Professional Interventions That Facilitate 12-Step Self-Help Group Involvement

Facilitating patients’ involvement with 12-step self-help organizations, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), is often a goal of substance abuse treatment.

Twelve-step-facilitation (TSF) interventions have been found to be more effective than comparison treatments in increasing patients’ 12-step group involvement and in promoting abstinence.

Evaluations of TSF Interventions

One large study, known as Project MATCH, compared a TSF intervention with cognitive-behavioral (CB) therapy and motivational enhancement therapy (MET) among 1,726 patients (76 percent male) diagnosed with either alcohol abuse or dependence, including 774 inpatients who were beginning outpatient aftercare and 952 patients receiving outpatient care as their primary treatment.

• CB therapy focuses on teaching coping skills to reduce alcohol use (i.e., patients who use alcohol to cope with stress learn and practice alternative coping methods).
• In contrast, MET employs motivational strategies to mobilize patients’ internal resources for change.
• The TSF intervention in the Project MATCH study was a form of one-on-one professional counseling explicitly designed to work synergistically with AA and other 12-step groups.

Major Goals of 12-Step Facilitation Therapy

Acceptance

• Acceptance by patients that they suffer from the chronic and progressive illness of alcoholism
• Acceptance by patients that they have lost the ability to control their drinking
• Acceptance by patients that because there is no effective cure for alcoholism, the only viable alternative is complete abstinence from the use of alcohol

Surrender

• Acknowledgment on the part of the patient that hope for recovery (i.e., sustained sobriety) exists, but only by accepting the reality of loss of control and by having faith that some higher power can help the patient, whose own willpower has been defeated by alcoholism
• Acknowledgment by the patient that the fellowship of Alcoholics Anonymous (AA) has helped millions of alcoholics sustain their sobriety and that the patient’s best chances for success are to follow the AA path.

Consistent with AA’s philosophy, TSF therapists presented alcohol dependence as a disease with spiritual, emotional, and physical components and emphasized that the disease could be arrested but not cured through permanent abstinence from alcohol.

Also consistent with AA’s approach, patients were strongly urged, but neither ordered nor forced, to attend AA meetings and to maintain a journal describing their reactions to the meetings.

At both 1- and 3-year follow ups, patients in all three conditions (i.e., CB therapy, MET, and TSF therapy) had improved significantly on drinking related (e.g., number of drinks per day and drinking consequences), psychological (e.g., depressive symptoms), and life-functioning (e.g., days of employment) outcomes.

Table one; Posttreatment 12-step self-help group involvement of 2,045 substance-dependent veterans treated by 12-step or cognitive-behavioral programs.

As predicted, TSF therapy was significantly more effective than either CB therapy or MET in increasing AA involvement, as indicated by the frequency of such patient behaviors as attending meetings, having and serving as a sponsor, following the 12 steps, and considering oneself an AA member.

In addition, TSF therapy was more effective than the other two treatments in promoting abstinence. For example, at the 3-year follow up, 36 percent of TSF patients in the outpatient group reported being abstinent for the previous 3 months, compared with about 25 percent of outpatients in the CB therapy and MET treatment conditions. This result is consistent with the goals of TSF therapy and with AA, neither of which views moderate drinking as an acceptable or attainable goal for alcohol dependent people.

Research report; Keith Humphreys. Professional Interventions That Facilitate 12-Step Self-Help Group Involvement Alcohol Research & Health, Vol. 23, No. 2, 1999

Dimensions of social interaction among sober female participants in Alcoholics Anonymous.

The peer-led, voluntary fellowship, Alcoholics Anonymous (AA), remains the predominant model for treatment within the field of substance abuse treatment and attainment of sobriety.

The social support network of AA has been documented as a powerful factor in the achievement of sobriety. However, for whom and in what manner does this social support network work?

This study examined the dimensions of

• perceived group,
• perceived personal, and overall
• perceived social support among 125 sober female members of AA using the Social Support Network Inventory (SSNI).

Of the SSNI’s five dimensions (available, practical, emotional, reciprocal, and sobriety-related social support), reciprocal support was the strongest contributor to group social support.

Those women who had a sponsor scored significantly higher in total social support and personal support.

Availability was the strongest contributor to both personal and overall perceived social support.

These findings indicate that availability and sponsorship are significant components of a supportive environment among women in sobriety.

