Drug and Alcohol Dependence

Drug and Alcohol Dependence 118 (2011) 194 201 Contents lists available at ScienceDirect Drug and Alcohol Dependence j ourna l ho me pag e: www.elsevier.com/locate/drugalcdep Intensive referral to 12-step dual-focused mutual-help groups Christine Timko, Anne Sutkowi, Ruth C. Cronkite, Kerry Makin-Byrd, Rudolf H. Moos Center for Health Care Evaluation, Department of Veterans Affairs Health Care System, and Stanford University Medical Center, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA a r t i c l e i n f o Article history: Received 19 November 2010 Received in revised form 15 March 2011 Accepted 24 March 2011 Available online 22 April 2011 Keywords: Dual diagnosis Mutual-help groups Referral practices Substance use and mental health outcomes a b s t r a c t Background: This study implemented and evaluated procedures to help clinicians effectively refer dually diagnosed (substance use and psychiatric disorders) patients to dual-focused mutual-help groups (DFGs). Methods: Using a cohort cyclical turnover design, individuals with dual diagnoses beginning a new outpatient mental health treatment episode (N = 287) entered a standard- or an intensive-referral condition. Participants provided self-reports of 12-step mutual-help (DFG and substance-focused group [SFG]) attendance and involvement and substance use and psychiatric symptoms at baseline and six-month follow-up. The intensive referral intervention focused on encouraging patients to attend DFG meetings. Results: Compared to patients in the standard condition, those in the intensive referral intervention were more likely to attend and be involved in DFGs and SFGs, and had less drug use and better psychiatric outcomes at follow-up. Attending more intensive-referral sessions was associated with more DFG and SFG meeting attendance. More need fulfillment in DFGs, and more readiness to participate in SFGs, were associated with better alcohol and psychiatric outcomes at six months. However, only 23% of patients in the intensive-referral group attended a DFG meeting during the six-month follow-up period. Conclusions: The intensive referral intervention enhanced participation in both DFGs and SFGs and was associated with better six-month outcomes. The findings suggest that intensive referral to mutual-help groups focus on its key components (e.g., linking patients to 12-step volunteers) rather than type of group. Published by Elsevier Ireland Ltd. 1. Introduction Patients with both substance use and psychiatric disorders have high rates of posttreatment relapse and additional care episodes (Chen et al., 2006). Mutual-help groups, especially those in which psychiatric medications are recognized as useful, may provide an element of continuing care that improves dual diagnosis patients treatment outcomes (American Psychiatric Association, 1995). Most treated dual diagnosis patients are referred to 12-step substance-focused groups (SFGs) such as Alcoholics Anonymous (Humphreys, 1997). However, under usual referral, many dual diagnosis patients do not attend SFGs, and those who do often drop out quickly (Noordsy et al., 1996). Furthermore, although dual diagnosis patients benefit from SFGs, they may benefit more from 12-step dual-focused groups (DFGs) (Magura, 2008). This study implemented and evaluated a procedure to help treatment providers make effective referrals to DFGs. We examined whether intensive referral, compared to standard referral, increased dual diagnosis outpatients DFG and SFG attendance and Corresponding author. Tel.: +1 650 493 5000x2 23336; fax: +1 650 617 2736. E-mail address: ctimko@stanford.edu (C. Timko). involvement over a six-month follow-up period. We also determined whether patients who received intensive referral had better substance use and psychiatric outcomes. Finally, we examined links between better attendance at intensive referral sessions and 12-step group participation, and between more 12-step group participation and outcomes. 1.1. Dual-focused mutual-help groups Dually diagnosed individuals benefit from membership in DFGs, which are designed for persons who have both substance use disorders and mental illness (Laudet et al., 2004). Magura (2008) found that more frequent and sustained attendance at Double Trouble in Recovery was associated with better substance use, psychiatric, and personal functioning outcomes. Members considered the group important for recovery, partly because they felt free to talk about their mental illness and psychiatric medications. Consistently, dually diagnosed individuals with experience in DFGs were positive about the groups (Bogenschutz et al., 2002), and dual diagnosis patients who attended DFGs had significant improvements in global functioning and housing, and decreased hospitalizations, over two years (Hensley, 2004). 0376-8716/$ see front matter Published by Elsevier Ireland Ltd. doi:10.1016/j.drugalcdep.2011.03.019

