean number of AA attendances was over 24 while it was less than 3 for the various professional appointments. Patients with a diagnosis of schizophrenia had a lower rate of attendance at AA. Other types of co-morbidity did not affect AA attendance but did increase rates of professional help-seeking . C onclusions. Better professional treatment attendance might be gained by integrating AA concepts while AA might benefit from professional input to address the prevalent co-morbid psychiatric disorders.
Reviews of research on Alcoholics Anonymous (AA) have speculated how findings may differ when grouped by client and study characteristics. A meta-analytic review by Emrick et al. in 1993 provided empirical support for this concern but did not explore its implications. This review divided results of AA affiliation and outcome research by sample origin and global rating of study quality. The review also examined the statistical power of studies on AA.
Meta-analytic procedures were used to summarize the findings of 74 studies that examined AA affiliation and outcome. Results were divided by whether samples were drawn from outpatient or inpatient settings and a global rating of study quality that jointly considered use of subject selection and assignment, reliability of measurement and corroboration of self-report. Efficacy of dividing study results was examined by changes in magnitude of correlations and unexplained variance.
AA participation and drinking outcomes were more strongly related in outpatient samples, and better designed studies were more likely to report positive psychosocial outcomes related to AA attendance. In general, AA studies lacked sufficient statistical power to detect relationships of interest.
AA experiences and outcomes are heterogeneous, and it makes little sense to seek omnibus profiles of AA affiliates or outcomes. Well-designed studies with large outpatient samples may afford the best opportunity to detect predictors and effects of AA involvement.
The comparative effectiveness of 12-step and cognitive-behavioral (C-B) models of substance abuse treatment was examined among 3,018 patients from 15 programs at U.S. Department of Veterans Affairs Medical Centers. Across program types, participants showed significant improvements in functioning from treatment admission to a 1-year follow-up. Although 12-step patients were somewhat more likely to be abstinent at the 1-year follow-up, 12-step, C-B, and combined 12-Step-C-B treatment programs were equally effective in reducing substance use and improving most other areas of functioning. The finding of equal effectiveness was consistent over several treatment subgroups: Patients attending the "purest" 12-step and C-B treatment programs, and patients who had received the "full dose" of treatment. Also, patients with only substance abuse diagnoses, those with concomitant psychiatric diagnoses, and patients who were mandated to treatment showed similar improvement at the 1-year follow-up, regardless of type of treatment received. These data provide important new evidence supporting the effectiveness of 12-step treatment.
The authors explored the relationship between social phobia and cocaine dependence in 158 individuals entering a pharmacologic treatment trial for cocaine dependence. Twenty-two patients met DSM-III-R criteria for social phobia. The social phobia group was compared with 22 age- and sex-matched cocaine-dependent control subjects. Those with social phobia and cocaine dependence were more likely to have additional psychiatric diagnoses and greater symptom severity, more likely to be polysubstance users, and more likely to have developed alcohol dependence at an early age. The authors discuss treatment implications of these data.
Relatively little is known about how substance abuse treatment facilitates positive outcomes. This study examined the therapeutic effects and mechanisms of action of affiliation with Alcoholics Anonymous (AA) after treatment. Patients (N = 100) in intensive 12-step substance abuse treatment were assessed during treatment and at 1- and 6-month follow-ups. Results indicated that increased affiliation with AA predicted better outcomes. The effects of AA affiliation were mediated by a set of common change factors. Affiliation with AA after treatment was related to maintenance of self-efficacy and motivation, as well as to increased active coping efforts. These processes, in turn, were significant predictors of outcome. Findings help to illustrate the value of embedding a test of explanatory models in an evaluation study.
This study examined whether substance abuse patients self-selecting into one of three aftercare groups (outpatient treatment only, 12-step groups only, and outpatient treatment and 12-step groups) and patients who did not participate in aftercare differed on 1-year substance use and psychosocial outcomes.
A total of 3,018 male patients filled out a questionnaire at intake and 1 year following discharge from treatment. Patients were classified into aftercare groups at follow-up using information from VA databases and self-reports.
Patients who participated in both outpatient treatment and 12-step groups fared the best on 1-year outcomes. Patients who did not obtain aftercare had the poorest outcomes. In terms of the amount of intervention received, patients who had more outpatient mental health treatment, who more frequently attended 12-step groups or were more involved in 12-step activities had better 1-year outcomes. In addition, patients who kept regular outpatient appointments over a longer time period fared better than those who did not.
