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Drug and Alcohol Dependence 118 (2011) 194– 201

Contents lists available at ScienceDirect

Drug and Alcohol Dependence

j ourna l ho me pag e: www.elsev ier .com/ locate /drugalcdep

ntensive referral to 12-step dual-focused mutual-help groups

hristine Timko ∗, Anne Sutkowi, Ruth C. Cronkite, Kerry Makin-Byrd, Rudolf H. Moosenter for Health Care Evaluation, Department of Veterans Affairs Health Care System, and Stanford University Medical Center, 795 Willow Road (152-MPD),enlo Park, CA 94025, USA

r t i c l e i n f o

rticle history:eceived 19 November 2010eceived in revised form 15 March 2011ccepted 24 March 2011vailable online 22 April 2011

eywords:ual diagnosisutual-help groups

eferral practicesubstance use and mental health outcomes

a b s t r a c t

Background: This study implemented and evaluated procedures to help clinicians effectively refer duallydiagnosed (substance use and psychiatric disorders) patients to dual-focused mutual-help groups (DFGs).

Methods: Using a cohort cyclical turnover design, individuals with dual diagnoses beginning a newoutpatient mental health treatment episode (N = 287) entered a standard- or an intensive-referral condi-tion. Participants provided self-reports of 12-step mutual-help (DFG and substance-focused group [SFG])attendance and involvement and substance use and psychiatric symptoms at baseline and six-monthfollow-up. The intensive referral intervention focused on encouraging patients to attend DFG meetings.

Results: Compared to patients in the standard condition, those in the intensive referral interventionwere more likely to attend and be involved in DFGs and SFGs, and had less drug use and better psychiatricoutcomes at follow-up. Attending more intensive-referral sessions was associated with more DFG andSFG meeting attendance. More need fulfillment in DFGs, and more readiness to participate in SFGs, were

associated with better alcohol and psychiatric outcomes at six months. However, only 23% of patients inthe intensive-referral group attended a DFG meeting during the six-month follow-up period.

Conclusions: The intensive referral intervention enhanced participation in both DFGs and SFGs and wasassociated with better six-month outcomes. The findings suggest that intensive referral to mutual-helpgroups focus on its key components (e.g., linking patients to 12-step volunteers) rather than type of group.

. Introduction

Patients with both substance use and psychiatric disordersave high rates of posttreatment relapse and additional carepisodes (Chen et al., 2006). Mutual-help groups, especially those inhich psychiatric medications are recognized as useful, may pro-

ide an element of continuing care that improves dual diagnosisatients’ treatment outcomes (American Psychiatric Association,995). Most treated dual diagnosis patients are referred to 12-stepubstance-focused groups (SFGs) such as Alcoholics AnonymousHumphreys, 1997). However, under usual referral, many dual diag-osis patients do not attend SFGs, and those who do often drop outuickly (Noordsy et al., 1996). Furthermore, although dual diagno-is patients benefit from SFGs, they may benefit more from 12-stepual-focused groups (DFGs) (Magura, 2008).

This study implemented and evaluated a procedure to help

reatment providers make effective referrals to DFGs. We exam-ned whether intensive referral, compared to standard referral,ncreased dual diagnosis outpatients’ DFG and SFG attendance and

∗ Corresponding author. Tel.: +1 650 493 5000x2 23336; fax: +1 650 617 2736.E-mail address: ctimko@stanford.edu (C. Timko).

376-8716/$ – see front matter Published by Elsevier Ireland Ltd.oi:10.1016/j.drugalcdep.2011.03.019

Published by Elsevier Ireland Ltd.

involvement over a six-month follow-up period. We also deter-mined whether patients who received intensive referral had bettersubstance use and psychiatric outcomes. Finally, we examinedlinks between better attendance at intensive referral sessions and12-step group participation, and between more 12-step group par-ticipation and outcomes.

1.1. Dual-focused mutual-help groups

Dually diagnosed individuals benefit from membership in DFGs,which are designed for persons who have both substance use disor-ders and mental illness (Laudet et al., 2004). Magura (2008) foundthat more frequent and sustained attendance at Double Troublein Recovery was associated with better substance use, psychi-atric, and personal functioning outcomes. Members considered thegroup important for recovery, partly because they felt free to talkabout their mental illness and psychiatric medications. Consis-tently, dually diagnosed individuals with experience in DFGs were

positive about the groups (Bogenschutz et al., 2002), and dual diag-nosis patients who attended DFGs had significant improvementsin global functioning and housing, and decreased hospitalizations,over two years (Hensley, 2004).