Rush, M.M. Perceived social support: Dimensions of social interaction among sober female participants in Alcoholics Anonymous. Journal of the American Psychiatric Nurses Association, 8(4):114-119, 2002.

The National Institute on Alcohol Abuse and Alcoholism has established through years of clinical research the effectiveness of the following interventions to treat alcohol problems.

Professional delivery of these interventions follows established protocols that have been published in manual form.

Cognitive behavioral therapy (CBT) primarily targets alcohol dependent individuals. It assumes that alcoholism is learned problematic behavior that begins and continues with the patient’s distorted belief that alcohol helps him or her cope with stress.

CBT therapists usually try to change how a patient thinks about alcohol, and to assist a patient in identifying stressful situations and alternative ways of coping with these situations. CBT allows patients to establish the goals of treatment. These can range from controlled drinking to abstinence.

Motivational enhancement therapy (MET) targets all problem drinkers, including alcohol dependent individuals.

It is based on principles of motivational psychology and focuses on increasing a patient’s internal motivation to change his or her drinking behavior.

MET doesn’t try to guide the patient through recovery step-by-step. Instead, it uses objective feedback and empathic listening techniques to influence positive change.

MET is a less intensive intervention, requiring only four sessions to complete.

Twelve-step facilitation therapy (TSF) primarily targets alcohol dependent individuals. It is grounded in the concept of alcoholism as spiritual and medical disease.

Patients are encouraged to accept an alcoholic identity and to become involved in support group activities (going to Alcoholics Anonymous meetings, getting a sponsor and working the 12 steps of AA). Abstinence is the goal of TSF.

Behavioral marital therapy (BMT) and other couples and family therapies primarily target alcohol-dependent individuals.

They recognize that spouses, significant others and family members of patients being treated for alcoholism can play a critical role in recovery.

These therapies seek to enhance communication between couples and among family members to improve the functioning of relationships.

This leads to longer retention in treatment for patients, longer periods of abstinence among patients, and less anxiety and enabling behavior among nonalcoholic spouses, significant others and family members.

Research Sources: Project MATCH Research Group. 1997; National Institute on Alcohol Abuse and Alcoholism. 2003. List of Alcohol Interventions for Substance Abuse and Mental Health Services

From; www.ensuringsolutions.org

Brief-TSF follows the principles of full TSF and is designed for non-specialist healthcare workers as an earlier intervention.

Brief Intervention Is Insufficient for Medical Inpatients With Unhealthy Drinking

Data show that brief intervention reduces consumption and consequences among outpatients with unhealthy, but not dependent, alcohol use. To assess whether brief interventions work among medical inpatients with unhealthy drinking,* researchers randomized 341 of such patients to a 30-minute session of motivational counseling in the hospital or to usual care. 

Most subjects had alcohol dependence, were unemployed during the previous 3 months, used other drugs, and had substantial psychiatric symptoms. Almost half were hospitalized for an alcohol-related medical diagnosis.

At 3 months among subjects with alcohol dependence, similar proportions of the intervention and control groups received alcohol assistance (e.g., specialty treatment) (49% and 44%, respectively).

At 12 months among all subjects, decreases in alcohol consumption did not significantly differ between the groups (e.g., adjusted mean decreases in drinks per day, 1.5 for intervention subjects and 3.1 for usual care subjects).

Comments:

Unlike most brief intervention studies in outpatients, this study enrolled a predominantly alcohol-dependent sample with major comorbidities—a group reflective of the treatment-resistant population identified when screening occurs in inpatient settings. The study suggests that screening, assessment, and brief counseling are necessary but not sufficient to change alcohol consumption in this population. Although the findings are disappointing, this study underscores that alcoholism—like cancer, atherosclerosis and other complex diseases—will not succumb to simple solutions.

References: Saitz R, Palfai TP, Cheng DM, et al. Brief intervention for medical inpatients with unhealthy alcohol use: a randomized controlled trial. Ann Intern Med. 2007;146(3):167–176.

Brief-TSF extends brief intervention to lifelong recovery.

Future of God in recovery from drug addiction

The purpose of the present paper was to explore the theory, concept and experience of God in relation to recovery from drug addiction from a scientific perspective.

