“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
Medical Director
Herrington Recovery Center
Rogers Memorial Hospital
Michael   M.
Miller,   MD
•
Herrington provides professional treatment to persons professional treatment at a less intensive level of care.
• Persons with addiction may try to quit on their own, or reduce their use so they don’t experience problems, or they may seek professional treatment: 1:1 visits with a enrollment in an IOP or PHP or in another residential program
Rogers   Memorial   Hospital 1

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
“Based on many years of clinical experience, reinforced by and physiological aspects of the effects of alcohol on living systems and of alcoholics and their families, the American
Society of Addiction Medicine finds that alcoholism is a complex primary physiological disease, and neither a primary other disease process.”
Adoption Date: October 1, 1983; revised October 1, 1996
Michael   M.
Miller,   MD
•
When substance use is still happening and the person
• When problems due to use keep accumulating
• When “addressing the problem yourself” hasn’t worked
•
When other professional help hasn’t worked
…then, people come to Herrington at Rogers
Rogers   Memorial   Hospital 2

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
• Residents at Herrington attend AA or NA almost nightly
•
Residents attend meetings on campus – these are ‘open meetings’ including persons from the community, but are almost like ‘institutional meetings’ established for persons in inpatient/residential treatment
• Other Rogers’ patients attend as well: from other residential and IOP programs, or from inpatient psychiatry unit or inpatient eating disorders unit
Michael   M.
Miller,   MD
•
AA is a supplement to treatment
•
It is for recovering people, and offered by recovering people, without a trained professional to ‘lead’ the group, without any charges or documentation
•
It is NOT treatment.
•
It promotes recovery.
Rogers   Memorial   Hospital 3

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
• Not just for persons with addiction
•
Not just for persons who identify themselves (admit it) that they have addiction
•
The only criterion for attendance: “A person with a desire to stop drinking.” (or, for N.A., “…using.”)
• It’s for persons not pursing professional treatment.
•
It’s for persons pursing professional treatment. (It can help treatment work better!)
Michael   M.
Miller,   MD
ASAM Public Policy Statement on Treatment for Alcohol and
• Addiction Treatment is the use of any planned, intentional intervention in the health, behavior, personal and/or family life of an individual suffering from alcoholism or from another drug addiction, and which is designed to enable the affected individual to achieve and maintain sobriety, physical, spiritual and mental health, and a maximum functional ability.
• Addiction Treatment services are professional healthcare services, offered to a professional. Addiction professionals providing addiction treatment services are licensed or certified to practice in their local jurisdiction and may be nationally certified by a professional certification body for their professional discipline.
Adopted by ASAM Board of Directors May 1980; revised September 1986, October 1997, July 2001, October 2009, and January 2010 .
Rogers   Memorial   Hospital 4

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
BEHAVIORAL CHANGES
• Eliminate alcohol and other drug use behaviors
•
Eliminate other problematic behaviors
•
Expand repertoire of healthy behaviors
•
Develop alternative behaviors
•
Identify triggers for using behaviors/relapses
BIOLOGICAL CHANGES
•
R l t l h l d th drug withdrawal symptoms
•
Physically stabilize the organism
•
Develop sense of personal responsibility for wellness
• Initiate health promotion activities (e g diet exercise safe sex, sober sex)
•
Address cravings through medical interventions (treatment medications)
Michael   M.
Miller,   MD
COGNITIVE CHANGES
•
Increase awareness of illness
•
Increase awareness of negative consequences of use
•
Increase awareness of addictive disease in self
•
Decrease denial
AFFECTIVE CHANGES
•
Increase emotional awareness of negative consequences of use
•
Increase ability to tolerate feelings without defenses
• Manage anxiety and depression
• Manage shame and guilt
Rogers   Memorial   Hospital 5

