12-STEP FACILITATION REHABILITATION:
SOME EVIDENCE OF EFFICACY
Philip Todd summarises statistics on alcohol dependence as a public-health problem and shares some research on the efficacy and cost effectiveness of 12-step facilitation treatment in treating patients with severe alcohol problems.
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Alcoholism is a significant public-health problem: deaths directly related to alcohol consumption have risen every year since 2001 (Department of Health 2008). In the UK, about 38% of men and 16% of women aged 16-64 have an alcohol use disorder – equating to over 8million people in England alone (Drummond et al 2005). The same study found that 6% of men and 2% of women meet the criteria for alcohol dependence, equating to over 1million people nationally.
The number of alcohol-dependent people seeking treatment each year is about 63,000 – a tiny proportion of the alcohol-dependent population. The consequences of the misuse of alcohol for society, communities, families and individuals are immense and the treatment of alcoholism is a public-health priority.
In arguing for a more rational scale of harm for drugs of misuse, David Nutt and colleagues concluded that, in relation to the physical harm to the individual, the potential for addiction, and the wider effects on families, communities and society, alcohol is of a similar class of harm as heroin and cocaine, and is ranked only behind heroin in terms of the social harm caused (Nutt, King, Saulsbury & Blakemore 2007). Others have commented that addiction to alcohol can be regarded as more serious in many respects than addiction to illegal drugs and affects many more people (Gossop 2003).
Many theories of addiction have been proposed to understand individual differences in drug-seeking and drug-taking behaviour, and to explain its continuation in the face of detrimental consequences (West 2001). But there is now general consensus that addiction is a biopsychosocial condition (Wanigaratne 2006) with multiple aetiologies, with genetic, psychological and environmental factors contributing in varying degrees across individuals.
In keeping with this model, modern approaches to treatment are multidimensional and consistent with a holistic view of addiction treatment requiring an individualistic approach. For those with severe alcohol use disorders, including dependence, a therapeutic approach based on a goal of long-term abstinence is usually seen as most appropriate.
This subcategory refers to those with severe dependence and typically serious alcohol-related problems, people who would have once been labelled as chronic alcoholics. Specific causative factors are seen of less relevance for recovery than an acceptance of both the loss of control and the need for abstinence. The goal is to increase the client’s self-understanding and to make changes in their cognitions, emotions and behaviour.
Many fitting into this subcategory will have serious and longstanding problems, will typically have experienced severe alcohol withdrawal and high tolerance, and might have had withdrawal fits or delirium tremens. They might have formed the habit of drinking to counter or avoid incipient withdrawal symptoms. In the Alcohol Needs Assessments Research Project, they are defined as scoring 30 or more on the SADQ. Many will have had several previous episodes of treatment. More intensive treatment in specialist settings is usually indicated for such people with severe alcohol dependence who are seeking treatment (Raistrick, Heather &Godfrey 1996).
This being so, a 12-step facilitation approach can often be the most efficacious therapeutic intervention. TSF combines many counselling elements of other psychosocial methods but also encourages attendance and participation at AA meetings during and after treatment.
In Project Match, three treatments were effective, but clients receiving 12-step counselling were more likely to achieve and maintain abstinence (Crits- Christoph et al 1999) and functioned better on secondary outcome variables relating to quality of life.
Project Match also found that those clients with a social network supportive of heavy drinking (eg, those with numerous heavy drinking friends and/or family members) performed better under TSF than alternative approaches. This is most likely because attendance at AA meetings is the most effective way of eliminating heavy-drinking friends from one’s social network (Longabaugh, Wirtz, Zweben &Stout 1998). Similarly, active participation in self-help groups in itself is thought likely to provide an alternative source of non-drinking social support (Connors, Tonigan & Miller 2001).
Clients undergoing TSF treatment were better able to adopt approach, rather than avoidance, coping strategies on discharge, had fewer psychological symptoms of distress, were more likely to maintain stable remission than clients from similar treatments which did not involve AA, and less likely to succumb to social pressure relapses (Ouimette, Moos & Finney 2002b).
AFTERCARE COST EFFECTIVENESS
Other studies also attested to the potential for interventions using self-help groups to reduce use and costs of health care post-treatment. In one study, people who engaged with AA compared to those treated without it had 45% lower alcohol-related healthcare costs over a three-year period. This was achieved despite the AA-facilitated people having relatively lower incomes and poorer educational attainment, and more adverse consequences of drinking pre-treatment, suggestive of worst prognoses (Humphreys & Moos 1996).
