# Presentation: 891656

## Self-help groups for chronic disorders: What can we learn from research on addiction-related “12-step”groups? 

- Keith Humphreys
- Director,Veterans Affairs Program Evaluation and Resource Center and Associate Professor of Psychiatry,
- Stanford University Medical Centers
- Palo Alto, California

- Presented December 11, 2004 at VA QUERI meeting

## Acknowledgement

- National Institute of Alcohol Abuse and Alcoholism
- Department of Veterans Affairs
- John McKellar, Ph.D., Rudy Moos, Ph.D., John Finney, Ph.D., Eric Mankowski, Ph.D.
- Research participants

## Overview

- Scope of health-related self-help groups
- Definition of 12-step groups
- Effectiveness and Cost-effectiveness
- Mediators of Change
- So what?: Clinical implications

## Self-help groups addressing major chronic conditions in the U.S.

- _Chronic Condition_
- Arthritis
- Visual impairment
- Hearing Impairment
- Ischemic Heart Disease
- COPD
- Diabetes Mellitus
- Malignant Neoplasms
- Any Life-Threatening       		 Chronic Illness

- _Example Groups_
- 	Young Et Heart
- 	Council of Citizens with Low Vision Support Groups
- 	Self-help for the Hard of Hearing
- 	Mended Hearts
- 	Asthma and Allergy Foundation Support Groups
- 	Diabetes Anonymous
- 	Candlelighters (Pediatric Cancer)
- 	Reach to Recovery (Breast Cancer)
- 	Man-to-Man (Prostate Cancer)
- 	Make Today Count

## Self-help groups addressing leading causes of mortality in the U.S.

- _Causes of Mortality_
- Tobacco
- Diet/Activity Patterns
- Alcohol
- Microbial Agents
- Toxic Agents
- Firearms
- Sexual Behavior
- Motor Vehicles
- Illicit Use of Drugs

- _Example Groups_
- Nicotine Anonymous
- Take Off Pounds Sensibly
- Alcoholics Anonymous
- Hepatitis B Foundation Support Groups
- Parents Against Lead
- Parents of Murdered Children
- National Association of People with AIDS
- Mothers against Drunk Driving
- Narcotics Anonymous

## Proportion of help-seeking visits for psychiatric and substance abuse problems by sector, 1990

## Definition of 12-step groups

- Peer-directed, self-governing groups
- Spiritually oriented
- Provide a 12-step “program”
- Provide fellowship
- Many but not all use “Anonymous” in name
*Easy access, long-term participation and low coast make them an ideal vehicle for support of chronic conditions*

## Alcohol and drug-related self-help/mutual aid organizations in the U.S. (12 step in red)

- 					_Estimated Number of Groups Worldwide_
- Alcoholics Anonymous				95,000
- Al-Anon						32,000
- Narcotics Anonymous				21,000
- Cocaine Anonymous				  2,000
- Adult Children of Alcoholics			  1,500
- Secular Organization for Society			  1,200
- Marijuana Anonymous				  1,000
- Women for Sobriety				     350
- SMART Recovery				     200
- Moderation Management 				       50
- Source: White and Madara (1998).  _Self-help sourcebook_.  Denville, NJ: American Self-help clearinghouse

## Selected data on clinical and cost-effectiveness

## Research Design

- Participants recruited at detoxification units and alcoholism information and referral services in the San Francisco Bay Area
- Inclusion criteria: Contact due to a personal alcohol problem
- Exclusion criteria: Prior formal treatment for alcohol problems
- Collateral data on drinking behavior collected where possible
- Follow-ups conducted at 1, 3 and 8 years

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

- 		**Total sample****	****AA****	****Outpatient**
**Characteristic****	****(n=201)****	****(n=135)****	****(n=66)**
**	****	**_**%**_**	**_**%**_**	**_**%**_
**Caucasian Race****	****86.6****	****88.9****	****81.8****	****   **
**Female****	****49.3****	****54.1****	****39.4****	**
**Married****	****25.9****	****23.7****	****30.3****	****	**
**Employed****	****52.2****	****48.1****	****60.6****	****	**
**	****	**_**Mean**_**	**_**Mean**_**	**_**Mean**__**	**_
**Age (years)****	****35.3****	****34.7****	****36.4****	**
**ETOH (oz)****	****11.5****	****12.3****	****10.0****	**
**ADS Score****	****10.1****	****10.9****	****8.6****	**
**Days 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)

## Replication of findings in Department of Veterans Affairs Sample

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

## Methods

- Participants recruited at intake to 10 VA substance abuse programs nationwide
- Self-administered inventory completed at baseline and 1-year follow-up (Biological assays on subset)
- Health care utilization data gathered from medical center records
- 1-year follow-up rate = 81.5%, with no evidence of attrition bias

## Treatment programs

- All provided 21-28 inpatient care with outpatient aftercare
- 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****	**

## Comparison Groups

**887 Admissions each were recruited from the 12-step and cognitive-behavioral treatment condition**
**At intake, groups did not differ on substance abuse problems, psychiatric problems, demographic variables, prior health care utilization, or prior involvement in self-help groups**

## 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

## 12 Step Facilitation Therapy Findings in Project Match	

- 1726 alcohol dependent patients were randomized to 12-step facilitation, cognitive-behavioral or motivational enhancement therapy
- Patients in all three conditions showed substantial and sustained reduction in quantity and frequency of alcohol consumption
- No main effects for type of therapy were evident by 15 month follow-up
- Among patients with low psychiatric problems, 12 step facilitation therapy was more effective at increasing percent of days abstinent

- Source:  Project Match Research Group (1997).  Matching alcoholism treatments to
- client heterogeneity.  _Journal of Studies on Alcohol, 58,_  7-29.

## What mediates these benefits?

## B “mediates” the relationship between A and C

- A>>>>>>>>>B>>>>>>>>C

## Structural equation modeling results from over 2,000 

- _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

## So what?:Clinical implications

## %

- 48%

- 18%

- 45%

- 48%

- 60%

- 36%

- 66%

- 58%

- 0

- 25

- 50

- 75

- 100

- attended meetings

- had a sponsor

- read 12-step

- literature

- had a friend who

- attends AA/NA

**12-step self-help group involvement**

- CB

- 12-Step

- Figure 1: Posttreatment 12-step self-help group involvement of 2,045 substance-dependent veterans treated by 12-step or cognitive-behavioral programs

- 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		 		No Substance	   					    		From Drugs		  		Abuse-Related	     

- 				    	Abstinence		 		No Substance	   					    		From Drugs		  		Abuse-Related
- 				   	And Alcohol		    		   Problems	   								_-1SD_	_+1SD_			_-1SD_	_+1SD_
- Treatment
- _Orientation_
- 12-step				**19%****	****75%****	****	****	****18%****	****45%**
- Non-12-step			**25%****	****65%****	****	****	****28%****	****41%****	**

## 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 abst.	36%		51%		64%
- TX/SH Init	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

- Prospective studies indicate that 12-step groups reduce drug and alcohol use.
- 12-step 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.