Addiction Treatment: Reach From Real-world To Evidence-based Practice

October 30, 2013

Terence T. Gorski
October 30, 2013

Across_BarriersThe challenge of all addiction treatment professionals will be to develop a uniform biopsychosocial model of addiction, a developmental model of recovery, and a relapse prevention model based upon identifying and managing early relapse warning signs and developing an emergency plan to stop relapse quickly should it occur.

This goal is well within the reach of addiction professionals to achieve. Professionals, however, would have to use the information provided by government researcher regarding best practice and evidence-based treatment. The professionals in the field determine the best-practice standards. They are at the front line of taking research results and dapping for use in the real world.

The 586-page tome, which was published by Columbia’s National Center on Addiction and Substance Abuse (CASA), is based on large surveys of treatment providers, people who suffer from addiction and those in the general public, as well as a review of more than 7,000 publications on addiction.

It finds that most addiction care is administered by “addiction counselors” for whom there are no national standards of practice. It finds also that 14 states don’t require any education or licensing at all for addiction counselors. The risks to those seeking treatment can be dire: California is one of the states that allows uncredentialed providers, for example. In a recent case in that state, a sexual predator was found to be offering “intimacy therapy” to addicted teenage girls; treatment consisted of sex with him. Without oversight, there’s no way to stop people from preying on vulnerable people under the guise of addiction care.

Only six states require addiction counselors to have a minimum of a bachelor’s degree; just one requires a master’s degree, according to the CASA report. The main qualification for treating addiction in this country is having suffered from the disorder oneself — a standard of care that would be considered absurd if any other medical condition were involved.

Moreover, addiction treatment providers are typically not held accountable for their patients’ outcomes: the report found that nearly half of all patients with illegal drug problems are referred to treatment by the criminal justice system and, of course, it is the patients, not the counselors or program directors, who go to prison if they fail.

The new publication is not free of CASA’s ttendency toward hyperbole, however. It overstates the breadth of the addiction-treatment problem in the U.S. by arguing that anyone who takes any illegal drug needs help. The report makes the exaggerated claim that 16% of the U.S. population suffers from addiction (this includes cigarette smokers) and that an additional 32% are engaged in “risky” substance use.

The report’s estimates do highlight some inherent problems in the definition of addiction, particularly in the proposed definition slated for the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)the standard manual used to diagnose all mental disorders. The new DSM-5 definition, which collapses addiction under one diagnosis, instead of the current two, may well result in widespread over-diagnosis, opponents of the new definition say.

In the current DSM, addiction is described under two diagnoses: the short-term and less severe “substance abuse” (a classic case would be a college binge drinker who outgrows the behavior), and the chronic and more dangerous “substance dependence” (classic case: a full-blown alcoholic). DSM-5 would define all alcohol and other drug problems as substance-use disorders, which would be further characterized as “mild” “moderate” or “severe.”

The DSM-5‘s definition of “severe” substance use disorder will replace what was formerly known as addiction or dependence. That means that anyone who uses a drug but will never have a chronic problem would be diagnosed as “mildly” addicted — a condition that most people would see as akin to being “mildly” pregnant.

The CASA report points out that even under the current diagnostic rules, the lack of professional training of most treatment providers means that severity is rarely assessed adequately. Most people are therefore slotted into one-size-fits-all programs, typically based on the 12 steps of Alcoholics Anonymous. Such programs advocate total abstinence, a tack that offers little help to the majority of people whose problems aren’t severe, since they need guidance on moderation.

The dominance of the 12-step approach also leads to a widespread opposition to change based on medical evidence, particularly the use of medications like methadone or buprenorphine to treat opioid addictions — maintenance treatments that data have shown to be most effective. Other medications that are known to treat alcohol and drug addiction, such as naltrexone (reVia, Vivitrol), are also underutilized, while philosophical opposition to the medicalization of care slows uptake.

To fix these problems, CASA recommends a more careful definition of addiction and substance-use problems, as well as the requirement that all treatment providers be licensed as health-care organizations. CASA calls for national standards for accreditation of such care and for all physicians to receive required education about substance-use disorders in medical school.

The report notes that only 10% of people with substance-use problems seek help for them: given its findings about the shortcomings of the treatment system, that’s hardly surprising.

