A professional perspective on mutual help organisations for addictions Keith Humphreys Professor of Psychiatry Veterans Affairs and Stanford University Medical Centers Palo Alto, California USA Scotlands Futures Forum, Edinburgh, Scotland UK 23 March 2009

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

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

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

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

Lifetime and past 12 months participation in self-help groups, 1995

Help-seeking visits in U.S. for psychiatric and substance abuse problems by sector

Alcohol and drug-related self-help/mutual aid organizations (12 step in red) Estimated Number of Groups Worldwide Alcoholics Anonymous95,000 Al-Anon32,000 Narcotics Anonymous21,000 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 Moderation Management 50 Source: White and Madara (1998). Self-help sourcebook. Denville, NJ: American Self-help clearinghouse and Humphreys, K. (2004) Circles of Recovery.

Note: NA is for all drugs not just narcotics 12-step groups have established themselves in the once-impenetrable Middle East

Selected data on clinical and cost-effectiveness of 12-step mutual help organizations

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

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,

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,

Study of cost consequences

Comparable baseline demographic and alcohol use characteristics of 201 alcoholic individuals who initially chose AA or outpatient treatment Total sampleAAOutpatient Characteristic(n=201)(n=135)(n=66) %% Caucasian Race Female Married Employed MeanMeanMean Age (years) ETOH (oz) ADS Score Days intox

Total alcohol-related health care costs over three years by comparable alcoholic individuals who initially chose Alcoholics Anonymous or professional outpatient treatment AA groupOutpatient group (n=135)(n=66)F meanSDmeanSD (df=1,199) 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, * Note *p<.05

Alcohol-related outcomes of individuals initially selecting AA or outpatient treatment (OP)

Replication of cost offset findings in Department of Veterans Affairs Sample Source: This study appeared in Alcoholism: Clinical and Experimental Research, 25,

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

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

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

1-Year Treatment Costs, Inpatient Days and Outpatient visits Note: All differences significant at p <.001

1-Year Clinical Outcomes (%) Note: Abstinence higher in 12-step, p<.001

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)

What mediates these benefits?

B mediates the relationship between A and C A>>>>>>>>> B>>>>>>>> C

Note All paths significant at p<.05. Goodness of Fit Index =.950. Self-Help Group Involvement Reduced Substance Use Active Coping General Friendship Quality Friends Support For Abstinence Structural equation modeling results from over 2,000 patients assessed at intake, 1-year, 2-year Motivation to change

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

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.

So what?:Clinical implications

48% 18% 45% 48% 60% 36% 66% 58% attended meetingshad sponsor read 12-step literature had a friend who Attends A A/NA 12-step self-help group involvement Cog Beh 12-Step % 12-step group involvement of 2,045 substance-dependent veterans after 12-step or cognitive-behavioral treatment 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,

Abstinence from illicit drugs and alcohol as a function of self-help involvement and treatment type in 3,018 patients Self-help group InvolvementProportional -1SD+1SD Difference Treatment Orientation 12-step19%75%1:4.0 Non-12-step25%65%1:2.6

How can referrals to self-help groups be more effective? Sample:20 alcohol outpatients Design:Outpatients 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,

Self-help referral can be beneficial in non-specialty settings ControlBI BI+Peer 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

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

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.

Collaboration and competition between self-help groups and professionals Keith Humphreys Veterans Affairs and Stanford University School of Medicine

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

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

We love humanity in general, but we dont much like anyone in particular The code of the Minnesota Liberal, as described by Garrison Keillor

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

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

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

Example poster with tear off

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

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