Relapse prevention planning: Findings from investigations of SMART Recovery participants

Transcription

1 Relapse prevention planning: Findings from investigations of SMART Recovery participants Deirdre O Sullivan, PhD, CRC Justin Watts, MEd Yi Xiao, MEd The Pennsylvania State University Department of Educational Psychology, Counseling, and Special Education

2 Overview of presentation Peer support is critical for long-term recovery and relapse prevention 12 step models and SMART Recovery have recovery capital features Lots of support for the positive impact of 12 step models on recovery outcomes Emerging research findings on SMART Recovery participants and facilitators Meeting frequency and affiliation are connected to increases in refusal self efficacy Recovery capital and Quality of Life considerations for Relapse planning

3 Treatment Specialized treatment works and long-term treatment is recommended (minimum of 90 days inpatient or intensive OP) 1 Many theoretical interventions are effective CBT, M.I., 12 Step Facilitation (Project MATCH research findings) Common therapeutic factors include self efficacy, social support, coping, motivation Treatment should match needs on severity, life issues, client preferences 1: NIDA (2012), Scott, Dennis & Fotz, (2005); White and Kelly, 2011; 2: Kelly, Magill, Stout (2009)

4 Defining the treatment problem Only 9.2% of those in need of treatment for SUD s receive it at a specialty facility. 1 Additionally, the relapse rate is estimated to be between 60-80% in the U.S. 2 Barriers to treatment include COST, TIME, WORK AND FAMILY OBLIGATIONS, LACK OF INSURANCE, CULTURE/LANGUAGE DIFFERENCES, SOCIAL AND SELF STIGMA, GEOGRAPHIC BARRIERS, POLY-DIAGNOSES, FRAGMENTED SERVICE DELIVERY 3 1: SAMSHA (2013); 2: NIDA (2013); 3: Appel, Ellison Jansky & Oldak, 2004; Gabriel & Deck, 2006

5 Peer Support Groups Peer support groups are free, widely available, and thus circumnavigate some of the barriers to Tx including cost, time, work and family obligations and stigma These programs continue to be the most predominant method of treatment for substance abuse disorders. Of the 3.8 million persons who received treatment for substance abuse in 2011, 2.1 million received treatment exclusively at a peer support group. Extensive and rigorous researching findings indicate peer support group attendance enhances remission rates

6 Peer support groups: hypothesized Social support mechanisms for change Sober role models (sponsors) Regularity, repetition of meetings Processing triggers, cravings Structured activities (working the 12 steps) Enhanced self esteem and self efficacy over time Shift in identity from addict to person in recovery, person paying it forward, strong person who can overcome adversity?

7 Specific findings supporting 12 Step groups Oldest, most widely available is AA, NA, 12 step Increased 12-step involvement is associated with a higher likelihood of abstinence over time Reduction in self-help group involvement results in abstinence reduction Project MATCH Research Group (1998) found that clients who took part in twelve-step groups had higher percentage of days abstinent and a lower number of drinks per drinking days 3 years after the initial study compared to those in other treatment conditions Religious/spiritual participants had better outcomes

8 Twelve-step groups AA is the foundational organization Free, global, widely accessible and available Extensive membership, led by non-professional members, story telling, sponsors guide new members through the 12 steps to sobriety Basic beliefs include Persons with SUDs cannot manage their lives and stop drinking along (Disease model) In order to stop drinking, surrender to a higher power is necessary Generally, this is a life-long commitment and daily or weekly re-affirmation process Working through the 12 steps is the path to sobriety

9 SMART Recovery Facilitator-led, structured discussion groups reliance on established, evidence based theories and techniques (CBT, REBT, ME) Growing, but not as pervasive and available as 12-step groups, utilizes online meetings Distinctions btwn SMART and 12 step groups: Cope with stress, maintain motivation, manage Thoughts, Behaviors, Feeling, focus on living a balanced life Focus on self-empowerment (Free-will model) Members are invited to stay involved with group after gaining independence from addiction

10 Methods for study 1 Self selected adult participants affiliated with SMART Recovery, including facilitators Phase 1 included participants who affiliated 3 months or more Phase 2 included participants who affiliated less than three months Overall response rates 54% - 74% Research questions focused on descriptive data related to health, abuse history, demographics, motivations for attendance

