It’s no coincidence that my best subjects at school were the ones where my teachers taught enthusiastically, connected me up to useful resources, had high expectations of me and who gave affirmation and encouraged progress. From my experience of working in addiction treatment, while accepting teaching is not the same as treatment, I think effective practitioners are likely to share many of these qualities. The quality and nature of our therapeutic relationship and what we do will have powerful effects on outcomes.
Mutual Aid Guidelines
We know that there is a solid (and growing) body of evidence that connection to community recovery resources results in better outcomes for those seeking recovery. Mutual aid is particularly well researched. In the UK, our national Guidelines on Clinical Management (known as the ‘Orange Book’) state:
The combination of mutual aid with treatment is associated with enhanced outcomes. Participation in mutual-aid groups is associated with improved long-term recovery rates, improved functioning across a range of domains, and a reduction in post-recovery costs to society. The risk of relapse following recovery initiation rises in relation to the density of drug users in the post-treatment social network and declines in tandem with social network support for abstinence.
The guidelines also note:
The likelihood of a service user’s engagement with mutual aid is influenced by professional attitudes towards it.
Guidelines to Practice
A few years ago, one of the alcohol and drug treatment commissioning bodies in a Scottish city undertook a needs assessment. One of the many things they asked a sample of 250 service users at that time in a range of treatment services in the city was ‘have you ever been to Alcoholics Anonymous or Narcotics Anonymous?’ (This was in the days before SMART Recovery and Cocaine Anonymous). The answers were pretty stunning.
Fewer than 1% of service users had ever been to AA and fewer than 0.5% of service users had ever been to NA. Given that these service users were in regular contact with treatment professionals, it seems reasonable to say that we weren’t doing our jobs quite as well as we might have. Times move on and where it was once unusual to come across people who self-identified as being in recovery in our services, we now have peer supporters in many services acting as a bridge to recovery community resources. We also have guidance on how to facilitate attendance at meetings.
Here and Now
I was heartened to find this week that, in in the Midlands of England at any rate, things are much better than they apparently used to be. However, closer analysis shows that we’ve still a way to go on this.
Ed Day from Birmingham and Sabrina Kirberg & Nicola Metrebian from London have just published a paper (1) looking at affiliation to AA or NA in a sample of 200 patients attending a specialist treatment service in a metropolitan borough in the West Midlands. Using a questionnaire, they explored past attendance and affiliation and also future readiness to attend AA or NA meetings.
What did they find? Well, 31% had ever attended AA and 41% NA. But when they asked about attendance in the last year only 14% had attended AA and 24% NA. Now we know that attendance at mutual aid is associated with fewer relapses – Mark Litt and colleagues found in their randomised controlled trial (2) that ‘the addition of just one abstinent person to a social network increased the probability of abstinence for the next year by 27%.’ We can’t get this sort of reduction of relapse with medication, so it’s a very important finding. This should be a no-brainer. Why are we still so poor at connecting people up to other recovering people?
Day and colleagues have something to say on this. They highlight expressed barriers including professional objections to elements of the 12-step programme and patient embarrassment at attending meetings. They also point out that data from their study is reassuring that patients are more likely to see the benefits of engagement than the negatives.
A highly relevant issue is that many of the patients with drug problems in the study were on opiate replacement therapy and that not all of them had abstinence as a primary goal, raising questions about whether NA is the right philosophical match.
The authors suggest some solutions:
- Encourage the development of non-12-step groups as an alternative to NA (they acknowledge the relative lack of research on other groups)
- Educate professionals about 12-step groups on the basis that increased staff knowledge is associated with staff recommending attendance
- Develop a broader approach which increases knowledge, changes staff patient interactions and looks at organisational change.
It is the last of these three that intrigues me. I’m drawn to the idea that those with lived experience of addiction and recovery and members of NA, AA and SMART Recovery have much to offer in terms of being the bridge from treatment to mutual aid. Have meetings in community treatment settings. Invite mutual aid members in to talk to service users and use the skills of recovering people as peer supporters in treatment and support settings. They are, after all, the recovery experts on this issue. Such an approach will increase the number of successful connections and is also likely to significantly influence professional attitudes for the better.
(1) Day, E., Kirberg, S. and Metrebian, N. (2019), “Affiliation to alcoholics anonymous or narcotics anonymous among patients attending an English specialist addiction service”, Drugs and Alcohol Today, Vol. 19 No. 4, pp. 257-269. https://doi.org/10.1108/DAT-05-2019-0017
(2) Litt, M. D., Kadden, R. M., Kabela-Cormier, E., & Petry, N. M. (2009). Changing network support for drinking: network support project 2-year follow-up. Journal of consulting and clinical psychology, 77(2), 229–242. doi:10.1037/a0015252