Research Methods Paper
Substance Use & Misuse, 50:1786–1794, 2015 Copyright C© 2015 Taylor & Francis Group, LLC ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2015.1050111
ORIGINAL ARTICLE
How Do Females With PTSD and Substance Abuse View 12-Step Groups? An Empirical Study of Attitudes and Attendance Patterns
Lisa M. Najavits1, Hein de Haan2 and Tim Kok2
1Boston University School of Medicine, Boston, Massachusetts, USA; 2Tactus Addiction Treatment, Deventer, Netherlands
Background. Self-help groups are beneficial for many people with addiction, predominantly through 12- step models. Yet obstacles to attendance also oc- cur. Objectives. We explored attendance patterns and attitudes toward self-help groups by 165 outpatient females with co-occurring posttraumatic stress disor- der (PTSD) and substance use disorder (SUD), the first study of its kind. Methods. Cross-sectional self- report data compared adults versus adolescents, and those currently attending self-help versus not attend- ing. We also explored attendance in relation to per- ceptions of the PTSD/SUD relationship and symptom severity. Results. Adults reported higher attendance at self-help than adolescents, both lifetime and currently. Among current attendees, adults also attended more weekly groups than adolescents. Yet only a minority of both age cohorts attended any self-help in the past week. Adults perceived a stronger relationship between PTSD and SUD than adolescents, but both age groups gave low ratings to the fact that self-help groups do not address PTSD. That item also had low ratings by both those currently attending and not attending self-help. Analysis of those not currently attending identified ad- ditional negative attitudes toward self-help (spiritual- ity, addiction as a life-long illness, sayings, and the fel- lowship). Symptom severity was not associated with attendance, but may reflect a floor effect. Finally, a surprising finding was that all-female groups were not preferred by any subsample. Conclusions/Importance. Creative solutions are needed to address obstacles to self-help among this population. Addressing trauma and PTSD, not just SUD, was valued by females we surveyed, and may be more helpful than all-female groups per se.
Keywords PTSD, substance abuse, 12-step groups, self-help, attitudes, females
Address correspondence to Lisa M. Najavits, VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130, USA; E-mail: najavits@bu.edu
Twelve-step self-help groups are one of the most com- mon resources for recovery from substance use disorder. Alcoholics Anonymous (AA) is the most well-known 12- step group and, from its start in 1935, has grown to over two million members world-wide across 170 countries (Alcoholics Anonymous, 2013). Indeed, membership has increased steadily over the past 40 years (Donovan, In- galsbe, Benbow, & Daley, 2013). There are also numerous 12-step groups for addictions of all kinds, such as Gam- blers Anonymous, Overeaters Anonymous, and Sex Ad- dicts Anonymous. The range of spin-off groups has be- come remarkably broad, with groups such as Clutterers Anonymous and Underearners Anonymous (Wikipedia, 2014).
Twelve-step groups have been studied primarily in relation to substances, with consistent positive findings (Donovan et al., 2013; Pagano, White, Kelly, Stout, & Tonigan, 2013; Tonigan, Toscova, & Miller, 1996). Yet repeated concerns have been raised about obstacles to 12- step attendance. Most people with addiction do not attend 12-step groups, despite the fact that they are free and exist in many geographic areas. Perceived difficulties include issues such as their spiritual focus; the assumption that addiction is a life-long disease; the emphasis on groups, which can be challenging for people with social phobia; and the predominance of men at meetings (Donovan et al., 2013; Najavits, 2002).
Aside from these general obstacles, there have been questions about whether some populations may have par- ticular difficulty with 12-step groups—such as women, minorities, youth, and people with comorbid mental ill- ness. Such subgroups may feel outnumbered at meet- ings or may feel marginalized due to their life experi- ences. Thus, specialized meetings have arisen for women, young people, some ethnic and racial minorities, les- bian/gay/bisexual/transgendered (LGBT), and the men- tally ill (the latter with groups such as “Double Trou- ble” and “Dual Disorders Anonymous” groups). There
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have also been reworking of the 12-steps, such as steps for women (Kasl, 1992) and Native Americans (Travers, 2009).
