Catholic University of America Alcoholics Anonymous Social Work Paper

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Soc Work Public Health. Author manuscript; available in PMC 2013 August 26.
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Published in final edited form as:
Soc Work Public Health. 2013 ; 28(0): 313?332. doi:10.1080/19371918.2013.774663.
12-Step Interventions and Mutual Support Programs for
Substance Use Disorders: An Overview
Dennis M. Donovan,
Alcohol and Drug Abuse Institute, University of Washington and Department of Psychiatry &
Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
Michelle H. Ingalsbe,
Alcohol and Drug Abuse Institute, University of Washington, Seattle, Washington, USA
James Benbow, and
Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health
Care System, Seattle, Washington, USA
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Dennis C. Daley
Department of Psychiatry, Western Psychiatric Institute & Clinic, University of Pittsburgh Medical
Center, Pittsburgh, Pennsylvania, USA
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Keywords
Abstract
Social workers and other behavioral health professionals are likely to encounter individuals with
substance use disorders in a variety of practice settings outside of specialty treatment. 12-Step
mutual support programs represent readily available, no cost community-based resources for such
individuals; however, practitioners are often unfamiliar with such programs. The present article
provides a brief overview of 12-Step programs, the positive substance use and psychosocial
outcomes associated with active 12-Step involvement, and approaches ranging from ones that can
be utilized by social workers in any practice setting to those developed for specialty treatment
programs to facilitate engagement in 12-Step meetings and recovery activities. The goal is to
familiarize social workers with 12-Step approaches so that they are better able to make informed
referrals that match clients to mutual support groups that best meet the individual?s needs and
maximize the likelihood of engagement and positive outcomes.
12-Step; mutual support; self-help; recovery activities
INTRODUCTION
Substance use disorders (SUDs) are highly prevalent and negatively affect physical,
psychological, social, legal, vocational, familial, educational, and other areas of life
function. Because of the widespread problems associated with alcohol and drugs, and given
that the majority of individuals with SUDs do not seek substance abuse treatment, social
workers and other behavioral health professionals are likely to encounter individuals with
SUDs in a variety of practice settings outside of specialty treatment (Caldwell, 1999; Kelly
& McCrady, 2008). Recognizing this with respect to problematic alcohol use, the Institute of
Copyright ? Taylor & Francis Group, LLC
Address correspondence to Dennis M. Donovan, PhD, Alcohol and Drug Abuse Institute, University of Washington, 1107 NE 45th
Street, Suite 120, Seattle, WA 98105, USA. [email protected].
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Medicine (1990) recommended broadening the base of alcohol treatment beyond specialty
programs to medical, mental health, and social service agencies where the prevalence of
hazardous or harmful drinking is likely to be relatively high. As health care reform is
currently moving forward, an increasing amount of care for SUDs will be provided in
nonspecialty settings, and social workers and other professionals will need to become more
facile in identifying and intervening with individuals with alcohol and drug problems.
However, given all the constraints faced by providers in nonspecialty settings and given
generalist training without a specialized focus on SUDs, many professionals in such settings
feel ill prepared to address SUDs. They also may feel that there are few resources available
to which such clients with alcohol and drug problems can be referred and that provide a
likelihood of success. Practitioners often fall back on Alcoholics Anonymous (AA) or other
12-Step self-help groups, discharging their responsibility to do something, because they are
readily available and free, but lack conviction that such programs will be effective or that
the client will go.
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This article provides a brief overview of 12-Step programs; the positive substance use,
psychosocial, quality of life, and cost-offset outcomes associated with active 12-Step
involvement; and approaches ranging from ones that can be utilized by social workers in
nonspecialty practice settings to those developed for specialty treatment programs to
facilitate engagement in 12-Step meetings and recovery activities. The goal is to familiarize
social workers and other behavioral health providers with 12-Step approaches so that they
are better able to make informed referrals that match clients to mutual support groups that
best meet the individual?s needs and maximize the likelihood of engagement and positive
outcomes (Caldwell, 1999; Humphreys, 1997; Kelly & McCrady, 2008).
EPIDEMIOLOGY OF 12-STEP PROGRAMS AND MEMBERS
There are many paths to recovery from alcohol and SUDs, and one that has been travelled
by many and is associated with positive long-term outcomes is involvement in 12-Step and
mutual/self-help groups (Laudet, Savage, & Mahmood, 2002; Moos & Moos, 2005, 2006).