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Based on these studies and recommendations (Kelly et al., 2003;acks et al., 2008a; Westermeyer, 2006) that clinicians foster stableffiliation with DFGs, Bogenschutz (2005) piloted an interventiono help dually diagnosed individuals engage with Double Trouble inecovery. The intervention modified 12-Step facilitation (Tonigant al., 2002a,b) by addressing psychiatric issues, eliminating Step 4made an inventory of ourselves), assigning patients a case man-ger, giving rides to meetings, and introducing patients to a groupember. Attendance at both DFGs and SFGs increased, and alco-

ol use and psychiatric symptoms decreased, during treatment.lthough Bogenschutz (2005) and Magura (2008) studies indicate

hat dually diagnosed patients respond positively to DFGs, rel-tively few individuals treated for dual diagnoses attend DFGs,nd little is known about the extent to which DFG attendancend involvement are associated with better outcomes (Kelly andeterian, 2008). In the short-term, dual-focused interventions mayave more positive benefits for psychiatric than for substance useutcomes (Back et al., 2006a,b; Hien et al., 2010; Read et al., 2004;acks et al., 2008b).

.2. SFGs for dual diagnosis patients

In debate about dually diagnosed patients’ participation in andenefit from SFGs (Bogenschutz et al., 2006; Ouimette et al., 2003),

concern is that SFGs emphasizing the primacy of addictionsay invalidate patients’ perceptions of mental illness as the pri-ary problem and increase their distress (Ouimette et al., 2001).

FGs may be perceived as objecting to psychotropic medicationsBogenschutz and Akin, 2000; Ortman, 2001) and SFG members

ay be seen as lacking empathy and acceptance (Magura, 2008;owbray et al., 1995). Dually diagnosed patients often fail to

ndorse the 12-step philosophy that they are powerless over sub-tances (Handymaker et al., 2002; Luke et al., 2002), minimize theirubstance use (Jordan et al., 2002), and have difficulty accepting thedea of a Higher Power (Satel et al., 1993). Interpersonal avoidancessociated with psychiatric disorders may also make membershipnd sponsorship in SFGs problematic (Jordan et al., 2002).

Despite these concerns, dually diagnosed patients attend SFGst rates approaching those of individuals with only substance useisorders (Westermeyer and Schneekloth, 1999). When dual diag-osis patients attend AA or NA, they benefit from participationChi et al., 2006; Ouimette et al., 2001; Timko and Sempel, 2004).owever, these studies have focused primarily on associations ofeeting attendance with substance use outcomes, and little on

ther aspects of SFG involvement, such as sponsorship and workinghe steps, or on psychiatric symptoms (Bogenschutz et al., 2006).

In summary, dual diagnosis patients may benefit more fromFGs than SFGs. Because effective approaches for referral to DFGsre needed, we developed an intensive referral procedure. Dualiagnosis patients entering outpatient mental health treatmenteceived either standard or intensive referral to DFGs, and wereollowed at six months to determine whether intensive referralesulted in more DFG and SFG attendance and involvement, and inetter substance use and psychiatric outcomes. We also examinedssociations between intensive referral attendance and 12-steparticipation, and between 12-step participation and outcomes.

. Methods

.1. Sample

Patients were included on the basis of: (1) entering outpatient mental healthreatment at a Department of Veterans Affairs (VA) program in northern Califor-

ia, (2) identified by case managers as having dual substance use and psychiatricisorders based on the program’s standard assessment procedures and medicalecord review (see Seal et al., 2007, 2010, regarding VA medical record diagnoses),nd (3) screened by case managers as cognitively able to understand study proce-ures. Of 343 patients screened, 17 were ineligible and 39 refused to participate,

endence 118 (2011) 194– 201 195

leaving a sample of 287 individuals. Of the 287 patients, at six months, nine weredeceased or incarcerated. An additional 57 were not located, or were located andeither refused participation or did not participate in scheduled assessments. Thesix-month follow-up rate was 80% (N = 221) among patients still alive and not incar-cerated. The followed and not-followed groups did not differ (using chi-square andt-tests) on condition or baseline characteristics (see Table 1 for a list) except thatfollowed patients were somewhat better educated and less likely to be homeless(p < .05).

The treatment was evidence-based (e.g., using Cognitive-Behavioral and Mind-fulness approaches), multidisciplinary, and emphasized teaching skills (e.g., relapseprevention, symptom or stress management), typically in two group sessions perweek. After being introduced to the study, participants provided written consent.Stanford University’s Institutional Review Board approved study procedures.

2.2. Procedure

2.2.1. Counselor training. Counselors (Social Workers, Addiction Therapists whoprovided treatment and both conditions; N = 5) attended a training that detailedthe standard and intensive intervention protocols. In a practice phase, counselorswere monitored by senior project staff while they implemented the interventionswith patients who were training cases; their data were not analyzed for this report.Specifically, two groups per counselor were observed, rated, and supervised usingthe fidelity checklist (see below), and counselors were then certified.

2.2.2. Condition assignment. Patients were assigned to the intensive-referral(N = 142) or standard-referral (N = 145) condition using a recurrent institutionalcycle design (Shadish et al., 2002). Under this design, the intensive and standardreferral conditions were delivered in a group counseling format and run in alternatethree-month periods over 12 months. The main reason for using the cycling designwas that patients in the same program talk to each other and, under random assign-ment and simultaneous intensive and standard groups, would become aware thatsome were receiving intensive referral whereas others were not. This would haveraised a risk of contamination between conditions (Kahler et al., 2004).

