نقش فرآیندهای خودیاری در اجتناب اکتسابی میان افراد دوجانبه تشخیص داده شده

The effectiveness of participation in dual-focus groups (i.e., focusing on both mental health and substance use) has not been studied empirically. The study examined whether three hypothesized active ingredients of self-help (helper-therapy, reciprocal-learning, and emotional-support processes) are associated with drug/alcohol abstinence outcomes for members of a 12-step dual-focus fellowship, Double Trouble in Recovery (DTR). The study was able to control for member attitudes and behaviors at baseline, which might be related to both self-help processes and outcomes, i.e., extent of participation in DTR and traditional 12-step groups, prior drug/alcohol use, severity of psychiatric symptoms, motivation for change, stressful life events, perceived coping, self-efficacy for recovery, and social support. Members of 24 DTR groups in New York City were recruited, interviewed, and reinterviewed after 1 year. Drug/alcohol abstinence in the past year increased from 54% at baseline to 72% at follow-up. Helper-therapy and reciprocal-learning activities were associated with better abstinence outcomes, independent of other attitudes and behaviors of the members. However, emotional support was not related to outcome. We conclude that specific elements of self-help participation contribute substantially to progress in recovery for members of dual-focus groups; facilitating such self-help processes should be encouraged by clinicians and senior fellowship members.

Self-help groups are based on the premise that a group of individuals who share a common behavior they identify as destructive can collectively support each other and eliminate that behavior. Members learn more about their problem and share their experiences, strengths, and hopes for recovery. The group is a setting where socially stigmatized behaviors can be discussed in an accepting, trusting environment. It also provides a source of strategies to cope with the behavior and, as a person's recovery progresses, the opportunity to become a role model. Many self-help groups follow some version of the 12-step recovery model originally developed by the founders of Alcoholics Anonymous [AA] (1952). There is research-based evidence that self-help can contribute to achieving or maintaining abstinence from alcohol and drugs. Most such studies have examined the association between 12-step group (usually AA) participation during or after formal treatment and subsequent outcomes Devine et al., 1997, Humphreys et al., 1997, Humpreys et al., 1999, Rosenheck & Leda, 1997, Thurstin et al., 1987 and Timko et al., 1995. For instance, Moos, Finney, Ouimette, and Suchinsky (1999) found that stronger 12-step affiliation (i.e., more meetings made, speaking with sponsor, reading 12-step literature, etc.) was related to abstinence from alcohol and drugs, less psychological distress, and more employment at 1 year after treatment. The benefits of self-help affiliation before, during, and after treatment, as well as the additive benefits of treatment and self-help, have been shown for drug-dependent persons Fiorentine, 1999, Fiorentine & Hillhouse, 2000a and Fiorentine & Hillhouse, 2000b. However, very little research has examined the processes by which mutual aid and especially 12-step participation may lead to positive outcomes. For example, it appears that 12-step attendance alone is less effective than greater involvement in 12-step, including practices and activities such as having between-meeting contacts with other members, reading 12-step literature, “working the steps,” and having or being a sponsor Caldwell &Cutter, 1998, Cross et al., 1990, Humphreys et al., 1998, Montgomery et al., 1995 and Vaillant, 1983/1995. In addition, the influence of AA affiliation on abstinence appears to be mediated by a set of “common change factors,” specifically the maintenance of self-efficacy and motivation, and increased active coping efforts (Morgenstern, Labouvie, McCrady, Kahler, & Frey, 1997). Dual diagnosis is highly prevalent among individuals with chemical dependency or psychiatric disorders, e.g., of respondents with lifetime illicit drug dependence or abuse, 59% also had a lifetime mental disorder (Kessler, 1995). Dually diagnosed individuals face more challenges than those with a “single” disorder (Laudet, Magura, Vogel, & Knight, 2000a). Yet, for several reasons, the potential benefits of 12-step self-help participation are not always available to them. Identifying and bonding with other group members may be difficult for dually diagnosed individuals insofar as they feel different from other members. Dually diagnosed persons who are newcomers to 12-step meetings often find a lack of acceptance and empathy Noordsy et al., 1996 and Vogel, 1993. Dually diagnosed individuals' experiences when attempting to use self-help as a recovery resource include avoiding initial attendance, dropping out or finding it hard to make a regular commitment, and difficulties identifying with other members (Noordsy et al., 1996). Some dually diagnosed members report receiving misguided advice about psychiatric illness and the use of medications, which are viewed as “drugs” (e.g., Hazelden Foundation, 1993), although this is not the official view of AA or Narcotics Anonymous (NA) (e.g., AA, 1984). However, aversion remains against the use of medication in local 12-step chapters, where the potential for abuse of certain psychiatric medications makes use of any psychoactive medications unacceptable to the membership. Noordsy et al. (1996) concluded that few dually diagnosed individuals use self-help consistently over time. The recognition of the limitations of “single-focus,” 12-step groups for dually diagnosed persons has led to the development of several “dual-focus,” self-help groups. AA holds meetings for individuals with a mental disorder; Kurtz et al. (1995) reported that dually diagnosed members not only participated in those groups but subsequently became involved in traditional AA groups as well. In addition to specialized AA groups, several fellowships have emerged specifically to address dual-focus recovery: Double Trouble in Recovery (DTR; Vogel, Knight, Laudet, & Magura, 1998); Dual Recovery Anonymous (DRA; Hazelden Foundation, 1993); and Dual Disorders Anonymous (DDA). The effects of participating in such dual-focus groups have not been studied empirically, and indeed, clinicians surveyed often question whether the 12-step model is suitable and feasible for persons with dual diagnoses (e.g., Humphreys et al., 1997 and Meissen et al., 1991), who as a group are relatively more impaired than persons with single diagnoses (Kessler, 1995). DTR is a mutual aid program adapted from the 12 steps of AA, specifically embracing those who have a dual diagnosis of substance abuse/dependency and mental health disorder. DTR seeks to create “a safe environment where members can discuss openly the issues of mental disorders, medication, medication side effects, psychiatric hospitalizations, and experiences with the mental health system, without shame or stigma” (DTR, 1998). The present study examines the association between participation in DTR groups and drug/alcohol abstinence outcomes within a prospective longitudinal study design. DTR attendance and involvement are distinguished in the analysis, and several self-help group processes often identified in the theoretical literature are hypothesized to be associated with abstinence outcomes. 