C. Timko et al. / Drug and Alcohol Dependence 118 (2011) 194 201 195 Based on these studies and recommendations (Kelly et al., 2003; Sacks et al., 2008a; Westermeyer, 2006) that clinicians foster stable affiliation with DFGs, Bogenschutz (2005) piloted an intervention to help dually diagnosed individuals engage with Double Trouble in Recovery. The intervention modified 12-Step facilitation (Tonigan et al., 2002a,b) by addressing psychiatric issues, eliminating Step 4 (made an inventory of ourselves), assigning patients a case manager, giving rides to meetings, and introducing patients to a group member. Attendance at both DFGs and SFGs increased, and alcohol use and psychiatric symptoms decreased, during treatment. Although Bogenschutz (2005) and Magura (2008) studies indicate that dually diagnosed patients respond positively to DFGs, relatively few individuals treated for dual diagnoses attend DFGs, and little is known about the extent to which DFG attendance and involvement are associated with better outcomes (Kelly and Yeterian, 2008). In the short-term, dual-focused interventions may have more positive benefits for psychiatric than for substance use outcomes (Back et al., 2006a,b; Hien et al., 2010; Read et al., 2004; Sacks et al., 2008b). 1.2. SFGs for dual diagnosis patients In debate about dually diagnosed patients participation in and benefit from SFGs (Bogenschutz et al., 2006; Ouimette et al., 2003), a concern is that SFGs emphasizing the primacy of addictions may invalidate patients perceptions of mental illness as the primary problem and increase their distress (Ouimette et al., 2001). SFGs may be perceived as objecting to psychotropic medications (Bogenschutz and Akin, 2000; Ortman, 2001) and SFG members may be seen as lacking empathy and acceptance (Magura, 2008; Mowbray et al., 1995). Dually diagnosed patients often fail to endorse the 12-step philosophy that they are powerless over substances (Handymaker et al., 2002; Luke et al., 2002), minimize their substance use (Jordan et al., 2002), and have difficulty accepting the idea of a Higher Power (Satel et al., 1993). Interpersonal avoidance associated with psychiatric disorders may also make membership and sponsorship in SFGs problematic (Jordan et al., 2002). Despite these concerns, dually diagnosed patients attend SFGs at rates approaching those of individuals with only substance use disorders (Westermeyer and Schneekloth, 1999). When dual diagnosis patients attend AA or NA, they benefit from participation (Chi et al., 2006; Ouimette et al., 2001; Timko and Sempel, 2004). However, these studies have focused primarily on associations of meeting attendance with substance use outcomes, and little on other aspects of SFG involvement, such as sponsorship and working the steps, or on psychiatric symptoms (Bogenschutz et al., 2006). In summary, dual diagnosis patients may benefit more from DFGs than SFGs. Because effective approaches for referral to DFGs are needed, we developed an intensive referral procedure. Dual diagnosis patients entering outpatient mental health treatment received either standard or intensive referral to DFGs, and were followed at six months to determine whether intensive referral resulted in more DFG and SFG attendance and involvement, and in better substance use and psychiatric outcomes. We also examined associations between intensive referral attendance and 12-step participation, and between 12-step participation and outcomes. 2. Methods 2.1. Sample Patients were included on the basis of: (1) entering outpatient mental health treatment at a Department of Veterans Affairs (VA) program in northern California, (2) identified by case managers as having dual substance use and psychiatric disorders based on the program s standard assessment procedures and medical record review (see Seal et al., 2007, 2010, regarding VA medical record diagnoses), and (3) screened by case managers as cognitively able to understand study procedures. Of 343 patients screened, 17 were ineligible and 39 refused to participate, leaving a sample of 287 individuals. Of the 287 patients, at six months, nine were deceased or incarcerated. An additional 57 were not located, or were located and either refused participation or did not participate in scheduled assessments. The six-month follow-up rate was 80% (N = 221) among patients still alive and not incarcerated. The followed and not-followed groups did not differ (using chi-square and t-tests) on condition or baseline characteristics (see Table 1 for a list) except that followed patients were somewhat better educated and less likely to be homeless (p <.05). The treatment was evidence-based (e.g., using Cognitive-Behavioral and Mindfulness approaches), multidisciplinary, and emphasized teaching skills (e.g., relapse prevention, symptom or stress management), typically in two group sessions per week. After being introduced to the study, participants provided written consent. Stanford University s Institutional Review Board approved study procedures. 