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National Drug Abuse Treatment Clinical Trials Network

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  1. NIDA NATIONAL INSTITUTE ON DRUG ABUSE National Drug Abuse Treatment Clinical Trials Network 12-Step Facilitation: New Evidence from the National Drug Abuse Clinical Trials Network Dennis M. Donovan, Ph.D. University of Washington Dennis C. Daley, Ph.D. University of Pittsburgh Presented at the 22nd Annual Meeting of the American Academy of Addiction Psychiatry Scottsdale, Arizona December 11, 2011

  2. Objectives of Session • Review evidence supporting benefit of engaging individuals in 12-step programs • Provide background and rationale for development of STAGE-12 • Review the clinical components of the STAGE-12 intervention • Provide an overview of initial preliminary results from a multi-site clinical trial

  3. Professionals need to understand the 12-steps of AA and AA members need to understand what professional counseling is all about, because it is the interaction between these two programs that brings about the powerful result of recovery. ~Terence Gorski

  4. Background and Rationale for STAGE-12 Addiction, 102 (Supplement 1), 121-129, 2007

  5. Why Consider 12-Step Approaches? • 12-step orientation/philosophy is the predominant approach found in U.S. substance abuse treatment • 12-step groups represent a readily available, no-cost recovery resource • An annual average of 5.0 million persons aged 12 or older in the U.S attended a self-help group in the past year because of their use of alcohol or illicit drugs, with increased evidence of its effectiveness • Consistent with community-based treatment program and counselor treatment philosophy

  6. Why Consider 12-Step Approaches? • Applicable to a broad range of clients in different settings and can augment a wide range of standard treatments • A high priority of the NIDA Clinical Trials Network community-based treatment programs • Recent development of efficacious interventions to facilitate 12-Step involvement • Availability of 12-Step Facilitation therapy manuals and training materials

  7. Does Involvement in 12-Step Programs Improve Outcomes? YES!!!

  8. The Crushing Weight of the Data Support the Potential Positive Benefits of 12-Step Involvement

  9. Findings from Previous Research on 12-Step Involvement • AA and NA participation is associated with greater likelihood of abstinence, improved psychosocial functioning, and greater self-efficacy • 12-Step self-help groups significantly reduce health care utilization and costs • Combined 12-Step and formal treatment leads to better outcomes than found for either alone • Engaging in other 12-Step group activities seems more helpful than merely attending meetings

  10. Findings from Previous Research on 12-Step Involvement • Consistent and early attendance/involvement leads to better substance use outcomes • Even small amounts of participation may be helpful in increasing abstinence, whereas higher doses may be needed to reduce relapse intensity • Reductions in substance use associated with 12-Step involvement are not attributable to potential third variable influences such as motivation, psychopathology, or severity

  11. Summary and Recommendations from William Miller on 12-Step Involvement • 12-Step approaches cannot be ignored in understanding treatment outcomes. • Treatment is the time to initiate 12-Step attendance. If 12-Step attendance is not initiated during the period of treatment, it is quite unlikely to happen. Treatment, then, is a good time to encourage sampling of the program and meetings of 12-Step. • It is possible to facilitate 12-Step attendance. Without question, there are counseling procedures that significantly increase 12-Step attendance, at least during and often after treatment.TSF therapy clearly did this in Project MATCH. Systematic encouragement can significantly increase attendance. Owen, Slaymaker et al. 2003

  12. Summary and Recommendations from William Miller on 12-Step Involvement • Attendance is not involvement. When frequency of 12-Step meeting attendance is measured separately from behavioral indicators of involvement in the 12-Step program and fellowship, the two measures are moderately correlated . • 12-Step attendance may decline over the course of time while 12-Step involvement may remain steady or increase. This suggests a gradual process of internalization of the 12-Step. • 12-Step involvement tends to be a stronger predictor of outcome than 12-Step attendance. Owen, Slaymaker et al. 2003

  13. Beating a Dead Horse Using evidence-based 12-step facilitative approaches increases self-help group attendance and improves substance use outcomes!!!

