Evidence for 12-step addiction programe
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Transcript of Evidence for 12-step addiction programe
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Evidence for 12-Step FacilitationDennis M. Donovan, Ph.D.
Alcohol & Drug Abuse Institute
and
Department of Psychiatry & Behavioral Sciences
University of Washington
NIDA Blending Conference, Blending Addiction Science &Treatment: The Impact of Evidence-Based Practices on
Individuals, Families, and Communities.
Cincinnati, OH, June, 2008
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Pacific Northwest
12-Step Salmon Recovery Program
http://www.grist.org/comments/ha/2002/02/04/becker-salmon/
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Why Consider 12-Step Approaches?
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Why climb amountain? Becauseits there.
Why study 12-Step?Because its amountain in the
substance abuse
field because itsthere.
Why Consider 12-Step Approaches?
Mt. Rainier
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Why Consider 12-Step Approaches? 12-step orientation/philosophy is thepredominant approach found in U.S.
substance abuse treatment 12-step groups represent a readilyavailable, no-cost recovery resource Millions of substance abusers benefitfrom 12-step involvement, with increased
evidence of its effectiveness
Consistent with community-basedtreatment program and counselortreatment philosophy
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Why Consider 12-Step Approaches? Applicable to a broad range of clients indifferent settings and can augment a wide
range of standard treatments
A high priority of the CTNs CTP Caucus
Recent development of efficaciousinterventions to facilitate 12-Stepinvolvement
Availability of 12-Step Facilitation therapymanuals and training materials
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What Is the Relationship Between 12-StepAttendance/Involvement and Outcomes?
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CAUTION!!The Following Slides Contain
Graphic Information
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Abstinence Rates at 1-Year Follow-Up as aFunction Posttreatment 12-Step Group Attendance
67.2
51.6
30.728.9
0
10
20
30
40
50
60
70
80
PercentA
bstinent
Moos, et al., 1999
None 1-9 10-29 30+
Number of Meetings Attended
(n = 1326) (n = 614) (n = 570) (n = 506)
x
2
= 248.3, p < .001
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Abstinence Rates at 8-Year Follow-Up by Durationof 12-Step Meeting Attendance in the First Year
71.3
56.2
42.7
35.3
0
10
20
30
40
50
60
70
80
PercentAb
stinent
Moos, et al., 2004
None 1-16 17-32 33+
Weeks of Participation in 12-Step Groups
(n = 201) (n = 89) (n = 89) (n = 94)
x
2
= 25.5, p < .01
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Abstinence Rates at 8 Years by Duration
of Meeting Attendance in Years 2 to 8
88.7
64.1
32.6
47.7
0
1020
30
40
50
60
70
8090
100
PercentAb
stinent
Moos, et al., 2004
None 1-12 13-48 49+
Months of Additional Participation in AA
(n = 128) (n = 43) (n = 39) (n = 62)
x
2
= 28.3, p < .01
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Drug and Alcohol Use During 6 Months Prior to 24-
Month Posttreatment Follow-Up as a Function
Frequency of 12-Step Group Attendance
0
10
20
30
40
50
60
70
Yes No Yes No
Drug UseAlcohol Use
Any 12-Step Participation Weekly or More Frequent
Participation
%SubjectsRep
ortingAnyUse
(n = 128) (n = 134) (n = 103) (n = 25)
Fiorentine, 1999
** *** * ***
* p < .05** p < .01
*** p < .001
27.3
44.0
22.3
44.0
32.0
61.2
25.2
60.0
Drug and Alcohol Abstinence During 6 Months Prior to
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Drug and Alcohol Abstinence During 6 Months Prior to
24-Month Posttreatment Follow-Up as a Function
Frequency of 12-Step Group Attendance
20
30
40
50
60
70
80
Never Less than
Weekly
Weekly
Drug UseAlcohol Use
Fiorentine , 1999
12-Step Meeting Attendance
%AbstinentfromD
rugandAlcoholUse
inPrior6Months
(n = 134)
(n = 25)
(n = 103)
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Percent of Clients Abstinent at Both 6-
and 12-Month
Follow-Ups Based on SHG Meeting Attendance
0
10
20
30
40
50
60
No Yes No Yes
At least 1 Meeting At least 1 Meetingper Week
PercentA
bstinent
Timko & DeBenedetti, 2007
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Percent Abstinent from Alcohol & Drugs at
Both
6-
and 12-month Follow-ups According
to 12-Step Involvement