Encouraging substance abuse patients to regularly attend both outpatient aftercare and self-help groups may improve long-term outcomes.
Male substance abuse patients with posttraumatic stress disorder (PTSD) (SA-PTSD; N = 140) were compared to patients with only substance use disorders (SA-only; N = 1,262), and those with other Axis I diagnoses (SA-PSY; N = 228) on changes during substance abuse treatment. Diagnoses were determined by chart review, and patients completed questionnaires assessing coping, cognitions, and psychological distress. Although SA-PTSD patients improved on outcomes during treatment, they showed less benefit relative to SA-only patients. At discharge, SA-PTSD patients reported less use of effective coping styles, and endorsed more positive beliefs about substance use than SA-only patients. They had more psychological distress than SA-only and SA-PSY patients. More counseling sessions devoted to substance abuse and family problems, and increased involvement in 12-step activities partially counteracted the negative effects of having a PTSD diagnosis on several outcomes. SA-PTSD patients reported fewer psychological symptoms at discharge in programs that were high in support and order/organization.
The authors compared the course of Substance Use Disorders (SUD) in patients with SUD plus schizophrenia (SCZ) with those having SUD only. Data were obtained through diagnostic interviews and questionnaires on consecutive out-patients and in-patients referred for SUD to two university medical centers with alcohol-drug programs. This study revealed the SCZ-SUD patients (n = 29) had demographic characteristics, onset of their substance use, course of use/abuse, and lifetime SUD diagnoses that closely resembled those with SUD-only (n = 296). The marked similarities argue for a course of SUD in schizophrenic patients that is fully as morbid as that in SUD-only patients. The few differences in course appear linked to the following: (1) patients with SCZ using caffeine early, perhaps to relieve prodromal manifestations of schizophrenia, (2) patients with SCZ-SUD later using less or avoiding use of substances that exacerbate symptoms of schizophrenia (e.g., caffeine, cocaine, opiates), and (3) using tobacco more often to ameliorate the symptoms of schizophrenia or the side effects of medications used to treat schizophrenia. Contrary to expectation, those with comorbid SCZ-SUD employed self-help to deal with SUD as often as did the SUD-only patients.
Recent surveys of the substance abuse patient population have shown a striking increase in the proportion of patients with a comorbid psychiatric disorder. In this study, patients with substance abuse and psychotic, anxiety/depressive, or personality disorders were compared with patients with only substance use disorders on treatment experiences and outcomes. Regardless of dual diagnosis status, patients generally improved on both substance use and social functioning outcomes after substance abuse treatment. At the 1-year follow-up, dually diagnosed patients, and patients with only substance use disorders, had comparable substance use outcomes. However, patients with major psychiatric disorders, specifically psychotic and anxiety/depressive disorders, fared worse on psychological symptoms and employment outcomes than did patients with personality disorders and only substance use disorders. Although there were some group differences on the amount of index treatment received and continuing care, the overall pattern of relationships between treatment variables and outcomes was comparable for the patient groups. In addition, there was no diagnostic group by treatment orientation matching effects, which indicated that the dual diagnosis patient groups improved as much in 12-Step as in cognitive-behavioral substance abuse programs.
This study examined several hypotheses for matching patients to 12-Step and cognitive-behavioral (CB) treatments in a multisite evaluation of VA inpatient substance abuse programs. A total of 804 male patients in five 12-Step programs, and 1069 male patients in five CB programs completed an intake, discharge, and 1-year follow-up questionnaire. The findings did not support the notion that certain patient characteristics would differentially predict better outcomes after 12-Step and CB treatment This conclusion held when the purest 12-Step and CB programs were used, and when patients who received the full dose of treatment (i.e., treatment completers) were examined separately. Process analyses of the hypothesized mechanisms underlying the patient-treatment matching effects did not yield the expected links among patient characteristics, proximal outcomes, and 1-year outcomes. Our conclusion is that there is no advantage to matching men with substance abuse problems to 12-Step or CB treatments based on the patient attributes measured here.
To study prospectively the type and extent of aftercare sought by patients following their admission for alcohol and other substance abuse treatment as a function of psychiatric co-morbidity.
Prospective cohort study with follow-up after 16 months.
A nationwide sample of alcoholics discharged from inpatient treatment (N = 351) in Iceland.
The Diagnostic Interview Schedule was used to assign psychiatric diagnoses at the time of index admission. A questionnaire on the type and number of aftercare attendances was mailed to all participants to obtain information about aftercare.