2.3. Conditions

2.3.1. Standard referral. In the standard referral condition, during the outpatientsession after study entry, the counselor gave patients a schedule of local 12-stepDFG meetings and used a standardized script to encourage attendance. Counselorswere asked not to provide patients in the standard condition with components ofintensive referral. They were not asked to refrain from referring patients to 12-stepSFGs, which is the usual practice.

2.3.2. Intensive referral. The intensive referral condition included patients’ atten-dance at four additional outpatient group sessions within one month; four sessionskept the intervention brief yet allowed patients to build rapport. During Session 1,the counselor gave patients a schedule of local DFG meetings with specific directionsto them, and reviewed a handout on DFG meetings from Dual Recovery Anonymous.The counselor elicited and discussed patients’ pros and cons of attending DFGs.

At Session 2, the counselor asked if patients had questions about the handout.This session consisted mainly of a 12-step DFG orientation (Mueser et al., 2003).The counselor outlined what meetings are like and the group had a practice meet-ing. The counselor discussed group etiquette and patients role-played introducingthemselves to someone new (Bellack et al., 1997; Mueser and Glynn, 1999).

At Session 3, the counselor arranged for a DFG member to volunteer to come tothe session. Volunteers gave a brief personal history and arranged to meet patientsand attend a meeting together.

At Session 4, the counselor asked patients if they had attended a DFG meeting;if not, the counselor helped the patient contact a volunteer by phone to arrangeanother opportunity to attend a meeting together. The counselor reviewed a hand-out (from Double Trouble in Recovery) on how and why to obtain a sponsor, provideda list of available local DFG sponsors, and explained how to obtain a temporary spon-sor. The counselor addressed patients’ concerns about asking for and working witha sponsor and patients role-played (Bellack et al., 1997; Mueser and Glynn, 1999)asking someone to be a temporary sponsor.

2.4. Fidelity

Patients completed checklists rating each of the four group sessions. When rat-ings were aggregated across sessions, most participants indicated having receivedthe main components of the intensive referral intervention: e.g., did the group talkabout going to 12-step meetings (100% said yes); counselors checked that patientshad local DFG meeting schedules (100%); counselors reviewed the DFG handout(100%); group discussed pros and cons of different self-help groups (100%); group

role-played introductions to someone new (97%); group practiced a DFG meeting(98%); DFG volunteer visited (97%); patient agreed to attend a DFG meeting withthe volunteer (98%); group discussed getting a DFG sponsor (100%); and counselorsgave patients a list of DFG sponsors (80%). In addition, observers rated intensivesessions as to whether they delivered their key components; ratings ranged from

196 C. Timko et al. / Drug and Alcohol Dependence 118 (2011) 194– 201

Table 1Comparisons of patients in the standard- or intensive-referral condition on baseline characteristics.

Standard Intensive X2(p) t(p) Overall Sample

Percent male 89.7 92.3 .59(.44) 90.9Percent Caucasian 51.7 45.8 1.02(.31) 48.8Mean age (SD) 51.2(8.8) 50.9(9.0) .28(.78) 51.0(8.9)Mean years education (SD) 13.4(1.8) 13.5(1.8) −.65(.52) 13.5(1.8)Percent employed 40.7 50.4 2.68(.10) 45.5Percent married 9.0 12.0 .66(.42) 10.5Percent homeless 30.3 33.1 .28(.62) 31.7

Percent diagnosed with:a

Major depression, mood disorder 61.4 64.1 .22(.64) 62.7PTSD 36.6 35.9 .01(.91) 36.2Other anxiety disorder 19.3 26.1 1.86(.17) 22.6Schizophrenia, schizoaffective disorder 12.4 11.3 .09(.76) 11.8Bipolar disorder 11.7 14.1 .35(.55) 12.9

Percent diagnosed with: 2.91(.23)Alcohol use disorder only 8.3 14.0 11.1Drug use disorder only 22.2 24.5 23.3Alcohol and drug use disorder 69.4 61.5 65.5

Mean ASI composite score (SD):Alcohol .157(.230) .190(.213) −1.24(.21) .174(.222)Drugs .068(.085) .079(.083) −1.11(.27) .073(.084)Psychiatric .404(.201) .408(.191) −.16(.87) .406(.196)

Mean no. of days use in past 30 (SD)Alcohol 10.0(5.7) 8.4(5.7) .87(.38) 9.3(5.7)Drugs 16.8(9.0) 17.4(9.1) .88(.41) 17.1(9.1)

Mean no. psychiatric symptoms (SD) 2.1(1.4) 2.2(1.4) −.55(.58) 2.2(1.4)Mean importance, additional psychiatric treatment 2.7(1.5) 2.9(1.4) −1.31(.19) 2.7(1.5)Mean medication adherence (SD) 1.4(1.3) 1.4(1.2) −.33(.75) 1.4 (1.3)

