Studies and testimonials have shown that 12-step mutual-help organizations such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) can play an important role in addiction recovery among young adults with substance use disorders (SUDs). However, concerns exist regarding the suitability of 12-step programs for clinical subgroups such as those with co-occurring substance use and psychiatric disorders, called dual diagnosis (DD). A study of the influence of a DD or SUD-only diagnostic status on post-treatment attendance, active involvement in, and derived benefits from 12-step programs has found that young adult DD patients and SUD-only patients benefitted similarly from program attendance and involvement.
Results will be published in the February 2014 issue of Alcoholism: Clinical & Experimental Research
and are currently available at Early View.
"There are two major clinical concerns about purely addiction-focused 12-step groups for DD patients" said Brandon Bergman, a postdoctoral fellow at the Massachusetts General Hospital Center for Addiction Medicine as well as corresponding author for the study. "First, some think a DD will make it difficult for patients to attend and connect with others; for example, depressed patients may not see potential positives in attending, or struggle with the social aspects of the meetings. Second, anecdotal reports suggest some AA/NA members may be anti-medication and in some cases, anti-psychotherapy. However, research suggests the majority of members are in favor of psychotropic and anti-relapse/anti-craving medication use, though there may be a vocal minority of members who oppose it. Also anecdotally, there are concerns that DD patients will be told, if they are feeling depressed or anxious, they are simply not 'working their program.'"
"Understanding the role of 12-step mutual-help groups in recovery is extremely important, especially given the widespread use of these groups and their easy accessibility as a long-term, ongoing source of help," added Christine Timko, a senior research career scientist at the Department of Veterans Affairs, and consulting professor in the Department of Psychiatry and Behavioral Sciences at Stanford University. "The field has moved on from examining whether mutual-help groups are beneficial - they are - to examining the mechanisms by which they are effective. For example: 'what are the mediators explaining their effectiveness?' 'What are the moderators?' 'For whom are they more or less effective?'"
"Because studies suggest patients with co-occurring psychiatric disorders typically comprise somewhere between 50 and 75 percent of SUD treatment seekers," noted Bergman, "it's a clinical subgroup that has garnered empirical attention. And because their rates of SUD are about three times higher than other cohorts, young adults are another group of patients the field has begun to examine in more detail."
Bergman and his colleagues followed 296 young adults (218 men, 78 women), aged 18 to 24 years and primarily Caucasian, who attended a private not-for-profit residential SUD treatment program in the upper Midwestern United States between October 2006 and April 2008. All participants were assessed at intake, and three, six, and 12 months post-treatment on 12-step attendance, active involvement (having a sponsor, social interaction with other members, completing step work, etc.), and percent days abstinent.
"We found that young adults in SUD treatment with at least one comorbid psychiatric disorder - mostly depressive and anxiety disorders - had more severe problems when coming into treatment and were a bit more motivated to change their substance use," said Bergman. "In the year following treatment discharge, [DD patients] showed about the same rates of participation in 12-step groups compared with their SUD-only peers. This included both attendance and active involvement. However, DD patients had worse abstinence rates than SUD-only patients."
Neither Bergman nor Timko could firmly speak to 'why' DD patients had worse abstinence rates, however, Bergman noted that having a co-occurring psychiatric disorder compounds challenges in recovery. "Specifically, added emotional and cognitive stress of the psychiatric disorder, in addition to addiction-specific recovery tasks, may make it tougher for DD young adults to maintain abstinence," he said.
"In addition," said Timko, "greater severity of substance use problems earlier on is a predictor of continued greater severity later on."
"Nevertheless," said Bergman, "we found that all patients benefitted from participation, whether or not they also had a psychiatric disorder. If anything, clinicians should make a concerted attempt to foster active 12-step involvement among their DD young adult patients because, despite overall worse abstinence rates in the DD group, those involved at the highest levels had rates similar to their SUD-only counterparts. It's important to remember, however, that our DD group had primarily depressive and anxiety disorders, so our findings may not apply to young adults with more severe psychiatric conditions, like psychotic disorders."
"These findings also suggest that 12-step group facilitation efforts for DD patients might focus on how to obtain and work with a sponsor," said Timko. "More generally, facilitation efforts may have to incorporate particular sensitivity to DD patients' more frequent discomfort with social interactions and with personal disclosures, especially regarding their mental health-related issues. Stigma may be especially salient and need addressing in 12-step facilitation for DD clients."
"Young adulthood is a crucial developmental period for clinical researchers because prevalence rates of SUD and psychiatric disorders are at their peak," said Bergman. "An important implication of the findings here is that as health care organizations, both publically and privately funded, keep a close eye on health care spending, free and widely accessible 12-step organizations can be a powerful recovery resource for young adults - including those with co-occurring psychiatric disorders. Participation is very likely to bolster abstinence and remission, which helps keep people out of the emergency room and hospital beds."
"SUD treatment programs should use evidence-based mutual-help group facilitation practices with clients, including those who are dually diagnosed," Timko recommended. "These methods should emphasize not only group attendance, but also involvement. Because DD patients benefit from AA, which is widely available, facilitation can focus on AA and does not need to focus on dual-focused groups, which are quite limited in availability in most regions. Future research should also look at specific groups of DD patients to see if there are differences in their benefits from mutual-help groups, such as depressed alcoholics versus those with PTSD using opiates for pain. In addition, research needs to broaden its focus from substance use and psychiatric outcomes to include true, comprehensive recovery such as quality of life and well-being."