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12 AA & SMART Recovery Comparison Average Age: 49 years AA Gender: 65% Male; 35% Female Race/Ethnicity: White: 87% Hispanic: 5% Black: 4% Native: 2% Asian: 1% Other: 1% Marital Status: Married: 36% Single: 34% Divorced: 22% Other: 8% Counseling outside program: 62% Employment: Employed: 67% Unemployed: 10% Retired: 17% Disabled: 6% AA Meetings: 2.6 per week Average Age: 49.7 years SMART RECOVERY Gender: 66.7% Male; 33.3% Female Race/Ethnicity: White: 90.1% Hispanic: 3.7% Asian: 2.5% Black: 1.2% Other: 2.5 Marital Status: Married/Partner: 43.2% Single: 34.6% Divorced: 18.5% Separated: 3.7% Counseling outside program: 56.8% Employment: Employed: 63% Unemployed: 37% Meeting attendance: 4.69 per month.

13 Results

14 Percentage of factors ranked in top Changing Thoughts & Behaviors Feeling Better about Themselves Understanding Past Experiences Contribution Support From Others Attending Regular Meetings Active Participation in Group Activities and Homework Belief in Higher Power Figure 1. This figure illustrates SMART members ranking of the top 3 factors facilitating recovery

15 Member Categories 4 categories emerged when asked to explain membership motivations 1. Alignment with SMART Recovery program s philosophy, principles, and format. 2. Difficulties with surrendering to a higher power, and the adoption of a powerlessness identity. 3. Attending both 12-step meetings and SMART Recovery meetings. 4. Outlier responses

16 Alignment with SMART Recovery philosophy and structure Thirty-three participants (51.6%) stated the benefit of connecting with SMART Recovery philosophy, principles, and format as compared to 12-step models. The cognitive-behavioral approach used in SMART Recovery is a foundational appeal for some SMART Recovery members. This essence was captured in one participant who stated, I ve had good results with [cognitive behavioral therapy]. I sometimes see the rituals of 12 step programs as obstacles What attracted me to SMART were the trained facilitators and the conversation - I feel much more supportive using reason - makes a lot more sense to me then (sic) 12 steps which you have to rely on an addict to help you through

17 Difficulties surrendering to higher power Seventeen participants (26.6%) reported switching as a result of viewing the low utility for a higher power and an aversion to adopt a powerlessness identity. One participant reported: I am not a 12 stepper and I don't believe that a higher power has any utility for me. If there is a God, it does not intervene in human affairs. Admitting that you are powerless against addiction, and need divine intervention to overcome that addiction is not a constructive mindset.

18 Attending both 12 step and SMART meetings Twelve participants (18.8%) maintained membership in both SMART Recovery and traditional 12-step communities. One participant reported that he/she is, Currently doing both. With a home group for SMART recovery and a separate one for [Alcoholics Anonymous]. Another participant reported, I haven t switched. I find different perspectives valuable.

19 Facilitator Descriptive Data

20 Percentage of goals ranked in top Abstinence from addiction Identify & correcting irrational thoughts/beh Learning how to cope with urges Reduced use of addiction Increase in self-awareness Increase motivation Establishing balance in life Identification of relapse triggers Understand the purpose of one's life Reducing stigma Figure 2 This figure illustrates SMART Recovery facilitators ranking of the top three program goals that help members with their recovery. Incorporating spirituatlity into one's life

21 Overview of rank ordering of recovery goals findings from our samples Top 3 recovery goals for facilitators: Abstinence Correcting irrational beliefs/behaviors Learning to cope with urges Top 3 recovery goals for members: Changing thoughts and behaviors Feeling better about self Connecting past events to current use/abuse

22 Why did you become a facilitator? 4 overarching categories emerged from analyzing the participants (n = 38) responses regarding reasons for becoming a SMART Recovery facilitator. 1. To give back by helping others. 2. Personal benefit for their own recovery. 3. Accidental Facilitator. 4. To provide an alternative recovery group

23 What prepared you to be a facilitator? 3 overarching categories emerged from analyzing the participants (n = 35) responses to what prepared them to be a SMART Recovery facilitator. 1. SMART Recovery training materials and resources. 2. Additional resources outside of SMART Recovery materials. 3. Formal training and education.

