Another Summary of a Study from Recovery Answers (Recovery Research Institute)


“What problem does this study address?

Research has shown treatments that help increase participation in groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) result in greater likelihood of abstinence and remission for those with substance use disorder (SUD). For patients who have another co-occurring psychiatric disorder, however, especially if the other psychiatric disorder is very debilitating, such as psychotic disorder or chronic major depressive disorder, studies have also shown that participation in 12-step mutual-help organizations that focus on both severe mental illness and SUD, such as Double Trouble in Recovery (DTR), is associated with better outcomes (see here for an example of DTR materials). Consequently, in this study, Bogenschutz and colleagues tested the added clinical benefit of proactively facilitating participation in DTR by adapting a Twelve-Step Facilitation (TSF) treatment for patients with a co-occurring alcohol use disorder (AUD) and severe mental illness, including bipolar disorder, major depressive disorder, or psychotic disorder, who were attending outpatient treatment.

Why is this study important?

If shown to be successful, TSF for individuals with co-occurring alcohol and severe psychiatric disorder could be a valuable clinical intervention by helping individuals with severe mental illness and AUD to function better in the community and have better quality of life.

What did this study do?

The research team randomized 121 individuals with AUD and co-occurring psychotic (18%), bipolar (36%), or major depressive disorder (46%) attending an outpatient program that caters specifically to individuals with co-occurring disorder to receive treatment as usual (TAU; n = 38) by itself, or with an add-on TSF intervention designed specifically for patients with severe co-occurring disorders (n = 83). The TSF treatment, adapted from the TSF intervention used in another large treatment study called Project MATCH, was tailored for those with co-occurring disorders by emphasizing:

  1. Double Trouble in Recovery (DTR) rather than Alcoholics Anonymous (AA) for recovery support
  2. The impact of psychiatric illness on one’s addiction
  3. Remaining engaged with psychiatric treatment
  4. Social skills training to prepare patients for the 12-step social milieu
  5. Transportation assistance to and from DTR meetings and therapy appointments
  6. Active linkage with a current member of DTR with 1+ years of continuous abstinence who attended the second session of treatment

The patients not randomized to receive the adapted TSF received only TAU, which consisted of medication monitoring, individual therapy, and case management. In other words, all patients received TAU, but TSF patients also received the intervention to encourage DTR attendance. Even though groups were randomized in such a way as to attempt to equate them on a number of characteristics so that the only thing that differed between the groups was whether they got TSF or not, the group of patients assigned to the TSF intervention, on average, still had greater alcohol abstinence and a higher percentage of individuals with another drug use disorder (e.g., marijuana) in addition to AUD at the start of treatment, which the authors mention in their study limitations.

The main clinical outcomes examined were percent days abstinent from alcohol (PDA) and drinking intensity (i.e., drinks per drinking day, or DDD), measured at the end of treatment (12 weeks), and 3-, 6-,  and 9-month follow-up assessments. Researchers tested whether TSF participants had significantly greater increases in PDA and significantly greater decreases in DDD during treatment and at the 9-month follow-up compared to patients receiving only TAU. Researchers used the 12-step Participation Questionnaire to measure participants’ completion of 12-step work in addition to other central 12-step activities and beliefs including having a sponsor and considering oneself a 12-step member…

What did this study find?

Compared to TAU patients, TSF patients were more likely to attend a 12-step meeting during treatment (66% vs. 30%) including DTR and traditional 12-step meetings, such as AA. They also attended a higher number of 12-step meetings during treatment (11 vs. 3 percent days attending a meeting), and reported greater levels of 12-step activities/beliefs both during treatment and at 9-month follow-up. Despite their greater participation in 12-step groups, TSF patients and TAU patients had similar positive changes in PDA and DDD during treatment, that were maintained, on average, by the 9-month follow-up with no group differences. See figures below for the change in PDA and DDD during treatment, and across the 3-, 6-, and 9-month follow-ups broken down by group. They also had similar percentage of days taking their prescribed psychiatric medication and attendance at psychiatric treatment sessions (not pictured).

Because TSF promoted more 12-step attendance, but participants only attended 5 of 12 sessions, on average, the researchers examined whether greater participation in TSF was associated with better outcomes. Indeed, more TSF treatment sessions attended was associated with better PDA and DDD during treatment and at the 9-month follow-up. Also, in a time-lagged analysis that investigated the combined influence of 12-step attendance for the whole sample (i.e., regardless of which treatment they received) across the entire 1-year study period, where 12-step attendance at one time point predicted alcohol outcome at the next time point (e.g., baseline attendance on end-treatment outcomes, end-treatment attendance on 3-month follow-up, 3-month follow-up on 6-month outcomes, etc.), 12-step attendance was associated both with better PDA and DDD.

What does this study add to our understanding of recovery?

There are several important contributions of this study. First, in this sample of patients with co-occurring AUD and psychiatric disorders including psychotic, bipolar, and major depressive disorder, 12-step mutual-help attendance across all types of organizations (including both AA and DTR) was associated with better PDA and DDD, irrespective of treatment group, raising confidence in clinical referral to 12-step groups for this patient group.

This supports other research studies that have found that patients with a range of co-occurring disorders can do well in groups such as AA and NA (see here, for example). Second, an intervention designed specifically for individuals with co-occurring disorders, including an emphasis on DTR – the most well known 12-step group for these individuals – may promote increased 12-step participation, which appears to be maintained well after treatment delivery (up to 9 months afterward). Third, consistent with previous studies, adults with co-occurring disorders present unique challenges. These patients attended, on average, only 5 of 12 TSF sessions (compared to 8 of 12, on average, among SUD-only patients in Project MATCH), and maxed out at 11% days attending a community 12-step meeting (compared to more than 20% during treatment among SUD-only patients in Project MATCH).

An intensive, tailored intervention for this group including peer linkage and transportation to meetings appeared to be an effective strategy, though more innovative approaches may be needed to increase their treatment participation. For example, future studies might test whether group – versus individual therapy – may be a strategy to increase cohesion among the patients, make treatment attendance more attractive and engaging, and facilitate increased treatment attendance and better outcomes. Indeed, this group effect is one of the presumed curative components inherent in mutual-help organizations like DTR and AA. Another possibility suggested by study authors is contingency management, where patients might receive a reward for attending a session, thereby increasing their likelihood of attendance.

Link to Summary of Study

Link to original Study

Bogenschutz, M. P., Rice, S. L., Tonigan, J. S., Vogel, H. S., Nowinski, J., Hume, D., & Arenella, P. B. (2014).12-step facilitation for the dually diagnosed: a randomized clinical trial. J Subst Abuse Treat, 46(4), 403-411. doi: 10.1016/j.jsat.2013.12.009

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