Such groups, including Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine
Anonymous (CA) and a number of others (Laudet, 2008), have served as the primary, if not
only, source of behavior change for many, as adjuncts to formal treatment, or as a form of
continuing care and community support following treatment. These groups are highly
accessible and are available at no cost in communities throughout the world, thus serving as
important and readily available resources in substance abuse recovery.
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In 2006 and 2007, an annual average of five million individuals age 12 or older in the
United States attended a self-help group as a means of trying to deal with alcohol or drug
use issues (Substance Abuse and Mental Health Services Administration, 2008). Of this
number, approximately 45% attended because of alcohol only, 22% because of illicit drug
use only, and 33% because of alcohol and illicit drug use. About one third of those who
attended a self-help group in the past year had also been involved in some type of formal
treatment over that same period. Conversely, about two thirds of those who were involved in
substance abuse treatment during the past year also attended a self-help group. As of
January, 2012, the AA General Service Office estimated that there were nearly 64,000
groups with 1.4 million members in the United States and Canada, and a worldwide estimate
of more than 114,000 groups and 2.1 million members (Alcoholics Anonymous [AA],
2012). The membership has increased steadily over the past four decades (Kaskutas, Ye,
Greenfield, Witbrodt, & Bond, 2008). Narcotics Anonymous (NA; 2010b) has similarly
expanded to become an international network of support groups, with more than 58,000
weekly meetings in 131 countries. Cocaine Anonymous (CA; 2011) has grown from its
origins in 1982 to more than 30,000 members and 2,000 groups internationally by 1996. In
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addition, AA, NA, and CA all have Internet-based ?chat? rooms and online meetings that
can be found easily by doing an online search (e.g., ?online NA meetings?); these online
resources are viewed as ways to supplement, not replace, attending meetings in person. The
only requirement for membership in 12-Step groups is a desire to stop drinking and/or using
drugs. There is also a strong emphasis placed on service and helping other members get and
stay clean and sober.
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The 12-Step philosophy refers to a particular view of the recovery process. It emphasizes the
importance of accepting addiction as a disease that can be arrested but never eliminated,
enhancing individual maturity and spiritual growth, minimizing self-centeredness, and
providing help to other individuals who are addicted (e.g., sharing recovery stories in group
meetings, sponsoring new members; Humphreys et al., 2004). Self-help groups based on this
philosophy outline 12 consecutive activities, or steps, that substance abusers should achieve
during the recovery process. These steps specify that substance abusers must admit their
powerlessness over alcohol and drugs, take a moral inventory of themselves, admit the
nature of their wrongs, make a list of individuals whom they have harmed, and make
amends to those people. Involvement in such groups is meant to provide participants with
support for remaining substance free, a social network (the ?fellowship?) with which to
affiliate, and a set of 12 guiding principles (the ?steps?) to be followed in the recovery
process (Kaskutas, Bond, & Humphreys, 2002). The general guidelines for recovery based
on this philosophy have been distilled down to what has been described as the 12-Step ?six
pack?: don?t drink or use drugs, go to meetings, ask for help, get a sponsor, join a group, and
get active (Caldwell & Cutter, 1998).
EFFECTIVENESS OF 12-STEP PROGRAMS
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Although such mutual support groups are readily available, an important question is whether
they are effective in achieving their goal of members becoming alcohol and drug free. Each
of the three main 12-Step programs conducts periodic surveys of its members to assess
demographic characteristics and to determine the length of members? abstinence. Table 1
provides information from the most recently available AA, NA, and CA membership
surveys. Although viewed as not being scientifically rigorous and as based on self-selected
convenience samples, the findings with respect to meeting attendance and length of
abstinence are of interest. The median length of abstinence reported by AA and NA
members is greater than 5 years, with roughly one third of each of the three groups having
between 1 to 5 years of abstinence. Respondents reported attending, on average, two to four
meetings per week. These findings, given the caveats about sample representativeness and
the correlational nature of the results, suggest that longer term abstinence is achievable and
sustainable among those with relatively regular meeting attendance.