2.2. Procedure 2.2.1. Counselor training. Counselors (Social Workers, Addiction Therapists who provided treatment and both conditions; N = 5) attended a training that detailed the standard and intensive intervention protocols. In a practice phase, counselors were monitored by senior project staff while they implemented the interventions with patients who were training cases; their data were not analyzed for this report. Specifically, two groups per counselor were observed, rated, and supervised using the fidelity checklist (see below), and counselors were then certified. 2.2.2. Condition assignment. Patients were assigned to the intensive-referral (N = 142) or standard-referral (N = 145) condition using a recurrent institutional cycle design (Shadish et al., 2002). Under this design, the intensive and standard referral conditions were delivered in a group counseling format and run in alternate three-month periods over 12 months. The main reason for using the cycling design was that patients in the same program talk to each other and, under random assignment and simultaneous intensive and standard groups, would become aware that some were receiving intensive referral whereas others were not. This would have raised a risk of contamination between conditions (Kahler et al., 2004). 2.3. Conditions 2.3.1. Standard referral. In the standard referral condition, during the outpatient session after study entry, the counselor gave patients a schedule of local 12-step DFG meetings and used a standardized script to encourage attendance. Counselors were asked not to provide patients in the standard condition with components of intensive referral. They were not asked to refrain from referring patients to 12-step SFGs, which is the usual practice. 2.3.2. Intensive referral. The intensive referral condition included patients attendance at four additional outpatient group sessions within one month; four sessions kept the intervention brief yet allowed patients to build rapport. During Session 1, the counselor gave patients a schedule of local DFG meetings with specific directions to them, and reviewed a handout on DFG meetings from Dual Recovery Anonymous. The counselor elicited and discussed patients pros and cons of attending DFGs. At Session 2, the counselor asked if patients had questions about the handout. This session consisted mainly of a 12-step DFG orientation (Mueser et al., 2003). The counselor outlined what meetings are like and the group had a practice meeting. The counselor discussed group etiquette and patients role-played introducing themselves to someone new (Bellack et al., 1997; Mueser and Glynn, 1999). At Session 3, the counselor arranged for a DFG member to volunteer to come to the session. Volunteers gave a brief personal history and arranged to meet patients and attend a meeting together. At Session 4, the counselor asked patients if they had attended a DFG meeting; if not, the counselor helped the patient contact a volunteer by phone to arrange another opportunity to attend a meeting together. The counselor reviewed a handout (from Double Trouble in Recovery) on how and why to obtain a sponsor, provided a list of available local DFG sponsors, and explained how to obtain a temporary sponsor. The counselor addressed patients concerns about asking for and working with a sponsor and patients role-played (Bellack et al., 1997; Mueser and Glynn, 1999) asking someone to be a temporary sponsor. 2.4. Fidelity Patients completed checklists rating each of the four group sessions. When ratings were aggregated across sessions, most participants indicated having received the main components of the intensive referral intervention: e.g., did the group talk about going to 12-step meetings (100% said yes); counselors checked that patients had local DFG meeting schedules (100%); counselors reviewed the DFG handout (100%); group discussed pros and cons of different self-help groups (100%); group role-played introductions to someone new (97%); group practiced a DFG meeting (98%); DFG volunteer visited (97%); patient agreed to attend a DFG meeting with the volunteer (98%); group discussed getting a DFG sponsor (100%); and counselors gave patients a list of DFG sponsors (80%). In addition, observers rated intensive sessions as to whether they delivered their key components; ratings ranged from