A combination of attendance at Alcoholics Anonymous (AA) and professional care was the most common aftercare (49%); while only 8% received no aftercare whatsoever. The mean number of AA attendances was over 24 while it was less than 3 for the various professional appointments. Patients with a diagnosis of schizophrenia had a lower rate of attendance at AA. Other types of co-morbidity did not affect AA attendance but did increase rates of professional help-seeking.
Better professional treatment attendance might be gained by integrating AA concepts while AA might benefit from professional input to address the prevalent co-morbid psychiatric disorders.
Self-help programs such as Alcoholics Anonymous (AA) have been viewed as beneficial adjuncts to comprehensive treatment programs for the treatment of alcohol use disorders. The usefulness of such programs for individuals with dual psychiatric disorders has not been established. This study examined the alcohol and psychiatric treatment histories of 60 psychiatric inpatients with concomitant alcohol use or abuse with attention to the frequency and correlates with past AA attendance. Most subjects reported feeling comfortable with the basic tenets of AA; neither diagnosis nor gender was related to AA participation, belief in its basic tenets, or willingness to attend AA in the future. Regular, past attendance at AA was surprisingly high (37%) and was not different for individuals with schizophrenic spectrum disorders compared to those with other psychiatric disorders. The majority reported plans to attend AA as part of their outpatient treatment program. The potential benefits of AA for dual diagnosis individuals deserve further attention.
This study examined general and substance-specific coping skills and their relationship to treatment climate, continuing care and 1-year post-treatment functioning among dual diagnosis patients (i.e. co-occurrence of substance use and psychiatric disorders).
In a prospective multi-site study, dual diagnosis patients participating in substance abuse treatment were assessed at intake, discharge and at a 1-year follow-up.
Patients were recruited from 15 substance abuse treatment programs, which were selected from a larger pool of 174 inpatient treatment programs in the Department of Veterans Affairs Health Care System.
A total of 981 male dual diagnosis patients participated in the study.
Assessments included general and substance-specific coping skills, treatment climate, continuing outpatient care, abstinence and clinically significant psychiatric symptoms.
Dual diagnosis patients modestly improved on general and substance-specific coping skills over the 1-year follow-up period. Patients who were in programs with a 'dual diagnosis treatment climate' and who participated in more 12-Step self-help groups showed slightly more gains in adaptive coping. Both general and substance-specific coping were associated with abstinence, but only general coping was associated with freedom from significant psychiatric symptoms.
Enhancing general and substance-specific coping skills in substance abuse treatment may reduce dual diagnosis patients' post-treatment substance use and improve their psychological functioning.
Debate has ensued about whether substance use disorder (SUD) patients with comorbid posttraumatic stress disorder (PTSD) participate in and benefit from 12-step groups. One hundred fifty-nine SUD-PTSD and 1,429 SUD-only male patients were compared on participation in 12-step activities following an index episode of treatment. Twelve-step participation was similar for SUD patients with and without PTSD. PTSD patients with worldviews (e.g., holding disease model beliefs) that more closely matched 12-step philosophy participated more in 12-step activities. Although greater participation was associated with better concurrent functioning, participation did not prospectively predict outcomes after case mix adjustment. An exception was that greater participation predicted decreased distress among PTSD patients whose identity was more consistent with 12-step philosophy. In summary, PTSD patients participate in and benefit from 12-step participation; continuing involvement may be necessary to maintain positive benefits.
Over 3,000 patients from 15 VA inpatient, substance abuse treatment programs showed considerable improvement from intake to
a one-year follow-up. Patients in 12-step programs, as opposed to cognitive-behavioral (CB) or eclectic programs, and those
with more extended continuing outpatient mental health care and 12-step self-help group involvement, were more likely to be
abstinent and free of substance use problems at follow-up. Consistent with their better one-year outcomes, patients in 12-step
programs improved more between intake and discharge than CB patients on proximal outcomes assumed to be specific to 12-step
treatment (e.g., disease model beliefs) and as much or more on CB proximal outcomes. Proximal outcomes assessed at treatment
discharge and follow-up were, at best, modestly related to one-year substance use and other outcomes. No evidence was found
that CB or 12-step treatment is more beneficial for certain types of patients.
