The Mechanisms of Behavior Change through which Mutual-help Organizations aid addiction Recovery

Transcription

1 The Mechanisms of Behavior Change through which Mutual-help Organizations aid addiction Recovery John F. Kelly, Ph.D. President, Society of Addiction Psychology, American Psychological Association Associate Professor in Psychiatry Harvard Medical School Program Director Addiction Recovery Management Service Associate Director MGH Center for Addiction Medicine Merrill Scott Symposium, Sundown M. Ranch, Aug 23 rd 2013

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3 Diverse Opinions about AA abound Three years ago when my head doctor, Silkworth, began to tell me of the idea of helping drunks by spirituality, I thought it was crackpot stuff, but I ve changed my mind. One day this bunch of ex-drunks of yours is going to fill Madison Square Garden (1937) Alcoholics Anonymous, 1952, p.136

4 Potential Advantages of Community Mutual-help» Cost-effective -free; attend as intensively, as long as desired» Focused on addiction recovery management over long term» Widely available, easily accessible/flexible» Provide access at high risk times when professional services not available (e.g., nights/ weekends/ holidays)» Entry threshold (no paperwork, insurance); anonymous (stigma)» Adaptive community based system that is responsive to undulating relapse risk

5 Potential Disadvantages of Mutualhelp» No clinical oversight/iaotragenic effects/safety concerns» No quality control ; between-group variability» Myriad organizations of varying size, with varying structures, format, scope, expectations, etiquette» With exception of AA, little evidence of effectiveness

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7 Name Substance Focused Mutual-help Groups Year of Origin Number of groups in U.S. Location of groups in U.S. Evidence base* (0-3) Alcoholics Anonymous (AA) ,651 all 50 States 1, 2, 3 Narcotics Anonymous (NA) 1940s Approx. 15,000 all 50 States 1, 2 Cocaine Anonymous (CA) 1982 Approx groups most States; 6 online meetings at 0 Methadone Anonymous (MA) 1990s Approx. 100 groups 25 States; online meetings at 1, 2 Marijuana Anonymous (MA) 1989 Rational Recovery (RR) 1988 Self-Management and Recovery Training (S.M.A.R.T. Recovery) 1994 Approx. 200 groups No group meetings or mutual helping; emphasis is on individual control and responsibility Approx. 250 groups 24 States; online meetings at , 2 40 States; 19 online meetings at olschedule.htm 0 1, 3 Secular Organization for Sobriety, a.k.a. Save Ourselves (SOS) 1986 Approx. 480 groups all 50 States; Online chat at 1 Women for Sobriety (WFS) groups Online meetings at WomenforSobriety 1 Moderation Management (MM) 1994 Approx.16 face-to-face meetings 12 States; Most meetings are online at 1 *0= None 1=Descriptive studies only 2 = Observational (correlational, longitudinal) 3= Experimental (random assignment, controlled). Source: Kelly & Yeterian, 2008

8 Table 2. Dual-Diagnosis Focused Mutual-help Groups Name Year of Origin Number of groups in U.S. Location of groups in U.S. Double Trouble in Recovery (DTR) Highest number of groups in NY, GA, CA, CO, NM, FL Dual Recovery Anonymous (DRA) Highest number of groups in CA, OH, PA, MA Dual Disorders Anonymous in IL Dual Diagnosis Anonymous (DDA) in CA Source: Kelly & Yeterian, 2008)

9 Table 3. Non-Substance Focused Addictive Behavior Mutualhelp Groups Name Year of Origin Number of groups in U.S. Location of groups in U.S. Gamblers Anonymous (GA) 1957 Approx chapters all 50 States Sex Addicts Anonymous (SAA) 1977 Approx. 700 meetings most States; Online meetings at Telephone meetings Sex and Love Addicts Anonymous (SLAA) 1976 Approx groups worldwide (including in all 50 States), Online meetings at onlinemeet.html; Regional teleconference calls Overeaters Anonymous (OA) 1960 Approx. thousands of meetings all 50 States; Numerous online ( OnlineMeetingsList.pdf) and telephone meetings ( phone_mtgs.pdf) Source: Kelly & Yeterian, 2008

10 12-step Research- Recent History» AA most commonly sought source of help for alcohol problems in the US (SAMHSA, 2010; Weisner et al, 2005).» Given public health significance, Institute of Medicine (IOM, 1990) called for AA research.» State of science summarized and further research opportunities outlined (McCrady and Miller, 1993)» Past 20 yrs significant

11 Given the prodigious economic, social and medical burden attributable to substance-related problems and the diverse experiences and preferences of those attempting to recovery from SUD, there is potentially immense value in societies maintaining and supporting the growth of a diverse array of mutual-help options.