Timko & DeBenedetti, 2007
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The Crushing Weight of the Data Support the
Potential Positive Benefits of 12-Step Involvement
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Results from Previous Research on 12-Step Involvement AA and NA participation is associated withgreater likelihood of abstinence, improved
social functioning, and greater self-efficacy
12-Step self-help groups significantly reducehealth care utilization and costs Combined 12-Step and formal treatment leadsto better outcomes than found for either alone Engaging in other 12-Step group activitiesseems more helpful than attending meetings
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Results from Previous Research on
12-Step Involvement Consistent and early attendance/involvementleads to better substance use outcomes Even small amounts of participation may behelpful in increasing abstinence, whereas
higher doses may be needed to reducerelapse intensity
Reductions in substance use associated with
12-Step involvement are not attributable topotential third variable influences such asmotivation, psychopathology, or severity
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Do People Use 12-Step SupportDuring or After Treatment?
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Do People Use 12-Step Support
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Do People Use 12-Step Support
During or After Treatment?
75% of alcoholics entering residentialtreatment reported they had attended AAmeetings previously. However, only 16%indicated that they had ever worked any ofthe 12 Steps.
Despite strong encouragement to attend, 30% of cocaine abusers receivingoutpatient treatment and
40%
of those
discharged from inpatient treatmentreported that they had attended 12-Stepgroups.
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Do People Use 12-Step Support
During or After Treatment?
During the follow-up period in the NIDA
Collaborative Cocaine TreatmentStudy 33.6% were classified asconsistently high attenders,
47.9%
as
consistently low attenders, and 18.5% as decreasing attendance.
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Jones would walk through a blizzard to score his
dope. The question remains: what will he do to get
to a meeting?http://recoveryjonescartoons.com/book_1.htm
Factors Contributing to Greater
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Factors Contributing to Greater
12-Step Involvement
Patients are less likely to become involved in 12-stepactivities if left to do so on their own than if more activeencouragement and referral are provided in treatment.
Treatment programs that are 12-Step based producehigher rates of Self-Help participation than programsthat are not 12-Step based.
Patients from 12-Step based treatment seem to gainmore (have better outcomes) from self-help participationthen patients from non-
12-Step based treatment .
Programs that are 12-Step oriented and have a higher
percentage of staff in recovery are more likely to refer to12-Step Self-Help groups.
Professional facilitation strategies increase engagementin mutual help groups
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Influence of General ProgramTreatment Orientation
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Posttreatment 12-Step Self-Help Group Involvementof Substance-Dependent Veterans Treated by 12-tep or Cognitive-Behavioral Programs
48
59
18
36
45
66
48
58
0
10
20
30
40
50
60
70
Mtng Attend Sponsor Read Liter AA Friend
CBT
12-Step
12-Step InvolvementNote: Involvement was measured 1 year after discharge by patient reports of activities in the past 3 months.
Source: Humphreys et al. 1999.
Initial Treatment
Orientation
Pa
tientInv
olvement (%
)
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Why Focus on Facilitating12-Step Involvement?
Dont We Already Do 12 Step Facilitation?
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Making the case that treatment programsshould prioritize self-help group involvementcan be difficult because many treatment
providers believe they do this already;indeed, that every program does.
In practice, however, what this often meansis that at some point during treatment acounselor gives the patient a list of local
self-help groups and suggests that thepatient attend a meeting, which is a
minimally effective clinical practice.
Humphreys & Moos, 2007
Don t We Already Do 12-Step Facilitation?
