Dually diagnosed patients' benefits of mutual-help groups and the role of social anxiety Christine Timko, Ph.D. a, ⁎, Ruth C. Cronkite, Ph.D. a , John McKellar, Ph.D. a , Sarah Zemore, Ph.D. b , Rudolf H. Moos, Ph.D. a a Center for Health Care Evaluation, Department of Veterans Affairs Health Care System and Stanford University Medical Center, Palo Alto, CA, USA b Alcohol Research Group, Emeryville, CA, USA abstract article info Article history: Received 28 November 2011 Received in revised form 3 May 2012 Accepted 30 May 2012 Keywords: Dual diagnosis Mutual-help Self-help Dual diagnosis outcomes Social anxiety There is debate about whether dually diagnosed patients benefit from mutual-help groups (MHGs), partly because social anxiety may make participation problematic. We examined dually diagnosed patients' participation in MHGs and outcomes at 6, 12, and 24 months post-treatment, and the extent to which social anxiety was associated with participation. We also examined whether MHG participation and social anxiety were related to outcomes, and whether social anxiety moderated associations between participation and outcomes. We found high rates of MHG participation. Among patients who attended at least one meeting, outcomes were positive. Social anxiety was not associated with levels of MHG participation, but more participation was associated with better outcomes. When social anxiety moderated associations between MHG participation and outcomes, patients with more social anxiety benefited more from participation. Treated dually diagnosed patients participate in, and benefit from, MHGs, and participation and benefits are comparable, or even strengthened, among more socially-anxious patients. Published by Elsevier Inc. 1. Introduction Patients with both substance use and psychiatric disorders have high rates of posttreatment relapse and additional care episodes (Chen, Barnett, Sempel, & Timko 2006). Mutual-help groups (MHGs), especially those in which psychiatric medications are recognized as useful, may provide an element of continuing care that improves dual diagnosis patients' treatment outcomes (American Psychiatric Association 1995). In addition, MHGs may help dually diagnosed individuals build and maintain protective resources associated with better long-term outcomes, including the health and citizenship achievements emphasized in recovery-oriented care (Moos & Moos 2007; White 2008). However, there is debate about whether dually diagnosed patients should participate in and will benefit from MHGs (Bogenschutz, Geppert, & George 2006; Ouimette, Finney, & Moos 2003). One concern is that symptoms of social anxiety experienced by many dually diagnosed individuals may make participation in MHGs problematic (Jordan, Davidson, Herman, & Bootsmiller 2002; Kurtz 1995). This study examined the extent to which dually diagnosed patients entering mental health treatment participated in MHGs over a 2-year follow-up period, and the extent to which social anxiety at treatment intake was associated with MHG participation at 6-month, 1-year, and 2-year follow-ups. We also investigated the extent to which dually diagnosed patients benefited from MHG participation on substance use and psychiatric outcomes. Finally, we examined associations between social anxiety and outcomes, and whether social anxiety moderated associations between MHG participation and outcomes. 1.1. MHGs for dual diagnosis patients Despite concerns about dually diagnosed patients participating in 12-step MHGs (Bogenschutz et al. 2006; Ouimette et al. 2003), dually diagnosed patients attend MHGs at rates approaching those of in- dividuals with only substance use disorders (Westermeyer & Schneek- loth 1999). In addition, when dual diagnosis patients attend Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings, they benefit from participation (Chi, Satre, & Weisner 2006; Herman et al. 2000; Ouimette et al. 2001; Timko & Sempel 2004). However, these studies have focused primarily on describing meeting attendance, and little on other aspects of dual diagnosis patients' MHG participation, such as involvement in group practices (e.g., speaking at meetings, having a sponsor) or working the steps. In addition, studies of benefits of meeting attendance have focused on substance use outcomes, with little attention to psychiatric symptoms or patients being troubled by their substance- or psychiatric-related problems (Bogenschutz et al. 2006). The present study described dually diagnosed patients' participa- tion in MHGs using several indicators of MHG attendance and Journal of Substance Abuse Treatment 44 (2013) 216–223 ⁎ Corresponding author. Center for Health Care Evaluation, VA Health Care System (152-MPD), 795 Willow Road, Menlo Park, CA 94025, USA. Tel.: +1 650 493 5000x23336; fax: +1 650 617 2736. E-mail address: ctimko@stanford.edu (C. Timko). 0740-5472/$ – see front matter. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jsat.2012.05.007 Contents lists available at SciVerse ScienceDirect Journal of Substance Abuse Treatment