The results from a number of recent empirical studies corroborate the results from these
mutual support group membership surveys, supporting the clinical effectiveness of 12-Step
approaches. Reviews of this literature (Humphreys, 2003; Humphreys et al., 2004; Kaskutas,
2009; Krentzman et al., 2010; Owen et al., 2003) have noted, among other positive findings,
that AA and NA participation is associated with greater likelihood of abstinence, often for
prolonged periods up to 16 years (Moos & Moos, 2006), improved psychosocial
functioning, and greater levels of self-efficacy. Beginning 12-Step participation while in
treatment, especially at group meetings held at the treatment program, and 12-Step
attendance at the same time that one is enrolled in specialty treatment, are associated with
better outcomes. In addition, consistent, early, and frequent attendance/involvement (e.g.,
three or more meetings per week) is associated with better substance use outcomes.
Although even small amounts of participation may be helpful in increasing abstinence,
higher ?doses? may be needed to reduce the likelihood of relapse. Engaging in other 12-Step
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group activities (e.g., doing service at meetings, reading 12-Step literature, doing ?step
work,? getting a sponsor, or calling other 12-Step group members or one?s sponsor) may be
a better indicator of engagement and a better predictor of abstinence than merely attending
meetings. In addition, increased involvement in 12-Step meetings and activities following
formal treatment may serve as an important source of support and a form of continuing care
that has been shown to lead to decreased utilization of mental health and substance abuse
treatment services and associated costs (Humphreys & Moos, 2001, 2007).
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Although the positive relationship between 12-Step involvement and clinical outcomes is
compelling, it is not possible to infer a causal relationship from correlational findings. Three
recent studies, using cross-lagged analyses of longitudinal data or structural equation
modeling, have begun to elucidate the nature of this relationship (Connors, Tonigan, Miller,
& Project MATCH Research Group, 2001; McKellar, Stewart, & Humphreys, 2003; Weiss
et al., 2005). The results of these studies suggest that the reductions in substance use
associated with 12-Step involvement are not attributable to potential third variable
influences such as ?good prognosis? participants, level of motivation, presence of comorbid
psychopathology, or the severity of the individuals? alcohol or drug problem. These findings
provide increasingly supportive evidence for the hypothesis that 12-Step involvement
?works?; that is, increased 12-Step meeting attendance and/or involvement appear to lead to
a decrease in subsequent alcohol and drug use, leading to the conclusion that the evidence
supports a causal pathway between 12-Step attendance and abstinence (Kaskutas, 2009;
Krentzman et al., 2010).
SPECIAL POPULATIONS?WHO MAY NEED MORE OR DIFFERENT HELP?
A question of concern is whether certain subgroups or special populations benefit as fully, or
in the same way, from participation in 12-Step support groups. For example, are women,
youth, ethnic minorities, and those diagnosed with substance use and psychiatric disorders,
apt to derive the same benefits from 12-Step participation as White, non-dually diagnosed
male adults? A related question is whether special populations benefit equally from
traditional 12-Step groups versus groups that are uniquely focused on their subgroup (i.e.,
Spanish speaking or Native American, women-only, youth 12-Step, dually diagnosed 12Step, or groups within a certain geographical community that may attract primarily those of
a certain ethnic group).
Women
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Some have speculated that women may not identify as well as men with 12-Step programs,
in part because women may resist the notion of powerlessness and surrender based on their
historically subservient status in society (Hillhouse & Fiorentine, 2001; Krentzman, Brower,
Cranford, Bradley, & Robinson, 2012; Matheson & McCollum, 2008; Timko, 2008). Others
have suggested that women may be more likely to identify with the 12-Step approach
because of their tendency toward lower self-esteem, an external locus of control, and a
greater willingness to admit their mistakes and to disclose negative things about themselves
(Beckman, 1994; Kaskutas, 1994; Timko, 2008). Although women make up only about one
third of AA members, there is evidence that they may affiliate just as strongly as men with
12-Step groups and that they may benefit just as much from attendance when it comes to
drinking outcomes (Beckman, 1994; Del Boca & Mattson, 2001; Hillhouse & Fiorentine,
2001; Timko, 2008; Timko, Moos, Finney, & Connell, 2002; Witbrodt & Delucchi, 2011).