  14. Why Focus on Facilitating 12-Step Involvement?

  15. Jones would walk through a blizzard to score his dope. The question remains: what will he do to get to a meeting? Will he go? Maybe, but maybe not!!

  16. “An increasingly rigorous body of evidence suggests consistent benefits of self-help group involvement. Dropout and nonattendance rates are high, despite clinical recommendations to attend.” (emphasis added) Kelly, 2003

  17. Recommendations from Expert VA/CSAT Consensus Panel on Self-Help Organizations • Community-based treatment programs, even those that label and represent themselves as “12-step oriented,” should evaluate whether their current program practices actively support involvement in 12-step self-help groups.  • Further, they should examine the methods employed by their counselors. Typically when counselors do attempt to support 12-step self-help group involvement, they rarely use empirically supported methods. • When clinicians use empirically validated techniques to support mutual help group involvement, it is far more likely to occur. Humphreys, et al., 2004

  18. Don’t We Already Do 12-Step Facilitation? • “Making the case that treatment programs should prioritize self-help group involvement can be difficult because many treatment providers believe they ‘do this already’; indeed, that every program does.” • “In practice, however, what this often means is that at some point during treatment a counselor gives the patient a list of local self-help groups and suggests that the patient attend a meeting, which is a minimally effective clinical practice.” • “We therefore encourage treatment providers to use the more intensive methods of promoting self-help group involvement empirically demonstrated to be effective…such efforts will maximize the maintenance of treatment gains.” Humphreys & Moos, 2007

  19. Elements of the STAGE-12 Intervention

  20. Objectives of This Portion of Session • Review clinical details of the STAGE-12 group sessions that patients attend • Review clinical details of the STAGE-12 individual sessions that patients attend • Engage in interactive discussion on addiction physicians’ roles in helping clients understand, engage in, and actively utilize 12-step programs

  21. STAGE-12 Therapy Manual • Based on and adapted from Twelve Step Facilitation Therapy for Drug Abuse and Dependence • Adapted for use in group delivery format fromBrown, et al. 2002 • Integrated with Intensive Referral procedures developed by Timko, et al., 2006

  22. What Is STAGE-12? • Combined group- and individual-based intervention • Combines elements of Twelve-Step Facilitation Therapy and Intensive Referral • Introduces participants to concepts and principles involved in 12-Step groups • Actively attempts to get participants involved in 12-Step meetings

  23. Rationale for Combining Intensive Referral with Twelve Step Facilitation • Interventions that are effective in increasing attendance may be insufficient to ensure active involvement. • Early attrition from attending meetings may, in part, be due to individuals’ inability to embrace or utilize other aspects of the 12-step program • Individuals who are attending 12-step groups but are having difficulty embracing key aspects of the program may need professional assistance that focuses more on 12-step practices and tenets and less on meeting attendance Caldwell & Cutter,1998

  24. STAGE-12 Interventions -5 group sessions -3 individual sessions

  25. 12-Step “Six Pack”: General Guidelines for Recovery Based on 12-Step Philosophy • Don’t drink or use drugs • Go to meetings • Ask for help • Get a sponsor • Join a group • Get active (Caldwell & Cutter 1998)

  26. Twelve-Step Facilitation Therapy

  27. Discussion Questions • What is the addiction physician’s roles in helping patients learn about, engage in, and use 12-step programs? • How do you deal with patients who resist 12-step programs (or other mutual support programs)?

