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Double Trouble in Recovery

Double Trouble in Recovery (DTR) is a mutual aid, self-help program for adults ages 18-55 who have been dually diagnosed with mental illness and a substance use disorder. In a mutual aid program, people help each other address a common problem, usually in a group led by consumer facilitators rather than by professional treatment or service providers. DTR is adapted from the Twelve Steps of Alcoholics Anonymous. DTR meetings follow the traditional 12-step format, which includes group member introductions, a presentation by a speaker with experiences similar to those of the meeting attendees, and time for all attendees to share their experiences with the group. Meetings typically last 60-90 minutes. DTR encourages members to discuss their addiction, mental illness, psychotropic medications, and experiences with formal treatment without the stigma they might encounter in traditional 12-step programs, which have a single focus. DTR groups are structured to create an environment in which people with an active addiction and psychiatric diagnosis can identify with other members and explore their dual recovery needs.

Descriptive Information

Areas of Interest Co-occurring disorders
Outcomes Review Date: December 2007
1: Substance use
2: Psychiatric medication adherence
3: Attendance at traditional 12-step meetings
Outcome Categories Drugs
Mental health
Treatment/recovery
Ages 26-55 (Adult)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Settings Outpatient
Other community settings
Geographic Locations Urban
Implementation History Since DTR was first implemented in 1989, thousands of individuals have participated in the program. More than 200 DTR groups are currently operating in the United States.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: December 2007

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Magura, S., Rosenblum, A., Villano, C. L., Vogel, H. S., Fong, C., & Betzler, T. (2008). Dual-focus mutual aid for co-occurring disorders: A quasi-experimental outcome evaluation study. American Journal of Drug and Alcohol Abuse, 34(1), 61-74.  Pub Med icon

Outcomes

Outcome 1: Substance use
Description of Measures At baseline and follow-up, study participants reported the number of days during the past 90 days on which they used drugs or alcohol. Drugs included heroin and other illicit opioids, cocaine/crack, marijuana, sedatives, barbiturates, inhalants, and hallucinogens.
Key Findings At 6-month follow-up, study participants exposed to DTR group meetings reported fewer days of drug or alcohol use during the past 90 days than study participants not exposed to DTR group meetings (intent-to-treat analysis, p < .05).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.7 (0.0-4.0 scale)
Outcome 2: Psychiatric medication adherence
Description of Measures The Medication Adherence Rating Scale (MARS) was used to measure the extent to which participants took their psychiatric medication, prescribed in the past 6 months. The MARS is an additive scale of 10 items, each coded 0 (no) or 1 (yes). Lower scores indicate greater adherence.
Key Findings At 6-month follow-up, study participants exposed to DTR group meetings had better psychiatric medication adherence than study participants not exposed to DTR group meetings (intent-to-treat analysis, p < .05).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.5 (0.0-4.0 scale)
Outcome 3: Attendance at traditional 12-step meetings
Description of Measures Study participants reported the number of traditional 12-step meetings they attended in the previous 30 days.
Key Findings At 6-month follow-up, study partipants exposed to DTR group meetings attended traditional 12-step groups more frequently than study participants not exposed to DTR group meetings (intent-to-treat analysis, p = .01).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 60% Male
40% Female 		42% Black or African American
41% Hispanic or Latino
17% White

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Substance use 3.5 2.5 2.0 2.5 3.0 2.5 2.7
2: Psychiatric medication adherence 3.5 2.5 2.0 1.5 3.0 2.5 2.5
3: Attendance at traditional 12-step meetings 3.0 2.5 2.0 2.5 2.5 2.5 2.5

Study Strengths

The measures used have established reliability and validity. All consumer facilitators in the study received orientations led by the executive director of Double Trouble in Recovery, Inc. There were no significant differences between the two cohorts in terms of those who refused participation and their reasons for refusal. The sample included in the follow-up was comparable to the group that was not included in the follow-up. The study used a comparison condition, and outcome data were systematically collected to evaluate the impact of DTR. The analyses were appropriate and adequately controlled for pretreatment differences between groups.

Study Weaknesses

Although the measures used have established reliability and validity, the Medication Adherence Rating Scale had a marginally acceptable level of reliability in this study. The authors reported problems with forms being completed inconsistently, which led to large amounts of missing data. No information was provided about ongoing supervision or fidelity checks.
Readiness for Dissemination
Review Date: December 2007

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Double Trouble in Recovery Group Fidelity Scale

Double Trouble in Recovery Group Questionnaire

Double Trouble in Recovery, Inc. (2000). Double Trouble in Recovery: Basic guide. Brooklyn, NY: Author.

Program Web site, http://www.doubletroubleinrecovery.org

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
2.0 1.5 1.0 1.5

Dissemination Strengths

Available materials provide information on implementation, such as how to organize a group. Personalized training is available for interested group leaders. A fidelity checklist and participant survey are available to support quality assurance.

Dissemination Weaknesses

While some general minimum requirements are listed for group leaders, it is unclear whether DTR groups could be implemented by any dually diagnosed individual without training and support. Training is not required, and supplemental information on DTR group facilitation is not available to assist implementers who choose not to take the training. Materials do not explain how the fidelity checklist and participant survey are integrated into a quality assurance process or how information derived from these instruments are to be used to improve implementation.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
How To Start a Double Trouble in Recovery Group guide with CD-ROM $17.95 each Yes
Double Trouble in Recovery Basic Guide $9 per participant for the book, $6.99 per participant for the ebook Yes
Starting and Running a Double Trouble in Recovery Group (DVD) $175 No
Double Trouble in Recovery collection (includes How To Start a Double Trouble in Recovery Group guide with CD-ROM, Double Trouble in Recovery Basic Guide, and Starting and Running a Double Trouble in Recovery Group) $225 No
Training Contact the developer No
Technical assistance and consultation Varies depending on site needs No
Double Trouble in Recovery group fidelity scale Free No
Double Trouble in Recovery group questionnaire Free No

Additional Information

Meeting space is generally provided for free by community-based organizations or within treatment facilities. There should be no charges for DTR meeting attendance. Meeting refreshments and other incidentals may be purchased through voluntary contributions of members or charitable sources.
Replications

No replications were identified by the developer.
Contact Information

To learn more about implementation, contact:
Howard Vogel, M.S.W.
HV613@aol.com

To learn more about research, contact:
Stephen Magura, Ph.D., CSW
(269) 387-5895
stephen.magura@wmich.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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