Also, a number of 12-Step programs, including AA and NA, have women?s-only groups that
may be seen by many women as more welcoming and supportive and, thus, are more likely
to be attended than mixed gender groups. Additionally, Women for Sobriety provides
another mutual-support recovery resource that differs from 12-Step approaches in structure,
format, and program philosophy (Kaskutas, 1994).
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Youth
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Although there is reason to believe that 12-Step attendance can benefit youth, only 11% and
16% of AA and NA members, respectively, are younger than age 30, and only about 2% in
both groups are younger than age 21 (AA, 2008; NA, 2010a). In addition, there may be high
drop-out rates for youth (Kelly, Myers, & Brown, 2002; Kelly, Myers, & Rodolico, 2008).
Various factors have been proposed as to why youth may not affiliate as strongly with 12Step programs. These include difficulty accepting the concept of never drinking or using
again, inability to relate to the struggles of older adults (i.e., employment, marriage, health,
and parenting issues), issues of adolescent brain development, logistical barriers to accessing
12-Step groups (e.g., transportation), lack of interest in spiritual matters, boredom with 12Step groups, and difficulty relating to some of the ?steps? of the program (Kelly et al., 2008;
Kelly & Urbanoski, 2012; Sussman, 2010; Timko, 2008). In spite of possible barriers for
youth, several studies have found a significant relationship between greater AA/NA
participation and improved alcohol and substance use outcomes (Kelly, Dow, Yeterian, &
Kahler, 2010; Kelly et al., 2002; Kelly & Urbanoski, 2012).
Ethnic Minorities
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Researchers have also explored whether ethnic minorities participate in and/or benefit from
traditional 12-Step groups in the same way as Whites. Some have speculated that, like
women, ethnic minorities may bristle at the notion of powerlessness inherent in the 12-Step
program because of past societal oppression (Timko, 2008) or that they may have trouble
accepting the notion of alcoholism or drug addiction as a disease (Durant, 2005). Similar to
described for women, ethnic minority groups also may view 12-Step group meetings
comprising primarily majority White members as less welcoming and supportive. However,
there does appear to be evidence that ethnic minorities may involve themselves to the same
extent in and derive comparable benefits as Whites from 12-Step programs (Hillhouse &
Fiorentine, 2001). For example, Black Americans were found to be just as likely as Whites
to have attended AA as a part of their treatment and were more likely to affiliate as a
member of AA, to report having had a spiritual awakening, and to have performed service in
AA (Kaskutas, Weisner, Lee, & Humphreys, 1999).
Individuals with Dual Diagnoses
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Individuals with concurrent psychiatric and substance use disorders (e.g., dual disorders or
co-occurring disorders) often have more and greater challenges in their recovery process and
poorer outcomes than individuals with only a SUD (Laudet, Magura, Vogel, & Knight,
2000). There is evidence that individuals diagnosed with substance-use and psychiatric
disorders can benefit from 12-Step involvement (Bogenschutz, 2007; Bogenschutz, Geppert,
& George, 2006; Laudet, Cleland et al., 2004; Laudet, Magura et al., 2004; Laudet, Magura,
Vogel, & Knight, 2003; Magura, 2008; Magura, Laudet, et al., 2003; Timko & Sempel,
2004). It is possible, however, that attendance rates may be affected by diagnosis. For
instance, individuals diagnosed with schizophrenia or schizoaffective disorder reported
attending fewer 12-Step meetings than those with other co-occurring psychiatric diagnoses
(Jordan, Davidson, Herman, & BootsMiller, 2002). It has also been suggested that
specialized 12-Step support groups for the dually diagnosed, such as Double Trouble in
Recovery (DTR) or Dual Recovery Anonymous, could be even more valuable for this
population than traditional groups (Bogenschutz, 2005, 2007; Magura, 2008; Timko, 2008;
Vogel, Knight, Laudet, & Magura, 1998). One aspect related to this is that individuals with
dual disorders may feel more comfortable and safe discussing their dual recovery needs and
their use of psychotropic medications as part of their ongoing treatment than would be true
in traditional 12-Step groups (Bogenschutz, et al., 2006; Magura, Laudet, Mahmood,
Rosenblum, & Knight, 2002; Vogel et al., 1998). Higher levels of attendance at DTR
meetings by individuals with co-occurring disorders was associated with better medication
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compliance, as well as with reductions in substance use and psychiatric symptoms and
improved quality of life and self-efficacy (Magura, 2008; Magura et al., 2002).