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
SOCIAL CHANGES SPIRITUAL CHANGES
•
I Increase personal responsibility in all areas of life
• Increase self-love/esteem; decrease self-loathing
•
Increase reliability and trustworthiness
•
Reestablish personal values
•
Enhance connectedness
•
Become resocialized: reestablished sober social •
Increase appreciation of transcendence
•
Increase social coping skills: with spouse/partner, with colleagues, with neighbors, with strangers
Taken from: Miller, Michael M. Principles of
Addiction Medicine , 1994; published by
American Society of Addiction Medicine, Chevy
Chase, MD
Michael   M.
Miller,   MD
Follow the Steps
1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over…
4 .Made a searching and fearless moral inventory of ourselves.
5. Admitted the exact nature of our wrongs (and stated this openly to another human begin)
6. Were entirely ready to have…all these defects of character [removed].
7. [Humbly asked to have these shortcomings removed ].
harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
Rogers   Memorial   Hospital 6

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
• Precontemplative
• Contemplative
•
Preparation
•
Action
•
Maintenance
[Motivational Enhancement Therapy]
Michael   M.
Miller,   MD
Addiction
(constriction –of affects, behaviors, social network)
Rogers   Memorial   Hospital 7

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
•
Of social network
–
People
•
Of activities / interests
–
Places, Things
• Of emotions
–
Flatness, less expressive, dysthymic / alexithymic
–
Everything is anger/resentment
•
Of rewards
–
Salience
Michael   M.
Miller,   MD
Addiction
(constriction –of affects, behaviors, social network)
Copyright (c)2011, Covington, Griffin, & Dauer
Rogers   Memorial   Hospital
Recovery
(expansion— of feelings, rewards, activities, social connections)
8

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
•
“Re-people-ization”
– AA
– Sponsor
–
Church
–
Social clubs
–
Activities with others
– Family
•
Professional Treatment (group therapy, meet others)
•
Re-Connectedness
Michael   M.
Miller,   MD
•
A place to go (structured daily activity)
– y
–
Accountability to ‘be somewhere’
– Be reliable: keep your promises
•
A place to be
–
A supportive physical environment
–
A place that is alcohol/drug free
– S ti f l / l /thi th t h lth
•
People to be with
–
A group of folks you can identify with
–
Identify similarities to others, not focus on differences
– Find real-life examples of persons who are succeeding
Rogers   Memorial   Hospital 9

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
•
People to be with
–
“Whenever two or more are gathered ”
–
Overcome isolation
–
Supportive recovery environment (people support your abstinence vs. oppose/sabotage it)
• People to listen
–
“b th ith ” j
–
Accept, not criticize, not debate, not berate
–
No “cross talk”: people talk, people listen
Michael   M.
Miller,   MD
•
A Group
– even if it’s not a professionally-led psychotherapy group
– it’s different from professionally-directed group therapy, where a therapist might provide active “advice” (vs. the “feedback” that comes in the hallways at an AA clubhouse after a meeting)
– but the “curative factors” seen in professionally-led groups, can happen in AA groups
Rogers   Memorial   Hospital 10

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
• Instillation of Hope - faith that the treatment mode can and will be effective.
•
Universality - demonstration that we are not alone in our misery or our
"problems".
• Imparting of information - didactic instruction about mental health, mental illness, psychodynamics or whatever else might be the focal problem of the group (Ex. ACOA, Alanon; learning about the disease process itself).
•
Altruism - opportunity to rise out of oneself and help somebody else; the
• Corrective recapitulation of primary family group - experiencing transference relationships growing out of primary family experiences, providing the opportunity to relearn and clarify distortions.
The Theory and Practice of Group Psychotherapy, 4th Ed., 1995.
Michael   M.
Miller,   MD
•
Direct Advice - receiving and giving suggestions for strategies for
•
Interpersonal learning - receiving feedback from others and experimenting with new ways of relating.
• Development of socializing techniques - social learning or development of interpersonal skills
•
Imitative behavior - taking on the manner of group members who
•
Catharsis - opportunity for expression of strong emotions
•
Existential factors - recognition of the basic features of existence through sharing with others (e.g. ultimate aloneness, ultimate death, ultimate responsibility for our own actions).
Rogers   Memorial   Hospital 11

