A randomized controlled trial of intensive referral to 12-step self-help groups: One-year outcomes

Abstract

Objective

This study implemented and evaluated procedures to help clinicians make effective referrals to 12-step self-help groups (SHGs).

Methods

In this randomized controlled trial, individuals with substance use disorders (SUDs) entering a new outpatient treatment episode (N = 345; 96% had previous SUD treatment) were randomly assigned to a standard referral or an intensive referral-to-self-help condition and provided self-reports of 12-step group attendance and involvement and substance use at baseline and at six-month and one-year follow-ups (93%). In standard referral, patients received a schedule for local 12-step SHG meetings and were encouraged to attend. Intensive referral had the key elements of counselors linking patients to 12-step volunteers and using 12-step journals to check on meeting attendance.

Results

Compared with patients who received standard referral, patients who received intensive referral were more likely to attend and be involved with 12-step groups during both the first and second six-month follow-up periods, and improved more on alcohol and drug use outcomes over the year. Specifically, during both follow-up periods, patients in intensive referral were more likely to attend at least one meeting per week (70% versus 61%, p = .049) and had higher SHG involvement (mean = 4.9 versus 3.7, p = .021) and abstinence rates (51% versus 41%, p = .048). Twelve-step involvement mediated the association between referral condition and alcohol and drug outcomes, and was associated with better outcomes above and beyond group attendance.

Conclusions

The intensive referral intervention was associated with improved 12-step group attendance and involvement and substance use outcomes. To most benefit patients, SUD treatment providers should focus 12-step referral procedures on encouraging broad 12-step group involvement, such as reading 12-step literature, doing service at meetings, and gaining self-identity as a SHG member.

Introduction

Twelve-step self-help groups (SHGs) are recognized as important to the system of care for substance use disorder (SUD) patients. By providing continuing support and structure, SHGs serve to reduce rates of post-treatment relapse and subsequent treatment utilization (O’Brien and McClellan, 1996). The American Psychiatric Association (1995) recommends referrals to SHGs for patients with SUDs, and large proportions of active 12-step group members first initiated meeting attendance because of a referral from a SUD treatment program (Thomassen, 2002).

This study implemented and evaluated procedures to help clinicians make more effective referrals to 12-step SHGs. SUD outpatients were randomly assigned to a standard referral or an intensive referral-to-self-help condition. We examined whether intensive referral, compared to standard referral, increased patients’ SHG attendance and involvement (e.g., having a sponsor) over two consecutive six-month follow-up periods. We also determined whether patients who received intensive referral had better substance use outcomes over the year. Further, we determined the extent to which more 12-step SHG attendance and involvement were related to better substance use outcomes.

Although most formally treated SUD patients are referred to SHGs (Humphreys, 1997), under usual referral, patients often do not attend or drop out of these groups quickly (Chappel, 1991, Humphreys et al., 1999, Littrell, 1991). An early study of individuals with alcohol use disorders (AUDs) and spouses of such individuals found that all 10 clients in an intensive referral condition attended SHGs (Alcoholics Anonymous [AA] or Al-Anon) over four weeks, compared to none of 10 clients in the standard referral condition (Sisson and Mallams, 1981). In intensive referral, the client called a SHG member during a counseling session to arrange to go to a meeting together. In standard referral, the counselor provided a description of self-help, a meeting schedule, and encouragement to attend SHG meetings.

Project MATCH found that outpatients in a 12-week Twelve Step Facilitation (TSF) treatment condition, which encouraged AA attendance, had more AA attendance and involvement during treatment, and at one- and three-year follow-ups, than did clients in a Cognitive Behavioral (CB) Therapy or Motivational Enhancement Therapy condition (Carroll et al., 1998, Project MATCH Research Group, 1998, Tonigan et al., 2002). Consistent with Project MATCH, the VA Multisite Evaluation of Substance Abuse Treatment found that, at a one-year follow-up, SUD patients in TSF or combined TSF/CB programs were more likely than patients in CB programs to have attended SHG meetings, and were more involved in self-help (e.g., were more likely to talk with a sponsor, and to read AA and/or Narcotics Anonymous [NA] literature) (Humphreys et al., 1999). In contrast to Sisson and Mallams’ (1981) intensive referral condition, TSF was much more than a referral to AA (Project MATCH Research Group, 1997), but the intensive referral and TSF were broadly comparable in that both encouraged participation in SHGs. Based on these and preliminary findings from the sample of SUD patients studied here (Timko et al., 2006), we expected that intensive referral to self-help, compared to standard referral, would result in more 12-step SHG meeting attendance and involvement at both six months post-referral and six months after that.

Preliminary findings on this sample also indicated that, compared to patients who received standard referral, those who received intensive referral had better alcohol and drug use outcomes at six months. In this paper, we extend this work by examining the effects of referral condition on SHG attendance and involvement and SUD outcomes at one year, and considering the extent to which involvement mediated the association between referral condition and one-year outcomes. With regard to mediation, among cocaine-dependent patients, higher scores on an index assessing both 12-step group involvement and endorsement of 12-step philosophy partially mediated the positive relationship between receiving outpatient counseling that encouraged participation in 12-step groups and more improvement on drug use outcomes during a six-month follow-up period (Crits-Christoph et al., 2003). Another study of cocaine-dependent patients found that 12-step SHG attendance did not predict subsequent drug use, but more 12-step SHG involvement in a given month predicted less cocaine use in the next month (Weiss et al., 2005). These results underscore the distinction between attendance and involvement and the need to consider the role of involvement in improved SUD outcomes over time.

To summarize, this project used a randomized design in which patients entering outpatient SUD treatment were assigned to either standard or intensive referral to 12-step SHGs. Patients were followed at six months and one year to determine whether intensive referral resulted in more 12-step SHG attendance and involvement and in better substance use outcomes. We also examined the extent to which 12-step involvement predicted better substance use outcomes above and beyond SHG meeting attendance, and mediated between referral condition and substance use outcomes.