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HOW DO 12-STEP GROUPS WORK? MECHANISMS OF ACTION
Researchers have investigated the mechanisms of action or the ?active ingredients? of 12Step programs that contribute to their effectiveness in increasing the likelihood of abstinence
and improved psychosocial function. The general categories of potential mediators that have
been investigated include 12-Step specific practices, social and spiritual processes, and
processes that are common across different types of therapies or behavior change (Kelly,
Magill, & Stout, 2009). It appears that those factors most highly related to abstinence are
social processes and common processes. A major factor appears to be the ?fellowship?
associated with 12-Step groups. Membership in such groups contributes to a shift in one?s
social network, with a reduction in the number of individuals who support drinking to an
expanding network of those who support abstinence (Bond, Kaskutas, & Weisner, 2003;
Groh, Jason, & Keys, 2008; Kelly, Hoeppner, Stout, & Pagano, 2012; Kelly, Stout, Magill,
& Tonigan, 2011; Longabaugh, Wirtz, Zweben, & Stout, 1998). This adaptive shift in the
social network is also accompanied by decreased exposure to drinking-related activities and
cues that induce craving, as well as increased nondrinking activities, social abstinence selfefficacy, and rewarding social relationships (Kelly et al., 2012; Kelly, Stout, et al., 2011).
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Other more common behavior change processes are also active ingredients in 12-Step selfhelp groups. These include the groups? encouraging bonding with other members in the
fellowship, providing structure and a sense of goal directedness; the provision of behavioral
norms about and role models for how to work toward abstinence; the development and
engagement in non-substance-related activities that are rewarding and can take the place of
substance-related activities; and the development of more effective coping skills with an
associated increase in self-efficacy (Kelly et al., 2009; Moos, 2008). The changes in the
individual?s social network and these common behavior change processes appear to
contribute more to the positive benefits of 12-Step mutual support groups than do 12-Step
specific factors or spiritual mechanisms (Kelly et al., 2012).
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The prominence of more general behavior change mechanisms found in the overall 12-Step
participant population also appears to be the case with youth and individuals with dual
disorders. In a manner consistent with findings of adults, youth report finding general grouptherapeutic aspects of 12-Step programs as most helpful to them (e.g., ?universality? or not
feeling as alone with their problems, getting support from others, the installation of hope),
whereas 12-Step specific factors (e.g., 12-Steps practices and principles, belief in a Higher
Power, and core AA philosophy) were not rated as highly in importance (Kelly et al., 2002;
Kelly et al., 2008; Kelly & Urbanoski, 2012). Mediators of the positive benefits associated
with dual-focused groups for individuals with co-occurring substance use and psychiatric
disorders include higher level of social support, sociability, internal locus of control, and
self-efficacy (Bogenschutz, 2007; Laudet, Cleland, Magura, Vogel, & Knight, 2004;
Magura, Knight, et al., 2003; Magura, Laudet, et al., 2003). However, for this population
involved in DTR groups, some more specific self-help factors may also be active
ingredients. These include helper therapy and reciprocal learning that were found to be
related to increased abstinence (Magura, Laudet, et al., 2003) and spirituality and installation
of hope that were associated with health promoting behavior but not substance use outcomes
(Magura, Knight, et al., 2003).
BARRIERS TO ATTENDANCE AND ENGAGEMENT
Despite the benefit that can be derived from attending meetings and engaging in 12-Step
activities, many individuals with SUDs are reluctant to do so. A number of real or perceived
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barriers contribute to high attrition and low or inconsistent participation rates. Some of the
prominent barriers are listed in Table 2.
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Many individuals who are substance dependent view 12-Step groups as helpful resources in
the recovery process, but even following treatment, many are ambivalent, fluctuate in their
readiness and commitment to change, and question their need for help. These motivational
factors may pose more of a barrier than aspects of 12-Step philosophy and ideology, such as
spirituality, religiosity, the need to surrender, and the sense of powerlessness (Laudet &
White, 2005), although the compatibility between personal and treatment belief systems and
philosophies is an important predictor of engagement in 12-Step programs (Mankowski,
Humphreys, & Moos, 2001). Such barriers may reduce the likelihood of initially engaging in
12-Step meetings and activities, as reflected by high rates of dropouts by those who do
initiate involvement (Cloud & Kingree, 2008; Kelly & Moos, 2003). As noted by Kaskutas
and colleagues, there are a number of different trajectories of involvement: some individuals
with SUDs never connect with 12-Step programs, some connect briefly but then drop out,
and others strongly affiliate and maintain stable and often high rates of attendance (Caldwell
& Cutter, 1998; Kaskutas et al., 2005).