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
Twelve Step Facilitation treatment nrepp samhsa go /Vie Inter ention asp ?id 55
• The principles include acknowledging that willpower alone cannot achieve sustained sobriety, that surrender to the group conscience must replace self-centeredness, and that long-term recovery consists of a process of spiritual renewal.
•
Therapy focuses on two general goals: (1) acceptance of the need for abstinence from alcohol and other drug use and (2) surrender, or the willingness to participate actively in 12-Step fellowships as a means of sustaining sobriety.
Michael   M.
Miller,   MD
•
The TSF counselor assesses the client's alcohol or drug use, advocates facilitates initial involvement and ongoing participation in AA. The counselor also discusses specific readings from the AA/NA literature with the client, aids the client in using AA/NA resources in crisis times, and presents more advanced concepts such as moral inventories.
•
A key is for the therapist to ask follow-up questions to the patient about their experiences when they attend AA meetings, what’s working for them, what
•
Setting goals is important: Are you attending the number of meetings you said you would? Are you talking with a sponsor? Are you talking with people you got phone numbers from? Are you talking when you attend, or just saying “I pass”?
Rogers   Memorial   Hospital 12

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
• A place for “re-people-ization” and to establish a new
•
A place to “try out new things” – SAY SOMETHING, get out of your shell, break the “No Talk” rule of your family of origin
• A place to “ASK FOR HELP” from someone else
–
It’s not ‘all me’
–
Help comes from outside, to ‘turn it over’
Michael   M.
Miller,   MD
•
Fake it till you make it – Just Do It! (Nike)
•
Show Up! (attend; establish the habit/regimen)
• Talk!
–
Be a participant in A.A.
–
Don’t just be a spectator at A.A.
–
Don’t just “pass” each time
• Do SOMETHING different. Take a (healthy) risk.
Rogers   Memorial   Hospital 13

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
•
Listen!
–
To the stories
–
To those who have ‘made it’
–
“vicarious learning”
–
“modeling”
•
Do more than ‘just listen’ – be a part of it!
– take a risk and share your experiences, what’s going on for you
– this can decrease your shame and guilt as you experience acceptance
– when you do this, you’ll end up being able to identify with others at the level of shared experience.
• The ‘bottom line’ – like they say ‘around the tables’ at AA –
“It works only if you work it.”
Michael   M.
Miller,   MD
(paraphrased from Chap. 5 of The Big Book)
•
Remember that we deal with alcohol – cunning, baffling, than us.
• But there is help: outside of yourself, beyond yourself.
May you find it now.
•
Half measures availed us nothing. We stood at the turning point. We asked our Higher Power for protection and care, with complete abandon.
Rogers   Memorial   Hospital 14

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
• What does this mean?????????
•
Does this mean being religious?
•
Does this mean I have to believe in God?
–
Have a ‘religious faith’
–
Not be agnostic or atheistic
Michael   M.
Miller,   MD
Addiction is a primary, chronic disease of brain reward, circuits leads to characteristic biological, psychological, social and spiritual manifestations.
Addiction is a Bio-Psycho-Social-Spiritual Disease
Rogers   Memorial   Hospital 15

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
The orientation of the ASAM work group was that the spiritual which give meaning to a person’s life and which provide a framework for a human being’s relationship beyond oneself and with the transcendent.
Michael   M.
Miller,   MD
“Spirituality has many definitions, but at its core spirituality a specific belief system or even religious worship. Instead, it arises from your connection with yourself and with others, the development of your personal value system and your search for meaning in life. For many, this takes the form of religious
For others, it can be found in nature, music…art or a secular community. Spirituality is different for everyone.”
Rogers   Memorial   Hospital 16

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
•
•
•
►
►
Michael   M.
Miller,   MD
•
•
•
•
Rogers   Memorial   Hospital 17

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
• Persons who have long-term recovery
–
Regular/long-term attendees of AA are over-represented among those in long-term recovery
•
Some persons can ‘do it on their own’
–
Strong-willed; will-power
–
This actually isn’t that common
• Fellowship is the key – plus some accountability to others as well as yourself
Michael   M.
Miller,   MD
Rogers   Memorial   Hospital 18