196 C. Timko et al. / Drug and Alcohol Dependence 118 (2011) 194 201 Table 1 Comparisons of patients in the standard- or intensive-referral condition on baseline characteristics. Standard Intensive X 2 (p) t(p) Overall Sample Percent male 89.7 92.3.59(.44) 90.9 Percent Caucasian 51.7 45.8 1.02(.31) 48.8 Mean age (SD) 51.2(8.8) 50.9(9.0).28(.78) 51.0(8.9) Mean years education (SD) 13.4(1.8) 13.5(1.8).65(.52) 13.5(1.8) Percent employed 40.7 50.4 2.68(.10) 45.5 Percent married 9.0 12.0.66(.42) 10.5 Percent homeless 30.3 33.1.28(.62) 31.7 Percent diagnosed with: a Major depression, mood disorder 61.4 64.1.22(.64) 62.7 PTSD 36.6 35.9.01(.91) 36.2 Other anxiety disorder 19.3 26.1 1.86(.17) 22.6 Schizophrenia, schizoaffective disorder 12.4 11.3.09(.76) 11.8 Bipolar disorder 11.7 14.1.35(.55) 12.9 Percent diagnosed with: 2.91(.23) Alcohol use disorder only 8.3 14.0 11.1 Drug use disorder only 22.2 24.5 23.3 Alcohol and drug use disorder 69.4 61.5 65.5 Mean ASI composite score (SD): Alcohol.157(.230).190(.213) 1.24(.21).174(.222) Drugs.068(.085).079(.083) 1.11(.27).073(.084) Psychiatric.404(.201).408(.191).16(.87).406(.196) Mean no. of days use in past 30 (SD) Alcohol 10.0(5.7) 8.4(5.7).87(.38) 9.3(5.7) Drugs 16.8(9.0) 17.4(9.1).88(.41) 17.1(9.1) Mean no. psychiatric symptoms (SD) 2.1(1.4) 2.2(1.4).55(.58) 2.2(1.4) Mean importance, additional psychiatric treatment 2.7(1.5) 2.9(1.4) 1.31(.19) 2.7(1.5) Mean medication adherence (SD) 1.4(1.3) 1.4(1.2).33(.75) 1.4 (1.3) Percent attended DFG, lifetime 23.4 21.8.11(.74) 22.6 Percent attended DFG, past two years 17.9 16.2.15(.70) 17.1 Mean no. DFG meetings, lifetime (SD) 3.3(11.5) 1.8(5.9) 1.45(.11) 2.5(9.2) Mean no. DFG meetings, past two years (SD) 1.2(3.9).8(2.9).90(.18) 1.0(3.4) Percent attended SFG, lifetime 96.6 98.6 1.30(.26) 97.6 Percent attended SFG, past two years 90.3 93.0.64(.42) 91.6 Mean no. SFG meetings, lifetime (SD) 458.9(874.1) 524.5(1148.1).55(.59) 491.3(1017.7) Mean no. SFG meetings, past two years (SD) 95.3(142.4) 71.6(105.8) 1.60(.11) 83.5(125.9) a Total percentage is >100% because some patients were diagnosed with more than one disorder. 75% (Session 4: role-played asking for a sponsor) to 100% for most components (e.g., Session 3: visit by DFG volunteer). 2.5. Measures 2.5.1. Baseline. Self-report data, including demographics, previous mutual-help group utilization, and substance use and psychiatric status, were collected from patients at intake. 2.5.2. DFG and SFG participation. At baseline, patients reported whether they had attended any DFG meetings in their lifetime and during the past two years, and if so, how many. Patients were reminded that DFGs are for people with both mental illness and substance abuse, and include groups such as Dual Recovery Anonymous and Double Trouble in Recovery. At baseline, patients reported on whether they had attended any SFG meetings in their lifetime and during the past two years, and if so, how many. They were reminded that SFGs include Alcoholics Anonymous and Narcotics Anonymous, and not the DFGs asked about before. Support is good for the reliability and validity of self-reports regarding mutual-help group participation (Morgenstern et al., 1997; Tonigan et al., 2002a,b; Walitzer et al., 2009). 2.5.3. Substance use and psychiatric status. The Addiction Severity Index (ASI) (McLellan et al., 1985a,b), a structured clinical research interview, assessed alcohol use, drug use, and psychiatric functioning. In each area, questions focus on the number and duration of symptoms in the patient s lifetime and past 30 days (McKay et al., 1994). ASI composites range from 0 to 1, with higher scores indicating poorer outcomes. Studies support the validity of self-reports of alcohol and drug use (Babor et al., 1987; Calhoun et al., 2000; Darke, 1998; Hersh et al., 1999) and psychiatric symptoms (Herman et al., 2002; Kirsner et al., 2003; Ready et al., 2002; Voruganti et al., 1998). We also used two clinically-relevant ASI measures of substance use status, and two of psychiatric status. For substance use, we used the number of days patients used alcohol, and used drugs, in the past 30. For psychiatric status, one measure was the count of six symptoms measured dichotomously (0 = no, 1 = yes) that patients reported in the past month (e.g., serious depression, serious anxiety/tension). For the other measure, patients rated the importance of additional treatment for their psychological problems (0 = not at all, 4 = extremely). 2.5.4. Medication adherence. Patients completed the four-item Medication Adherence Questionnaire (e.g., When you feel better do you sometimes stop taking your medicine? Yes/No; alpha =.74) (Thompson et al., 2000). Lower scores indicate better adherence. Self-reports of medication adherence are valid and reliable (DiMatteo, 2004; Garber et al., 2004; Sirey et al., 2001). 2.5.5. Follow-up. The six-month telephone follow-up was conducted by trained research assistants blinded to patients condition. It covered DFG and SFG participation, and substance use and psychiatric outcomes. ASI follow-up interviews are conducted validly and reliably over the telephone (Fureman et al., 1990). 