WHAT CAN SOCIAL WORKERS AND PROFESSIONALS DO TO HELP?
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To benefit maximally from 12-Step programs it is necessary to attend meetings and engage
in recovery activities, yet, as noted, meeting attendance and engagement may be limited,
inconsistent, and sporadic. Social workers and other health and behavioral health providers
working in substance abuse treatment programs, medical settings such as emergency
departments, trauma centers, or primary care clinics, or social service agencies, all encounter
populations in which SUDs are prevalent. As such, there are opportunities to attempt to
inform the substance abuser about the availability and potential benefits of 12-Step
programs. The 2007 AA membership survey, for example, found that 39% of members
reported that they were referred to AA by a health care professional (AA, 2008). As Laudet
(2003) noted, it is important to attempt to enhance the individual?s motivation for change,
assess his or her beliefs about and prior experiences with 12-Step self-help groups, and find
a good fit or match between clients? needs and inclinations and the help and support
available from such groups. In the process, there are some general principles and approaches
to keep in mind and to guide the social worker or behavioral health professional in this
process.
Professionals? Knowledge, Perceptions, and Attitudes
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A major concern is that many behavioral health professionals working in nonspecialty
settings are unfamiliar with the general philosophy (e.g., the 12 Steps and Traditions) of 12Step-based mutual support groups in general (Stewart, 1990), about the different types of
meetings and the way they are conducted (Kelly & McCrady, 2008). They are also often less
aware of the positive outcomes associated with involvement in 12-Step programs. To
accurately match the individual to the appropriate type of group, whether a 12-Step group or
a mutual support group that is not necessarily based on 12-Step principles, it is important to
become familiar with the variety of resources available (Fenster, 2006; Humphreys, 1997;
Kelly & McCrady, 2008). Although clinicians have been found to view 12-Step programs as
important in the recovery process, 86% of clinicians in one survey expressed extremely
great interest in obtaining further training or information about 12-Step groups (Laudet,
2003). This is important, because just as the substance abusers may perceive barriers to and
have negative perceptions of or attitudes toward involvement in 12-Step programs, so might
some providers (Vederhus, Kristensen, Laudet, & Clausen, 2009; Vederhus, Laudet,
Kristensen, & Clausen, 2010). It is also important to become aware of what resources exist
in the local community. The professional and the substance abuser can find meetings and
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informational resources by looking in the phone book or on the Internet under the specific
group (e.g., AA, NA, CA) or ?12-Step programs.? It is also helpful to read materials from
and about the different groups (again, readily available on the Internet) and attend some
meetings that are open to the public (i.e., ?open meetings?) to become more familiar with
the programs and specific groups to which you might be referring a client. Informed
referrals are more likely to result in a better match, which, in turn, is likely to increase the
possibility of client engagement (Humphreys, 1997).
Client?s Readiness and Expectations
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Another important component in matching the client to the appropriate 12-Step program or
to some other type of mutual support group is to explore or more formally assess the
individual?s prior experiences with and expectations about 12-Step groups. Some have had
little or no experience with 12-Step groups and may benefit from education about them. This
might involve the provider sharing information derived from his or her knowledge of and
visits to different self-help meetings in the area. Useful information that explains how 12Step programs work and what one might expect by affiliating with them can be obtained
from pamphlets, such as, ?So You?ve Been Asked to Go to AA? (http://www.seattleaa.org/
asked.html), ?44 Questions? (http://www.recovery.linderweb.net/44questions.pdf), or ?What
is the Narcotics Anonymous Program? (http://www.na.org/admin/include/spaw2/uploads/
pdf/litfiles/us_english/misc/What%20Is%20the%20NA%20Program.pdf), that are available
through local 12-Step chapters or online.
Another resource is that of active AA or other recovery self-help group members who are
willing to share their experience with clients who are less familiar with the programs. It has
been found that a combination of a brief 5- to 15-minute physi