Examination of a diverse literature was undertaken, including five key threads:

• the universality of the experience of God;
• the induction of spiritual experiences of God through hallucinogenic drugs;
• the nature of drug addiction from an evolutionary neurobiological perspective;
• the 12 Step movement as the prototype for the place of God in recovery from drug addiction; and
• identified ingredients for successful recovery from addiction.

The diverse threads of literature examined can be integrated around the concept of higher power as an important factor in recovery from drug addiction.

Higher power can be manifested in individuals in diverse ways:

• religious,
• ethnic,
• spiritual including the use of entheogens [a psychoactive plant or substance, esp. when taken for spiritual or religious purposes], as well as
• cognitive behavioural development,

But a common final pathway for all is the strengthening of executive functions (the brain’s ‘higher power’).

Practical implications for assisting people with drug addiction to achieve recovery through their own experience of God/development of higher power are outlined.

Research report; John D. Sellman;  Michael P. Baker;  Simon J. Adamson; Lloyd G. Geering. Future of God in recovery from drug addiction. Australian and New Zealand Journal of Psychiatry, Volume 41, Issue 10 October 2007 , pages 800 – 808

Spiritual Connections: How to Find Spirituality Throughout All the Relationships in Your Life by Sylvia Browne Read more about this title…

Review of the book ’Alcoholics Anonymous’

From; The NEW ENGLAND JOURNAL OF MEDICINE, Vol. 221(15), October 12, 1939

ALCOHOLICS ANONYMOUS: The story of how more than one hundred men have recovered from alcoholism. 400 pp. New York Works Publishing Co., 1939, $3.50.

The psychological aspect of alcoholism taxes the entire skill and intuition of the therapist, and the authors of this book claim that in the long run the ex-alcoholic patient who is properly trained in psychological method is an extremely effective person to bring about the cure of the neurotic alcoholic individual.

The first part of the book discusses methods, with particular stress on twelve steps in the recovery program. This program includes the general principles of psychotherapy found in such books as those by Durfee and Peabody. There is, however, an essentially new note, namely, that the alcoholic individual should be helped to admit to God, to himself and to another human being (preferably an ex-alcoholic patient) the exact nature of his personality deficit Some will perhaps shy from the emphasis on God and religion until it is realized that the alcoholic patient is asked in this relation to believe sincerely in a power greater than himself. He then sees that his life is really unmanageable without this power.

The second part contains the stories of twenty-nine individuals who were cured by the method of working out their character problems in relation to God, themselves and another human being. All these individuals were "convinced by an ex-alcoholic therapist" Those who at some time must deal with the problem of alcoholism are urged to read this stimulating account

The authors have presented their case well, in fact, in such good style that it may be of considerable influence when read by alcoholic patients.

Bloggers note; Its now sold over 25 million copies and has helped over 100 million people recover from alcoholism and about 500 other maladies – not just alcoholism.

Encouraging post-treatment self-help group involvement to reduce demand for continuing care services: two-year clinical and utilization outcomes

Background: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients’ health care costs in the first year after treatment, but such initially impressive effects may wane over time.

This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up.

Methods: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step-based (n = 887 patients) or cognitive-behavioral (CB, n = 887 patients) treatment programs.

The 12-step-based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs.

The 2-year follow-up assessed patients’ substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs.

substantially higher abstinence rate among patients treated in 12-step

Results: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) in contrast to CB (37.0%) programs.

Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs.

30% lower costs in the 12-step treatment programs

In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p = 0.01).

Conclusions:

• Promoting self-help group involvement appears to improve post-treatment outcomes while reducing the costs of continuing care.
• Even cost offsets that somewhat diminish over the long term can yield substantial savings.
• Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

Research; Keith Humphreys, and Rudolf H. Moos Alcoholism: Clinical and Experimental Research 2007; 31(1):64-68) – 1 This computation is in 2006 dollars, to which we converted for comparative purposes our prior findings, which had been originally reported in 1999 dollars (Humphreys and Moos, 2001).

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What does recovery mean to you? Lessons from the recovery experience for research and practice.

Recovery from alcoholism and addiction is a ubiquitous concept but remains poorly understood and ill defined, hindering the development of assessment tools necessary to evaluate treatment effectiveness. This study examines recovery definitions and experiences among persons who self-identify as “in recovery.”

Two questions are addressed:

1. Does recovery require total abstinence from all drugs and alcohol?
2. Is recovery defined solely in terms of substance use or does it extend to other areas of functioning as well?