2.5.6. DFG participation. To measure 12-step DFG attendance and involvement, we used the AA Inventory (Tonigan et al., 1996, 2002a,b) and the AA Affiliation Scale (Humphreys et al., 1998). We replaced items use of AA with 12-step dual-focused self-help group, and specified to what the latter term referred. Items are listed in Table 2; for dichotomous items, no = 0 and yes = 1. Toward the top of Table 2, four composites are listed: (1) overall involvement, which is the sum of the 14 involvement items (alpha =.91), (2) number of DFG steps worked, (3) need fulfillment in DFGs attended (alpha =.86), and (4) readiness for DFG participation (alpha =.96). Need fulfillment was the sum of five items (e.g., extent to which group meetings met your needs) rated on a 0 to 3 scale; higher scores represented more fulfillment. Readiness was the sum of six items (e.g., how ready are you to attend a DFG, work the steps, obtain a sponsor) rated 1 = not ready, 2 = thinking about, 3 = ready, or 4 = already doing; higher scores represented greater readiness to participate in DFGs. 2.5.7. SFG participation. Procedures to measure SFG attendance and involvement paralleled those for DFG participation (see Table 3). Patients were reminded about

C. Timko et al. / Drug and Alcohol Dependence 118 (2011) 194 201 197 Table 2 Comparisons of patients in the standard- or intensive-referral condition on dualfocused group (DFG) attendance and involvement at the six-month follow-up. Standard Intensive X 2 /t DFG attendance Attended meeting (percent) a 13.5 23.1 3.62 * Number of meetings 3.7 (3.3) 9.7 (8.9) 2.70 ** attended (mean, SD) DFG involvement Overall involvement (mean, 4.3 (2.6) 5.4 (3.1) 1.18 SD) No. steps worked (mean, SD).8 (1.4) 2.7 (3.5) 2.45 * Needs fulfillment in groups 8.6 (4.0) 9.6 (2.7).89 (mean, SD) Readiness (mean, SD) 6.5 (2.4) 7.3 (2.5) 1.08 DFG involvement items (percent) Read literature 83.3 83.3.00 Shared honestly at meetings 72.2 79.2.27 Socialized with group peers 70.8 83.3.91 Read out loud at a meeting 58.3 72.2.87 Did service at meetings 33.3 38.9.14 Gave a talk at a meeting 29.2 33.3.08 Had a spiritual awakening 16.7 25.0.43 Consider self to be a group 25.0 66.7 7.46 ** member Made phone calls to group 12.5 16.7.15 peers Celebrated a sobriety birthday 8.3 27.8 2.81 * Called a member for help 4.2 16.7 1.88 Chaired a meeting 4.2 11.1.74 Attended 90 meetings in 90 0 0 days Have a sponsor 0 0 * p <.05, ** p <.01. a Analysis for this variable used all participants; otherwise, analyses used participants who went to a DFG meeting. the groups referred to (e.g., AA, NA). Alphas were.92,.83, and.95 for overall involvement, need fulfillment from SFGs attended, and readiness, respectively. 2.5.8. Substance use and psychiatric status. The ASI provided composite scores on patients alcohol and drug use and psychiatric functioning at the six-month followup. Participants were also asked how many days out of the past 30 they had used alcohol and drugs. No use of alcohol or drugs was classified as abstinent; and any use as not abstinent. Psychiatric status was measured, as at baseline, by the count of six psychiatric symptoms reported, and patients perceived need of additional help for psychiatric problems. 2.5.9. Medication adherence. Medication adherence was assessed at follow-up as at baseline. 2.6. Analysis After comparing the standard and intensive referral groups at baseline on demographic and diagnostic characteristics, psychiatric and substance use status, and prior DFG and SFG attendance (N = 287, all baseline participants), we compared the groups on DFG and SFG attendance and involvement at follow-up by conducting chisquare analyses and t-tests (N = 221, all participants followed). We also compared patients in the standard and intensive referral groups on substance use and psychiatric outcomes at follow-up by conducting Analyses of Covariance; the covariate was the baseline value of the outcome. We used correlations to examine associations between attending intensive referral sessions and six-month indices of DFG and SHG participation. Regressions were also conducted predicting ASI alcohol, drug, and psychiatric composite scores at six months, entering the baseline value of the composite and condition (block 1), an indicator of DFG or SFG participation (block 2), and the interaction between condition and the block 2 indicator (block 3). Table 3 Comparisons of patients in the standard- or intensive-referral condition on substance-focused group (SFG) attendance and involvement at the six-month follow-up. Standard Intensive X 2 /t SFG attendance Attended meeting (percent) a 69.9 84.5 7.00 ** Number of meetings attended (mean, SD) 54.9 (44.9) 73.7 (97.3) 3.73 * SFG involvement Overall involvement (mean, 7.9 (3.2) 8.1 (3.2).25 SD) No. steps worked (mean, SD) 3.1 (3.9) 4.2 (3.3) 1.84 * Needs