12 How might MHOs like AA reduce relapse risk and aid the recovery process? Do these mechanisms differ for different people? Cue Induced Stress Induced RELAPSE Social Drug Induced Psych AA-related social network changes may help avoid cues, reduce and tolerate distress, and maintain abstinence minimizing drug-induced relapse risks Bio-Neuro MHO Kelly JF, Yeterian, JD, (2013). Mutual help groups. In McCrady and Epstein. Addictions: A Comprehensive Guide, Oxford Univ Press. 12

13 How do mutual-help groups enhance outcomes? Possible mechanisms Social 12-step AA Spiritual Negative

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16 Caveats and Limitations of Construct identification and content validity Measures Temporal resolution Aggregate/ average effects Clinical samples

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19 Anger as a mechanism of behavior change in AA» Anger, irritability, depression, boredom and other indices of negative affect implicated in a stress-induced pathway to relapse among SUD individuals (Shaham, Shalev, Lu, de Wit, & Stewart, 2003; Cummings, Gordon, & Marlatt, 1980; Marlatt and Gordon, 1980; 1985; Greenfield et al, 1998).» From the AA core literature, anger singled out as a uniquely potent and high-risk emotion for relapse to alcohol use: Resentment is the number one offender. It destroys more alcoholics than anything else. If we were to live we had to be free of anger (AA, 2001, p. 64, 66).» Consequently, a key emphasis in the 12-step program documented in AA s main text, Alcoholics Anonymous (1939; 2001) is to reduce anger and, thus reduce the probability of relapse (AA, 2001, p. 64).» anger the only construct in the AA literature for which a detailed column-based

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22 Reduced Depression as a mechanism of behavior change in AA» While AA does not make as explicit a case for the role of depression in alcohol relapse as it does for other indices of negative affect such as anger (e.g., [19], pg 64), there are allusions to it throughout the AA literature (e.g., we couldn t control our emotional natures, we were a prey to misery and depression, we couldn t make a living, we had a feeling of uselessness, we were full of fear, we were unhappy ; ([19], pg 52).» Also, focus on spirituality and the joy of

23 Reduced Depression as mechanism of behavior change in AA» Effect of AA on PDA and DDD was partially mediated by reductions in depression symptoms» But not when concurrent PDA and DDD were included in the model (this was done to see if AA attendance reduced depression more than what might occur through abstinence/reduce drinking alone)» AA led to both greater abstinence and reduced drinking and to reduced

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25 Spirituality as a mechanism of behavior change in AA» Spiritual practices were found to mediate the effect of AA on subsequent alcohol use outcomes» From a psychological perspective unclear exactly how this occurs: spiritual practices may help individuals attribute different meanings to stressors leading to re-appraisal and positive reframing thereby reducing relapse risk ( Pain is the touchstone of all spiritual progress ; AA, 1953) also, given that certain spiritual activities and prayers (e.g., Serenity Prayer) are learned explicitly within the AA recovery context, it is possible that the use of prayers such as the Serenity Prayer may serve as a cue to action that triggers a global recovery schema that mobilizes cognitive and behavioral

26 Among Aftercare Patients: 28% of direct effect of AA on frequency of alcohol consumption (PDA) was explained by S R (Mack Z = 4.38, p < 0.01) 24% of the direct effect of AA on intensity of alcohol consumption (DDD) was explained by S R (DDD; Mack Z = )3.97, p < 0.01). Among outpatients: 14% of the direct effect of AA on frequency of alcohol consumption (PDA) was explained by S R (Mack Z = 3.35, p < 0.01) 13% of the direct effect of AA on intensity of drinking (DDD) was explained by S R (Mack Z = )3.31, p < 0.01)

27 How exactly do increases in spiritual beliefs/practices translate into reductions in» Using stress and coping theory (Glanz, Rimer, & Lewis, 2002; Lazarus, 1966) as conceptual framework, 4 possible causal chains help clarify psychological mechanisms through which spirituality may explain AA-related increases in abstinence and remission:» 1. Spiritually-oriented, AA-specific, conditioned cues (e.g., the Serenity Prayer) that activate recovery schema and increase active coping;» 2. The provision of a compassionate framework for self-forgiveness that decreases shame and guilt;» 3. The focus on positive cognitive reframing of suffering and stressors;» 4. The provision of a coherent spiritual framework that gives meaning and purpose to individuals

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29 Figure 2a. AA attendance and the % change in both pro-abstinent and pro-drinking network ties from treatment intake to the 9-m (OP sample) Source: Kelly et al, 2011, Drug and Alcohol Dependence

30 Figure 2b. AA attendance and the % change in both pro-abstinent and pro-drinking network ties from treatment intake to the 9-m (AC sample) Source: Kelly et al, 2011, Drug and Alcohol Dependence

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32 Source: Kelly, Hoeppner, Stout, Pagano (2012), Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2):289-99