Percent attended DFG, lifetime 23.4 21.8 .11(.74) 22.6Percent attended DFG, past two years 17.9 16.2 .15(.70) 17.1Mean no. DFG meetings, lifetime (SD) 3.3(11.5) 1.8(5.9) 1.45(.11) 2.5(9.2)Mean no. DFG meetings, past two years (SD) 1.2(3.9) .8(2.9) .90(.18) 1.0(3.4)

Percent attended SFG, lifetime 96.6 98.6 1.30(.26) 97.6Percent attended SFG, past two years 90.3 93.0 .64(.42) 91.6Mean no. SFG meetings, lifetime (SD) 458.9(874.1) 524.5(1148.1) −.55(.59) 491.3(1017.7)

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5% (Session 4: role-played asking for a sponsor) to 100% for most components (e.g.,ession 3: visit by DFG volunteer).

.5. Measures

.5.1. Baseline. Self-report data, including demographics, previous mutual-helproup utilization, and substance use and psychiatric status, were collected fromatients at intake.

.5.2. DFG and SFG participation. At baseline, patients reported whether they hadttended any DFG meetings in their lifetime and during the past two years, and ifo, how many. Patients were reminded that DFGs are for people with both mentalllness and substance abuse, and include groups such as Dual Recovery Anonymousnd Double Trouble in Recovery.

At baseline, patients reported on whether they had attended any SFG meetingsn their lifetime and during the past two years, and if so, how many. They wereeminded that SFGs include Alcoholics Anonymous and Narcotics Anonymous, andot the DFGs asked about before. Support is good for the reliability and validity ofelf-reports regarding mutual-help group participation (Morgenstern et al., 1997;onigan et al., 2002a,b; Walitzer et al., 2009).

.5.3. Substance use and psychiatric status. The Addiction Severity Index (ASI)McLellan et al., 1985a,b), a structured clinical research interview, assessed alco-ol use, drug use, and psychiatric functioning. In each area, questions focus on theumber and duration of symptoms in the patient’s lifetime and past 30 days (McKayt al., 1994). ASI composites range from 0 to 1, with higher scores indicating poorerutcomes. Studies support the validity of self-reports of alcohol and drug use (Babort al., 1987; Calhoun et al., 2000; Darke, 1998; Hersh et al., 1999) and psychiatricymptoms (Herman et al., 2002; Kirsner et al., 2003; Ready et al., 2002; Voruganti

t al., 1998).

We also used two clinically-relevant ASI measures of substance use status, andwo of psychiatric status. For substance use, we used the number of days patientssed alcohol, and used drugs, in the past 30. For psychiatric status, one measure washe count of six symptoms measured dichotomously (0 = no, 1 = yes) that patients

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reported in the past month (e.g., serious depression, serious anxiety/tension). Forthe other measure, patients rated the importance of additional treatment for theirpsychological problems (0 = not at all, 4 = extremely).

2.5.4. Medication adherence. Patients completed the four-item Medication Adher-ence Questionnaire (e.g., When you feel better do you sometimes stop taking yourmedicine? Yes/No; alpha = .74) (Thompson et al., 2000). Lower scores indicate betteradherence. Self-reports of medication adherence are valid and reliable (DiMatteo,2004; Garber et al., 2004; Sirey et al., 2001).

2.5.5. Follow-up. The six-month telephone follow-up was conducted by trainedresearch assistants blinded to patients’ condition. It covered DFG and SFG partic-ipation, and substance use and psychiatric outcomes. ASI follow-up interviews areconducted validly and reliably over the telephone (Fureman et al., 1990).

2.5.6. DFG participation. To measure 12-step DFG attendance and involvement, weused the AA Inventory (Tonigan et al., 1996, 2002a,b) and the AA Affiliation Scale(Humphreys et al., 1998). We replaced items’ use of “AA” with “12-step dual-focusedself-help group,” and specified to what the latter term referred. Items are listedin Table 2; for dichotomous items, no = 0 and yes = 1. Toward the top of Table 2,four composites are listed: (1) overall involvement, which is the sum of the 14involvement items (alpha = .91), (2) number of DFG steps worked, (3) need ful-fillment in DFGs attended (alpha = .86), and (4) readiness for DFG participation(alpha = .96).

Need fulfillment was the sum of five items (e.g., extent to which group meetingsmet your needs) rated on a 0 to 3 scale; higher scores represented more fulfill-ment. Readiness was the sum of six items (e.g., how ready are you to attend a DFG,work the steps, obtain a sponsor) rated 1 = not ready, 2 = thinking about, 3 = ready,

or 4 = already doing; higher scores represented greater readiness to participate inDFGs.

2.5.7. SFG participation. Procedures to measure SFG attendance and involvementparalleled those for DFG participation (see Table 3). Patients were reminded about

C. Timko et al. / Drug and Alcohol Dependence 118 (2011) 194– 201 197

Table 2Comparisons of patients in the standard- or intensive-referral condition on dual-focused group (DFG) attendance and involvement at the six-month follow-up.

