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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The Co-Occurrence of Depression and Alcohol Dependence Symptoms in a Community Sample of Lesbians

Numerous studies have found an association between depression and alcohol use disorders in women.

Little is known, however, about the relationship between depression and alcohol use among lesbians.

We examined the prevalence of depression and alcohol dependence symptoms as well as the co-occurrence of these two health problems in a large community-based sample of women who self-identified as lesbian.

Past year alcohol dependence symptoms were significantly associated with both past year and lifetime depression.

Lifetime depression was higher among White and Latina lesbians than among African American lesbians.

Younger women and those not currently in a committed relationship more commonly reported past year depression.

Younger age was the strongest predictor of the co-occurrence of depression and alcohol dependence symptoms.

Research report; Wendy B Bostwick, Tonda L. Hughes & Timothy Johnson. The Co-Occurrence of Depression and Alcohol Dependence Symptoms in a Community Sample of Lesbians. Journal of Lesbian Studies, Volume: 9 Issue: 3, 2005

Primary care doctors’ perception of treatment demand and need for training in drug addiction issues.

Aim: To learn the opinion of primary care physicians (PCPs) on healthcare provision for the drug addict population and to determine their knowledge and needs as regards to continuing training and their attitudes towards drug addiction.

Methods: We conducted a cross-sectional survey of 301 PCPs in Castilla-La Mancha, Spain using a questionnaire designed to elicit physician’s opinions about drug addiction.

Results: The response rate was 85.0% (256 cases). 84.2% of the doctors considered that 10% of patient visits to primary care centres were related to drug addiction.

The doctors frequently experienced difficulty in:

• the diagnosis and treatment of organic diseases associated with addiction (18.4%),
• the assessment of the situation and level of dependence (36.7%),
• support to treatment of some aspects of drug addiction (51.3%) and,
• above all, the treatment of these addictions (62.9%).

Of all respondents, 53.8% reported they had received some form of postgraduate training in drug addiction issues.

Only 28.5% considered they had received sufficient information on specialised drug addiction services.

Conclusions: As regards to PCPs’ attitudes to drug addiction, we observed a positive attitude regarding the needs of those who abuse drugs, and the development of intervention programmes.

PCPs believe that addicts deserve treatment, that there should be more treatment programmes and that primary healthcare centres should establish links with specialised services.

José Latorre;  Jesús López-Torres;  Trinidad Sanchez-Nuñez;  Juan Pedro Serrano;  Juan Montañés; Francisco Escobar. Primary care doctors’ perception of treatment demand and need for training in drug addiction issues. Primary Care & Community Psychiatry, Volume 12, Issue 1 January 2007 , pages 33 – 41.

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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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 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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TARGET POPULATIONS

Clients Best Suited for This Approach

Twelve Step Facilitation has been utilized in controlled outcome studies with alcohol abusers and alcoholics and with persons who have concurrent alcohol-cocaine abuse and dependency. It has been used with clients of diverse socioeconomic, educational, and cultural backgrounds and a range of maladjustment.

Clients Poorly Suited for This Approach

Individuals who have severe symptoms of addiction to cocaine or opiates. That is not to say that alternative treatments have proven effective with that group of individuals.

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Exhaustive Review of the Literature Reveals Even Moderate Alcohol Intake Increases Risk of Cancer

The Cancer Institute of New South Wales, Australia, has released a comprehensive analysis of current evidence for the association between alcohol consumption and risk of cancer. Limited to systematic reviews and meta-analyses of the highest methodological quality, the 194-page monograph, entitled Alcohol as a Cause of Cancer, revealed that even moderate alcohol consumption is associated with an often dramatic increase in the risk of several types of cancer.

Key findings are as follows:

Alcohol intake of approximately 2 drinks per day increases the risk of

• cancer of the oral cavity and pharynx by 75 percent,
• the risk of esophageal cancer by 50 percent, and
• the risk of laryngeal cancer by 40 percent.

Moderate intake also significantly increases the risk of colorectal cancer, liver cancer, and stomach cancer.

• Intake of approximately 4 drinks per day increases the risk of any cancer by 22 percent, while
• 8 drinks per day increases the risk by 90 percent.

The risk of breast cancer is 11 to 22 percent higher in women who drink alcohol than in women who do not.

