Transcript Self-Change: Findings and Implications for the Treatment

Self-Change:
Common Pathway to Recovery
From Alcohol and Drug Problems
Scotland’s Future Forum
Fresh Perspective on
Alcohol and Drugs
December 6, 2007
Linda C. Sobell, Ph.D., ABPP
[email protected]
Objectives
• Briefly look at where addictions field was 35
years ago and highlight selected major
changes with respect to providing treatment
services
• Look at prevalence and process of selfchange and its implications for clinical
treatment
• Present results from a large scale
community mail in intervention designed to
promote self-change
• Consider public health and policy
implications of this work
• Questions after talk relating to Scotland’s
Future Forum
Addictions Field Circa 1970
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Research scare; most knowledge
derived from folk science
Very few treatment programs; inpatient norm
Treatment services then and now PRIMARILY
for severely dependent substance abusers
Abstinence ONLY goal!
Motivation something clients brought to
treatment; if not, not ready to change
Gambling not an addiction under study
Nicotine dependence not diagnosis until DSM III
Dominant treatment approaches: AA and 28day Minnesota Model
35 Years Ago Addictions
Field Looked Very Different
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Concept of continuum did not exist:
Everyone viewed and treated as
severely dependent
Cognitive-behavioural treatments for
substance abusers nonexistent
Brief treatments and self-change were
considered as heresy
Terms like problem drinker and harm
reduction not in our vocabulary
Addictions problems viewed as progressive
and irreversible; and
Recovery only possible through treatment or
traditional self-help groups
Recovery Only
Possible Through
Treatment
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Robert Dupont, 1993, "Addiction is not self–curing.
Left alone addiction only gets worse, leading to total
degradation, to prison, and ultimately to death.”
V. E. Johnson,1980, "Alcoholism is a fatal disease,
100% fatal. We estimate that 10% of drinkers in
America will become alcoholic, and that these
people will not be able to stop drinking by
themselves. They are forced to seek help; and when
they don’t, they perish miserably.”
Hazelden, 2003, “Untreated addiction will ultimately
kill you.”
Where We Are Today
All treatments look very similar;
consequently, field seen as at impasse
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Instead of continuing to look at effective
treatments NEED to
• Look at the change process in general
• Take broad perspective on change process
• Looking ONLY at clinical cases obscures big
picture
• To complete the picture, field needs to
understand process of SELF-CHANGE and its
implication for treatment
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Why Study the
Self-Change Process?
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“Addiction looks very different if you study it in
general populations compared to treated cases”
Robins 1993
“If you only study the tip of the iceberg your view of
the disorder will be very biased.” Cahalan, 1987
“We cannot understand the natural history of
alcoholism by only studying clinic populations.”
Vaillant & Milofsky 1984
• “Way ahead in alcoholism treatment research
should embrace study of ‘natural forces’ that
can then be captured and exploited by planned
interventions.”
Orford & Edwards 1977
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Natural Recovery Studies Not New
1814: Dr. Benjamin Rush, signer of
Declaration of Independence, described
several cases of natural recoveries from
alcohol problems
• Early Classic Pioneering Studies (‘60s-’70s):
Winick, Vaillant, Tuchfeld, Rozien, Fillmore
• Vietnam Veterans’ Study: one of largest
natural recovery studies (Robins)
• Different Types of Natural Recovery Studies
• Longitudinal studies
• Population surveys
• Convenience samples
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Review of Studies of Natural Recovery
From Alcohol and Drug Problems
(Sobell, et al., Addictions, 2000, pp.749-764;
recent update Carballo et al, 2007)
1960s-1997: 38 studies met inclusion criteria
• # Respondents: Mean = 141; Median = 43
• Advertisements = 40%; Females = 30%
• Mean recovery = 6.3 yrs; Mean problem =
10.9 yrs
• Problem Type: Alcohol, 75%; Heroin, 22.5%;
Cocaine, 7.5%; Marijuana, 2.5%
• Recovery Status: Low-risk Drinking = 40.3%;
Limited Drug Use = 11.5%
• 1999-2005: 22 studies met inclusion criteria
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Self-Change Well Recognized
Phenomenon Outside of Addictions Field
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Most psychological problems never discussed with
mental heath professionals; rather shared with ‘natural
helpers’ who have no training (Toro, 1986)
More Americans try to change health behaviours
through self-help than all other forms of professional
programs (Davison et al, 2000)
Natural recovery rule rather than exception for problem
gambling (Slutske et al., 2003)
Persistent stuttering not intractable — improvement
occurs without professional help--most learned to selfmanage their disorder (Finn, in press)
25% of people successfully lose weight and 83% do so on
own (Consumer Reports, 2002)
Major Findings From
Self-Change Studies
Today there are over 60 studies of the selfchange process in the addiction field
• Self-change is very enduring: Almost all
recoveries > 1 year and 50% > 5 years
• Vast majority of moderate drinking
recoveries occur outside of treatment
programs
• While multiple pathways to recovery (e.g.,
treatment, self-help), predominant pathway
is self-change
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Individuals Who Have Recovered
from Alcohol Dependence
For At Least 1 Year (N = 4,422)
Majority
Recovered
Without
Treatment
Dawson et al., (2005) Recovery from DSM-IV alcohol dependence:
US, 2001-2002. Addiction. 100(3):281-92
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Three quarters of those who
were previously alcohol
dependent, recovered on
their own; that is, without
treatment
21% of of those who
changed without treatment
did so for 5 or more years
18% were low risk drinkers
Next Step
How Does SelfChange Occur?
