Professional Interventions That Facilitate 12-Step Self-Help Group Involvement

Home , Alcoholics Anonymous, Narcotics Anonymous

Keith Humphreys, Ph.D.

Facilitating patients’ involvement with 12-step self-help organizations, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), is often a goal of substance abuse treatment. Twelve-step-facilitation (TSF) interventions have been found to be more effective than comparison treatments in increasing patients’ 12-step group involvement and in promoting abstinence. Future TSF evaluation research should address the effectiveness of incorporating TSF interventions with cognitive-behavioral treatment methods, the relative impact of brief versus extended TSF interventions, and the cost-effectiveness and health care cost-offset of TSF interventions within managed health care systems. KEY WORDS: twelve step program; intervention; treatment outcome; cognitive therapy; behavior therapy; cost effectiveness; managed care; AODD (alcohol and other drug dependence) recovery; treatment program; evaluation; motivational interviewing; AOD (alcohol and other drug) abstinence; comparative study; literature review

lthough the United States has Importance of 12-Step ues, sense of identity, and spiritual developed an extensive array of Group Affiliation in outlook (see Kurtz 1993 for a review). Aprofessional alcohol treatment Alcohol Treatment The few AA outcome studies that were services over the past 30 years, the conducted typically did not study AA peer-led, voluntary fellowship known The rationale for facilitating patients’ members over time or include non-AA as Alcoholics Anonymous (AA) con- involvement in 12-step self-help groups members for comparison purposes, tinues to be the most widely accessed stems primarily from recent AA out- making conclusions about AA’s effec- resource for people with alcohol prob- come research and from developments tiveness tenuous. Given this limited lems (McCrady and Miller 1993). in the management and organization empirical base, many clinicians and This article discusses the rationale for of health care in the United States. researchers doubted whether AA truly interventions that facilitate alcohol- From the 1940s through the 1980s, helped its members recover from alcohol dependent patients’ affiliations with most studies on AA did not directly dependence. AA and related mutual-help organiza- evaluate AA’s effectiveness. Rather, In the 1990s, the breadth and depth tions (e.g., Narcotics Anonymous researchers examined AA’s organiza- of AA research increased significantly, [NA]). The article also reviews recent tional structure and functioning; its as evidenced by a National Institute on research comparing those interventions history; and the ways in which AA Alcohol Abuse and Alcoholism (NIAAA)- with other treatment methods. participation changed members’ val- sponsored conference on AA (McCrady