Comments: The authors were unable to identify levels of consumption associated with no risk of cancer. Although the World Health Organization lists alcohol as a Group-1 carcinogen, as noted in the introduction to this study, few people are aware that even moderate consumption can cause cancer. These findings may be limited by possible underreporting of alcohol use or misclassification of exposure (e.g., light or ex-drinkers classified as nondrinkers).

Nonetheless, information about the association between alcohol and cancer needs to be more widely available so that the public can make informed choices about their behavior.

Richard Saitz, MD, MPH. Research Reference; Lewis S, Campbell S, Proudfoot E, et al. Alcohol as a Cause of Cancer. Sydney, Cancer Institute NSW, May 2008.

See also;

• Brief-TSF can assist patients cease alcohol consumption.
• Twelve Step Facilitation
• 12-Step Treatment More Effective than Alternative
• Subscribe to BriefTSF by e-Mail

Counselling for Alcohol Problems (Counselling in Practice series) by Richard D B Velleman Read more about this title…

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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Antidepressant Induced Mania (ADM) Among People with Co-Occurring Disorders (COD). Sometimes, informally called Bipolar III disorder.

A recent study of medical charts at a bipolar specialty clinic gives new support to the idea that antidepressants can induce mania in some bipolar patients.

For some time, clinicians have been concerned about the problem of antidepressant-induced mania (ADM), but most research has not supported the connection between antidepressants and manic or hypomanic episodes.

This study looked at ADM and examined differences between patients with bipolar disorder and a substance use disorder (SUD) and patients without SUD.

The article presents solid evidence for a significantly increased risk of ADM in patients with co-occurring bipolar disorder and SUD. The article also comments about why the increased risk to these clients may not have been identified in prior research.

Manwani and colleagues investigated medical charts from 98 patients who were treated at a bipolar clinic between 2000 and 2004. These patients accounted for 335 antidepressant trials during that period. Of the sample, 55 patients (accounting for 184 of the trials) had a lifetime history of a SUD.

For this study, an episode of ADM was defined as hypomanic or manic symptoms within 12 weeks of beginning a new antidepressant medication.

There were some substantial differences between patients who did and did not have a SUD history—e.g., clients with SUD were almost twice as likely as those without SUD to be prescribed lithium (48.3% vs. 28.5%), and clients without SUD were twice as likely to receive divalproex as those with SUD (43% vs. 20.1%) and almost three times as likely to be prescribed an antipsychotic (31.8% vs. 11.4%).

The univariate analysis of differences in the number of antidepressant trials leading to ADM between patients with and without a SUD history showed little difference in the percentage of ADM episodes they experienced (20.7% of trials for those with SUD and 21.4% of trials for those without).

However, using a multivariate regression model of analysis, the authors found that:

• Patients with a lifetime SUD were five times as likely to experience ADM,
• The incidence of an antidepressant trial leading to an ADM was greater for clients with Type II or with bipolar disorder not otherwise specified than for Type I,
• Females were more likely than males to have an episode of ADM in response to an antidepressant trial, and
• Bupropion was the antidepressant least likely to cause an ADM.

The authors surmise that older research studies excluding people with a SUD might have led to subject pools that underrepresented individuals considerably more likely to experience an ADM than the subjects studied. Additionally, they describe how other confounding factors might have served to hide the effects of having a history of SUD on the likelihood of suffering an ADM.

A discussion of the limitations of their study (e.g., it was non-randomized, non-blind; concomitant therapy may have obscured treatment effect; no measures of adherence to medication regimens) is also given.

Research; Manwani, S. G., Pardo, T. B., Albanese, M. J., Zablotsky, B., Goodwin, F. K., & Ghaemi, S. N. (2006). Substance use disorder and other predictors of antidepressant-induced mania: a retrospective chart review. Journal of Clinical Psychiatry, 67(9), 1341–1345.

Co-Occurring Disorders Research and Resources Monthly Review. The Co-Occurring Center for Excellence (COCE), of the Substance Abuse and Mental Health Services Administration (SAMHSA), Vol. 1, No. 5, December 2006. Readers interested in finding out more about COCE should visit the Web site: http://coce.samhsa.gov/

See also;

• Double Trouble in Recovery
• Double Trouble in Recovery for Alcoholics
• Dual Recovery Anonymous
• Dual Diagnosis Anonymous
• Subscribe to BriefTSF by e-Mail

Dual Diagnosis, Counseling the Mentally Ill Substance Abuser by Katie Evans, J. Michael Sullivan Read more about this title…