24 Study 2: Refusal Self Efficacy and Engagement with SMART Recovery Research Questions 1. Do established members (3 mos +) report higher refusal self efficacy compared to new members? The groups were matched on demographic variables including counseling, belief in program, age, education, race, etc. 2. Do members who attend meetings the most frequently report higher refusal self efficacy compared to low attenders?

25 Refusal Self Efficacy Strong predictor of long-term recovery outcomes, including: 1)reduced drinking/using, 2) more days abstinent, 3) longer affiliation with peer support groups 4) Transition to stable recovery stage Volumes of research supports Self Efficacy as an important consideration for many health behavioral changes including drinking/drug use SMART Recovery asked that we not explicitly inquire about abstinence; RSE is a known predictor of abstinence, so a good proxy We didn t want participants to be prompted to feel guilty if lapsed, or if they were taking prescribed pain or mood altering medications due to injury/disability, or psychiatric conditions

26 Instrument and variables Brief Situational Confidence Questionnaire 10 items rate from 0 to 100 Respond to emotional and situation triggers, such as feeling depressed, wanting to celebrate with friends, etc. Strong psychometrics BSCQ has a cut off score: 45+ indicates lower risk for relapse New (affiliated for less than 3 mos) vs Established membership (affiliated for 3 months or more) Low, (less than moderate, frequent attenders

27 Results Established members reported significantly higher refusal self efficacy compared to new members Established (M = 57.58) New (M = 39.20), p =.006 New members reported BSCQ scores that are indicative of relapse vulnerability Frequent attenders reported significantly higher refusal self efficacy compared to infrequent attenders 10+ meetings/month (M = 83.2) Fewer than 4 meetings/month (M = 70.58), p =.03 No differences among moderate attenders and other groups, but medium effects indicating meaningfully higher scores as meeting attendance increases

28 Implications for counselors Longer affiliation improves refusal self efficacy This is critical for the early stages of recovery first 90 days present highest risk for relapse More frequent attendance improves self refusal efficacy Encourage clients to affiliate with appropriate peer support group for at least 3 months at least, and attend meetings frequently Online meetings can supplement in-person meetings Facilitator can help identify sober role model, similar to twelve-step tradition Members did not highly rank support and meeting attendance as critical for recovery These are critical for recovery, educating clients about these factors is important in counseling

29 In progress Quality of life matters in recovery High QofL reduces stress, which reduces relapse threat GOAL = INCREASE Q of L Recovery capital (supports, self esteem, self efficacy, resources such as employment, health) should improve quality of life

30 Preliminary findings Individual counseling and health status are NOT related to Quality of Life Self efficacy is significantly and positively related Relapse history and employment tenure are important to consider as we look for ways to shore up efficacy and quality of life

31 Take home messages Peer support is an important element of relapse prevention planning Longer affiliation and more frequent meetings enhance refusal self efficacy Refusal self efficacy is strongly related to higher quality of life BOTH are important counseling goals for longterm recovery Understanding each client s unique goals, life circumstances, recovery needs, barriers to treatment, will help us match client to peer support networks. Better matches should lead to stronger affiliations and more frequent meetings Addiction is a complicated illness, which often requires a range of interventions and supports One-size-does-NOT-fit-all

32 Case study 1 Bill is a 59 year old white male, a veteran, who has hypertension, liver damage, and diabetes, and who lives in a rural area. He has initiated counseling with you due to relationship issues and depression. Bill s employer and pastor were involved in an intervention that his wife initiated. He mentioned that he was broadsided by the intervention because he does not drink that much, and because he still shows up to work everyday and does a good job. Upon intake, Bill neglected to mention that he abuses alcohol frequently, over the course of a few sessions you learn that he meets the criteria for substance dependence. He still continues to drink despite health issues. He has mentioned that his wife is concerned that he is unable to stop drinking, and that his drinking has had a major impact on his marriage of 29 years. Bill is a religious man, who says he wants to get help for his drinking and depression and believes he can do this with God s help. Bill indicates that he is open to participating in counseling and support groups in order to achieve sobriety. What are the relevant factors in Bill s life that are important considerations for referral to a peer support group?