Vol. 23, No. 2, 1999 93 and Miller 1993), the International Collaborative Study of AA (Mäkelä et al. 1996), and other projects. Recent Major Goals of 12-Step Facilitation Therapy AA outcome research, which has in Project MATCH demonstrated the benefits of treat- Acceptance ments intended to facilitate AA involvement, as well as of AA involve- • Acceptance by patients that they suffer from the chronic and progressive ment per se, has typically employed illness of alcoholism longitudinal designs (i.e., studied AA members over time), reliable measures, • Acceptance by patients that they have lost the ability to control their comparison groups and, in some cases, drinking random assignment to conditions. The improved methodological quality of • Acceptance by patients that because there is no effective cure for alco- AA research has reduced skepticism in holism, the only viable alternative is complete abstinence from the use the treatment community about AA’s of alcohol effectiveness and has increased clinicians’ interest in facilitating connections Surrender between substance abuse treatment and 12-step self-help groups. • Acknowledgment on the part of the patient that hope for recovery The other major factor that has (i.e., sustained sobriety) exists, but only by accepting the reality of loss enhanced interest in 12-step facilitation of control and by having faith that some higher power can help the (TSF) interventions is the growth of patient, whose own willpower has been defeated by alcoholism managed health care. In both the pub- lic and private sectors, managed care • Acknowledgment by the patient that the fellowship of Alcoholics Anon- has reduced the length and intensity of ymous (AA) has helped millions of alcoholics sustain their sobriety and professional addiction treatment services that the patient’s best chances for success are to follow the AA path (Humphreys et al. 1997) and increased the pressure for cost-effective care. Because managed care has reduced the SOURCE: Adapted from Nowinski et al. 1992. amount of time available for practition- ers to work with patients, clinicians are increasingly interested in facilitating Recent Evaluations to work synergistically with AA and other patient involvement in self-help groups of TSF Interventions 12-step groups (Nowinski et al. 1992). as an inexpensive way to achieve and Consistent with AA’s philosophy, TSF maintain treatment gains. Three One large study, known as Project therapists presented alcohol dependence recent studies (Tonigan et al. in press; MATCH, compared a TSF interven- as a disease with spiritual, emotional, Humphreys et al. 1999; McCrady et tion with cognitive-behavioral (CB) and physical components and emphasized al. in press) have evaluated the effec- therapy and motivational enhancement that the disease could be arrested but tiveness of such efforts. therapy (MET) among 1,726 patients not cured through permanent abstinence (76 percent male) diagnosed with either from alcohol. Also consistent with AA’s alcohol abuse or dependence, including approach, patients were strongly urged, KEITH HUMPHREYS, PH.D., is a research 774 inpatients who were beginning but neither ordered nor forced, to attend psychologist at the Center for Health Care outpatient aftercare and 952 patients AA meetings and to maintain a journal Evaluation, Veterans Affairs Palo Alto receiving outpatient care as their primary describing their reactions to the meet- Health Care System, and an assistant treatment (Project MATCH Research ings. The textbox above lists the major research professor of psychiatry and Group 1997, 1998). CB therapy focuses goals of the 12-session TSF intervention behavioral sciences at Stanford University on teaching coping skills to reduce alco- employed in Project MATCH. School of Medicine, Stanford, CA. hol use (i.e., patients who use alcohol to At both 1- and 3-year followups, cope with stress learn and practice alter- patients in all three conditions (i.e., CB Support for this work was provided by native coping methods). In contrast, therapy, MET, and TSF therapy) had National Institute on Alcohol Abuse and MET employs motivational strategies improved significantly on drinking- Alcoholism grants P50–AA–05595 and to mobilize patients’ internal resources related (e.g., number of drinks per day R21–AA–11700 and by the Department for change. and drinking consequences), psycho- of Veterans Affairs Mental Health Strategic The TSF intervention in the Project logical (e.g., depressive symptoms), and Health Group and Health Services Research MATCH study was a form of one-on-one life-functioning (e.g., days of employ- and Development Service. professional counseling explicitly designed ment) outcomes. As predicted, TSF

94 Alcohol Research & Health Facilitating 12-Step Self-Help Group Involvement

they were discharged, and 1 year later. (For an overview, see Moos and colleagues 100 1999; for results related to self-help groups, see Humphreys and colleagues 90 12-step program 1999). Results presented here focus on 80 the subset of inpatients treated in 21- to Cognitive-behavioral program 28-day programs that exemplified either 70 66 a 12-step approach or a CB approach. 59 60 58 The VA study included five 12-step- 48 48 oriented inpatient programs, which 50 45 emphasized treatment activities such as 40 36 attending 12-step group meetings in the community and onsite, following the 12 30 steps, reading the Big Book (the primary Patient Involvement (%) Involvement Patient 20 18 text of AA, which presents AA’s philoso- 10 phy mainly through narratives of members’ life stories) and other AA/NA liter- 0 ature, and accepting the identity of alco- Attended Had a Read 12-step Had a friend who meetings sponsor literature attends AA/NA* holic/addict. Staff members in these programs strongly endorsed the disease 12-Step Involvement model of addiction and reported spending most of their time on 12-step treatment activities. The study’s five CB treatment Posttreatment 12-step self-help group involvement of 2,045 substance-dependent programs required that patients participate veterans treated by 12-step or cognitive-behavioral programs. in relapse prevention groups, cognitive