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Drug War Policy: Get Tough and Be Dumb Approaches To Addiction That Don’t Work

October 30, 2013

October 30, 2013

BARS_Black_HandsThe abuse and addiction to alcohol and other drugs are primarily and health problems, not criminal problems. Alcoholics and Drug Addicts are sick people who need to get well, not bad people who need to be punished. More investment should be made in early intervention and treatment.

Enforcement should once again focus upon major producers and dealers. Individual who break the law while using alcohol and other drugs should be punished for the crime they committed and referred to treatment for the related alcohol or drug use disorder.

Treatment has proven to be less expensive and more effective than criminal justice interventions.  Imprisonment for drug status offenses is the most expensive and least effective way to deal with the nation’s alcohol and drug problems. A primary focus on enforcement at the expense of treatment is a GET TOUGH – BE DUMB policy that has not, cannot, and will not work.

People should be prosecuted for crimes committed under the influence of alcohol and/or drugs, the only exception being drug status offenses (i.e. personal possession and use). Drunk driving, for example, is a crime and people should be responsible for putting others in harm’s way. Mandatory drunk driving programs that include treatment have much lower recidivism rates than just legal punishment of the drunk driving. Drunk driving is and should be a crime. Public intoxication is not a crime in most states. Separating the symptoms of addiction from other criminal behaviors makes it easier to see when treatment vs. punishment is most appropriate.

We need to separate the disease of alcoholism and drug addiction from criminal behavior.  This is hard to do under two conditions:

(1) When people attempt to excuse all criminal behavior as a symptom of addiction and use treatment to avoid punishment; and

(2) When all alcohol and drug use is viewed as a crime to be severely punished under the mistaken belief that punishment will somehow cure addiction.

To make these distinctions we need to carefully think about our drug laws, the war on drugs, and the diagnostic standards used for both addiction and antisocial personality disorder.

Getting convicted of a drug felony can be a real buzz-killer when looking for a job in a crumbling economy. It seems like in America today no one can ever repay his or her debt to society. I know addicts with over 20 years of sobriety who were arrested and convicted on drug status offenses for personal possession and use who still find it to be a problem when trying to get a job or a security clearance.

“Only alcoholics or addicts can make themselves sober responsible people.
The only thing the legal system can do 
is to make them miserable if they refuse to try.”
~  Judge Dennis Challeen ~

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Twelve Step Programs – Conclusions From Research

October 29, 2013

Alcoholics ?anonymous (A.A.) is a science-based intervention with proven effectiveness. A.A. is more effective than non-treated control groups and equally effective to Cognitive Behavioral Therapy (CBT) and Motivational Interviewing. This issue is settled in the scientific literature. I have a bibliography of over 200 published articles that support the effectiveness of 12-Step Programs.

Nothing works for everyone. 12-step programs are no exception. People who had a bad experience with 12-Step programs are not reliable reporters. Neither are A.A. advocates who see 12-Step Programs doing all things for all people.

Twelve Step Programs are well-known and utilized in the United States. Of the US adult population:

  • 9% have been to an AA meeting at some time,
  • 3.6% in the prior year, only about one-third of these for problems of their own.
  • About one-half these percentages, mostly women, have attended Al-Anon.
  • Of the same population, 13.3% indicate ever attending a 12-step meeting (including non-alcohol-oriented groups), 5.3% in the last year.
  • During the prior year a further 2.1% used other support/therapy groups and 5.5% sought individual counseling/therapy for personal problems other than alcohol. In contrast to this high reported utilization, only 4.9% (ever) and 2.3% (12-months) reported going to anyone including AA for a problem (of their own) related to drinking. (Room and Greenfield 1993)

Research into 12-Step effectiveness shows clearly that Twelve Step Programs are effective in helping many people recover from alcoholism and drug dependence. Twelve-step programs get many of their members as a result of referrals from professional counselors, therapist, and doctors.

Many people who achieve long-term recovery use other forms of counseling and therapy at various points in their recovery. They use what I call a “12-Step Plus” Approach. Most people use professional counseling and therapy in addiction to working the 12-Step Program. Some people, however, have found recovery through professional therapy and support groups, like SMART Recovery, that are not based on the 12-Steps.

Many people in long-term recovery use 12-Step Programs very heavily in the first one to three years although the frequency of meetings goes down after that. Many people who start in 12-Step programs and achieve a stable recovery significantly reduce or stop attending meetings and do well. Most in this category start attending meetings again or increase the frequency of meeting during highly stressful periods of life.