33 Case study 2 Taylor is a 32-year-old, recently separated, African-American mother of a 3- year old boy, who is currently in graduate school pursuing a master s degree in accounting. She realized she needed help after getting a DUI. In order to avoid a jail sentence, Taylor agreed to participate in 12 court-mandated counseling sessions. She reported having success with her efforts to control her drinking with the help of her counselor. Taylor isn t completely sure if she needs to abstain from alcohol forever. She reports that she learned helpful insights and strategies from her counselor regarding how her thoughts and feelings are connected to her desire to drink. Taylor reports that she plans to drink again in the future, and has abstained during the court-mandated time period because she fears she will lose custody of her daughter if she is caught drinking. Taylor is graduating in 2 months and has strong job prospects. She reports low motivation to continue individual counseling. She says she s not sure she needs it, and she doesn t think she ll have time to devote to counseling while juggling a new job and motherhood. What are the relevant factors in Taylor s life when considering referral to a peer support group?

34 Case study 3 Charles is a 45-year-old, divorced male who has been unemployed for the past 6 months. He was formerly employed as an assistant manager for a medium sized manufacturing plant that downsized due to economic strain. He has struggled with substance abuse at different times in his life since adolescence. He says his drinking has gotten worse since he was laid off, and he has fears he is developing other behavioral addictions, such as too much time spent chatting with people online. Charles has not participated in any formal counseling in the past for his drinking or other life issues, nor has he affiliated with any type of peer support group in the past. What are the relevant factors in Charles life when considering a referral to a support group?

35 Selected references Alcoholic Anonymous World Services. (1939). Alcoholics anonymous. New York: Author. Beattie, M. (2001). Meta-analysis of social relationships and post treatment drinking outcomes: Comparison of relationship structure, function and quality. Journal of Studies on Alcohol, 62, Bond, J., Kaskutas, L., Weisner, C. (2003). The persistent influence of social networks and alcoholics anonymous on abstinence. Journal of Studies on Alcohol, 62, Ferri, M., Amato, L., Davoli, M. (2006). Alcoholics Anonymous and other 12-step programmes for alcohol dependence. Cochrane Database of Systematic Reviews, 3, DOI: / CD pub2. Humphreys, K., Wing, S., McCarty, D., Chappel, J., Gallant, L., Haberle, B., Horvath, T., Kaskutas, L., Kirk, T., Kivlahan, D., Laudet, A., McCrady, B., McLellan, T., Morgenstern, J., Townsend. M., Weiss, R. (2004). Self-help organizations for alcohol and drug problems: Toward evidence-based practice and policy. Journal of Substance Abuse Treatment, 26, Kelly, Magill, & Stout (2009). How do people recover from Alcohol dependence? A systematic review.alcoholics Anonymous. Addiction Research and Theory, 17 (3). Laudet & White (2008). Recovery capital stress former poly drug users. Substance Use and Misuse Moos, R. (2007). Theory-based processes that promote the remission of substance abuse disorders. Clinical Psychology Review, 27, National Institute on Drug Abuse (2012). DrugFacts: Nationwide Trends. Retrieved from: O Sullivan, Blum, Watts, Bates (2015) SMART Recovery: Continuing care considerations for rehabilitation counselors. Rehabilitation Counseling Bulletin, 58(4) O Sullivan, Watts, Xiao, Bates-Maves (in press) Journal of Addictions and Offenders Counseling. SMART Recovery: Self-Management and Recovery Training (2012). Retrieved from Scott, Dennis, & Foss (2005). Utilizing recovery management checkups to shorten the relapse lifecycle. Drug and Alcohol Dependence, 78(3). U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality (2011). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings. Retrieved from White, B. J., & Madara, E. J. (2002). The self-help sourcebook: Your guide to community and online support groups (7th ed.). Denville, NJ: American Self-Help Clearinghouse