*AA/NA = Alcoholics Anonymous/Narcotics Anonymous. skills training, and cognitive-behavioral NOTE: Involvement was measured 1 year after discharge by patient reports of activities in the past 3 months. group therapy. Analysis of program sched- SOURCE: Humphreys et al. 1999. ules showed that CB programs spent less than 5 percent of treatment time on activities based on 12-step principles. therapy was significantly more effective The Project MATCH team examined The study participants (2,045 men) than either CB therapy or MET in whether those patients benefited less were treated in either a 12-step-oriented increasing AA involvement, as indicated from AA affiliation than did those or a CB inpatient program and were by the frequency of such patient behav- patients who had received TSF therapy followed up 1 year after discharge. iors as attending meetings, having and (Tonigan et al. in press). Among the Thirty-six percent of the participants serving as a sponsor, following the 12 inpatient (aftercare) group, the positive had either an alcohol abuse or depen- steps, and considering oneself an AA relationship between AA attendance and dence diagnosis only, 13 percent had member (Tonigan et al. in press). In more abstinent days and fewer drinks only a drug abuse or dependence diag- addition, TSF therapy was more effec- on drinking days was similar for all nosis, and 51 percent had both drug tive than the other two treatments in three treatment conditions. However, and alcohol diagnoses. promoting abstinence. For example, at among the outpatients who received Before treatment, patients in 12- the 3-year followup, 36 percent of TSF CB therapy, AA attendance was posi- step-oriented and CB programs had patients in the outpatient group reported tively related to drinking in the first 6 similar levels of self-help group involve- being abstinent for the previous 3 months of the study (i.e., the patients ment. However, 1 year after treatment, months, compared with about 25 per- in this group who attended the most AA the patients who had received 12-step- cent of outpatients in the CB therapy meetings consumed the most alcohol). oriented treatment reported substantially and MET treatment conditions. This This result was not found at the 1-year greater involvement in AA/NA during result is consistent with the goals of TSF followup and is the only exception to the previous 3 months than did patients therapy and with AA, neither of which the general pattern of AA involvement who had received CB treatment. Patients views moderate drinking as an accept- associated with decreased drinking. in 12-step-oriented treatment were sig- able or attainable goal for alcohol- Concurrent with Project MATCH, nificantly more likely than those in CB dependent people. the Department of Veterans Affairs treatment to have attended 12-step meet- Some Project MATCH participants (VA) conducted a nationwide treatment ings, to have a sponsor, to have read who had received MET or CB therapy evaluation with more than 3,000 male 12-step literature, and to have a friend attended AA on their own, even though substance abuse inpatients, who provided who attends meetings (see figure, above), AA was not a focus of their treatment. data when they entered treatment, when indicating that 12-step-oriented treat-

