A professional perspective on mutual help organisations for

addictions

Keith HumphreysProfessor of Psychiatry

Veterans Affairs and Stanford University Medical CentersPalo Alto, California USA

Scotland’s 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

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Note: Based on MIDUS survey (N=3032)

Source: Kessler, R.C. et al., 1997, Patterns and correlates of self-help group membership in the United States. Social Policy, 27, 27-46.

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

8.1%

16.5%

35.3%

40.1% Self-help

General Medical

Human Services

Mental HealthSpecialty

Source: Kessler, R.C. et al. (1997). Differences in the use if psychiatric outpatient services between the U.S. and Ontario. NEJM. 336. 551-557.

Alcohol and drug-related self-help/mutual aid organizations (12 step in red)

Estimated Number of Groups Worldwide

Alcoholics Anonymous 95,000Al-Anon 32,000Narcotics Anonymous 21,000Cocaine Anonymous 2,000Adult Children of Alcoholics 1,500LifeRing/Secular Organization for Sobriety 1,200Marijuana Anonymous 1,000Women for Sobriety 350SMART Recovery 300++Moderation Management 50

Source: White and Madara (1998). Self-help sourcebook. Denville, NJ: American Self-help clearinghouse and Humphreys, K. (2004) Circles of Recovery.

Note: NA is for all drugs not just narcotics

12-step groups have established themselvesin 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

0

10

20

30

40

50

60

70

80

Abstinent Employed Incarc

OH

TAU

Jason et al. (2006). Communal housing settings enhance substance abuse recovery. American J Public Health, 96, 1727-1729.

Veterans Affairs RCT on AA/NA referral for outpatients

• 345 VA outpatients randomized to standard or intensive 12-step group referral

• 81.4% FU at 6 months

• Higher rates of 12-step involvement in intensive condition

• Over 60% greater improvement in ASI alcohol and drug composite scores in intensive referral condition

Source: Timko, C. (2006). Intensive referral to 12-step self-help groups and 6-month substance use disorder outcomes. Addiction, 101, 678-688.

Study of cost consequences

Comparable baseline demographic and alcohol use characteristics of 201 alcoholic individuals who initially chose AA or outpatient treatment

Total sample AA OutpatientCharacteristic (n=201) (n=135) (n=66)

% % %

Caucasian Race 86.6 88.9 81.8 Female 49.3 54.1 39.4Married 25.9 23.7 30.3Employed 52.2 48.1 60.6

Mean Mean MeanAge (years) 35.3 34.7 36.4ETOH (oz) 11.5 12.3 10.0ADS Score 10.1 10.9 8.6Days intox 11.7 11.9 11.4

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

AA group Outpatient group

(n=135) (n=66) F

mean SD mean SD (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, 371 5.52*

Note *p<.05

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

0

2

4

6

8

10

12

14

Baseline1 Year3 Year

AA

OP

AA OP AAOP

Ozs. of Ethanol per day

Days Intoxicated in past month

Alcohol Dependence Symptoms

Source: Humphreys, K., Moos, R.H. (1995). Reduced substance abuse related health-care costs among voluntary participants in Alcoholics Anonymous. Psychiatric Services, 47, 709-713.

Replication of cost offset findings in Department of Veterans Affairs Sample

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

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

0 5 10 15 20 25

OP Visits

IP Days

$1000 costCog-Beh12-step

Note: All differences significant at p <.001

1-Year Clinical Outcomes (%)

0

10

20

30

40

50

60

70

80

90

Abstinent No SA Prob Pos MH

12-stepCog-Beh

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

GeneralFriendship Quality

Friends’ SupportFor 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

01020

3040

5060

708090

100

%friends in 12S %Abstainers

12-stepNon

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%

0

25

50

75

100

attended meetings had sponsor read 12-stepliterature

had a friend whoAttends AA/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, 558-563.

Abstinence from illicit drugs and alcohol as a function of self-help involvement and treatment type in 3,018 patients

Self-help group Involvement Proportional

-1SD +1SD DifferenceTreatment Orientation

12-step 19% 75% 1:4.0

Non-12-step 25% 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, 371-376.

Self-help referral can be beneficial in non-specialty settings

Control BI 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 don’t 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

Example poster with tear off

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Vis

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Oakland (prior tointervention)

Oakland (duringintervention)

Los Angeles (priorto intervention)

Los Angeles(during intervention)

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