Response to Slips and Relapses
Slips and relapses are considered normal and even expected parts of early recovery, as are frequent urges to drink.
The 12 step model regards addiction as an illness characterized by compulsion that overwhelms individual willpower. Until the client is solidly connected to a 12 step fellowship, he or she is expected to experience difficulty sustaining sobriety even with the best of intentions.
The primary purpose of the review part of the Brief-TSF session is to assess the client’s recovery and to evaluate urges and slips and how the client dealt with them. This material becomes an important context in which the facilitator gradually shapes greater involvement in AA.
Typically, a pattern is discerned in slips. For example, it is common for a client to stay clean and sober for 1 or 2 days after a meeting and then to slip. Identifying this pattern (often with the aid of a calendar) can help to reinforce the importance of active involvement in AA.
In some circumstances a pattern of frequent slips despite attendance at meetings will lead the facilitator to recommend inpatient treatment.
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Therapeutic Alliance
In Brief-TSF, the facilitator is seen as an expert in interpersonal counseling techniques and as knowledgeable in the principles and practicalities of 12 step fellowships.
However, in Brief-TSF the facilitator is not regarded as the primary agent of change; rather, it is the 12 step fellowship (AA) that is seen as the agent of change. Accordingly, the Brief-TSF facilitator needs to conceptualize treatment as the product of a collaborative relationship and should assume responsibility for doing the best he or she can to establish that collaborative relationship.
However, it is not the facilitator’s goal to breakdown the client’s denial (but simply to disturb denial), or to provide all support needed to stay sober, or to take the client to meetings, and so forth.
Even in emergencies, the facilitator’s role and responsibilities are limited in the Brief-TSF model. For this reason the word "facilitator" was chosen rather than therapist or counselor, as it seems to describe the role better than those labels.
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ROLE OF SIGNIFICANT OTHERS IN TREATMENT
Brief-TSF includes a ‘Partner Brief-TSF’ program to be used as adjunctive therapy whenever possible when an alcoholic patient is in a relationship.
Partner Brief-TSF can also be applied when the alcoholic is not in treatment.
Like other aspects of Brief-TSF, the partner sessions are focused and aim to meet specific goals.
Partner Brief-TSF is not intended to be used as brief marital or relationship counseling, although one objective of these sessions is to help the patient(s) assess the impact of alcohol abuse on the relationship. Marital therapy may be briefly discussed, and significant others concerns, frustrations, and grievances are validated, but the facilitator also suggests that intensive relationship counseling (along with other therapies such as family therapy or sex therapy) be deferred, at least until the client has completed Brief-TSF and, preferably, 6 months of sobriety.
The Partner Brief-TSF sessions deal with the subjects of enabling and detaching. Both of these concepts have their origins in Al-Anon, a 12-step program similar to AA but for the affected rather than the addicted. A primary goal of the Partner Brief-TSF program is to encourage and briefly facilitate the partner’s use of Al-Anon as a resource for coping with being in a relationship with an alcoholic and also for healing personal wounds that typically derive from that kind of relationship.
Another goal is to assess initially the partner’s use of alcohol or other drugs and make an appropriate referral if necessary. Finally, the goals and objectives of Brief-TSF itself and AA are outlined.
Brief-TSF includes guidelines for handling emergency calls from a partner. The approach emphasizes support and efforts to facilitate the partner’s use of Al-Anon.
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Strategies for Dealing with Common Clinical Problems
Brief-TSF includes information on troubleshooting, which helps the facilitator anticipate and plan for common problems such as lateness, coming to sessions under the influence, and client resistance to new material.
Most often these strategies are consistent with AA philosophy and encourage the client to utilize the resources of 12-step fellowships. For example, the client who arrives drunk or high is asked how he or she will "not drink again for the rest of today."
Clients are never punished, rejected, or scolded within the Brief-TSF model for drinking, since it is accepted that loss of control is the essence of their illness.
However, sessions are cut short if the client is drunk. He or she will be strongly encouraged to call an AA hotline or a recovering friend and to go to a meeting immediately.
Chronic lateness or cancellations are dealt with as denial.
As a rule, the BriefTSF facilitator places ultimate responsibility for recovery on the client. The facilitator is a guide and a source of support, but the key to recovery is always seen as active involvement in one or more 12-step fellowships.
A common strategy for dealing with resistance in BriefTSF is to ask the client to keep an open mind or just give it an honest try.
The facilitator maintains a position of unconditional positive regard and acceptance of the client’s illness, regardless of whatever resistance emerges.
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Strategies for Dealing With Denial, Resistance, or Poor Motivation
Strategies for dealing with resistance within the Brief-TSF model all begin with an assumption that the client has an illness that is characterized by loss of control over alcohol or other drug use, which leads him or her to want to resist accepting that loss of control.
Though the only viable treatment goal from the Brief-TSF and 12 step perspective is abstinence from all alcohol, it is expected that the client will have a hard time accepting this limitation, as anyone has difficulty accepting limitation. Viewed in this light, resistance is seen as a natural part of the course of early recovery. Indeed, the Brief-TSF facilitator should be suspicious if too little resistance is encountered (a phenomenon known as compliance).