What are the
clinical
implications?
Major Processes Associated
with Self-Change and
Clinical Implications
Cognitive Appraisal of Risky
Behaviours
• Affect-Related Statements
• Behavioural Monitoring and
Actions Statements
• Supportive Statements from
Others
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Cognitive Appraisal of
Risky behaviours
Over 2/3’s of respondents’ reported
evaluating costs and benefits of
their behaviour; at some point they
say reported seeing that the
negatives outweighed the positives
and then the scale tipped in favor
of changes
• Clinical Implication: Incorporate
Decisional Balancing Exercises into
clinical interventions as they appear
to accelerate the self-change process
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Decisional Balance Exercise
Helps to Address Ambivalence and
Helps to Increases Motivation to Change
Benefits of Changing
Costs of Changing
Benefits of Not Changing
Costs of Not Changing
2nd Process Linked to Self-Change
Affect-Related Statements
It is not just the rationality that
drives the change process,
rather its the emotional
quality or affective context of
reasons for change
Reasons for Quitting Smoking
Emotional Content Differs
Potential
Informational
Threats
Smoking
causes cancer,
stroke, decreases
life expectancy
Imminent
Consequential
Threats
Health insult;
spot on lung;
spouse died
of smoking illness
Imminent Consequential Threats
SAMSA, 2002/2003; women ages 15-44.
Used Past Month*
Pregnant
Not Preg
Illicit Drug Use *
4.3%
10.4%
Cigarettes
18.0%
30.7%
Alcohol: use *
9.8%
53.0%
Alcohol: binge days *
4.1%
23.2%
Alcohol: heavy use
0.7%
4.3%
*Significant
#3: Behavioural Monitoring and
Actions Statements
• Respondents report engaging in
self-regulatory process
• Gave themselves feedback to enact those
changes
• Similar to motivational interventions
where self-monitoring and
advice/feedback routinely used to help
clients evaluate their behaviour with intent
of motivating them to change
#4: Supportive
Statements From Others
• Support from others reported
important to self-change process
• Parallels treatment studies where
positive outcomes associated
with positive social support
• Clinical implication: Successful
interventions need to consider
social support for clients
What Do
We
Know
Today?
2007
Self-Change: 2007
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Major route to recovery for multiple health and
mental health behaviours
Cigarettes, Alcohol, Drugs, Gambling, Obesity,
Stuttering, Juvenile Delinquency, Mental Health
Problems
Vast numbers of people do not enter treatment;
overwhelming reason relates to stigma of being
labeled (e.g., stutter, alcoholic, addict, obese)
Better understanding of what drives and
maintains change process (e.g., decisional
balance; cognitive appraisal)
Identifying mechanisms of change has major
implications for treatment and prevention
What is Happening
to the Masses?*
In 2003 ONLY 8% in US who met
criteria for Substance Use Disorder
received any services in past year
• And of those, 50% did not complete
treatment!
• For the 92% who received no
services, ONLY 5% reported needing
treatment
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*SAMSA
(2004). Results from the 2003
National Survey on Drug Use and Health.
Taking the Treatment
to the Masses
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Considerable evidence shows TREATED
alcohol abusers represent but a fraction of
those whose alcohol/drug causes them
problems
Only small percentage who have alcohol/drug
problems cross the clinical threshold
Why won’t they come for treatment?
Vast majority say STIGMA associated with
being labeled “alcoholic” or “drug addict”
Alternative: Use community mail-in
intervention to reduce alcohol/drug problems
Most of us don’t know self-change is possible!