Standard Intensive X2/t

DFG attendanceAttended meeting (percent)a 13.5 23.1 3.62*

Number of meetingsattended (mean, SD)

3.7 (3.3) 9.7 (8.9) 2.70**

DFG involvementOverall involvement (mean,SD)

4.3 (2.6) 5.4 (3.1) 1.18

No. steps worked (mean, SD) .8 (1.4) 2.7 (3.5) 2.45*

Needs fulfillment in groups(mean, SD)

8.6 (4.0) 9.6 (2.7) .89

Readiness (mean, SD) 6.5 (2.4) 7.3 (2.5) 1.08

DFG involvement items (percent)Read literature 83.3 83.3 .00Shared honestly at meetings 72.2 79.2 .27Socialized with group peers 70.8 83.3 .91Read out loud at a meeting 58.3 72.2 .87Did service at meetings 33.3 38.9 .14Gave a talk at a meeting 29.2 33.3 .08Had a spiritual awakening 16.7 25.0 .43Consider self to be a groupmember

25.0 66.7 7.46**

Made phone calls to grouppeers

12.5 16.7 .15

Celebrated a sobriety birthday 8.3 27.8 2.81*

Called a member for help 4.2 16.7 1.88Chaired a meeting 4.2 11.1 .74Attended 90 meetings in 90days

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Table 3Comparisons of patients in the standard- or intensive-referral condition onsubstance-focused group (SFG) attendance and involvement at the six-monthfollow-up.

Standard Intensive X2/t

SFG attendanceAttended meeting (percent)a 69.9 84.5 7.00**

Number of meetingsattended (mean, SD)

54.9 (44.9) 73.7 (97.3) 3.73*

SFG involvementOverall involvement (mean,SD)

7.9 (3.2) 8.1 (3.2) .25

No. steps worked (mean, SD) 3.1 (3.9) 4.2 (3.3) 1.84*

Needs fulfillment in groups(mean, SD)

11.0 (2.8) 11.1 (2.8) .28

Readiness (mean, SD) 9.4 (2.3) 9.5 (2.5) .30SFG involvement items (percent)

Read literature 88.4 90.3 .18Shared honestly at meetings 84.9 90.3 1.23Socialized with group peers 78.8 80.6 .09Read out loud at a meeting 84.9 89.5 .85Did service at meetings 62.0 65.1 .19Gave a talk at meetings 44.0 52.3 1.24Had a spiritual awakening 37.6 39.5 .07Consider self to be a groupmember

58.1 66.7 1.39

Made phone calls to grouppeers

54.8 64.8 1.54

Celebrated a sobrietybirthday

62.4 70.9 1.48

Called a group member forhelp

45.3 46.2 .01

Chaired a meeting 20.9 29.3 1.68Attended 90 meetings in 90days

15.1 9.4 1.32

Have a sponsor 33.3 41.9 1.39

* **

p < .05, p < .01.a Analysis for this variable used all participants; otherwise, analyses used partic-

pants who went to a DFG meeting.

he groups referred to (e.g., AA, NA). Alphas were .92, .83, and .95 for overall involve-ent, need fulfillment from SFGs attended, and readiness, respectively.

.5.8. Substance use and psychiatric status. The ASI provided composite scores onatients’ alcohol and drug use and psychiatric functioning at the six-month follow-p. Participants were also asked how many days out of the past 30 they had usedlcohol and drugs. No use of alcohol or drugs was classified as abstinent; and anyse as not abstinent. Psychiatric status was measured, as at baseline, by the count ofix psychiatric symptoms reported, and patients’ perceived need of additional helpor psychiatric problems.

.5.9. Medication adherence. Medication adherence was assessed at follow-up as ataseline.

.6. Analysis

After comparing the standard and intensive referral groups at baseline on demo-raphic and diagnostic characteristics, psychiatric and substance use status, andrior DFG and SFG attendance (N = 287, all baseline participants), we compared theroups on DFG and SFG attendance and involvement at follow-up by conducting chi-quare analyses and t-tests (N = 221, all participants followed). We also comparedatients in the standard and intensive referral groups on substance use and psy-hiatric outcomes at follow-up by conducting Analyses of Covariance; the covariateas the baseline value of the outcome. We used correlations to examine associa-

ions between attending intensive referral sessions and six-month indices of DFGnd SHG participation. Regressions were also conducted predicting ASI alcohol, drug,nd psychiatric composite scores at six months, entering the baseline value of theomposite and condition (block 1), an indicator of DFG or SFG participation (block), and the interaction between condition and the block 2 indicator (block 3).

. Results

.1. Baseline characteristics

There were no differences between patients in the standardnd intensive referral groups on baseline demographic or clinicalharacteristics (Table 1). The sample was mainly male, non-white,iddle aged, and, despite having had some college education,

p < .05 p < .01.a Analysis for this variable used all participants; otherwise, analyses used partic-

ipants who went to a SFG meeting.

unemployed. Few patients were married, and almost one-thirdwere homeless.