Eschers ‘Intersection’ illustrates the split motivation of the alcoholic
The BriefTSF facilitator seeks to deal with resistance through open discussion and through a process of shaping the client’s behavior and attitudes. The methods employed for this shaping include consistent reinforcement of progress, acceptance of resistance, reframing of 12-step concepts (which are not dogmatically set), and compromise.
The client is often asked to keep an open mind, to listen, and to try to identify with one or more of the people they hear at meetings. This is then discussed in the review part of any Brief-TSF session. The client is consistently told that he or she can accept or reject an aspect of 12-step philosophy and that the fellowship can still be a vital source of support for early recovery.
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Strategies for Dealing With Crises
In Brief-TSF, the facilitator is given specific guidelines for dealing with crises ranging from suicidal ideation to spouse abuse to divorce.
As a rule, only psychiatric emergencies and acute intoxication or overdose are grounds for suspending Brief-TSF. Otherwise, crises are assessed and triaged.
In many instances the facilitator will direct the client to the resources of 12-step fellowships (including Al-Anon and Alateen for partners and children of clients) as a means of coping with acute stressors.
Clients are encouraged to discover how ubiquitous their own problems are among people who have alcohol and how such issues are common topics of discussion at meetings. Indeed, the facilitator may very well be a less useful resource in this regard than the support of fellow recovering persons, many of whom have dealt with or are actively dealing with similar problems.
If an emergency session is deemed necessary, Brief-TSF includes specific facilitator guidelines.
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Risk, resilience, and natural recovery: a model of recovery from alcohol abuse for Alaska Natives
Aim; The People Awakening (PA) study explored an Alaska Native (AN) understanding of the recovery process from alcohol abuse and consequent sobriety.
Design; PA utilized a cross-sectional, qualitative research design and community-based participatory research methods.
Setting and participants; The study included a state-wide convenience sample of 57 participants representing all five major AN groups: Aleut/Alutiiq, Athabascan, Inupiaq, Yup’ik/Cup’ik and Tlingit/Haida/Tsimshian. Participants were nominated and self-identified as being alcohol-abstinent at least five years following a period of problem drinking.
Measurements; Open-ended and semistructured interviews gathered extensive personal life histories. A team of university and community co-researchers analyzed narratives using grounded theory and consensual data analysis techniques.
Findings; A heuristic model of AN recovery derived from our participants’ experiences describes recovery as a development process understood through five interrelated sequences:
- the person entered into a reflective process of continually thinking over the consequences of his/her alcohol abuse;
- that led to periods of experimenting with sobriety, typically, but not always, followed by repeated cycling through return to drinking, thinking it over, and experimenting with sobriety; culminating in
- a turning point, marked by the final decision to become sober. Subsequently, participants engaged in
- Stage 1 sobriety, active coping with craving and urges to drink followed for some participants, but not all, by
- Stage 2 sobriety, moving beyond coping to what one participant characterized as ‘living life as it was meant to be lived.
Conclusions; The PA heuristic model points to important cultural elements in AN conceptualizations of recovery.
Research; Mohatt GV, Rasmus SM, Thomas L, Allen J, Hazel K, Marlatt GA. Risk, resilience, and natural recovery: a model of recovery from alcohol abuse for Alaska Natives. Addiction. 2007 Nov 27
Brief-TSF is designed to address these issues.
Brief-TSF Agent of Change
The facilitator in the Brief-TSF treatment model is more truly a facilitator of change than an agent of change. The true agent of change (to sustained sobriety) lies in active participation in AA along with the principles set forth in the 12 steps and 12 traditions that guide this fellowship.
This is truly adjunctive therapy.
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TSF & Brief-TSF Theoretical Rationale/Mechanism of Action
The theoretical rationale is based in the 12 steps and 12 traditions of AA and includes the need to accept that willpower alone is not sufficient to achieve sustained sobriety, that self-centeredness must be replaced by surrender to the group process/conscience, and that long-term recovery consists of a process of spiritual renewal.
The primary mechanism action is active participation and a willingness to accept a higher power, even if it is the AA group at first, as the locus of change in one’s life.
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Brief-TSF ASSESSMENT
The assessment session in BriefTSF runs for up to 1 hour. The goals are to:
- Establish client-facilitator rapport.
- Conduct a collaborative assessment of alcohol (history).
- Discuss the client’s prior efforts to stop or control use.
- Discuss negative consequences associated with use.
- Share a diagnosis with the client and attempt to have it be a collaborative decision.
- Attempt to get a commitment from the client to sample several AA meetings and to try and to keep an open mind.
- Introduce an AA Peer Sponsor by phoning immediately the person indicates a commitment.
Assessment within the TSF model has both an informational and a motivational goal.
Consistent with 12 step philosophy, no client is excluded from treatment as a consequence of drinking, although with some clients it may become appropriate to discuss inpatient treatment.
Sessions with clients who are found to be (or who admit to being) drunk or under the influence of other psychotropic drugs are terminated, and arrangements are made to get the client home safely.
Further appointments are made as appropriate.
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