Humphreys & Moos, 2007
Dont We Already Do 12 Step Facilitation?
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Dont We Already Do 12-Step Facilitation?
We therefore encourage treatment
providers to use the more intensivemethods of promoting self-help group
involvement empirically demonstrated
to be effectivesuch efforts will
maximize the maintenance of
treatment gains.
Humphreys & Moos, 2007
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"Stop fighting and surrender, Jones. As your
sponsor, all I ask is that you attend 90 meetings
in 90 days."http://recoveryjonescartoons.com/more_cartoons!.htm
What methods to increase 12 step
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What methods to increase 12-step
involvement are empirically supported ?
TSF
Twelve Step Facilitation
(Project Match)GDC + IDC Group Drug Counseling plusIndividual Drug Counseling
(NIDA Collaborative Cocaine Study)
SECA
Systematic Encouragement and
Community Access / Intensive Referral(Sisson and Mallams, 1981; Timko, et al.,2006, 2007)
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http://pubs.niaaa.nih.gov/publications/match.htm
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Overview of TSF
Not12-Step support group
Written down in a manual(Project Match
reviewed and approved by Hazelden)
About twelve sessions (Individual in moststudies)
Facilitated by a drug counselor or therapist
3 Goals
(1) facilitate "acceptance"
(2) facilitate "surrender"
(3) facilitate active involvement in 12-Stepmeetings and related activities
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Mean Percent Days Abstinent as a Function ofTime Outpatient)
0
20
40
60
80
100
-2 -1 0 4 5 6 7 8 9 10 11 12 13 14 15
CBT MET TSF
Project MATCH Research Group, 1997
Time in Months
%
DaysAbs
tinent
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Mean Drinks per Drinking Day as a Function ofTime Outpatient)
0
2
4
6
8
10
1214
-2 -1 0 4 5 6 7 8 9 10 11 12 13 14 15
Time in Months
M
eanNumb
erofDrink
s
CBT MET TSF
Project MATCH Research Group, 1997
Percent of Project MATCH Outpatients
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Percent of Project MATCH Outpatients
Attending No Meetings during 1-Year Follow-Up
0
5
10
15
20
25
30
35
40
45
50
55
P
e
r
ce
n
t
Type of Treatment
CBT
MET
TSF
Connors et al. 2001
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Millions of people put their faith
in the Twelve Steps every day.As a treatment provider,
however, you need more than
faith: you need proof to show
accountability. The Twelve-StepFacilitation Handbook
documents the efficacy of TwelveStep Facilitation (TSF) as proven
in Project MATCH, a nationwide
study that found TSF as effective
as motivational enhancement
and cognitive-behavioraltreatment.
Suitable for group or individual
treatment programs.
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Days of 12-Step Attendance During 12-Week
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Treatment Phase of Cocaine Addicts as a Function of
Type of Treatment
13.8
1.1
5.4
0
2
4
6
8
10
12
14
TSF CBT CM
Type of Treatment
MeanNumberofDays
Carroll, Nich, et al., 1998
Days of 12-Step Attendance During 1-Year Follow-Up of
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Days of 12-Step Attendance During 1-Year Follow-Up ofCocaine Addicts as a Function of Type of Treatment
48.7
24.2
33.2
0
5
10
15
2025
30
35
40
45
50
TSF CBT CM
Type of Treatment
MeanNum
berofDays
Carroll, Nich, et al., 1998
Percent of Cocaine-Alcohol Dependent Clients
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Percent of Cocaine-Alcohol Dependent Clients
with 3 or More Consecutive Weeks of Abstinence
0
5
10
15
20
25
30
Cocaine Alcohol Coc+Alc
TSFCBT
PercentofSubjects
Carroll, Nich, et al., 1998
What is GDC + IDC?
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What is GDC IDC?