At baseline, the most common psychiatric diagnosis was majordepression, followed by PTSD, other anxiety disorders, schizophre-nia, and bipolar disorder (Table 1). In addition, patients were mostlikely to have both alcohol and drug use disorders; the main drugsof choice were cocaine, cannabis, and amphetamines. There wereno group differences on alcohol, drug, or psychiatric severity ormedication adherence.

At baseline, the two groups did not differ on lifetime or recentDFG meeting attendance (Table 1). Across groups, less than one-quarter of patients had ever attended a DFG meeting; they hadattended an average of only 2.5 such meetings in their lifetime.DFG attendance in the past two years was quite low.

At baseline, the two groups also did not differ on lifetime orrecent SFG meeting attendance (Table 1). In contrast to DFG partic-ipation, almost all patients had ever attended a SFG meeting; theyhad attended an average of almost 500 meetings in their lifetime.In addition, over 90% of patients had attended a SFG meeting in thepast two years, with an average of more than 80 meetings duringthat period.

3.2. DFG and SFG participation at follow-up

At the six-month follow-up, a higher proportion of patients inthe intensive-referral group attended a DFG meeting; however,

even among these patients, only 23.1% did so, compared to 13.5%in the standard group (Table 2). Among patients who attended aDFG, intensive-referral patients attended more DFG meetings thanstandard referral patients did. They also worked more dual-focused

198 C. Timko et al. / Drug and Alcohol Dep

Table 4Comparisons of patients in the standard or intensive referral condition on outcomesat six months controlling for the corresponding outcome at baseline.

Standard Intensive F

ASI composite (mean, SD)Alcohol .111 (.171) .095 (.178) .58Drugs .037 (.060) .030 (.059) .88Psychiatric .387 (.228) .333 (.199) 4.87**

Number of days used in past 30 (mean, SD)Alcohol 1.83(6.17) 1.31(4.56) .61Drugs 2.36(7.51) .66(2.66) 3.75*

Abstinent (percent)Alcohol 83.6 86.5 .40Other drugs 73.9 81.7 2.09Alcohol and other drugs 57.2 59.7 .20

Psychiatric statusNo. of symptoms 2.2 (1.5) 1.8 (1.4) 3.87*

Medication adherence (mean, SD) 1.1 (1.1) 1.1 (1.1) .08

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Need additional help (mean, SD) 1.9 (1.6) 1.4 (1.6) 4.54*

p < .05, **p < .01. Note: Adjusted means are displayed.

rogram steps and were more likely to consider themselves a DFGember, and to have celebrated a sobriety birthday with a DFG.A higher proportion of patients in the intensive-referral group

ttended a SFG meeting (Table 3). Among patients who attended aFG, intensive-referral patients attended more SFG meetings. How-ver, the groups did not differ on SFG involvement, except thatntensive-referral patients worked more of the 12 steps.

.3. Substance use and psychiatric outcomes

At six months, with baseline scores controlled, the groups didot differ on the ASI alcohol or drug composite, but patients inhe intensive referral group had less severe psychiatric problemsTable 4). Similarly, patients in the intensive referral group hadewer psychiatric symptoms and stated that they were less in needf additional treatment for psychiatric problems. Finally, intensive-eferral patients used drugs for a fewer number of days.

.4. Intensive referral attendance and DFG and SFG participation

Of patients assigned to the intensive referral condition, allttended at least one session (Mean = 2.6 sessions, SD = 1.1); 24.2%ttended one session, 23.2% attended two, 26.3% attended three,nd 26.3% attended all four. We examined associations betweenttending more intensive referral sessions and six-month indicesf DFG and SHG participation: attended at least one meeting; num-er of meetings attended; overall involvement; number of stepsorked; need fulfillment; and readiness. More attendance at inten-

ive referral sessions was associated with attending at least one DFGeeting (r = .189, p < .05) and greater readiness to attend DFG meet-

ngs (r = .177, p < .05). It was also associated with attending moreFG meetings (r = .234, p < .01) and being more involved overall inFGs (r = .169, p < .05).

.5. DFG and SFG participation and outcomes

The regressions showed that whether or not a DFG meeting wasttended (analyses included all patients followed at six months), orumber of DFG meetings attended (analyses included only patientsho attended a DFG meeting) did not predict ASI composite scores

t six months (with ASI scores at baseline and condition controlled).n addition, few indices of DFG involvement predicted ASI com-

osite scores at follow-up (controlling for ASI baseline scores andondition). Calling another DFG member for help (b = −.190) andore need fulfillment in DFGs (b = −.315) were associated with

better psychiatric outcome (p < .05). In addition, more need ful-

endence 118 (2011) 194– 201

fillment was associated with a better alcohol outcome (b = −.246,p < .05).