This study explores factors associated with self-help group meeting attendance in the aftercare of 81 clients with dual diagnoses of severe mental illness and chemical dependency following their discharge from an inpatient chemical dependency treatment program. It also explores the association between self-help group meeting attendance and treatment outcomes. Data were collected from patient records and results of the Addiction Severity Index (ASI) administered as part of an earlier experiment that evaluated the effectiveness of the treatment program. Collaterals also provided follow-up information. Of thirteen variables examined, only two were associated with increased self-help group meeting attendance: having more years of education and having a major substance problem that did not include alcohol. No association was found between self-help group meeting attendance and treatment outcome regarding psychiatric problem severity or five other domains of the ASI. A moderate association was found indicating that more self-help group meeting attendance was related to improvements in the legal problems domain of the ASI. Implications are discussed for future research and for improving self-help group meeting attendance and its influence on treatment outcomes for individuals with dual diagnoses.
The present study used data gathered in Project MATCH to longitudinally assess intake symptomatology, Alcoholics Anonymous (AA) participation, and outcome. Three primary constructs were considered: intake symptomatology, engagement in prescribed AA-related activities and functioning after engagement in AA-related behaviors.
The participants were 480 outpatient and 434 aftercare clients who participated in Project MATCH.
Similar findings were found for each sample. Intake symptomatology positively predicted AA participation during the first 6 months following treatment. Although network support for drinking was negatively related to AA participation, such support did not mediate the relationship between intake symptomatology and subsequent AA participation. AA participation, in turn. positively predicted frequency of abstinent days in Months 7-12 posttreatment. This latter relationship was mediated by perceived self-efficacy to avoid drinking (Month 6). AA participation was positively related to self-efficacy to avoid drinking, which, in turn, predicted more days abstinent. One difference between the outpatient and aftercare samples emerged, involving the latent construct intake symptomatology. Intake symptomatology among outpatients was not predictive of percentage of abstinent days (Months 7-12), whereas intake symptomatology was negatively predictive of percentage of abstinent days in the aftercare sample.
Intake symptomatology positively predicted participation in AA, which predicted subsequent abstinent days. The positive relationship between AA participation and self-efficacy to avoid drinking may explain in part why AA engagement predicts subsequent increases in abstinence.
Although many people with substance use problems are referred to Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), few studies have examined characteristics of persons who comply with such referrals. In particular, little is known about self-help meeting attendance by persons with dual diagnoses. This study examined rates of AA and NA attendance among 351 persons with dual diagnoses who were treated in a hospital setting. It also explored the relationship between diagnosis and meeting attendance. Ten months after hospitalization, the study participants demonstrated rates of AA or NA attendance that were similar to those of persons who were diagnosed as having substance use disorders without severe mental illness. However, patients with schizophrenia or schizoaffective disorders reported significantly fewer days of AA or NA meeting attendance.
In spite of the strong emphasis in AA on spiritual beliefs and practices, findings are mixed about the importance of such beliefs in predicting AA affiliation. This study of the Project MATCH outpatient (N = 952) and aftercare (N = 774) samples tested three hypotheses about the role of client God belief and subsequent AA attendance and benefit, taking into account that some individuals may, in fact, deny the existence of a God.
Longitudinal analyses were conducted (N = 1,526) investigating client God beliefs, AA attendance, patterns of AA attendance and alcohol use. Assessments were conducted at intake and in 3-month intervals using the Form 90, Religious Behaviors and Background, and the Alcoholics Anonymous Inventory.
12-Step treatment was significantly more likely to promote pre-post shifts in client God beliefs, and atheist and agnostic clients attended AA significantly less often throughout follow-up relative to clients self-labeled as spiritual and religious. AA attendance, however, was significantly associated with increased abstinence and reductions in drinking intensity regardless of God belief. Finally, no differences in percent days abstinence and drinking intensity were found between atheist and agnostic versus spiritual and religious clients, but clients unsure about their God belief reported significantly higher drinking frequency relative to the other groups.
God belief appears to be relatively unimportant in deriving AA-related benefit, but atheist and agnostic clients are less likely to initiate and sustain AA attendance relative to spiritual and religious clients. This apparent reticence to affiliate with AA ought to be clinically recognized when encouraging AA participation.
In a cohort of 2,595 male patients in VA intensive treatment programs for substance use disorders (SUD), we tested whether psychiatric comorbidity, outpatient care and mutual help group attendance during the first two follow-up years predicted remission status at Year 5, controlling for covariates.
Logistic regression modeling of longitudinal data was used to test the hypotheses.