fulfillment in groups 11.0 (2.8) 11.1 (2.8).28 (mean, SD) Readiness (mean, SD) 9.4 (2.3) 9.5 (2.5).30 SFG involvement items (percent) Read literature 88.4 90.3.18 Shared honestly at meetings 84.9 90.3 1.23 Socialized with group peers 78.8 80.6.09 Read out loud at a meeting 84.9 89.5.85 Did service at meetings 62.0 65.1.19 Gave a talk at meetings 44.0 52.3 1.24 Had a spiritual awakening 37.6 39.5.07 Consider self to be a group 58.1 66.7 1.39 member Made phone calls to group 54.8 64.8 1.54 peers Celebrated a sobriety 62.4 70.9 1.48 birthday Called a group member for 45.3 46.2.01 help Chaired a meeting 20.9 29.3 1.68 Attended 90 meetings in 90 15.1 9.4 1.32 days Have a sponsor 33.3 41.9 1.39 * p <.05 ** p <.01. a Analysis for this variable used all participants; otherwise, analyses used participants who went to a SFG meeting. unemployed. Few patients were married, and almost one-third were homeless. At baseline, the most common psychiatric diagnosis was major depression, followed by PTSD, other anxiety disorders, schizophrenia, and bipolar disorder (Table 1). In addition, patients were most likely to have both alcohol and drug use disorders; the main drugs of choice were cocaine, cannabis, and amphetamines. There were no group differences on alcohol, drug, or psychiatric severity or medication adherence. At baseline, the two groups did not differ on lifetime or recent DFG meeting attendance (Table 1). Across groups, less than onequarter of patients had ever attended a DFG meeting; they had attended an average of only 2.5 such meetings in their lifetime. DFG attendance in the past two years was quite low. At baseline, the two groups also did not differ on lifetime or recent SFG meeting attendance (Table 1). In contrast to DFG participation, almost all patients had ever attended a SFG meeting; they had attended an average of almost 500 meetings in their lifetime. In addition, over 90% of patients had attended a SFG meeting in the past two years, with an average of more than 80 meetings during that period. 3. Results 3.1. Baseline characteristics There were no differences between patients in the standard and intensive referral groups on baseline demographic or clinical characteristics (Table 1). The sample was mainly male, non-white, middle aged, and, despite having had some college education, 3.2. DFG and SFG participation at follow-up At the six-month follow-up, a higher proportion of patients in the intensive-referral group attended a DFG meeting; however, even among these patients, only 23.1% did so, compared to 13.5% in the standard group (Table 2). Among patients who attended a DFG, intensive-referral patients attended more DFG meetings than standard referral patients did. They also worked more dual-focused

198 C. Timko et al. / Drug and Alcohol Dependence 118 (2011) 194 201 Table 4 Comparisons of patients in the standard or intensive referral condition on outcomes at six months controlling for the corresponding outcome at baseline. Standard Intensive F ASI composite (mean, SD) Alcohol.111 (.171).095 (.178).58 Drugs.037 (.060).030 (.059).88 Psychiatric.387 (.228).333 (.199) 4.87 ** Number of days used in past 30 (mean, SD) Alcohol 1.83(6.17) 1.31(4.56).61 Drugs 2.36(7.51).66(2.66) 3.75 * Abstinent (percent) Alcohol 83.6 86.5.40 Other drugs 73.9 81.7 2.09 Alcohol and other drugs 57.2 59.7.20 Psychiatric status No. of symptoms 2.2 (1.5) 1.8 (1.4) 3.87 * Medication adherence (mean, SD) 1.1 (1.1) 1.1 (1.1).08 Need additional help (mean, SD) 1.9 (1.6) 1.4 (1.6) 4.54 * * p <.05, ** p <.01. Note: Adjusted means are displayed. program steps and were more likely to consider themselves a DFG member, and to have celebrated a sobriety birthday with a DFG. A higher proportion of patients in the intensive-referral group attended a SFG meeting (Table 3). Among patients who attended a SFG, intensive-referral patients attended more SFG meetings. However, the groups did not differ on SFG involvement, except that intensive-referral patients worked more of the 12 steps. The regressions showed that whether or not a DFG meeting was attended (analyses included all patients followed at six months), or number of DFG meetings attended (analyses included only patients who attended a DFG meeting) did not predict ASI composite scores at six months (with ASI scores at baseline and condition controlled). In addition, few indices of DFG involvement predicted ASI composite scores at follow-up (controlling for ASI baseline scores and condition). Calling another DFG member for help (b =.190) and more need fulfillment in DFGs (b =.315) were associated with a better psychiatric outcome (p <.05). In addition, more need fulfillment was associated with a better alcohol outcome (b =.246, p <.05). The interactions of condition by need fulfillment in DFGs (b =.401, p <.01), and by readiness to attend DFGs (b =.276, p <.05), predicted