The interactions of condition by need fulfillment in DFGs(b = .401, p < .01), and by readiness to attend DFGs (b = .276, p < .05),predicted psychiatric outcomes. For patients in the intensive con-dition, more need fulfillment was related to better psychiatricoutcomes (b = −.517, p < .05), but this was not observed for patientsin the standard condition (b = −.161, p > .05). Similarly, for patientsin the intensive condition, more readiness was related to betterpsychiatric outcomes (b = −.229, p < .05), but this did not hold forpatients in the standard condition (b = −.039, p > .05).

Regressions also showed that whether or not a SFG meetingwas attended, or number of SFG meetings attended, did not pre-dict ASI composite scores at six months (with ASI scores at baselineand condition controlled). When involvement indices were used aspredictors, more readiness to attend SFG meetings was related tobetter psychiatric functioning (b = −.114, p < .05). Greater readinessto attend SFGs (b = −.163; p < .01) was also related to better alcoholoutcomes, as was being more involved overall with SFGs (b = −.198,p < .05). On involvement items, having celebrated a sobriety birth-day (b = −.124), telephoning group members (b = −.129), and havinga sponsor (b = −.132) were associated with better alcohol outcomes(p < .05). Interactions of condition by SFG participation were notsignificant predictors of ASI composite scores. In regressions witha significant 12-step group participation predictor, adjusted R2sranged from .18 to .26 (p < .05)

4. Discussion

Compared to patients receiving standard referral, a higher pro-portion of dually diagnosed patients receiving intensive referral toDFGs attended a DFG meeting over the next six months. In addi-tion, patients in the intensive referral group who went to at leastone DFG meeting attended more such meetings than did patientsin the standard referral group. However, only about one-quarterof patients in the intensive referral group attended a DFG meeting,and patients who did attend went to an average of only 10 meetingsover six months.

In contrast, the majority of patients in both the intensive andstandard referral conditions attended SFGs over the six-monthfollow-up period. Nevertheless, patients in the intensive referralgroup were more likely to attend SFGs and attended more SFGmeetings. The standard referral group attended an average of twomeetings per week, whereas the intensive referral group attendedan average of three meetings per week.

4.1. Why didn’t intensive referral patients participate more inDFGs?

In light of the strong fidelity with which the intensive referralcondition was delivered, along with good attendance at intensivereferral sessions, it is surprising that only a minority of patientsparticipated in DFGs. In hindsight, we attribute the lack of greaterparticipation to aspects of the intervention and of the DFGs them-selves. Regarding the intervention, discussing the cons as well asthe pros of attending mutual help groups may have dissuadedsome participation. As framed by motivational interviewing (Millerand Rose, 2009), clients monitor their speech for clues about theirattitudes and intent to change. If they focus on reasons againstengaging in a specific behavior (attending DFGs), they may inferthat they do not want to engage in the behavior and become less

likely to do so (Moyers et al., 2007, 2009). Also, the intensive referralintervention’s emphasis on DFG attendance was not carried overinto other components of patients’ outpatient treatment, whichmay have lessened the intervention’s impact.

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The relative lack of easily accessible DFG meetings likely con-ributed to the low participation rate. There were only about eightual Recovery Anonymous groups meeting regularly in the county

n which this study was located, compared to about 205 AA groups.imilarly, Magura (2008) found that individuals dropped out ofouble Trouble in Recovery mainly because regular meetings wereiscontinued or took place at inconvenient locations. In light of 12-tep program recommendations to try different groups to attain aood fit, the low number of DFGs relative to SFGs decreased theptions for patients to find a comfortable match. Another point ishat AA and other SFGs may have become increasingly supportive of

embers with co-occurring mental illnesses, their use of psychi-tric medications, and discussion of mental health-related issuesLaudet, 2008). Accordingly, patients in our sample, relatively fewf whom were diagnosed with schizophrenia, may not have seenhe need to attend specialized DFGs. In addition, whereas SFGs areruly peer-run, the DFG meetings available to patients were oftened by individuals who, although dually diagnosed themselves,

ere formally affiliated with the facility in which the meeting wasocated and so may not have been perceived as peers.

Although the intensive referral intervention did not yield highates of participation in DFGs, it did result in more patientsttending SFGs, and more attendance and involvement in SFGs.hat is, preparing for DFG participation through intensive refer-al appeared to generalize to SFG participation. Because intensiveeferral involved reviewing 12-step philosophy and the 12 stepsnd identifying potential areas of difficulty, such as emotional dis-omfort, that may arise during meetings, dually diagnosed patientsho received the intervention may have experienced SFGs as less

lienating and more empathic about problems of living with psy-hiatric disabilities (Mueser et al., 2003; Noordsy et al., 1996).nother consideration is that study participants had very high SFGxposure at baseline, and it is unclear how this might have affectedheir openness to more engagement in SFGs or DFGs (Kaskutas andubbaraman, 2010).

