mutual help groups for people with co-occurring disorders joan e. zweben, ph.d. executive director,...
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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. [email protected]: www.ebcrp.org