psychiatric outcomes. For patients in the intensive condition, more need fulfillment was related to better psychiatric outcomes (b =.517, p <.05), but this was not observed for patients in the standard condition (b =.161, p >.05). Similarly, for patients in the intensive condition, more readiness was related to better psychiatric outcomes (b =.229, p <.05), but this did not hold for patients in the standard condition (b =.039, p >.05). Regressions also showed that whether or not a SFG meeting was attended, or number of SFG meetings attended, did not predict ASI composite scores at six months (with ASI scores at baseline and condition controlled). When involvement indices were used as predictors, more readiness to attend SFG meetings was related to better psychiatric functioning (b =.114, p <.05). Greater readiness to attend SFGs (b =.163; p <.01) was also related to better alcohol outcomes, as was being more involved overall with SFGs (b =.198, p <.05). On involvement items, having celebrated a sobriety birthday (b =.124), telephoning group members (b =.129), and having a sponsor (b =.132) were associated with better alcohol outcomes (p <.05). Interactions of condition by SFG participation were not significant predictors of ASI composite scores. In regressions with a significant 12-step group participation predictor, adjusted R 2 s ranged from.18 to.26 (p <.05) 3.3. Substance use and psychiatric outcomes At six months, with baseline scores controlled, the groups did not differ on the ASI alcohol or drug composite, but patients in the intensive referral group had less severe psychiatric problems (Table 4). Similarly, patients in the intensive referral group had fewer psychiatric symptoms and stated that they were less in need of additional treatment for psychiatric problems. Finally, intensivereferral patients used drugs for a fewer number of days. 3.4. Intensive referral attendance and DFG and SFG participation Of patients assigned to the intensive referral condition, all attended at least one session (Mean = 2.6 sessions, SD = 1.1); 24.2% attended one session, 23.2% attended two, 26.3% attended three, and 26.3% attended all four. We examined associations between attending more intensive referral sessions and six-month indices of DFG and SHG participation: attended at least one meeting; number of meetings attended; overall involvement; number of steps worked; need fulfillment; and readiness. More attendance at intensive referral sessions was associated with attending at least one DFG meeting (r =.189, p <.05) and greater readiness to attend DFG meetings (r =.177, p <.05). It was also associated with attending more SFG meetings (r =.234, p <.01) and being more involved overall in SFGs (r =.169, p <.05). 3.5. DFG and SFG participation and outcomes 4. Discussion Compared to patients receiving standard referral, a higher proportion of dually diagnosed patients receiving intensive referral to DFGs attended a DFG meeting over the next six months. In addition, patients in the intensive referral group who went to at least one DFG meeting attended more such meetings than did patients in the standard referral group. However, only about one-quarter of patients in the intensive referral group attended a DFG meeting, and patients who did attend went to an average of only 10 meetings over six months. In contrast, the majority of patients in both the intensive and standard referral conditions attended SFGs over the six-month follow-up period. Nevertheless, patients in the intensive referral group were more likely to attend SFGs and attended more SFG meetings. The standard referral group attended an average of two meetings per week, whereas the intensive referral group attended an average of three meetings per week. 4.1. Why didn t intensive referral patients participate more in DFGs? In light of the strong fidelity with which the intensive referral condition was delivered, along with good attendance at intensive referral sessions, it is surprising that only a minority of patients participated in DFGs. In hindsight, we attribute the lack of greater participation to aspects of the intervention and of the DFGs themselves. Regarding the intervention, discussing the cons as well as the pros of attending mutual help groups may have dissuaded some participation. As framed by motivational interviewing (Miller and Rose, 2009), clients monitor their speech for clues about their attitudes and intent to change. If they focus on reasons against engaging in a specific behavior (attending DFGs), they may infer that they do not want to engage in the behavior and become less likely to do so (Moyers et al., 2007, 2009). Also, the intensive referral intervention s emphasis on DFG attendance was not carried over into other components of patients outpatient treatment, which may have lessened the intervention s impact.