  28. Focus of Group Sessions • Acceptance (Step 1) • People, Places, Things • Surrender (Steps 2 & 3) • Getting Active • Managing Emotions

  29. Structure of Groups • Rolling admission to group • Held weekly x 90 minutes • Check-in 15-20 minutes • Experiences, concerns about 12-step programs • Close calls, cravings, lapses or relapses • Review educational material 45-50 minutes • Each group has objectives & points to cover • Check-out 15-20 minutes • Plan for upcoming week • Reading assignments

  30. Session #1: Acceptance (Step 1) • Review format of sessions and use of journals and reading assignments • Provide overview of 12-step programs • Review Step 1 • Powerlessness & Unmanageability • Grief (giving up active addiction) • Assign readings and task (e.g., Step 1 worksheet)

  31. Session #2: People, Places, Things • Check-in • Review journal, meetings, readings • Review experiences in 12-Step programs • Also discuss resistances • Discuss P,P,T and impact on recovery • Who to avoid • How to manage P,P,T (social pressure) • Check out & assign readings and tasks (e.g., changing old routines)

  32. Session #3: Surrender (Steps 2 & 3) • Check-in • Review journal, meetings, readings • Review experiences in 12-Step programs • Discuss Steps 2 & 3 • Spirituality in recovery (vs. religion) • Higher Power • Check out & assign readings and tasks (e.g., spirituality worksheet)

  33. Session #4: Getting Active • Check-in • Journal, meetings, readings • Review experiences in 12-Step programs • Discuss “program of action or change” • Recovery domains: physical, spiritual, mental, social; how 12-Step programs help • How to use a sponsor; telephone use • Check out and assign readings and tasks (e.g., NA Basic Text reading)

  34. Session #5: Managing Emotions • Check-in • Journal, meetings, readings • Review experiences in 12-Step programs • Also discuss resistances • Emotions and recovery and relapse • Anger, anxiety, boredom, depression, shame • Using 12-Step program to manage emotions • Meetings, sponsors, peers, slogans, readings • Assign readings and tasks (e.g., resentment worksheet; being grateful)

  35. Discussion Question • When you see a patient who is involved in group treatment programs at your agency or program, do you monitor attendance and discuss this experience with the patient? • If no, why not? • If yes, what is the benefit?

  36. Focus of Individual Sessions

  37. STAGE-12 Individual Session 1

  38. STAGE-12 Individual Sessions: General • Complement group sessions • Incorporate clinical strategies from the Intensive Referral Program (Timko et al) • Focus on client’s use of 12-Step program • Emphasize meeting attendance and active participation in 12-Step activities as a primary means to recovery from addiction

  39. STAGE-12 Individual Sessions: Encourage Client to • Attend 12-Step meetings • Secure a “sponsor” as a mentor in recovery • Turn to the fellowship to gain support from others to help change thinking and behaviors • “Work” the 12 Steps • Increase social involvement with other 12-Step members

  40. Intensive Referral Procedure

  41. "Did I hear a need for a sponsor?"

  42. Acceptance • Willpower alone isn’t enough to help client • Addiction is a chronic and progressive illness (disease) • Loss of ability to control substances • There is no effective “cure” for addiction • Abstinence is necessary for recovery

  43. "Stop fighting and surrender, Jones. As your sponsor, all I ask is that you attend 90 meetings in 90 days."!.htm

  44. Surrender • Reach out to others • Follow the 12-Step program • There is HOPEfor Recovery • Only through accepting loss of control and by having faith that a HIGHER POWER can help • The 12-Step fellowship has helped millions of addicts to sustain their recovery • The best chance for success is to follow the path of NA, CA, CMA or AA.

  45. “Guess what?! I think our Michael has finally surrendered!"

  46. STAGE-12 Individual Session 2

  47. STAGE-12 Individual Session 2 • The focus and content varies, depending on whether the client attended meetings since session #1 • If yes, the client’s reactions to the meeting and recovery tasks • If no, focus on the perceived and actual barriers to attendance and a 12-Step volunteer will again be contacted

  48. STAGE-12 Individual Session 2: Objectives • Determine if client has hooked up with 12-Step “buddy” • Determine if client has attended a 12-Step meeting • Focus of remaining portion of session varies based on whether or not the client has attended a meeting

  49. STAGE-12 Individual Session 2 • Discuss reactions to meetings attended • Provide a list of sponsors and recommend that the client obtain a temporary sponsor • Explain that this sponsor could be replaced by a more permanent one when the participant is more familiar with other 12-Step members • Address any concerns the client may have about asking for and working with a sponsor