Twelve Step programs are the single most effective, least expensive, and most readily available recovery program world-wide. As such, it is being supported by managed care companies in order to reduce the price of healthcare. The tendency to refer to A.A. is expected to increase as the Affordable Health Act (ACA) imposed greater demands for cost containment.

Twelve step programs work better when used in conjunction with other forms of counseling, therapy, and treatment.

Relapse rates in 12-Step Programs, and all forms of addiction treatment, are highest in the first 90 days. This is the period of recovery where people are most toxic from the effects of long-term alcohol and drug poisoning to the brain. It is a time of change and crisis. It is the period of time when recovery supports have not yet been firmly established. Detoxification and residential or day treatment are valuable to get people stabilized in this critical first 12 weeks of recovery.

After five years of continuous sobriety relapse in a group of alcoholics is less likely than having addiction develop in a similar group who has never had an addiction.

The comparative effectiveness of 12-step and cognitive-behavioral (C-B) models of substance abuse treatment was examined among 3,018 patients from 15 programs at the US Department of Veterans Affairs Medical Centers. Across program types, participants showed significant improvements in functioning from treatment admission to a 1-year follow-up. Although 12-step patients were somewhat more likely to be abstinent at the 1-year follow-up, 12-step, C-B, and combined 12-Step–C-B treatment programs were equally effective in reducing substance use and improving most other areas of functioning. The finding of equal effectiveness was consistency over several treatment subgroups: Patients attending the “purest” 12-step and C-B treatment programs, and patients who had received the “full dose” of treatment. Also, patients with only substance abuse diagnoses, those with concomitant psychiatric diagnoses, and patients who were mandated to treatment showed similar improvement at the 1-year follow-up, regardless of type of treatment received. These data provide important new evidence supporting the effectiveness of 12-step treatment. (Ouimette 1997)

References

Ouimette, Paige Crosby; Finney, John W.; Moos, Rudolf H., Twelve-step and cognitive-behavioral treatment for substance abuse: A comparison of treatment effectiveness. Journal of Consulting and Clinical Psychology, Vol 65(2), Apr 1997, 230-240.

ROOM, R. and GREENFIELD, T. (1993), Alcoholics anonymous, other 12-step movements and psychotherapy in the US population, 1990. Addiction, 88: 555–562.

You can find other studies with a simple search on Google scholar searching on Twelve Steps Outcomes and Twelve Step Facilitation (TSF).

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AMAZON: GORSKI’S UNDERSTANDING THE 12-STEPS

GORSKI BOOK: GORSKI’S UNDERSTANDING THE TWELVE STEPS

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Managing Relapse In Treatment – What’s The Best Policy?

October 28, 2013

spiral_staircaseBy Terence T. Gorski

Should patients be discharged if they have been caught using alcohol or other drugs?

This is a tough question. I see two conflicting values that have t be balanced:

  • The well-being of the individual vs.
  • The well-being of the treatment/ recovery program.

Treatment professionals need to carefully think about this issue and set a policy and procedure after looking at all sides of the issue. Here are some suggestions I have made to treatment programs:

1.         At admission, let patients clearly know that the program is based upon abstinence.

2.         Ask the patient to make a formal statement and sign an agreement documenting their decision to stop using alcohol and other drugs.

3.         Let them know the difference between a relapse (i.e. involuntarily giving in to a craving) and deception (choosing to use and deciding to hide it). Be clear that selling alcohol or drugs is grounds for immediate discharge.

3.         If someone starts to use and they self-report before being caught using, the treatment plan needs to be suspended and an evaluation done to determine the needs of the patients. Something didn’t work in the previous treatment plan if the person is using.

4.         If someone starts to use and hides it, stabilize and evaluate. Have a very high level of suspicion the patient didn’t lose control but got caught. The dishonesty about it is the problem. Once stable, give them a chance to explain what happened and what will be different. The burden is on them to prove they learned something.

5.         If the policy is punitive, especially with patients facing consequences in the real word for returning to use, the patient will have good reason to try to cover the initial lapse. The members of the recovering community in the treatment center will be more likely to protect and enable them.

6.         Make it the responsibility of the community to protect the sober environment. Do it in a way that does not reinforce the jail house mentality of “ratting someone out,” and neither does it set up a “witch hunt mentality.”