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
Michael   M.
Miller,   MD
Alcohol & Drug Abuse Institute
Alcohol & Drug Abuse Institute and Department of Psychiatry & Behavioral Sciences
The Impact of Evidence-Based Practices on Individuals, Families, and Communities.”
University of Washington
NIDA Blending Conference, “Blending Addiction Science & Treatment:
The Impact of Evidence-Based Practices on Individuals, Families, and
Communities.” Cincinnati, OH. June, 2008
• AA and NA participation is associated with greater likelihood of abstinence improved social functioning and greater self-efficacy
•
12-Step self-help groups significantly reduce health care utilization and costs
•
Combined 12-Step and formal treatment leads to better outcomes than found for either alone
•
Engaging in other 12-Step group activities seems more helpful than attending meetings
. Donovan, NIDA Blending Conference, June 2008
Rogers   Memorial   Hospital 19

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
•
Consistent and early attendance/involvement leads to better substance use outcomes
•
Even small amounts of participation may be helpful in increasing abstinence, whereas higher doses may be needed to reduce relapse intensity
• Reductions in substance use associated with 12-Step involvement are not attributable to potential third variable influences such as motivation, psychopathology, or severity
Michael   M.
Miller,   MD
. Donovan, NIDA Blending Conference, June 2008
Abstinence Rates at 1-Year Follow-Up as a Function
Post treatment 12-Step Group Attendance
80
70
60
50
40
30
51.6
28.9
30.7
10
0
None
(n = 1326)
1-9
(n = 614)
10-29
(n = 570)
Number of Meetings Attended
. Donovan, NIDA Blending Conference, June 2008
67.2
30 +
(n = 506) x 2 = 248.3, p < .001
Moos, et al., 1999
Rogers   Memorial   Hospital 20

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
Michael   M.
Miller,   MD
Abstinence Rates at 8-Year Follow-Up by Duration of
12-Step Meeting Attendance in the First Year
80
40
30
20
10
60
50
0
35.3
42.7
56.2
None
(n = 201)
1-16
(n = 89)
17-32
(n = 89)
Weeks of Participation in 12-Step Groups
33 +
(n = 94)
. Donovan, NIDA Blending Conference, June 2008 x 2 = 25.5, p < .01
Moos, et al., 2004
Abstinence Rates at 8 Years by Duration of Meeting
Attendance in Years 2 to 8
100
80
70
60
50
40
30
47.7
64.1
32.6
10
0
None
(n = 128)
1-12
(n = 43)
13-48
(n = 39)
Months of Additional Participation in AA
49 +
(n = 62)
. Donovan, NIDA Blending Conference, June 2008 x 2 = 28.3, p < .01
Moos, et al., 2004
Rogers   Memorial   Hospital 21

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
Michael
Drug and Alcohol Use (During the 6 Months Prior to 24-Month
Post-treatment Follow-Up) as a Function of Frequency of
Attendance at 12-Step Groups
70
60
50
40
30
27.3
32.0
44.0
61.2
22.3
25.2
44.0
60.0
Drug Use
Alcohol Use
** p < .01
*** p < .001
10
** ***
0
Any 12-Step Participation
. Donovan, NIDA Blending Conference, June 2008
* ***
Yes No
Weekly or More Frequent
Participation
Fiorentine, 1999
M.
Miller,   MD
Drug and Alcohol Abstinence (During the 6 Months Prior to 24-Month
Post-treatment Follow-Up) as a Function of Frequency of Attendance at
12-Step Groups
77.7
74.8
80
70
60 56
72.7
50
40
38.8
40
Drug Use
Alcohol Use
20
Never
(n = 134)
Less than
Weekly
(n = 25)
Weekly
(n = 103)
12-Step Meeting Attendance
. Donovan, NIDA Blending Conference, June 2008
Fiorentine , 1999
Rogers   Memorial   Hospital 22