Vol. 23, No. 2, 1999 95 ment programs were more effective seling designed to facilitate involvement related behaviors, patients were sub- than CB programs at increasing affilia- in 12-step self-help groups (MT+TSF) stantially more likely to be involved tion with 12-step self-help groups. (McCrady et al. in press). The TSF in self-help groups during and after The results of the VA study closely intervention introduced patients to the treatment. Hence, involvement in parallel those of Project MATCH. In philosophies and methods of AA and 12-step self-help groups is not (as is both 12-step-oriented and CB treat- Al-Anon,1 helped patients identify meet- sometimes claimed) simply an indi- ment, patients experienced substantial ings at convenient locations, set goals cator of patient motivation; rather, reductions in substance use, substance for meeting attendance, and encouraged it is a behavior that clinicians can abuse-related problems, psychological patients to choose a sponsor and to fol- influence. The optimistic implication problems, criminal behavior, and unem- low the 12 steps. The TSF therapists in is that by incorporating 12-step ployment (Moos et al. 1999). The reduc- this study assigned patients AA- or Al- facilitation into treatment, providers tions were comparable across treatments, Anon-related homework, as appropriate, can increase the likelihood that patients with the only notable exception again and emphasized parallels between the will continue to improve even after being that 12-step-oriented treatment initial CB therapy and AA techniques. professional treatment has ended. was more effective in promoting absti- Patients in both the MT-only condi- nence. For example, 1 year after treat- tion and the MT+TSF condition • Twelve-step-oriented treatments ment, 45 percent of patients treated in attended an average of approximately that increase involvement in 12-step 12-step-oriented programs reported 10 outpatient sessions. Patients in the self-help groups generally produce abstinence from alcohol and other drugs MT+TSF condition were more likely outcomes comparable with those of during the previous 3 months, compared than those in the MT-only group to CB treatments and are somewhat with 36 percent of patients treated in attend 12-step group meetings during more effective in promoting absti- CB programs. treatment. Eighty-two percent of MT+ nence. Project MATCH and the VA Like Project MATCH, the VA study TSF patients attended AA meetings, study provide strong evidence that also found some evidence suggesting and 58 percent attended Al-Anon meet- 12-step-oriented treatments are as that 12-step self-help group involvement ings, compared with attendance rates of effective as more heavily researched after treatment may be more beneficial 15 percent and 5 percent, respectively, CB interventions. This finding for patients who have received 12-step- among patients in the MT-only group. increases confidence in the U.S. oriented treatment, compared with At 6 months after treatment, however, substance abuse treatment system, patients who have received CB treatment. about half the patients in both groups because many of the prevalent Among patients who received 12-step- were either abstinent or engaged in treatment modalities in the United oriented treatment, abstinence rates nonproblem drinking, indicating that States draw heavily on 12-step 1 year after treatment varied from 19 supplementing CB marital therapy principles (Borkman et al. 1998). percent for patients with low involve- with TSF did not appear to enhance ment with self-help groups after treat- the effectiveness of the intervention. • Combining CB treatments with ment to 75 percent for patients with AA/NA affiliation may be less helpful high involvement. Among patients who to patients than combining 12-step received CB treatment, abstinence rates Conclusions From treatment with AA/NA affiliation. ranged from 25 percent for patients with Recent Research None of the studies discussed were low involvement in self-help groups specifically designed to address after treatment to 65 percent for patients When analyzed together, the results from whether positive results are maximized with high involvement. This difference Project MATCH, the VA study, and when treatment and self-help groups was statistically significant, indicating the couples study (reported by McCrady operate from a similar orientation; that 12-step self-help group involvement and colleagues [in press]) support the thus, this statement is more a working after treatment seems to benefit patients following three conclusions about TSF hypothesis than a firm conclusion. treated in 12-step-oriented programs interventions: Perhaps patients who hear contra- more than it does patients treated in dictory messages about substance CB programs (Humphreys et al. 1999). • Professional interventions can pow- abuse from treatment providers and A third study comparing a TSF erfully influence substance-abuse self-help groups have more difficulty intervention with other treatment focused patients’ level of affiliation with 12- understanding and practicing treat- on 60 heterosexual couples in which step self-help groups. All three studies ment regimens. To evaluate this the men were diagnosed with either found that when providers encour- possibility, CB treatment providers alcohol abuse or dependence and their aged patients to attend meetings, could develop interventions that female partners were not. As part of a follow the 12 steps, choose a sponsor, promote involvement in CB-oriented larger study, the couples received either and engage in other AA- or NA- self-help groups (e.g., SMART outpatient, alcohol-focused, CB mari- Recovery and Moderation Manage- tal therapy only (MT-only), or the MT 1Al-Anon is a self-help organization for spouses and ment both draw heavily on CB intervention supplemented with coun- significant others in alcohol-dependent people’s lives. intervention research and theory)