7.         Never, ever (did I say never) have the patient community vote on whether the patient stays or leaves. This is a clinical decision that needs to be made by professional staff.

This approach can be summarized as follows:

(1)       Stop business as usual.

(2)       Stabilize and evaluate the relapsed patient.

(3)       Do a comprehensive evaluation that takes into account the individual needs of the patient and the needs of the patient community.

(3)       Honestly involve the patients in the community in open fact-finding, putting the relapsed patient’s needs first until stabilized, and then seeing that a decision flows from an orderly decision-making process and not an emotional knee-jerk reaction.

(4)       If the decision is made for the patient to stay, the patient needs to present and analysis of the relapse warning signs that led up to the chemical use, the lessons learned in terms of what they can do differently if these warning start showing up again, and what is their new plan to recognize and manage the warning signs and work on the issues that trigger obsession, compulsion, drug seeking behavior, and use.

(5)       It is also important to openly talk about who knew this patient was in trouble before they used or was using but hid it from the staff and patient community. This should lead into a discussion of enabling. Each patient should discuss how they want the community to deal with them if they are showing warning signs or if someone in the community thinks they have started using.

A WORD ABOUT ALCOHOL AND DRUG TESTING

I find testing to be of limited value. Usually the staff suspects the person is in trouble with their recovery or has started using. This is what motivated them to have the patient tested. If the staff can’t notice the different response in patients who are abstinent and working at their recovery, and those who are using alcohol and other drugs, something is very wrong., It would be a priority to evaluate why the staff can’t develop close enough relationships with the patients to notice.

HAVING A POLICY brings all of these difficult ideas out into the daylight. This is a very important area that many professional are reluctant to discuss. There are no right or wrong policies in this regard. The policy is either well thought out, puts the needs of both the relapsed patient and the community as important concerns, stabilizes and assesses the relapsed patient, and develops a plan based on what the assessment reveals..

It to be the highest integrity and most consistent option to recognize the chemical use immediately, suspend the existing treatment plan (it’s obviously not working anyway), and then stabilize the patient and do an extensive guided self-assessment of what happened and what should be done.

RECOGNIZE –> INTERVENE –> STABILIZE –> ASSESS –> NEW PLAN 

 “I would say it is unethical to discharge a patient for being symptomatic of their disease. This is client abandonment, and violates the principle of Fidelity. I am pretty sure the state of California is actually going to put this into regulations. 

That doesn’t mean you ignore it and go back to business as usual. If the “common welfare” demands that they be out of the program they I would say you have an ethical obligation to try to place (not just refer) them in another program. Ideally you would have an MOU with other programs and agree to accept each other’s placements in cases like this. Just don’t kick them out with an outdated referral sheet. As professionals we have to consider that we may have failed the client in some way; another reason to not be too rigid.” ~ Fr. Jack Kearney, M.Div., CATC IVBoard Member/Past President at California Association for Alcohol & Drug Educators (CAADE) 

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Relapse Prevention (RP) Is An Evidence-Based Intervention

October 28, 2013

RP_CENAPSBy Terence T. Gorski

Prevention (RP) is an evidence-based intervention. There is compelling evidence in the literature documenting its effectiveness.

First, let’s look at the results of a meta-analysis of 26 published and unpublished studies with 70 hypothesis tests representing a sample of 9,504 participants. (Irvin et al, 1999)

  • Relapse Prevention (RP) was found to be a widely adopted cognitive-behavioral treatment (CBT) for alcohol, smoking, and other substance use.
  • RP was generally effective, particularly for alcohol problems.
  • RP was most effective with alcohol or polysubstance use disorders combined with the adjunctive use of medication

Validation of Gorski’s Relapse Warning Signs

Though it has enjoyed widespread popularity, Gorski’s post-acute withdrawal syndrome (PAWS) model of relapse has been subjected to little scientific scrutiny. A scale to operationalize Gorski’s 37 warning signs was developed and tested in a larger prospective study of predictors of relapse. Of central interest were: (1) whether the warning signs hypothesized by Gorski are interrelated in a meaningful single factor and (2) whether the hypothesized syndrome would accurately predict subsequent relapses.

A sample of 122 individuals (84 men) entering treatment for alcohol problems was followed at 2-month intervals for 1 year. The Assessment of Warning-signs of Relapse (AWARE) scale was administered at each assessment point, and the occurrence of both slips (any drinking) and relapses (heavy drinking) was monitored during each subsequent 2-month interval. Principal factor analysis was used to study the factor structure of the warning signs.