C. Timko et al. / Drug and Alcohol Dependence 118 (2011) 194 201 199 The relative lack of easily accessible DFG meetings likely contributed to the low participation rate. There were only about eight Dual Recovery Anonymous groups meeting regularly in the county in which this study was located, compared to about 205 AA groups. Similarly, Magura (2008) found that individuals dropped out of Double Trouble in Recovery mainly because regular meetings were discontinued or took place at inconvenient locations. In light of 12- step program recommendations to try different groups to attain a good fit, the low number of DFGs relative to SFGs decreased the options for patients to find a comfortable match. Another point is that AA and other SFGs may have become increasingly supportive of members with co-occurring mental illnesses, their use of psychiatric medications, and discussion of mental health-related issues (Laudet, 2008). Accordingly, patients in our sample, relatively few of whom were diagnosed with schizophrenia, may not have seen the need to attend specialized DFGs. In addition, whereas SFGs are truly peer-run, the DFG meetings available to patients were often led by individuals who, although dually diagnosed themselves, were formally affiliated with the facility in which the meeting was located and so may not have been perceived as peers. Although the intensive referral intervention did not yield high rates of participation in DFGs, it did result in more patients attending SFGs, and more attendance and involvement in SFGs. That is, preparing for DFG participation through intensive referral appeared to generalize to SFG participation. Because intensive referral involved reviewing 12-step philosophy and the 12 steps and identifying potential areas of difficulty, such as emotional discomfort, that may arise during meetings, dually diagnosed patients who received the intervention may have experienced SFGs as less alienating and more empathic about problems of living with psychiatric disabilities (Mueser et al., 2003; Noordsy et al., 1996). Another consideration is that study participants had very high SFG exposure at baseline, and it is unclear how this might have affected their openness to more engagement in SFGs or DFGs (Kaskutas and Subbaraman, 2010). Treatment programs that explain and prime individuals for mutual help may be especially effective at helping patients benefit from those groups (Humphreys et al., 1999). That is, when treatment staff educate (or re-educate) dually diagnosed patients about mutual-help concepts, and provide access to meetings and role models during treatment, these patients may find mutual-help groups, whether dual- or substance-focused, to be a logical, comfortable extension of treatment. Thus, during-treatment exposure to mutual-help groups, together with discussions about general principles underlying these groups, may promote mutual-help participation (Timko and DeBenedetti, 2007). 4.2. Intensive referral, 12-step participation, and outcomes Patients receiving intensive referral had consistently better sixmonth psychiatric outcomes but only one better substance-related outcome. This finding is in line with results of prior investigations of enhanced interventions for dually diagnosed patients (Hien et al., 2010; Sacks et al., 2008b). In addition to increased attendance at DFGs and SFGs, patients receiving intensive referral worked more DFG and SFG steps and were more likely to consider themselves members of a DFG and to have celebrated a sobriety birthday. Moreover, better psychiatric outcomes were associated with calling another DFG member for help, more need fulfillment in DFGs, and more readiness to attend SFG meetings. Better alcohol outcomes were also associated with more need fulfillment in DFGs, as well as greater readiness to attend SFG meetings, and more involvement with SFGs, especially celebrating a sobriety birthday, making phone calls to other group members, and having a sponsor. Each of these aspects of mutual-help group participation is an indicator of proposed 12-step group mechanisms of change (Moos, 2008). Proposed active ingredients of 12-step groups, both DFGs and SFGs, are support, goal direction, and structure; abstinence-oriented norms and role models; engagement in rewarding activities; and bolstering self-efficacy and coping skills (Bogenschutz, 2007; Moos, 2008). The 12-step group behaviors and experiences associated with the intensive-referral intervention and better psychiatric and alcohol outcomes are consistent with these higher-order active ingredients. For example, readiness to attend and more involvement are indicators of bonding, having a sponsor is associated with exposure to an abstinence-oriented model and norms, calling a group member for help reflects coping skills, and having a sobriety birthday is an indicator of self-efficacy. Once the higher-order active ingredients of mutual-help groups can be measured, it will be possible to examine how well and consistently different types of DFGs and SFGs deliver them, and the extent to which they are associated with outcomes for dually diagnosed and other groups of individuals. 4.3. Limitations and conclusions A limitation of this study is that all patients were treated within the VA, which is federally funded and operates the largest mental health treatment system in the US. Generally, VA substance abuse and other mental health services are of similar quality and effectiveness to those in the private sector (Asch et al., 2010; Rosenheck et al., 2000). However, the VA patient population has poorer health status compared with the general patient population (Agha et al., 2000; Grella et al., 2010). The extent to which our findings will be replicated in studies of patients in other health care systems remains to be determined. Also, this was not a randomized controlled trial; however, the two groups were closely comparable, and the cycling design avoided the likelihood that patients in the two conditions would perceive that they were obtaining nonequivalent treatments. Further, the study was limited by having a single follow-up focusing on the prior 30 days, and conducting multiple comparison tests with the risk of spurious differences between conditions. Our results suggest that, by incorporating intensive referral procedures into treatment, providers can increase the likelihood that dually diagnosed patients will participate in mutual-help groups and continue to improve after treatment has ended. Given the benefit that dually diagnosed patients appear to gain from participating in SFGs (Timko and Sempel, 2004), and SFGs widespread availability, treatment providers should link patients to 12-step group volunteers and consistently ask patients about their meeting participation. If a dual diagnosis patient is uncomfortable in a SFG, special procedures could be followed to identify and access a suitable DFG. Intensive referral could emphasize the common benefits of mutualhelp group participation, such as support, direction, and structure; abstinence-oriented role models and norms; and opportunities for rewarding activities, bolstering self-efficacy, and learning new coping skills (Bogenschutz, 2007; Moos, 2008). Role of funding source This work was supported by the Department of Veterans Affairs (VA) Office of Research and Development (Health Services Research & Development Service, IIR 05-014, RCS 00-001, and RCS 90-001), and the VA Office of Academic Affiliations (TPP 65-500). The funding agencies had no further role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. The views expressed here are the authors and do not necessarily represent the views of the Department of Veterans Affairs.

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