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
Michael
Percentage of Persons Abstinent at Both 6- and 12-Month
Follow-Ups, Based on Self-Help Group Meeting Attendance
60
50
40
30
20
10
0
33.8
No Yes
At least 1 Meeting
. Donovan, NIDA Blending Conference, June 2008
30.3
52.9
No Yes
At least 1 Meeting per Week
Timko & DeBenedetti, 2007
M.
Miller,   MD
•
75% of persons with alcohol use disorders entering meetings previously. However, only 16% indicated that they had ever worked any of the 12 Steps.
• Despite “strong encouragement” to attend, 30% of persons with cocaine use disorders receiving outpatient treatment reported that they had attended 12-Step groups.
. Donovan, NIDA Blending Conference, June 2008
Rogers   Memorial   Hospital 23

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
Michael   M.
Miller,   MD
http://recoveryjonescartoons.com/book_1.htm
. Donovan, NIDA Blending Conference, June 2008
•
That you’ll TRY IT
• Th t ’t “AA k it’ t f ” ith t having had your own personal experience with it
• That you’ll experience different groups
• That you’ll take risks and go on your own to new groups
•
That you’ll have some experience with the sponsorsponsee relationship before you leave
•
That you’ll attend AA in your home area and, ideally, secure a local sponsor, before you leave the structured/protected environment of residential treatment.
Rogers   Memorial   Hospital 24

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
• No, but we think you need to engage and participate in
•
Other 12-Step programs
–
Narcotics Anon, Cocaine Anon, Nicotine Anon, Gambling Anon,
Sex Addicts Anon, Overeaters Anon
–
Alanon
–
Adult Children of Alcoholics (ACOA) groups
• Rational Recovery (RR) / SMART Recovery
Michael   M.
Miller,   MD
•
Do something every day to affirm your recovery
• Establish a routine , a set of healthy behaviors
• Get outside of yourself; don’t ‘go it alone’
•
It’s available everywhere
–
Phone number lists for people in your ‘home group’
–
When out of town, you can go (plan ahead)
–
When in crisis: if it’s not unfamiliar to you, you’re more likely to use it
Rogers   Memorial   Hospital 25

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
1. ADMIT IT – your life wasn’t as rosy as you were making it out to be, you and others were being hurt; you were NOT
‘handling it’
2. The source of your life’s unmanageability is no mystery: it’s your pathological pursuit or reward or relief, your ‘drug’
3. Trying to overcome it by the sheer force it’ll leave you disappointed/frustrated and your loved ones not trusting your declarations and platitudes
4. There is hope – and getting outside of yourself is a path, and ‘doing it different’
• Acceptance. Willingness. Readiness to change. Actually changing.
• Admitting what you have done that you could have done differently/ better.
• Being fully prepared to behave differently
• Actually changing what you do.
• Have regrets, say you’re sorry, make amends.
• Changing how you deal with your
“feeling” life—be aware of your feelings, let yourself experience them, let yourself show them
• Changing how you relate to others.
• Getting connected with yourself, with others, and with the larger whole (H.P.)
Michael   M.
Miller,   MD
From “Alcoholics Anonymous”,
Rogers   Memorial   Hospital 26

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
• PRECISELY HOW WE HAVE RECOVERED
•
Better understand the alcoholic
–
The alcoholic is a very sick person
• Anonymity
•
Non alliance
Michael   M.
Miller,   MD
•
By 1955 a miracle has happened
–
6,000 groups; 150,000 members
•
The two elements of recovery
–
Carry the message – alcoholic to alcoholic
–
Spiritual principles
• •
A brief history of the early days
Rogers   Memorial   Hospital 27

“Why   AA?”   For   Patients   in   Residential   Treatment   at   the   Herrington   Recovery   Center
• By 1976 over 1,000,000 members and 28,000 groups
•
“…At its core it remains simple and personal. …One alcoholic talks to another alcoholic sharing experience strength and hope.”
Michael   M.
Miller,   MD
Michael M. Miller, MD, FASAM, FAPA
Medical Director
Herrington Recovery Center
262-646-1056 mmiller@rogershospital.org
Rogers   Memorial   Hospital 28