Treatment programs that explain and prime individuals forutual help may be especially effective at helping patients ben-

fit from those groups (Humphreys et al., 1999). That is, whenreatment staff educate (or re-educate) dually diagnosed patientsbout mutual-help concepts, and provide access to meetings andole models during treatment, these patients may find mutual-helproups, whether dual- or substance-focused, to be a logical, com-ortable extension of treatment. Thus, during-treatment exposureo mutual-help groups, together with discussions about generalrinciples underlying these groups, may promote mutual-help par-icipation (Timko and DeBenedetti, 2007).

.2. Intensive referral, 12-step participation, and outcomes

Patients receiving intensive referral had consistently better six-onth psychiatric outcomes but only one better substance-related

utcome. This finding is in line with results of prior investigations ofnhanced interventions for dually diagnosed patients (Hien et al.,010; Sacks et al., 2008b). In addition to increased attendance atFGs and SFGs, patients receiving intensive referral worked moreFG and SFG steps and were more likely to consider themselvesembers of a DFG and to have celebrated a sobriety birthday.oreover, better psychiatric outcomes were associated with calling

nother DFG member for help, more need fulfillment in DFGs, andore readiness to attend SFG meetings. Better alcohol outcomesere also associated with more need fulfillment in DFGs, as well as

reater readiness to attend SFG meetings, and more involvement

ith SFGs, especially celebrating a sobriety birthday, making phone

alls to other group members, and having a sponsor.Each of these aspects of mutual-help group participation is

n indicator of proposed 12-step group mechanisms of change

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(Moos, 2008). Proposed active ingredients of 12-step groups,both DFGs and SFGs, are support, goal direction, and struc-ture; abstinence-oriented norms and role models; engagement inrewarding activities; and bolstering self-efficacy and coping skills(Bogenschutz, 2007; Moos, 2008). The 12-step group behaviors andexperiences associated with the intensive-referral intervention andbetter psychiatric and alcohol outcomes are consistent with thesehigher-order active ingredients. For example, readiness to attendand more involvement are indicators of bonding, having a spon-sor is associated with exposure to an abstinence-oriented modeland norms, calling a group member for help reflects coping skills,and having a sobriety birthday is an indicator of self-efficacy. Oncethe higher-order active ingredients of mutual-help groups can bemeasured, it will be possible to examine how well and consistentlydifferent types of DFGs and SFGs deliver them, and the extent towhich they are associated with outcomes for dually diagnosed andother groups of individuals.

4.3. Limitations and conclusions

A limitation of this study is that all patients were treated withinthe VA, which is federally funded and operates the largest mentalhealth treatment system in the US. Generally, VA substance abuseand other mental health services are of similar quality and effec-tiveness to those in the private sector (Asch et al., 2010; Rosenhecket al., 2000). However, the VA patient population has poorer healthstatus compared with the general patient population (Agha et al.,2000; Grella et al., 2010). The extent to which our findings willbe replicated in studies of patients in other health care systemsremains to be determined. Also, this was not a randomized con-trolled trial; however, the two groups were closely comparable,and the cycling design avoided the likelihood that patients in thetwo conditions would perceive that they were obtaining nonequiv-alent treatments. Further, the study was limited by having a singlefollow-up focusing on the prior 30 days, and conducting multi-ple comparison tests with the risk of spurious differences betweenconditions.

Our results suggest that, by incorporating intensive referral pro-cedures into treatment, providers can increase the likelihood thatdually diagnosed patients will participate in mutual-help groupsand continue to improve after treatment has ended. Given the ben-efit that dually diagnosed patients appear to gain from participatingin SFGs (Timko and Sempel, 2004), and SFGs’ widespread avail-ability, treatment providers should link patients to 12-step groupvolunteers and consistently ask patients about their meeting partic-ipation. If a dual diagnosis patient is uncomfortable in a SFG, specialprocedures could be followed to identify and access a suitable DFG.Intensive referral could emphasize the common benefits of mutual-help group participation, such as support, direction, and structure;abstinence-oriented role models and norms; and opportunities forrewarding activities, bolstering self-efficacy, and learning new cop-ing skills (Bogenschutz, 2007; Moos, 2008).

Role of funding source

This work was supported by the Department of Veterans Affairs(VA) Office of Research and Development (Health Services Research& Development Service, IIR 05-014, RCS 00-001, and RCS 90-001), and the VA Office of Academic Affiliations (TPP 65-500).The funding agencies had no further role in study design; inthe collection, analysis, and interpretation of data; in the writing

of the report; or in the decision to submit the paper for pub-lication. The views expressed here are the authors’ and do notnecessarily represent the views of the Department of VeteransAffairs.

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ontributors

Christine Timko, Ruth Cronkite, and Rudolf Moos designed thetudy and directed the statistical analyses. Anne Sutkowi managedhe study and set up the data. Kerry Makin-Byrd helped with datanalysis and wrote the first manuscript draft using these data. Alluthors contributed to and approved the final manuscript.

onflicts of interest

There are no conflicts of interest.

cknowledgements

We thank Akash Desai, Stacy Lin, Daniel Kaplan, Susan Macus,nd Cassandra Snipes for help with the study.

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