1.1. Conceptual framework The study measured three self-help processes often identified in the literature as plausible active ingredients mediating the effect of self-help group participation on members' outcomes: helper-therapy, reciprocal-learning, and emotional-support processes. Each of these processes is known by several different names in the literature, depending on the author and the underlying theory, but as shown below, we suggest that there is considerable consensus on the existence and potential importance of these processes. 1.1.1. Helper-therapy process This key component of the mutual aid process, first defined by Frank Reissman (Gartner & Reissman, 1979), states that assuming a helping role actually strengthens a group member's emotional and behavioral commitment to change. By assisting, advising, and supporting others—through sharing and testifying at meetings, through informal contacts outside meetings, and by eventually sponsoring other members and becoming a meeting facilitator—a member reinforces his/her own learning of the valued attitudes, skills, and behaviors. Yalom (1985) terms a similar therapeutic element of the group process as “altruism,” the process by which giving something useful to others boosts the giver's self-esteem. Altruism also has a spiritual aspect, bringing a person out of his/her self-absorption by transcending personal problems in the act of serving others. In social learning theory, helping oneself through helping others is a type of “enactive attainment” that signals to the person a sense of his/her competence (Bandura, 1995). In cognitive consistency theory, advocating change in others could be dissonant if a person is ambivalent about personal change; the dissonance can be resolved by changing one's own attitudes and behaviors to conform to those being advocated (Petri, 1996). In self-psychology, instructing or advocating for change would reinforce a person's own self-concept as a changed person (Kaplan, 1996). Self-help participants perceived the change of role from being helped to being a helper to be one of the most important benefits of self-help (Carpinello & Knight, 1991). Although the terms used to describe this process vary among these different authors and researchers, the underlying construct that we call the helper-therapy process seems to be described by all of them. 1.1.2. Reciprocal-learning process Self-help group members have opportunities to learn new attitudes, skills, and behaviors both through general information sharing at meetings and the example of specific role models. Open meetings are sources of information about coping behaviors, including what has worked for others in advancing their recoveries and what has not. Members share experiences, failures, successes, and hopes. Members listen to others in similar situations and with similar problems to learn what has worked for them. In accordance with 12-step tradition, direct advice is not given from one member to another at meetings, but may be given on a one-on-one basis. Constructs similar to reciprocal learning in self-help have been previously identified as important in the group psychotherapy and social learning literatures. Yalom (1985) has identified various aspects of the reciprocal-learning process as active ingredients in group psychotherapy. Yalom's “identification” factor refers to the member's recognizing one or more other members who have histories of similar problems, but are coping better, and thus are suitable for patterning oneself after. We suggest that in social learning theory, this same process is described as the “attentional” process, which determines the relevance of a potential model's characteristics and experiences for oneself (Bandura, 1995). Moreover, Yalom's “imparting information” and “guidance” processes can be interpreted as the instruction and lessons contained in the personal experiences related by members at self-help meetings, as well as the direct advice offered one-on-one by meeting facilitators and other members. Similarly, in social learning theory, these activities constitute opportunities for vicarious learning provided by competent models through example or verbal description (Bandura, 1995). 1.1.3. Emotional support A key function of any mutual aid group is to communicate and demonstrate acceptance of the member as a valued human being. The concept of emotional support encompasses two of Yalom's (1985) therapeutic factors in group psychotherapy: “universality” (defined as learning others have the same type of problem or are in similar circumstances) and “group cohesiveness” (the perception that members of the group understand and accept each other). Carpinello and Knight (1991) found that a “common bond” was a major factor in the effectiveness of mental health self-help as perceived by members. This derives from the “collective experience of being diagnosed with a mental illness…and having survived the (resulting) hurts, abandonment and discrimination…” Emotional support includes demonstrations of approval by the group for the member's testimony about length of sobriety and other recent attainments, large and small. This form of reinforcement is extensively used in self-help. On the other hand, the group and its members assiduously avoid negative reinforcement or punishing behaviors. Members receive social approval for simply attending. Members who reappear after an absence receive a special welcome. Admonishment or criticism is avoided. As has been observed, the practices of 12-step self-help groups follow accepted behavioral principles (DiClemente, 1993). In the Trans-Theoretical Model of Change, emotional support within the self-help group is located in the process of the “helping relationship… which is marked by an empathic, open and receptive relationship…where the individual is comfortable in exploring the problem…” (DiClemente, 1993). Again, despite using different language, several theoreticians and researchers have identified the potential importance of what we term emotionally supportive experiences in self-help. The current study hypothesized that three active ingredients of self-help—helper-therapy, reciprocal-learning, and emotional-support processes—are associated with drug/alcohol abstinence outcomes for members of a 12-step dual-focus fellowship, independent of other personal and social factors that might explain such observed associations.