Research has shown that mutual aid is associated with improved substance use outcomes, both for singly diagnosed and dually diagnosed individuals.19,29
The present findings suggest reasons, from participants’ perspectives, why DTR attendance has been associated with reduced substance use and anxiety and improved medication adherence.30,31
For both the Michigan and New York City groups, developing a sense of affiliation in a safe, supportive environment—the essence of mutual aid fellowships—was a predominant theme. Participants appreciated the opportunity to gain knowledge and insight about their mental health symptoms, medications, and their relationship to substance use; the groups provide an environment in which such discussion is not only allowed but encouraged. Also, participants received affirmation for who they are, that is, individuals with substance use histories and also individuals with mental illness. Affirmation, that is, recognition/acceptance of being mentally ill rarely occurs in single-focus 12-step groups.16,32
These results distinguish dual-focus 12-step groups from groups with a single-focus orientation in that, rather than keeping substance use “relentlessly in the foreground,” the more inclusionary framework encourages members to express their concerns about both mental illness and substance use. Our findings are consistent with earlier research in which support from dually diagnosed peers emerged as a key ingredient of DTR participation.15
The sharing of ideas and the reciprocal exchange of information about mental illness, medication, and medication adherence are themes that echo earlier findings in which reciprocal learning was associated with improvements in self-efficacy, substance use outcomes, and attendance at DTR meetings.23
The importance of a spiritual orientation (eg, surrender to a higher power) has also been documented in empirical research on mutual aid groups.33–35
Spirituality, a theme that emerged in Staten Island, was not a topic of discussion among Michigan or Manhattan members. This may represent a study artifact since the Staten Island DTR chairperson had substantial experience with a variety of 12-step groups, including DTR, and repeatedly acknowledged in DTR meetings that he had benefited from reliance on a higher power.
Learning about and gaining access to needed services, a benefit cited by Michigan attendees but not those in New York, may stem from differences in living situations between these two samples in that New York participants lived primarily in supported housing, where medical and mental health services—a formal part of their treatment—are easily accessible and ongoing. In contrast, Michigan participants were far more likely to be in aftercare and living independently. In this situation, services are more challenging to access and can represent a substantial out-of-pocket expense.
The focus groups in this study were conducted in separate clinical locations with self-selected participants. Subjects had been participating in DTR for various lengths of time, had disparate backgrounds, and had different degrees of experience with 12-step programs. However, a more homogenous sample would likely limit external validity of the results since most 12-step groups, whether single-focus or dual-focus, include a diverse mix of participants. The most important feature of such groups, which includes DTR, is that all participants have a similar problem (mental illness and/or substance abuse).
It is unknown what effect, if any, differential time of DTR exposure had on participants’ perceptions of DTR benefits. A future research direction could be to examine factors that sustain participation in DTR groups. Such research would require individual interviews with subject identification (whereas the present study was conducted with subject anonymity) and a considerably larger sample wherein differences between newer and long-time DTR participants could be compared.
The present study is also limited by small sample size; a follow-up study should recruit more participants in more focus groups. The data presented here are more in line with a pilot study, intended to initiate procedures and determine whether a more extensive qualitative study of this kind would be of value.
Finally, different investigators conducted the focus groups in New York City and Michigan, and, thus, it is possible that questions were framed and responses elicited in ways influenced by their possibly different perspectives. This was necessary because the present study was conducted in two widely separated states. However, a follow-up study would be better advised to have the same facilitators conduct all focus groups.