% Who Know Someone Who Had Resolved
an Alcohol Problem on Their Own
100.0%
90.0%
Percent
80.0%
70.0%
60.0%
50.0%
40.0%
53.20%
37.80%
29.70%
25.70%
30.0%
20.0%
13.80%
10.0%
0.0%
Self-Changers Alcohol Abusers Alcohol AbusersSignificant Others
General
n=109
Unresolved
in Treatment of Self-Changers Population No
Untreated n=45
n=195
n=108
Alcohol Problem
n=435
Perceived Optimism for Self-Change:
Treatment Not Needed
100.0%
90.0%
80.0%
Percent
70.0%
60.0%
49.2%
50.0%
43.8%
32.5%
40.0%
32.3%
31.6%
30.0%
18.0%
20.0%
13.5%
10.0%
0.0%
Tobacco
(n=458)
Cannabis
(n=375)
Gambling
(n=400)
Medication
(n=402)
Alcohol
(n=452)
Cocaine
(n=376)
Heroin
(n=375)
% Who Know Someone Who Had Alcohol,
Tobacco, or Cocaine Problem
100.0%
Ever Have Problem
Dealt With Problem
90.2%
85.0%
82.6%
90.0%
Resolved On Own
82.00%
80.0%
0.0%
(423/512)
(347/408)
Cig Alc Coc
31.90%
Cig Alc Coc
(38/86)
10.0%
44.20%
(79/248)
20.0%
48.40%
(92/190)
30.0%
34.10%
54.60%
(254/465)
40.0%
(194/56)
50.0%
(469/572)
60.0%
(515/571)
Percent
70.0%
Cig Alc Coc
Attracting the Masses
What a Message Says
is Critical!
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Unwanted messages evoke resistance
and produce counter arguments
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For example, when high risk drinkers
told they are “alcoholic,” they start
thinking of reasons why they are not
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To attract intended target audience
messages need to be carefully crafted
Use Evidence Based Message
to Attract Those Who Do Not
Seek Treatment
Studies of the self-change process suggest it
is important to………
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Avoid labels (e.g., alcoholic, addict)
Promising confidentiality
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Send message that many people DO
RECOVER ON THEIR OWN
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Offer interventions outside of clinical
settings
1 year Empirically Crafted Message
Attracted Close to 2,500 Calls
NIAAA Funded Study
Promoting Self-Change
Community Mail Out Intervention
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People responded to ads
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Screened for eligibility: No past history of
treatment/help for alcohol problems
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Assessment materials mailed out
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Respondents completed assessments at home
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Respondents mail their completed
questionnaires to PO box
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Study materials sent to respondents based
on their group assignment
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12 month mail follow-up
Response to Empirically
Crafted Advertisements
# of respondents
# (%) met screening
criteria and sent
assessment materials
# (%) returned
assessment, met criteria,
in study
2,434
1,756
(72.1%)
825
(47.0%)
Promoting Self-Change:
Community Intervention for
825 Problem Drinkers
Randomly Assigned
Control Group
Experimental
Received 2 Alcohol
Group
Education Pamphlets
and Drinking
Guidelines Available in
the Community
Control Group
Received 2 Alcohol Education/Drinking Guideline
Pamphlets Available in the Community
Promoting Self-Change:
Community Intervention for 825
Problem Drinkers
Randomly Assigned
Control
Group
Experimental Group
Motivationally
Enhancing
Personalized
Feedback
Experimental Group: Answers to assessment
materials used to prepare advice feedback materials
Where Does Your Drinking Fit In?
Personalized Feedback
 Weekly alcohol consumption
 Health risks
 AUDIT score & problem level
 Self-confidence profile
 How much is too much?
 What do you do next?
Where Does Your Drinking Fit In?
Personal Feedback for _______
17+ Drinks
6%
Quic kTime™ and a
decompres sor
are needed to s ee t his pict ure.
7-16 Drinks
7%
0 Drinks
41%
1-6 Drinks
46%
You
reported
drinking
an
average
of
43 drinks
per week
Where Does Your Drinking Fit In?
Personal Feedback for _______
Quic kTime™ and a
dec ompr es sor
are needed to s ee this pic ture.
20%
18%
You
reported
drinking
an
average
of
43 drinks
per week
16%
14%
12%
10%
8%
6%
4%
2%
0%
0-17
18-39
> 39
Average number of drinks per week
Demographic Variables (N = 825)
Male
Employed (full or self)
Married or widowed
Completed high school
Completed some university
White collar
White (ethnicity)
Mean age (years)
67.7%
60.2%
63.5%
85.5%
30.8%
62.1%
94.4%
47.5
Alcohol Variables (N = 825)
Mean yrs drinking problem
11.4
Mean arrests
0.5
Mean hospitalizations
0.1
Mean AUDIT score (0-40)
20.2
% days drinking past year
77.7%
Mean drinks/drinking days
6.0
Promoting Self-Change
Mail Intervention
Results
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Several drinking and non-drinking
variables examined
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No significant differences between
the two interventions
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Both groups produced significant
drinking related changes 1 year preto 1-year post intervention
What Happened?