One important population that has received little atten- tion in relation to 12-step groups, despite its importance, is people with co-occurring posttraumatic stress disor- der (PTSD). PTSD co-occurs frequently with substance use disorder (SUD), gambling disorder, and other addic- tive behavior (Najavits, Meyer, Johnson, & Korn, 2011; Ouimette and Read, 2014). The two disorders also im- pact each other over time, with each typically making the other worse, in a downward spiral (Najavits, Weiss, & Shaw, 1997; Najavits, 2014). Various treatment options have been developed for the comorbidity over the past two decades (Najavits and Hien, 2013), including, recently, the first pilot study of a peer-led option (Najavits et al., 2014).
Twelve-step models, which are the most widely acces- sible and free option for addiction, do not directly address trauma or PTSD. This is likely due to the historical de- velopment of AA, which arose in an era with little focus on trauma. The 12 steps do not focus on harm done to the addict, such as trauma, but rather just on harm the ad- dict has done toward self and others. Thus, it has been un- clear whether people with comorbid PTSD and addiction would find 12-step groups appealing. Some of the 12 steps could be perceived negatively by trauma survivors. For ex- ample, Step 1, “We admitted we were powerless over our addiction. . .” may be at odds with the empowerment that is emphasized as helpful for trauma survivors (Najavits, 2002). Steps 4–9 focus on the addict’s shortcomings and do not address harm done to the addict: “Admitted. . .the exact nature of our wrongs”, “Were. . .ready to have God remove these defects of character,” “Made a list of all per- sons we had harmed”. Also, many trauma survivors are women and the predominance of males at 12-step meet- ings may be intimidating to them, especially if they suf- fered interpersonal violence by males. Trauma survivors may avoid social interactions (especially large groups), may have difficulty trusting others and talking about their past, and may have lost faith in a higher power, thus fur- ther making self-help group attendance potentially prob- lematic. The 12-step emphasis on the role of substance use as the primary cause of an individual’s current difficulties may differ from a trauma survivor who views her PTSD symptoms as primary.
However, there are also compelling reasons to believe that 12-step groups can be healing for people with PTSD. Such groups can provide a welcoming community to help counter the isolation and stigma that are common in trauma. The openness and acceptance of 12-step groups can mitigate secrecy and shame. The groups’ spirituality and sense of purpose can counteract hopelessness. Thus, various writers have stated that self-help group attendance may be a helpful component of aftercare for people with PTSD and SUD (Brown, 1994; Evans & Sullivan, 1995; Satel, Becker, & Dan, 1993), although even early on it was suggested that adaptations might be needed (Brown, 1994).
We know of no studies that have directly addressed 12-step attitudes and attendance among females with PTSD/SUD. There have been studies of male veterans with PTSD/SUD such as the research of Ouimette and colleagues (Ouimette, Moos, & Finney, 2000). However, male veterans’ response to 12-step groups may be very different than community-based females. Thus, we sought to explore several key topics in relation to females with PTSD/SUD and self-help groups: (1) attendance patterns; (2) attitudes toward such groups; and (3) beliefs about the linkages between PTSD and SUD. In addition, we compared adults versus adolescents and those currently attending self-help groups versus not attending, as these subsamples may differ in their results. We also evalu- ated whether addiction and mental health symptom sever- ity might help explain attendance versus nonattendance at self-help groups. We did not have a priori hypotheses on the direction of expected results as this is the first study we know of to explore this set of topics in this population.
METHODS
Participants We used data from four datasets, all of which were origi- nally collected with IRB approval from McLean Hospital, and on which the first author was either the principal in- vestigator (studies #1–3 below) or co-investigator (study # 4 below). For the current paper, IRB approval for sec- ondary data analysis was obtained in April, 2014 from Partners Healthcare System which is the current IRB of record for McLean Hospital. All four studies had rigor- ously diagnosed samples with current PTSD and current SUD, using DSM-IV criteria. The four studies were: (1) a pilot study of 32 adult women funded by the National Institute on Drug Abuse (NIDA; #DA-09400; Najavits, Weiss, Shaw, & Muenz, 1998); (2) a study of 34 adoles- cent girls funded by the National Institute on Alcohol and Alcoholism (#R21 AA-12181; Najavits, Gallop, & Weiss, 2006); (3) a study of 97 women funded by NIDA (#DA- 086321; Najavits, Sonn, Walsh, & Weiss, 2004); and (4) a study of 62 women, comparing those with PTSD/SUD to those with PTSD alone funded by the Falk Founda- tion (Najavits, Weiss, & Shaw, 1999), from which we used only the co-morbid portion of the sample. For all studies that had data at multiple timepoints, we used only base- line data, thus using…