By increasing patients’ use of self-help groups, TSF can thus lower subsequent healthcare costs in contrast to patients in alternative cognitive-behavioural programmes who received more inpatient and outpatient care after discharge, resulting in 64% higher one-year and 30% two-year annual healthcare costs (Humphreys& Moos 2001, 2007).
In relation to TSF residential and daycare rehabilitation, the cost savings are sometimes increased significantly by the provision of “aftercare for life” which provides counselling and advice at times of vulnerability to relapse in patients who successfully completed a treatment programme. This is likely to significantly enhance cost savings as patients remain abstinent – without a publicly funded healthcare regime.
EVIDENCE OF EFFICACY OF TSF
The tables (click print-friendly version at top) show the results from studies which sought to investigate the relationship between treatment and subsequent attendance at 12-step groups. The implications, that have been widely accepted from other studies, include that:
o Increased attendance and/or involvement in 12-step groups relate to reduced substance use
o Combined 12-step and formal treatment leads to better outcomes than found for either alone
o Consistent and early attendance/involvement leads to better substance-use outcomes than inconsistent, low levels, later or no involvement
o There might be a minimal ‘threshold’ of meeting attendance needed to lead to better substance-use outcomes; even small amounts of participation might help increase abstinence
o 12-step involvement during an initial period post-treatment predicts substance-use outcomes during subsequent months; these reductions in substance use were not attributable to potential third variable influences such as motivation, psychopathology, or severity
o Longitudinal studies associate AA participation with greater likelihood of abstinence, improved social functioning and greater self-efficacy; participation seems more helpful when members engage in other group activities in addition to attending meetings
o 12-step self-help groups significantly reduce healthcare use and costs
o Self-help groups are best viewed as a form of continuing care rather than as a substitute for acute treatment services
o Patients are less likely to become involved in 12-step activities if left to do so on their own than if more active encouragement and referral are provided in treatment (Humphreys 1999; Weiss 2000; Sisson & Mallams 1981)
o Treatment programs that are12-Step based produce higher rates of self-help participation than other types (Humphreys 1997)
o Professional facilitation strategies increase engagement in mutual-help groups (Project Match Research Group 1997; Carroll et al 1998; Humphreys et al 1999)
o Patients from 12-step based treatment seem to gain more (have better outcomes) from self-help participation then patients from non-12-step based treatment (Humphreys 1997)
o Treatment is the time to initiate 12-step attendance; if 12-step attendance is not initiated then, it is unlikely to happen
o 12-step meeting-attendance frequency effectively predicted both abstinence from substance use, as well as number of drinking days for 139 young women, age 17-23, attending 12-step-based residential treatment for a substance use disorder
Other supportive studies include an analysis of six-year outcomes of community residential treatment for patients with substance use disorders (2008) which examined systematically how predictors of substance-use treatment outcomes worked in over 2,000 male patients. “Greater substance use severity, more psychiatric symptoms, more prior arrests and stronger belief in AA-related philosophy at treatment entry predicted improvement significantly in substance-related problems four years later. At the one-year follow-up, being employed and greater use of AA-related coping predicted outcome significantly,” the research confirmed.
Taken overall, the available evidence shows that no one theoretical approach yields treatments which are more effective than any other – but there is evidence that some approaches might be more effective for particular categories of client.
Structured day-care programmes can be highly effective and can be the setting of choice for many people. There is evidence, however, that residential placements can bring added benefits to groups including: people with more severe dependencies, the homeless, people with unsupportive home environments, the socially isolated, the medically unwell, people who are psychiatrically disturbed, those with severe personality disorders, and those who ‘failed’ previously in daycare settings.
Intensive treatment, whether in residential or daycare settings, should be followed by ongoing professional aftercare. Without such follow-up, treatment is likely to prove of limited value. While it should not be seen as a substitute for professional aftercare, attendance at self-help groups can significantly enhance outcomes.
Abstinence-based recovery programmes via TSF rehabilitation can be the most appropriate and cost-effective treatment with severe substance use disorders. Evidence from well-controlled studies attests to the enhanced efficacy of such an approach for severely dependent drinkers. Part of the treatment effect is attributable to the facilitated entry to 12-step groups.
Such self-help groups provide many of the therapeutic ingredients of more formal interventions, while remaining free and readily available to those in recovery.
The TSF approach can therefore provide significant cost savings to the taxpayer. For the individual sufferer and their families, the route to recovery offered is of inestimable value.
PHILIP TODD has a MSc in addiction psychology and is a Mount Carmel rehab graduate. For a full reference list on request, contact PhilipTodd121@yahoo.co.uk.