33 Table 2. The effect of AA attendance (0-3m) on alcohol outcomes (12-15m) for AC and OP Samples 33

34 Table 2. The effect of AA attendance (0-3m) on alcohol outcomes (12-15m) for AC and OP Samples Overall, AA had smaller effect on DDD than on PDA More of this smaller effect, was explained by the mediators 33

35 The proportion of the effect of AA attendance (0-3m) on alcohol outcomes (12-15m) mediated by the six variables 34

36 Table 3. Overall tests of Mediation using Product of Coefficients (MacKinnon et al, 2002) and % mediated effect 35

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38 Relative unique Contribution of each mediator in explaining AA s effects on alcohol outcomes Source: Kelly, Hoeppner, Stout, Pagano (2012), Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2):

39 Relative unique Contribution of each mediator in explaining AA s effects on alcohol outcomes effect of AA on alcohol use for AC was explained by social factors but also by S/R and through negative affect (DDD only) Majority of effect of AA on alcohol use for OP was explained by social factors Source: Kelly, Hoeppner, Stout, Pagano (2012), Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: A multiple mediator analysis. Addiction 107(2):

40 Do men and women benefit from AA in the same ways? Percentage of effect of AA attendance on outcomes (PDA; DDD) for men and women accounted for by the six mediators 38

41 Moderated-Mechanisms: AA effects Moderated by Severity and Gender CONCLUSIONS Recovery benefits derived from AA differ in nature and magnitude between more severely alcohol involved/impaired and less severely alcohol involved/impaired; and between men and women These differences reflect differing needs based on recovery challenges related to differing symptom profiles, degree of subjective suffering and perceived severity/threat, recovery challenges, and gender-based social roles & drinking contexts Similar to psychotherapy literature (Bohart & Tollman, 1999) rather than thinking about how AA or similar organizations work, better to think how individuals use or make these organizations work for them to meet their most urgent needs at any given phase of recovery

42 Bill Wilson and Carl Jung» In correspondence between Carl Jung and Bill Wilson (1963), Jung stated two major ways he believed recovery from severe addiction was achieved: Real religious insight The protective wall of human community

43 THE TWELVE PROMISES OF ALCOHOLICS ANONYMOUS: PSYCHOMETRIC MEASURE VALIDATION AND MEDIATIONAL TESTING AS A 12-STEP SPECIFIC MECHANISM OF BEHAVIOR CHANGE John F. Kelly PhD M. Claire Greene, MPH IN PRESS: Drug and Alcohol Dependence

44 Study Rationale» central mechanism of recovery from addiction according to AA is psychic change (Alcoholics Anonymous, 2001, p. xxvi), spiritual experience, or spiritual awakening (. Alcoholics Anonymous, 2001, Appendix II) achieved through the 12-step program (as noted in Step 12: Having had a spiritual awakening as the result of these steps we tried to carry this message to other alcoholics and to practice these principles in all our affairs ).» Although AA states awakening can take form of sudden dramatic shift in belief and perspective, it also characterizes this transformation as gradual change of an educational variety that leads to a profound alteration in [his] reaction to life (Alcoholics Anonymous, 2001, Appendix II, pg 567).» This is not only associated with belief in a potentially more traditionally defined, higher power, but also involves concrete changes in specific attitudes and

45 Study Rationale» In Big Book (AA, 2001), AA states as a result of beginning to work AA program, members start to accrue twelve outcomes, or promises, that are rewarding shifts in quality of life that culminate from participation (AA, 2001, p ).» These Promises are often read out at the beginning or end of AA and other 12-step MHO meetings and describe benefits, such as: decreased cognitive-affective distress (e.g., freedom from craving/ addiction; elimination of past regrets; decreases in fear of people and economic insecurity) increases in psychological well-being (e.g., increased feelings of usefulness/meaning and purpose; increased intuition and gratitude).» Thus, Promises may capture elements of what is commonly referred to as spiritual awakening of educational variety ; attainment of Promises may play two important roles: 1. as recovery benefits and ultimate outcomes in their own right; in fact, some may argue that these are recovery - adding quality of life beyond mere abstinence 2. as an intermediate outcome, or mechanism, through which members are spurred on to continued sobriety.» In other words, 12-step MHO participation leads to negative reinforcing benefits (e.g., freedom from craving, decreased affective distress) and positive

46 Non-face valid items constructed to prevent yay-saying or overendorsement

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50 Summary & Conclusions» Nearly all research conducted on AA or other 12- step MHGs» Given the group format and social network emphases of most other MHOs (e.g., SMART Recovery; Lifering etc.) may confer similar benefits, but are much smaller and need more research» Widespread community recovery organizations, such as AA, can enhance treatment and longerterm recovery outcomes and shown to work through mechanisms similar to those operating in formal treatment» Recent research shows support for some of AAs purported benefits and mechanisms beyond abstinence that are associated with sobriety and