Dual diagnosis patients were less likely to be in remission at Year 5 than SUD-only patients. Outpatient care was at best only weakly related to Year 5 remission status. By contrast, mutual help involvement substantially improved the chances of substance use remission at Year 5 for both SUD-only and dual diagnosis patients. Mutual help involvement did not, however, offset the poorer prognosis for dual diagnosis patients.
Because mutual help groups specifically targeted to individuals with comorbid substance use and psychiatric disorders are currently rare, further research is recommended to investigate whether they are more effective than standard SUD mutual help groups in facilitating the recovery of persons with dual diagnoses.
The effectiveness of participation in dual-focus groups (i.e., focusing on both mental health and substance use) has not been studied empirically. The study examined whether three hypothesized active ingredients of self-help (helper-therapy, reciprocal-learning, and emotional-support processes) are associated with drug/alcohol abstinence outcomes for members of a 12-step dual-focus fellowship, Double Trouble in Recovery (DTR). The study was able to control for member attitudes and behaviors at baseline, which might be related to both self-help processes and outcomes, i.e., extent of participation in DTR and traditional 12-step groups, prior drug/alcohol use, severity of psychiatric symptoms, motivation for change, stressful life events, perceived coping, self-efficacy for recovery, and social support. Members of 24 DTR groups in New York City were recruited, interviewed, and reinterviewed after 1 year. Drug/alcohol abstinence in the past year increased from 54% at baseline to 72% at follow-up. Helper-therapy and reciprocal-learning activities were associated with better abstinence outcomes, independent of other attitudes and behaviors of the members. However, emotional support was not related to outcome. We conclude that specific elements of self-help participation contribute substantially to progress in recovery for members of dual-focus groups; facilitating such self-help processes should be encouraged by clinicians and senior fellowship members.
Many patients treated for substance use disorders (SUDs) who become involved in 12-Step self-help groups have improved treatment outcomes. However, due to high rates of psychiatric comorbidity and major depressive disorder (MDD), among SUD patients in particular, concerns have been raised over whether these benefits extend to dual diagnosis patients. This study examined the influence of comorbid MDD among patients with SUDs on 12-Step self-help group involvement and its relation to treatment outcome.
A quasi-experimental, prospective, intact group design was used with assessments completed during treatment, and 1 and 2 years postdischarge.
A total of 2161 male patients recruited during in-patient SUD treatment, of whom 110 had a comorbid MDD diagnosis (SUD-MDD) and 2051 were without psychiatric comorbidity (SUD-only).
SUD-MDD patients were initially less socially involved in and derived progressively less benefit from 12-Step groups over time compared to the SUD-only group. However, substance use outcomes did not differ by diagnostic cohort. In contrast, despite using substantially more professional out-patient services, the SUD-MDD cohort continued to suffer significant levels of depression.
Treatment providers should allocate more resources to targeting depressive symptoms in SUD-MDD patients. Furthermore, SUD-MDD patients may not assimilate as readily into, nor benefit as much from, traditional 12-Step self-help groups such as Alcoholics Anonymous, as psychiatrically non-comorbid patients. Newer, dual-diagnosis-specific, self-help groups may be a better fit for these patients, but await further study.
The authors reviewed the empirical literature concerning the use of twelve-step programs and treatments by patients with co-occurring substance use disorders and other psychiatric disorders. Strong evidence was found that dually diagnosed individuals (DDI), with the possible exception of those with psychotic disorders, attend twelve-step programs at rates comparable to non-DDI. Twelve-step involvement is consistently associated with improved substance use outcomes. Although there have been numerous clinical trials involving twelve step-oriented interventions for DDI, most of the studies suffered from substantial methodological limitations. More work is needed to determine what kinds of twelve-step treatments and programs are effective for various types of patients and elucidate the mechanisms by which these approaches facilitate recovery.
) in various populations with co-occurring disorders
- Ritsher
Ritsher et al., 2002), ''adaptive coping'' (Moggi et al., 1999), and level of distress (Ouimette et al., 1998b, 2001) in various populations with co-occurring disorders. Dually From the University of New Mexico Health Sciences Center, Department of Psychiatry and Center on Alcoholism, Substance Abuse, and Addictions, Albuquerque, New Mexico (MPB).
Double Trouble In Recovery Course of substance abuse in patients with and without schizophrenia
- Vogel
- Hs
Vogel HS (1993) Double Trouble In Recovery. Mental Health Empowerment Project, Albany, NY. Westermeyer JJ, Schneekloth TD (1999) Course of substance abuse in patients with and without schizophrenia. Am J Addict 8:55–64.