96 Alcohol Research & Health Facilitating 12-Step Self-Help Group Involvement

and determine whether such inter- lowing the intervention, 100 percent of costs (e.g., costs of counseling and detox- ventions enhance outcomes more patients in the enhanced TSF group ification) over the 3-year period compared than do TSF interventions. An attended at least one meeting (average with the outpatient treatment-seeking alternative explanation for the find- 2.3 meetings), compared with zero-per- group (Humphreys and Moos 1996). ings to date is that the subset of cent meeting attendance among patients Both studies suggest that when patients patients who switch from CB treat- in the simple TSF group. Although the with alcohol problems are connected ment to 12-step self-help groups do study only followed patients for 1 month, to the AA network, they lower their so because they find CB treatment the results suggest that a fairly brief inter- reliance on professional health care. A ineffective and seek an alternative vention (i.e., the enhanced TSF inter- priority for future research should be that is better matched to their needs. vention) can have a significant impact. to evaluate whether this reduction in A related research priority is to eval- health care costs is sufficient to offset This hypothesis would be an excel- uate whether TSF interventions can the cost of TSF interventions. Findings lent one for future research. Other promote AA/NA affiliation in the long from that research could inform and potential research directions are presented term to the same extent that they increase improve health care policy. For example, in the following section. meeting attendance in the short term. if clinicians could differentiate patients The fact that patients’ attendance at who were likely to recover with a brief meetings increases significantly during TSF intervention from patients who Directions for Future and in the months following a TSF required extensive professional treatment, Research intervention does not guarantee that the treatment system could become patients will become active affiliates of more cost efficient without compromis- The studies reviewed above clearly AA who continue to identify with the ing patient outcomes. demonstrate that TSF interventions organization, sponsor newcomers, cele- Thanks in part to support from that engage patients for a significant brate sober anniversaries, and read 12- Federal agencies, research on TSF inter- period (e.g., 10 to 12 sessions of outpa- step materials. To examine this impor- ventions and AA has expanded signifi- tient care, as in Project MATCH and tant issue, researchers must extend their cantly in recent years. The next decade the couples study [McCrady et al. in followups beyond the common 6- and will offer researchers and clinicians the press], or 21 to 28 days of 12-step- 12-month periods and continue to opportunity to build on this foundation. oriented inpatient care, as in the VA examine a broad range of AA affiliation AA and other self-help organizations study), can sharply increase the likeli- indices (i.e., indicators other than meet- are the most commonly sought resource hood that patients will attend AA/NA. ing attendance). for substance abuse problems in the However, many patients in primary A third key priority for future research United States, currently reaching more care and addiction treatment settings is to more fully understand the health than 1 million Americans (McCrady are not treated for extended periods. care cost offset and cost-effectiveness of and Miller 1993); determining how To make TSF interventions more useful TSF interventions. One study of 227 treatment providers and self-help groups in practice, researchers and clinicians industrial plant workers with alcohol can more effectively collaborate in our should develop and evaluate brief TSF problems (i.e., employees averaging 6 system of formal and informal care will interventions. In one promising study, drinks per day and 20 drinking days benefit many substance-dependent Sisson and Mallams (1981) randomly per month) found that patients assigned Americans. assigned alcohol outpatients to a “sim- directly to AA had similar work-related ple” or “enhanced” TSF intervention. outcomes but more relapses than did In the simple condition, a therapist patients assigned to inpatient treatment References suggested that the patient attend AA followed by AA. At the same time, or Al-Anon and provided a printed list patients initially assigned to AA had BORKMAN, T.J.; KASKUTAS, L.A.; ROOM, J.; BRYAN, of meeting times and locations. In the 10-percent lower alcohol-related health K.; AND BARROWS, D. An historical and develop- enhanced condition, the therapist sup- care costs over a 2-year period than did mental analysis of social model programs. Journal of plemented the aforementioned inter- patients initially assigned to inpatient Substance Abuse Treatment 15(1): 7–17, 1998. vention with an in-session telephone call treatment (Walsh et al. 1991). Similarly, HUMPHREYS, K., AND MOOS, R.H. Reduced substance to a current member of AA or Al-Anon, in a study of patients with serious alco- abuse-related health care costs among voluntary participants in Alcoholics Anonymous. Psychiatric who talked to the patient briefly and hol problems (e.g., alcohol dependence Services 47(7):709–713, 1996. arranged to attend a meeting with him symptoms such as shakes and halluci- or her. The 12-step group member nations), those who sought outpatient HUMPHREYS, K.; HAMILTON, E.G.; MOOS, R.H.; care and those who sought AA experi- AND SUCHINSKY, R.T. Policy-relevant program contacted the patient with a reminder evaluation in a national substance abuse treatment telephone call the night before the meet- enced similar improvement over a 3-year system. Journal of Mental Health Administration ing, drove the patient to the meeting, period on a variety of measures. The 24(4):373–385, 1997. and let the patient’s therapist know on AA-seeking group, however, had 45 HUMPHREYS, K.; HUEBSCH, P.D.; FINNEY, J.W.; the following day whether the patient percent lower (approximately $1,800 AND MOOS, R.H. A comparative evaluation of sub- had attended. During the month fol- per person) alcohol-related-treatment stance abuse treatment: V. Treatment can enhance

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