Monday, November 25, 2013

12-Step Familiarity vs 12-Step Facilitation

A pair of studies were published last month to little fanfare and which seem to be contradictory in nature. Both papers involve 12-step programs and focus on the role of the counselor in delivering Twelve-Step Facilitation (TSF), a SAMHSA-recognized evidence-based practice. Published in the American Journal of Drug and Alcohol Abuse, the studies come to the following conclusions: Therapist familiarity and personal experience with twelve-step programs (TSPs) improves their credibility among clients and, in turn, therapeutic alliance; yet therapists who viewed TSPs favorably and who described themselves as being in recovery tended to do a poorer job at maintaining fidelity and adherence to TSF in a large, multi-site trial.

In the first paper, researchers at the State University of New York administered surveys to clients and counselors at a host of treatment programs in and around Albany. Clients (n=180) rated counselors on their perceived familiarity with  TSPs, the amount of time in-session devoted to discussion of TSPs, and the credibility of each counselor, as rated in a 12-point questionnaire. In addition, counselors (n=30) answered a demographic questionnaire, reporting such information as education level, recovery status, and months of experience in the field. As hypothesized, counselors who were perceived to be in recovery and more personally-familiar with TSPs received higher ratings of credibility from their clients, presumably resulting in better therapeutic alliances and, therefore, better outcomes.

In the second paper, researchers in Oregon and California sought to determine the characteristics associated with fidelity and TSF adherence among therapists participating in a large trial of the EBP. Notably, the authors found that 1) "Therapists reporting more positive attitudes toward 12-step groups had lower adherence ratings;" 2) "Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis;" and 3), "Fidelity was higher for therapists reporting self-efficacy in basic counseling skills" (as well as for therapists with a graduate degree) "and lower for self-efficacy in addiction-specific counseling skills." 

The "juxtaposition" of the two outcomes, as Yale's Steve Martino puts it, leads the reader to believe that the ideal therapist in this setting can't possibly exist, or ar the very least is exceedingly rare. Someone who is very familiar with 12-step principles is likely to report a positive attitude toward them, and counselors in recovery are likely to rate themselves as possessing strong addiction-specific counseling skills. So, what is the moral to the story, if one exists? Where do we focus workforce development energy with mixed messages like these? It would be interesting to hear from readers who fall on either side (or both sides) of this issue...

Sunday, November 17, 2013

Sunday Alcohol Blue Laws: Keeping consumption in-check?

In a brand new paper by SUNY economist Bans Yoruk, the author analyzes alcohol consumption rates in five states which recently repealed laws banning the sale of alcohol on Sundays. The findings, published online this month in the journal Addiction, show that in three of the five states, per capita alcohol consumption rose significantly in the years following the repeals. Beer seems to be the type of alcohol responsible for most of the increase across the states, with wine and spirits seeing small, if any, changes in demand.

The five states studied were Delaware, which repealed its law against Sunday alcohol sales in 2003, as did Massachusetts and Pennsylvania; Rhode Island, which repealed in 2004; and New Mexico, where the law was changed in 1995. The three states whose per capita consumption increased were Delaware (from 4% pre-repeal to 4.7% post-repeal), Pennsylvania (4% to 4.6%), and New Mexico (6.5% to 7.1%). The increase in Rhode Island was “small and statistically insignificant,” and there was no change in Massachusetts. (Interestingly, the demand for beer seemed to drive the up-tick in sales – all three states where the overall demand rose saw beer consumption increase by about a full percentage point.) The five states were then compared to control states, like our beautiful Minnesota, where alcohol Blue Laws remain in effect. 

Here's the graph from the paper:

Professor Yoruk's analysis falls on the heels of another study which tracked the effects of, among other variables, perceived alcohol availability and bar density on adolescent alcohol consumption. Paschall, et al. found such environmental factors contributed significantly to higher rates of past-year alcohol use. Could it be that an archaic and puritanical relic could actually be saving some lives? Will be interesting to see what readers think about the issue…


        Paschall, M. J., Lipperman‐Kreda, S., & Grube, J. W. (2013). Effects of the Local Alcohol Environment on Adolescents’ Drinking Behaviors and Beliefs.Addiction.
        Yörük, B. K. (2013). Legalization of Sunday alcohol sales and alcohol consumption in the United States. Addiction.

Sunday, November 10, 2013

Advice for Consumers of Addiction Services

In the November issue of the prestigious journal Health Affairs, Anne Fletcher's book Inside Rehab got a very favorable review. Yours truly was highlighted with this paragraph from the review:

"Certainly the most useful part of the book is the advice provided by Mark Willenbring, former director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. He recommends that those seeking treatment should see themselves as customers and seek the best treatment that will work for them. They should get a comprehensive evaluation from someone not financially invested in a specific treatment program, demand nothing less than master’s degree–prepared therapists, and make sure the program treats any co-occurring issues. They should also not go through the same treatment protocols over and over again when it is obvious that they aren't working."

Thanks to Anne of course, and also to the reviewer, Rick Mathis (, a a health
researcher at the BlueCross BlueShield of Tennessee Health Institute.