Mutual Help Groups for People with Co-Occurring Disorders

Joan E. Zweben, Ph.D.Executive Director, East Bay Community Recovery

ProjectClinical Professor of Psychiatry, UCSF

Staff Psychologist, VA Medical Center, San Francisco

ASAM Med Sci – Chicago – April 27, 2013

Dilemmas for People with COD COD’s are the norm, not the exception Mental illness is an “outside” issue in

the 12-Step system Individuals describe lack of empathy

and acceptance in traditional groups (Magura 2008)

Bill W. castigated when he sought psychotherapy for severe depression (Hartigan 2000)

Where to find a “home”?

Outline

Mutual help groups within mental health

Integrated support groups for people with COD

Preparing people with COD to attend meetings

Mutual Help within Mental Health

Basic Characteristics Antipsychotics fueled

deinstitutionalization (1960’s forward); support groups flourished

Many groups are supported by outside organizations: psychiatric institutions, govt entities, community organizations

Membership need not consist of people with psychiatric disorders

Some collect membership fees

Recovery International Founder: Abraham Low, MD, 1937 Goal: reduce negative consequences of

habituated thoughts and behaviors; prevent relapses leading to hospitalization (precursor to CBT)

Peer-based training Five levels of fees: $30 - $1000 Currently 600 peer led community

meetings in US and elsewhere

Study Report: Univ Illinois, Chicago (2011) Decreased mental health sx Reduction in use of mental health &

social services Improved self esteem; confidence in

ability to achieve recovery Willingness to ask for help & support Increased social connectedness, hope,

coping mastery ability, overall mental health

Fountain House

WANA (We Are Not Alone) Started in 1940’s in NY by Michael

Obolensky to help transition and provide vehicle for socializing and fellowship

Evolved into Fountain House, a psychosocial rehabilitation clubhouse community in the 1950’s, with the addition of professional staff.

Emotions Anonymous (EA)

Founded in St. Paul in 1971 Goal: working toward recovery

from emotional difficulties through adapted version of 12-Steps

Seen as a complementary support activity; recommended by mental health professionals

Depressed Anonymous (DA)

Founded 1986; formalized late 1990’s

Goal: Empower people into therapeutic healing; “help ourselves and others escape the prison of depression”

Medication, religion, not discussed at meetings

Has closed online group; limited number of face-to-face meetings

Schizophrenia Anonymous (SA)

Founded 1985; 150 groups, 30 states and international

Partner: SARDAA (Schiz & Related Disorders Alliance of America)

Purpose: restore dignity; increase sense of purpose; improve attitudes and lives regarding illness; disseminate latest info; encourage recovery

Effectiveness of Mutual-Aid Self-Help Participation (MH) Does involvement lead to improve

psychological and social functioning? 12 studies met criteria for group

characteristics, target problems, outcome measures, research design

Promising evidence of benefits for people with chronic mental illness, depression/anxiety, bereavement

Variable design quality; need more and better research

Integrated Mutual Support Groups for People with Co-Occurring Disorders

Challenging Issues

COD population is heterogeneous, varying in diagnosis and severity

Emerged late 1980’s, but # groups still limited

50% with SMI have substance issues, but tailoring groups for them is difficult

DRA: Dual Recovery Anonymous

Launched 1989; Central Office established 1993; international by 2001

Requirements: desire to stop AOD use; desire to manage emotional & psychiatric illness in a constructive way

Addresses concerns about misguided advice at other 12-Step mtgs

Mtgs chaired and run by DRA members

Double Trouble

Founded in Philadelphia in 1987 Mtgs initially run by peers Professionals acted as advisors; later

began running the groups Shifted away from self-help, grew into

an agency providing psychiatric services

Currently a component of psychiatric services

DTR: Double Trouble in Recovery - I

Started by Howard Vogel in 1989; moved to greater control by professional organizations

Financial assistance by NY allowed them to train peer group leaders; consumers start and conduct groups, can get ongoing support

Estimated 200-250 grps, mostly in NY area

DTR: Double Trouble in Recovery - II

Increasingly intertwined with federal, state, local agencies in provision of services

Do not adhere to their stated nonaffiliation policy

Hazelden now the exclusive publisher of materials and supplies

Research on Dual Focus Groups - I

Overemphasis on abstinence and insufficient attention to mental health issues were barriers to participation in single-topic groups (Havassy et al 2009)

SMI: barriers were stigma, meds issues not addressed, difficulty in finding peers, decreased referrals from clinicians (Villano et al 2005).

Research on Dual Focus Groups - II

Enhanced engagement promotes participation (Bogenshutz 2005)

Modified 12-step facilitation intervention increased attendance and decreased substance use during 12 week of tx (Nowinski et al, 1994).

Change mechanisms (self efficacy, social support) similar to others (Bogenshutz 2007)

Research on Dual Focus Groups - III

Intensive referral intervention enhanced participation; better 6 month outcomes (Timko et al 2011)

Pts attended 4 sessions; given information, discussion, practice opportunities

Volunteer available to accompany them to meetings

Male veterans also benefit from intensive referral efforts (Makin-Byrd et al 2011)

Preparing People with COD to Attend Meetings

Specialized & Mainstream Meetings

Limited # specialized groups are available

Mainstream clients in addition for stronger support system

Prepare them to attend mainstream meetings; handle issues that can arise

Use existing manuals & materials

Benefits for People with COD

Predictable, clear structure can be container for anxiety

Pts who are anxious and depressed can be linked with assistance to get to mtg

Simplicity & redundancy beneficial (e.g., cognitive impairment, thought disorder)

“No crosstalk” is protective; relatively nonintrusive

Preparing People with COD to Attend Meetings - I

Familiarize pts with history, culture, traditions, rituals and other practices

Address fears about groups (MAAEZ)

SMI – case managers take pts to initial meetings; provide cell phone access when clients begin to go alone

Preparing People with COD to Attend Meetings - II

Select meetings carefully for people with SMI; look for tolerance of eccentric behavior

Instruct pts how to behave (e.g., do not discuss delusions and hallucinations)

Be alert for possibility that higher power can be incorporated into delusional system

Preparing People with COD to Address Medication Issues

Medication issues can be considered private, though honesty is strong value

Use AA materials to validate the view that medication is compatible with recovery

Role play handling of the medication issue if challenged in a meeting

References

Zweben, Joan E., & Ashbrook, Sarah. (2012). Mutual Help Groups for People with Co-Occurring Disorders. Journal of Groups in Addiction & Recovery, 7, 202-222. Joan.Zweben@UCSF.eduSlides: www.ebcrp.org