Inner-city residents with resolved dependence to crack or heroin were interviewed yearly three times (N = 289).

Most defined recovery as total abstinence.

However, recovery goes well beyond abstinence;

• it is experienced as a bountiful “new life,”
• an ongoing process of growth,
• self-change, and
• reclaiming the self.

Implications for clinical and assessment practice are discussed, including the need to effect paradigmatic shifts from pathology to wellness and from acute to continuing models.

Research; Alexandre B. Laudet. What does recovery mean to you? Lessons from the recovery experience for research and practice. Journal of Substance Abuse Treatment. Volume 33, Issue 3, October 2007, Pages 243-256

A NATURALISTIC COMPARISON OF OUTCOMES AT SOCIAL AND CLINICAL MODEL SUBSTANCE ABUSE TREATMENT PROGRAMS.

Abstract:

Since the 1970s, much of the public treatment system in California has been based on a social model orientation to recovery for alcoholics, but there has been minimal research on program outcomes.

This article reports on follow-up interviews conducted with a representative sample of 722 people who had entered treatment about a year earlier in public and private programs, including publicly-funded social model detoxification and residential programs, and clinical model programs in hospitals and HMO clinics.

Social model clients came to treatment with more severe legal and employment problems, whereas those seeking treatment at clinical programs reported more severe family problems.

At follow-up, clients at both types of programs reported attending a similar number of Alcoholics Anonymous (AA) meetings, but social model clients reported going to more Narcotics Anonymous (NA) meetings and being involved in more AA activities.

Social model clients were less likely than clinical model clients to report problems with alcohol or drugs at follow-up, but the odds of reporting other problems (e.g., medical, psychological, legal, family/social) were similar.

The program effect for better alcohol outcomes at the social model programs was partially explained by their clients’ higher levels of 12-step program involvement during follow-up, which strongly predicted an absence of alcohol problems.

Social networks supportive of abstinence also were predictive of reporting no alcohol problems at follow-up.

In contrast, subsequent detoxification treatment events between baseline and follow-up were associated with a higher odds of reporting alcohol, drug, psychiatric and family/social problems at follow-up.

These findings are consistent with the growing body of literature reporting higher rates of abstinence among those who are able to construct more positive social networks, and who attend and become involved in 12-step programs during and following treatment.

It is important that these results be replicated, as they suggest that social model programs are successful in engaging their clients in AA activities and in NA meeting attendance, and could represent for some an effective alternative to clinical model treatment programs.

Lee Ann Kaskutas, Lyndsay Ammon, Constance Weisner. A Naturalistic Comparison Of Outcomes At Social And Clinical Model Substance Abuse Treatment Programs. International Journal of Self Help and Self Care. Issue: Volume 2, Number 2 / 2003-2004 Pages: 111 – 133

The concepts, principles, practices, and suggested 12 steps to recovery of the 12-step recovery approach to treating addictive disorders are examined.

Twelve-step recovery approaches are complex, multidimensional, biopsychosocial, and spiritual programs widely available in the United States and some other countries to people with addictive disorders, their family members, and significant others.

it has not been widely recognized that these programs are complex programs for living and address many issues other than alcohol and drug consumption.

Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Al-Anon, Alateen, and other 12-step recovery groups have flourished for the better part of the twentieth century, whereas many other treatment approaches have been tried and abandoned.

Although much discussion has centered on their spiritual emphasis, 12-step recovery approaches are clearly psychosocial recovery programs in which many important features entirely consistent with

• behavior modification,
• recent cognitive therapies,
• modern social learning theories,
• social psychology, and
• sociology are very much in evidence.

Although many people are aware that 12-step recovery approaches are designed to deal specifically with drinking and drug misuse, it has not been widely recognized that these programs are complex programs for living and address many issues other than alcohol and drug consumption.

By JACK Wallace. In: P.J. Ott, R.E. Tarter, and R.T. Ammerman (Eds.), Sourcebook On Substance Abuse: Etiology Epidemiology, Assessment, and treatment. Allyn & Bacon 1999.

Sourcebook on Substance Abuse: Etiology, Epidemiology, Assessment, and Treatment by Peggy J. Ott, Ralph E. Tarter, Robert T. Ammerman Read more about this title…