1 Year Pre-Post Intervention
Significant Decreases
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15% reduction number of drinking
days
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18% reduction number of drinks
per drinking day
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28% reduction mean drinks per
per week
If Motivational Materials
Had No Value Beyond
the Two Informational
Pamphlets, What Caused
Participants to Change
Their Drinking?
What Precipitated the
Change in Both Groups?
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Seeing ad increased motivation to
change, thus facilitating change
Brief telephone screening triggered
self-evaluation process leading to
change
Completing in-depth assessment
materials (2-3 hours)
All of the above
None of the above
Answer
Responding to Ads
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For all major drinking measures,
significant reductions occurred between
seeing ads and calling, but before
receiving assessment materials
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Ads, like brief interventions, appear to
catalyzed respondents’ motivation and
commitment to change
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Similar to trigger events or tipping point
in natural recovery studies
First Contact: Respondents
Asked Why They Responded To Ad
Ad Title: “Thinking of
Changing Your Drinking
29%
Statement: “75% of people
changed on their own”
27%
“Wanted to change on their
own” or “Didn’t want to
come to treatment”
25%
Fig. 1: Mean Days Drinking/Wee k
6
35
5
30
5.41
5.25
4
3
4.66
25
4.54
4.49
Fig. 3: Mean Drinks/Week
30.23 29.82
P< .001
20
P< .05
P< .001
15
P< .05
2
22.36 21.71 21.03
10
1
5
0
Pre 1-11 Pre 1
7
Assess Post 12
Fig. 2: Mean Drinks/Drinking Day
6
5
Ad
Pre-1 11
4.31
3
4.45
4.58
Ad
Assess
Post 12
50
5.8
4
Pre 1
Fig. 4: % Days Drinking 5 or More Drinks
40
P< .001
5.74
0
43.74 43.03
P< .05
P< .001
30
30.98 29.93
28.31
20
2
10
1
0
Pre 1-11
Pre 1
Ad
Assess Post 12
0
Pre 1-11
Pre 1
Ad
Assess
Post 12
Future Research
Directions
Clinical trials MUST examine and
control for Mechanisms of Change
beyond treatment effects—ads,
assessments, talking with
screener, online material
• Use time course analysis to
examine changes at critical
hypothesized time junctures using
sensitive measure of change (e.g.,
daily drinking)
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Where Do Mail
Interventions Fit in Overall
System of
Health Care With Finite
Number of Resources?
Sensible 1st Step in
Stepped Care Model of
Treatment
Stepped Care Model
Services/interventions need to be
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Least restrictive
Least intrusive
Least costly
Likely to have
good outcomes
Have consumer
appeal
Population newly
entering
entering treatment
treatment
STEPPED
STEPPED CARE
CARE
M
Matched
atched to
to treatment
treatment
base
basedd on
on rese
research
arch and
and
clinical
clinical judgment
judgment
Treatment
Treatment "A"
"A"
Negative
Treatment
intensity
increases
Positive
Outcome
Outcome
Treatment
Treatment "C"
"C"
Negative
Outcome
Outcome
Treatment
Treatment "B"
"B"
Negative
Positive
Outcome
Treatment
Treatment "D",
"D", etc.
etc.
Positive
Continued
positive
outcome:
Monitor
only
Serious
relapse
Outcome
Serious relapse requires
further treatment at
appropriate intensity
Public Health and Policy
Implications of Mail Interventions
• In context of a Stepped Care Model, promoting
self-change through mail-in interventions is
consistent with efficient approach to health
care
• As a 1st STEP, mail-in interventions are least
restrictive, least intrusive, and to date have
good outcomes, and CONSUMER APPEAL
• From Harm Reduction perspective, stepped
care looks at incremental improvements
• When intervention does not work, step up care
Public Health and Policy
Implications
• Ad was change mechanism that appeared
to motivate many to change drinking
• Low cost population approaches can reach
large numbers who are unwilling or not
ready to access traditional health care
settings
• Such interventions could be coupled with
messages to seek treatment if self-change
was not successful
• Interestingly, during 12 months after mail
intervention some participants never
previously in treatment reported stepping
up own care
Post Intervention
Treatment Seeking
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28% sought some help or
treatment during 1 year after
intervention
Treatment seekers significantly
more impaired pre-intervention
Added benefit of mail
interventions some problem
drinkers never in treatment
sought additional help, stepped
up their own care
Providing Interventions
Outside the Clinical Arena
Addiction field needs to respond to
full range of addictive behaviours
by offering multiple and varied
pathways to change
• Such efforts, however, will require
FIELD TO SHIFT from its
longstanding clinical focus to a
broader public health perspective
•