The results showed that: (1) Of the 37 warning signs, 28 clustered as a robust single factor with excellent internal consistency (Cronbach’s alpha: 0.92-0.93); (2) A conservative evaluation of test-retest stability across 2-month intervals estimated reliability at r = 0.80. (3) After covarying for prior drinking status, clients’ AWARE scores significantly predicted subsequent slips and relapses. Relapse rates for clients with highest AWARE scores, as projected by regression equations, were 33 to 46 percentage points higher than those for clients with lowest AWARE scores, after taking into account prior drinking status.

The conclusion is that this scale of Gorski’s warning signs appears to be a reliable and valid predictor of alcohol relapses. (J. Stud. Alcohol 61: 759-765, 2000)

Relapse Prevention (RP): Controlled Clinical Trials (Carroll 1996)

(1)       More than 24 randomized controlled trials have evaluated the effectiveness of cognitive-behavioral relapse prevention treatment on substance use outcomes among adult smokers, alcohol, cocaine, marijuana, and other types of substance abusers. Review of this body of literature suggests that, across substances of abuse but most strongly for smoking cessation,

(2)      There is evidence for the effectiveness of relapse prevention compared with no-treatment controls across all drug categories.

(3)       Outcomes in which relapse prevention may hold particular promise include reducing:

  • Severity of relapse episodes when they occur;
  • Maintaining the positive effects of improvements made during treatment (enhanced durability of effects)

(4)       The positive effects of RP are enhanced by patient-treatment matching.

(5)       Patient-treatment matches improves outcomes for patients at higher levels of impairment along dimensions such as psychopathology or dependence severity.

References

The CENAPS Model of Relapse Prevention was originally developed by Terence T. Gorski and continually updated to integrate new research findings. (Gorski 1990, )

Carroll, Kathleen M., Relapse prevention as a psychosocial treatment: A review of controlled clinical trials. Experimental and Clinical Psychopharmacology, Vol 4(1), Feb 1996, 46-54.

Gorski, Terence T., The CENAPS Model of Relapse Prevention: Basic Principles and Procedures, Journal of Psychoactive Drugs, Vol. 22, Issue 2, 1990, pages 125- 133, ON THE INTERNET: http://www.tandfonline.com/doi/abs/10.1080/02791072.1990.10472538

Irvin, Jennifer E.; Bowers, Clint A.; Dunn, Michael E.; Wang, Efficacy of relapse prevention: A meta-analytic review. Journal of Consulting and Clinical Psychology, Vol 67(4), Aug 1999, 563-570.

Miller, William R. and Harris, Richard J.  A Simple Scale of Gorski’s Warning Signs for Relapse, Journal of Studies on Alcohol and Drugs, Volume 61, 2000, Issue 5: September 2000 ON THE INTERNET: http://www.jsad.com/jsad/article/A_Simple_Scale_of_Gorskis_Warning_Signs_for_Relapse/814.html

 


Post-Acute Withdrawal (PAW): The Symptoms

October 27, 2013

By Terence T. Gorski

Post Acute Withdrawal (PAW) is a cluster of symptoms that occur in recovering addicts and alcoholics. PAW symptoms usually begin to occur between seven and fourteen days after the acute period of withdrawal, and usually peak between three and six months after the start of abstinence.

Post-Acute Withdrawal (PAW) Syndrome is also referred to as:

– The protracted withdrawal syndrome,

– Chronic brain toxicity,

– Long-term neuropsychological impairment

– Long-term neuro-cognitive impairment

Acute withdrawal (AW) is composed of physical symptoms that occur as a result of stopping the use of a drug after the addict has develop tolerance and dependence.

– Tolerance means that the body adapts to the constant use of large quantities of the primary drug of choice. As a result it takes more and more of the drug to experience the desired effect from taking the drug.

– Dependence means that the body learns to function normally with a high dose of the drug. When they stop taking the drug they experience symptoms of acute withdrawal.

– Symptoms of Acute Withdrawal (AW) includes shakes, vomiting, chills, muscle soreness and cramps, headaches, diarrhea or constipation, extreme skin sensitivity, sensitivity to light, and more. PAW begins to emerge as AW symptoms begin to subside.