Group Drug Counseling
Education about addiction
Strong encouragement of 12-stepinvolvement
Individual Drug Counseling
12-Step oriented
Education about disease and about 12
steps
Strong encouragement of 12-stepinvolvement
NIDA Collaborative Cocaine Group
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p
Drug CounselingThe GDC model strongly encourages
participation in 12-Step self-helprecovery programs such as CocaineAnonymous (CA), Narcotics
Anonymous (NA), and AlcoholicsAnonymous (AA). The importance ofactively participating in these
programs is emphasized in groupsessions
NIDA Collaborative Cocaine Study:Combined Group plus Individual Drug
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Combined Group plus Individual Drug
Counseling Superior
0
20
40
60
80
100
%
consec.
abst.
IDC+GDC CT+GDC SE+GDC GDC
3 months abst.
2 months abst.
1 month abst.
Crits-Christoph et al.,1999
Systematic Encouragement and Community
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Access (SECA)
A Buddy System
Counselor suggests that patient attend AA or Al-
Anon Counselor provides a printed list of meeting timesand locations
In-session telephone call to current member of AA,NA or CA, who talks to the patient briefly andarranges to attend a meeting with him or her
Reminder telephone call from the 12-step groupmember the night before the meeting
12-step group member drives the patient to or
arranges to meet the patient at the meeting
Sisson & Mallams, 1981
Enhancing the Effectiveness of Referrals to
Self-Help: Systematic Encouragement and
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Self Help: Systematic Encouragement and
Community Access (SECA)Sample:
20 alcohol dependent outpatients and spouses
Design:
Participants randomly assigned to standard 12-
step self-help group referral or intensive referralIntervention:
Standard
-
description of self-help, a meeting schedule,
and encouragement to attend self-help meetings
Intensive
-
as above plus
in-session phone call to active
group member to arrange to go to a meeting
togetherResults:
Attendance rate at AA or Al-Anon meetings over
after intensive referral: 100%after standard referral: 0%
Sisson & Mallams, 1981
Abstinence Rates at 6-month Follow-Up as
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pa Function of 12-Step Referral Procedure
50
55
60
65
70
75
80
Drug Alcohol Both
StandardIntensive
P < .05 P < .12
P < .06
P
ercentAbs
tinent
Substance Use Outcome
Timko, et al., 2006
Standard, n=164
Intensive, n=181
Change in ASI Drug and Alcohol CompositeScores from Baseline to 6 month Follow Up as
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Scores from Baseline to 6-month Follow-Up as
a Function of 12-Step Referral Procedure
0
0.05
0.1
0.15
0.2
0.25
Drug Alcohol
StandardIntensive
P < .05
P < .01
ASI Composite Score
Timko, et al., 2006
Magnitude
ofChange
Standard, n=164
Intensive, n=181
Comparison of Standard and Intensive Referral
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Clients
12-Step Attendance and Engagement
Compared to individuals assigned to thestandard referral condition, those in the
intensive referral condition: did not differ on 12-step meeting
attendance
had greater engagement in 12-stepactivities
doing service workhaving experienced a spiritual awakening
and overall involvement
Timko, et al., 2006
TSF Research to Practice:
I t C id
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Issues to Consider
Available research-based manuals arebased on individual counseling
Most community-based programs provideprimarily group treatment
Need research on group applications of TSF(e.g., Wells, et al., 1994; Brown, et al., 2002)
12 sessions of manual-based treatment may
be too lengthy for some outpatient programs
Need research on briefer approaches, such
as SECA / Intensive Referral
STAGE-12 Therapy Manual
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Based on and adaptedfrom Twelve StepFacilitation Therapy forDrug Abuse andDependence
Adapted for use in
group delivery formatfrom
Brown, et al. 2002
Integrated with
Intensive Referralprocedures developedby Timko, et al., 2006
What Is STAGE-12?
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What Is STAGE-12?
Combined group- and individual-basedintervention Combines elements of Twelve-StepFacilitation Therapy and Intensive Referral Introduces participants to concepts andprinciples involved in 12-Step groups Actively attempts to get participantsinvolved in 12-Step meetings
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http://www.recoverygreetings.com/cards/threads003.html