Mutual Help Groups for People
with Co-Occurring Disorders
Joan E. Zweben, Ph.D.
Executive Director, East Bay Community Recovery Project
Clinical Professor of Psychiatry, UCSF
Staff Psychologist, VA Medical Center, San Francisco
ASAM Med Sci – Chicago – April 27, 2013
Dilemmas for People with COD
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COD’s are the norm, not the exception
Mental illness is an “outside” issue in the 12Step system
Individuals describe lack of empathy and
acceptance in traditional groups (Magura 2008)
Bill W. castigated when he sought
psychotherapy for severe depression (Hartigan
2000)
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Where to find a “home”?
Outline
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Mutual help groups within mental
health
Integrated support groups for people
with COD
Preparing people with COD to attend
meetings
Mutual Help within
Mental Health
Basic Characteristics
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Antipsychotics fueled deinstitutionalization
(1960’s forward); support groups flourished
Many groups are supported by outside
organizations: psychiatric institutions, govt
entities, community organizations
Membership need not consist of people with
psychiatric disorders
Some collect membership fees
Recovery International
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Founder: Abraham Low, MD, 1937
Goal: reduce negative consequences of
habituated thoughts and behaviors; prevent
relapses leading to hospitalization (precursor
to CBT)
Peer-based training
Five levels of fees: $30 - $1000
Currently 600 peer led community meetings
in US and elsewhere
Study Report: Univ Illinois,
Chicago (2011)
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Decreased mental health sx
Reduction in use of mental health & social
services
Improved self esteem; confidence in ability to
achieve recovery
Willingness to ask for help & support
Increased social connectedness, hope, coping
mastery ability, overall mental health
Fountain House
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WANA (We Are Not Alone)
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Started in 1940’s in NY by Michael
Obolensky to help transition and provide
vehicle for socializing and fellowship
Evolved into Fountain House, a
psychosocial rehabilitation clubhouse
community in the 1950’s, with the addition
of professional staff.
Emotions Anonymous (EA)
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Founded in St. Paul in 1971
Goal: working toward recovery from
emotional difficulties through adapted
version of 12-Steps
Seen as a complementary support
activity; recommended by mental health
professionals
Depressed Anonymous (DA)
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Founded 1986; formalized late 1990’s
Goal: Empower people into therapeutic
healing; “help ourselves and others
escape the prison of depression”
Medication, religion, not discussed at
meetings
Has closed online group; limited
number of face-to-face meetings
Schizophrenia Anonymous
(SA)
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Founded 1985; 150 groups, 30 states
and international
Partner: SARDAA (Schiz & Related
Disorders Alliance of America)
Purpose: restore dignity; increase sense
of purpose; improve attitudes and lives
regarding illness; disseminate latest
info; encourage recovery
Effectiveness of Mutual-Aid
Self-Help Participation (MH)
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Does involvement lead to improve psychological
and social functioning?
12 studies met criteria for group characteristics,
target problems, outcome measures, research
design
Promising evidence of benefits for people with
chronic mental illness, depression/anxiety,
bereavement
Variable design quality; need more and better
research
Integrated Mutual Support
Groups for People with CoOccurring Disorders
Challenging Issues
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COD population is heterogeneous,
varying in diagnosis and severity
Emerged late 1980’s, but # groups still
limited
50% with SMI have substance issues,
but tailoring groups for them is difficult
DRA: Dual Recovery
Anonymous
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Launched 1989; Central Office established
1993; international by 2001
Requirements: desire to stop AOD use;
desire to manage emotional & psychiatric
illness in a constructive way
Addresses concerns about misguided
advice at other 12-Step mtgs
Mtgs chaired and run by DRA members
Double Trouble
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Founded in Philadelphia in 1987
Mtgs initially run by peers
Professionals acted as advisors; later
began running the groups
Shifted away from self-help, grew into an
agency providing psychiatric services
Currently a component of psychiatric
services
DTR: Double Trouble in
Recovery - I
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Started by Howard Vogel in 1989; moved
to greater control by professional
organizations
Financial assistance by NY allowed them to
train peer group leaders; consumers start
and conduct groups, can get ongoing
support
Estimated 200-250 grps, mostly in NY area
DTR: Double Trouble in
Recovery - II
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Increasingly intertwined with federal,
state, local agencies in provision of
services
Do not adhere to their stated
nonaffiliation policy
Hazelden now the exclusive publisher of
materials and supplies
Research on Dual Focus
Groups - I
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Overemphasis on abstinence and
insufficient attention to mental health
issues were barriers to participation in
single-topic groups (Havassy et al 2009)
SMI: barriers were stigma, meds issues
not addressed, difficulty in finding
peers, decreased referrals from
clinicians (Villano et al 2005).
Research on Dual Focus
Groups - II
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Enhanced engagement promotes
participation (Bogenshutz 2005)
Modified 12-step facilitation intervention
increased attendance and decreased
substance use during 12 week of tx (Nowinski
et al, 1994).
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Change mechanisms (self efficacy, social
support) similar to others (Bogenshutz 2007)
Research on Dual Focus
Groups - III
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Intensive referral intervention enhanced
participation; better 6 month outcomes
(Timko et al 2011)
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Pts attended 4 sessions; given information, discussion,
practice opportunities
Volunteer available to accompany them to meetings
Male veterans also benefit from
intensive referral efforts (Makin-Byrd et al 2011)
Preparing People with COD to
Attend Meetings
Specialized & Mainstream
Meetings
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Limited # specialized groups are
available
Mainstream clients in addition for
stronger support system
Prepare them to attend mainstream
meetings; handle issues that can arise
Use existing manuals & materials
Benefits for People with COD
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Predictable, clear structure can be
container for anxiety
Pts who are anxious and depressed can
be linked with assistance to get to mtg
Simplicity & redundancy beneficial (e.g.,
cognitive impairment, thought disorder)
“No crosstalk” is protective; relatively
nonintrusive
Preparing People with COD to
Attend Meetings - I
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Familiarize pts with history, culture,
traditions, rituals and other practices
Address fears about groups (MAAEZ)
SMI – case managers take pts to initial
meetings; provide cell phone access
when clients begin to go alone
Preparing People with COD to
Attend Meetings - II
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Select meetings carefully for people
with SMI; look for tolerance of eccentric
behavior
Instruct pts how to behave (e.g., do not
discuss delusions and hallucinations)
Be alert for possibility that higher power
can be incorporated into delusional
system
Preparing People with COD to
Address Medication Issues
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Medication issues can be considered
private, though honesty is strong value
Use AA materials to validate the view
that medication is compatible with
recovery
Role play handling of the medication
issue if challenged in a meeting
References
Zweben, Joan E., & Ashbrook, Sarah.
(2012). Mutual Help Groups for People
with Co-Occurring Disorders. Journal of
Groups in Addiction & Recovery, 7, 202222.
Joan.Zweben@UCSF.edu
Slides: www.ebcrp.org