PAW is a bio-psycho-social syndrome that results from the combination of damage to the nervous system caused by alcohol or drugs and the psychosocial stress of coping with life without drugs or alcohol.

PAW symptoms can be divided into the following six groups or clusters:

1.  Difficulty Thinking Clearly:  PAW causes recovering people to have difficulty recognizing and solving usually simple problems, making decisions, concentrating, understanding abstract concepts, and stopping rigid and repetitive ways of thinking.

2.  Difficulty Managing Feelings: PAW creates the tendency to vacillate between emotional overreactions or emotional numbness;

3.  Difficulty Remembering Things: PAW causes people to have difficulty remembering what they learn and understand. The memories tend to fade after several hours something. It’s as if the memories are not shifted from short-term memory to long-term memory.

4.  Difficulty Sleeping Restfully: PAW causes sleep disturbances. Many recovering people have difficulty falling asleep and sleeping restfully. Their sleep is fitful; they awaken many times during the night, and do not feel rested after sleep.

5.  Problems With Physical Coordination: Recovering people often have difficulty with hand-eye coordination and controlling fine muscle movements. They also have problems with balance and can easily feel dizzy and disoriented.

6.  Stress Sensitivity: Recovering people tend to be stress sensitive. This means that a low level of stress can cause an exaggerated reaction on their brain and nervous system. Living in high stress, which is necessary in facing the challenges of early recovery, cause the problems with managing thoughts, feelings, memory, and sleep to become even more severe.

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Twelve Step Facilitation (TSF) – An Evidence-based Intervention

October 27, 2013
TSF is an evidence based approach for educating, motivating, and referring people to A.A. and other 12- Step Programs.The information in the book is a complete compilation of all the information used in the TSF programs that I helped many treatment programs to develop. The book is based upon my personal interpretation of 12-Step Programs and information that proved effective in getting people to attend with and open mind.Many like it. Some hate it. Most say that it is worth the read. The book makes it easy to easy to pick and choose the information that you think is important and quickly build your own Twelve Step Facilitation Program.The book presents practical information about how to understand and get involved in 12-Step Programs. The book is written in a way that helps people to bridge the gap between Cognitive Restructuring for Addiction and the principles and practices that underlie 12-Step Programs.Studies of patterns of A.A. attendance over a seven you period of time show that people tend to follow one of four distinct patterns:A.A. ATTENDANCE IN LONG-TERM RECOVERYMany people assume that people who find sobriety in A.A. or other 12-Step Programs must regularly attend 12-Step meetings for the rest of their lives or they will relapse.

I have not believed that since the 1970’s. The A.A. Membership Survey shows that people often attend 12-Steps meetings heavily in the first two years of recovery, and then reduce attendance during the 3rd. thru 7th. years of recovery.

A recent study followed the A.A. attendance of 586 dependent alcoholics interviewed by telephone 1, 3, 5 and 7 years after initial referral and a starting base-line of meeting attendance was determined right after treatment. All patients were referred to A.A. as a result of addiction treatment. This referral process today is called Twelve-Step Facilitation (TSF).

This following classification of recovering people based upon their patterns of A.A. attendance was developed. These were:

Group 1: Low Attendance Group: Averaging fewer than 5 meetings at most follow-ups;
Group 2: Medium Attendance Group: Averaging about 50 meetings a year at each follow-up;
Group 3: Descending Attendance Group: About 150 meetings in year 1, then decreasing steeply);
Group 4: High Attendance Group: (about 200 meetings at 1 year, then decreasing gradually by year 7).

DECLINES IN MEETING ATTENDANCE WERE NOT ALWAYS ACCOMPANIED BY DECREASES IN ABSTINENCE.

After accounting for the effect of time on AA attendance, treatment exposure was minimally related to AA attendance in all but the descending AA group, where it was negatively associated (p < 0.001).

Considering AA patterns over time highlights a different role for treatment in AA attendance than what is gleaned from analyses at single time points.

Research; Lee Ann Kaskutas, Jason Bond and Lyndsay Ammon Avalos. Addictive Behaviors, Volume 34, Issue 12, December 2009, Pages 1029-1035

Gorski Book:
Understanding The Twelve Steps

RELATED GORSKI BLOGS
– Personality Change and The Twelve Step Plus Approach
– Is A.A. Legally A Religion?
– Twelve-Step Facilitation (TSF): An Evidence-based Approach


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