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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Spirituality religiosity promotes acceptance based responding and 12-step involvement.

BACKGROUND: Previous investigations have observed that spirituality/religiosity (S/R) is associated with enhanced 12-step involvement. However, relatively few studies have attempted to examine the mechanisms for this effect. For the present investigation, we examined whether acceptance-based responding (ABR) - awareness or acknowledgement of internal experiences that allows one to consider and perform potentially adaptive responses - accounted for the effect of S/R on 12-step self-help group involvement 2 years after a treatment episode.

METHODS: Data were collected as part of a multi-site treatment outcome study with 3698 substance-dependent male veterans recruited at baseline. Assessments were conducted at baseline, discharge, 1-year follow-up, and 2-year follow-up. We utilized structural equation modeling to examine the relationships among latent variables of S/R, ABR, and 12-step involvement over time.

RESULTS: In the final model, S/R was not directly related to 12-step involvement at 2-year follow-up. However, S/R predicted enhanced ABR at 1-year follow-up after accounting for discharge levels of ABR. In turn, ABR at 1-year follow-up predicted increased 12-step involvement at 2-year follow-up after accounting for discharge levels of 12-step involvement.

CONCLUSIONS: S/R promotes the use of post-treatment self-regulation skills that, in turn, directly contribute to ongoing 12-step self-help group involvement.

Research report; Carrico AW, Gifford EV, Moos RH. Spirituality religiosity promotes acceptance based responding and 12-step involvement Drug Alcohol Depend. 2007 Jun 15;89(1):66-73.

Conversations with God : An Uncommon Dialogue (Book 1)

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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Concise TSF and Brief-TSF Research Summary

All the elements of TSF have moderate to strong research support, most of which has been replicated.

NB: AA does not participate in research but individual members do. The huge volume of peripheral research supports a strong case for recommending AA participation by alcoholics.

We know: -

• that Twelve Step Facilitation reduces alcohol abuse , improves related consequences, and improves employment prospects.
• that Alcoholics Anonymous has good efficacy, and that Peer Sponsoring/social support is an essential element in AA’s success.
• that recovering people who help recovering people maintain better sobriety and have greater involvement in the general community.
• that men, women, adolescence, African-Americans, Hispanics and gay men benefit from AA. That all socio-demographic groups are represented.
• that AA is suitable for head trauma victims, and methadone patients.
• that AA has wide acceptance and is readily available in almost all communities. The current global membership of AA is approximately 2.06 million.
• that participation in Alcoholics Anonymous improves medication compliance for mental health patients, improves psychological functioning, Improves coping, reduces child abuse and domestic violence, reduces healthcare usage, reduces hospitalisation, reduces medical symptoms, reduces subsequent treatment demand, reduces mortality, and reduces associated costs.
• that healthcare workers have good success rates for substance abuse treatment and recovery from alcoholism that can be improved with AA participation.
• that alcoholics with social networks supportive of drinking have better outcomes if they initiate AA attendance while in treatment.
• that affiliation with AA is enhanced if prospects gain an awareness of the culture and methods used by AA and that sobriety is better than drinking prior to attending AA.
• that 80% of Australian, 87% of USA, and 65% of UK doctors believe that Alcoholics Anonymous is the treatment of choice for alcoholism, but overall they do not understand how AA works.
• that more than 80% of specialist alcohol and drug treatment staff support Alcoholics Anonymous treatment referral and 92% of another specialist A & D service requested training in 12 Step approaches.
• that AA Peer Sponsor contact at the healthcare worker office/institution increases initiation and sustained attendance at AA meetings.
• that active and regular AA participation is one of the more effective ways to effect lifestyle changes for alcoholics.
• that routinely engaging patients in continuing outpatient care is likely to yield better outcomes..
• that most people in the early stages of alcoholism seek help from GP’s or Community Health Centres.
• that individuals with substance abuse medical conditions benefit from integrated medical and substance abuse treatment, and approaches such as TSF can be cost-effective.
• that for every $1.00 invested in intervention $4.30 is saved in future healthcare costs.

Predictors of changes in alcohol-related self-efficacy over 16 years.

Self-efficacy is a robust predictor of short and long term remission after treatment.

This study examined the predictors of self-efficacy in the year after treatment and 15 years later.

A sample of 420 individuals with alcohol use disorders was assessed five times over the course of 16 years.

Predictors of self-efficacy at 1 year included

• improvement from baseline to 1 year in heavy drinking,
• alcohol-related problems,
• depression,
• impulsivity,
• avoidance coping,
• social support from friends, and
• longer duration of participation in Alcoholics Anonymous (AA).
• Female gender,
• more education,
• less change in substance use problems, and
• impulsivity during the first year predicted improvement in self-efficacy over 16 years.
• Clinicians should focus on keeping patients engaged in AA,
• addressing depressive symptoms,
• improving patient’s coping, and
• enhancing social support during the first year and reduce the risk of relapse by monitoring individuals whose alcohol problems and impulsivity improve unusually quickly.

Predictors of changes in alcohol- efficacy- over 16 years. J Subst Abuse Treat. 2007 Nov 23. McKellar J, Ilgen M, Moos BS, Moos R.

Understanding And Counseling Persons With Alcohol, Drug, And Behavioral Addictions by Howard Clinebell Read more about this title…

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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Brief-TSF COUNSELOR CHARACTERISTICS AND TRAINING

Educational Requirements

Brief-TSF requires considerable clinical skill to implement properly. Issues in implementation include the ability to stay focused, maintain structure within each session, and engage in constructive confrontation. Accordingly, it is recommended that prospective facilitators have counseling experience and/or training.

Counselor’s Recovery Status

Brief-TSF facilitators need not be in recovery personally. Any serious Brief-TSF facilitator, however, should have read all relevant AA literature that clients will be asked to read and should be familiar with at least AA and Al-Anon meetings from personal experience. In addition, it is not recommended that a facilitator whose own views are unsympathetic to the primary goals of Brief-TSF (e.g., abstinence, active involvement in 12 step fellowships) seek to implement this model, for obvious reasons.

Balance

Ideal Personal Characteristics of Counselor

The best Brief-TSF facilitators have a good working grasp of basic Rogerian non-specific, client-centered therapeutic skills, including unconditional positive regard and good active listening skills, combined with a good-working knowledge of 12 step philosophy and the practicalities of getting active in 12 step fellowships. The ideal Brief-TSF facilitator is able to maintain session focus without excessive drift while also maintaining rapport. The Brief-TSF facilitator establishes a collaborative relationship with the client and utilises confrontation in a constructive, non-punitive manner.

Counselor’s Behaviours Prescribed

The Brief-TSF facilitator will help the client:

• Assess his or her alcohol and advocate abstinence.
• Explain basic 12 step concepts (e.g., surrender, acceptance & action).
• Advocate and actively support and facilitate initial involvement in AA.
• Facilitate introduction to an AA Peer Sponsor.
• Facilitate ongoing participation in AA.
• Suggest and discuss specific readings from AA literature.
• Help the client learn to use AA members as resources in times of crisis and to support and celebrate sobriety.
• Conduct sessions that helps the client assess critically his or her progress in the program.

Counselor’s Behaviours Proscribed

The Brief-TSF facilitator does not:

• Conduct sessions with an intoxicated client.
• Attend AA meetings with the client.
• Act as an AA sponsor.
• Threaten reprisals for non-compliance.
• Advocate controlled drinking or other drug use.
• Allow therapy to drift excessively onto collateral issues, such as marital or job conflict.

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