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

A popular aid is the Just for Today card that AA and Al-anon members carry in their pocket or purse and refer to when thinking of a drink or they are disturbed by a life event.

• Just for today I will try to live through this day only, and not tackle all my problems at once. I can do something for twelve hours that would appall me if I felt that I had to keep it up for a lifetime.
• Just for today I will be happy. This assumes to be true what Abraham Lincoln said, that most folks are as happy as they make up their minds to be.
• Just for today I will adjust myself to what is, and not try to adjust everything to my own desires. I will take my luck as it comes, and fit myself to it.
• Just for today I will try to strengthen my mind. I will study. I will learn something useful. I will not be a mental loafer. I will read something that requires effort, thought and concentration.
• Just for today I will exercise my soul in three ways: I will do somebody a good turn, and not get found out; if anybody knows of it, it will not count. I will do at least two things I don’t want to do just for exercise. I will not show anyone that my feelings are hurt; they may be hurt, but today I will not show it.
• Just for today I will be agreeable. I will look as well as I can, dress becomingly, keep my voice low, be courteous, criticize not one bit. I won’t find fault with anything, nor try to improve or regulate anybody but myself.
• Just for today I will have a program. I may not follow it exactly, but I will have it. I will save myself from two pests: hurry and indecision.
• Just for today I will have a quiet half hour all by myself and relax. During this half hour, sometime, I will try to get a better perspective of my life.
• Just for today I will be unafraid. Especially I will not be afraid to enjoy what is beautiful and to believe that as I give to the world, so the world will give to me.

A pocket sized version of this is available at most 12-Step meetings such as Alcoholics Anonymous or Al-Anon

Download a PDF copy to printout and give to your patients.

Attached Files:

• just-for-today.pdf (21 KB)

What does the Brief-TSF model look like?

How does the Brief-TSF model work?

Defining the Brief-TSF processes

This model brings together three people to achieve sobriety in one of them. These are the;

• experiential contributor (AA Peer Sponsor) and
• professional care (Twelve Step Facilitator) to collaborate in facilitating self help recovery for the
• alcoholic (normally known as the patient or client).

Each of the three people brings to the intervention knowledge’s and functions known as ‘domains of praxes’. Within each domain are the constituents of experience, training, perceptions, goals and capabilities.

Functional Domain

The Brief Twelve Step Facilitator facilitates self-assessment by the patient, introduces them to a ‘Peer Sponsor’ and facilitates understanding of the ‘Program of Recovery’. In addition the healthcare worker assesses and addresses or refers the patient for any co-morbidities.

The Peer Sponsor shares their ‘experience, strength and hope’ with the patient, provides initial resources to attend meetings, introduces the ‘Newcomer’ to Alcoholics Anonymous members and explains the program of recovery from drinking.

The patient chooses what, when, and how they can use information, from each of the providers. This is true Self help within a paradigm of mutual help.

Additionally, the patient is supported in seeking professional treatment/therapy for other issues.

Recovery Domain

Each participant maintains their integrity and independence within their domain.

The primary goal of Brief-TSF is affiliation with Alcoholics Anonymous as described in the Stages of AA Affiliation.

Recovery includes attending AA meetings and other activities, stopping drinking, ‘working’ the program of recovery and consulting with a peer sponsor within an affiliation scheme.

The whole facilitated process producing a ‘Domain of Recovery’.

Disease Domain

Alcoholism is a primary, chronic, progressive three fold disease – mental, physical and spiritual. Alcohol dependence is fatal if not arrested by abstaining from alcohol.

Each participant has a hand in recovery

A comparative evaluation of substance abuse treatment

This article first explains the conceptual framework and plan of a naturalistic, multisite evaluation of Department of Veterans Affairs (VA) substance abuse treatment programs. It then examines the effectiveness of an index episode of inpatient treatment and the effectiveness of continuing outpatient care and participation in self-help groups.

The study was conducted among 3018 patients from 15 VA programs that emphasized 12-Step, cognitive-behavioral (CB), or eclectic treatment.

Casemix-adjusted 1-year outcomes showed that patients in 12-Step programs were the most likely to be abstinent, free of substance abuse problems, and employed at the 1-year follow-up.

Patients who obtained more regular and more intensive outpatient mental health care, and those who participated more in 12-Step self-help groups, were more likely to be abstinent and free of substance use problems at the 1-year follow-up.

These findings support the effectiveness of 12-Step treatment and show that patients with substance use disorders who become more involved in outpatient care and self-help groups tend to experience better short-term substance use outcomes.

Moos RH, Finney JW, Ouimette PC, Suchinsky RT. A comparative evaluation of substance abuse treatment. Alcohol Clin Exp Res. 1999 Mar;23(3):529-36.

Beyond Codependency: And Getting Better All the Time

By Melody Beattie

Review By Neal J. Pollock (VA USA)

While I have not read Melody Beattie’s other works, I thought this a very valuable book in and of itself. It sheds much light on the topic and helped me to become sensitized to the obvious signs of codependency in people. By doing this, it enabled me to avoid situations where I could become codependent in a relationship.

I think that, as in the Diagnostic and Statistical Manual, there are levels of psychological situations and/or problems. Thus, there may be people inherently inclined towards codependency, but there may also be people who are thrust into it due to the demands of others. The latter may find this book incredibly helpful in avoiding such relationships and in helping their dependent person seek real help vs. codependency from another person. There are also a number of great quotes by the author in this book. A few are:

p. 70: “It’s hard to feel compassion for someone while that person is using or victimizing us.”

p. 71: “If everything looks black, we’ve probably got our eyes shut.”

p. 164: “Who we’re in a relationship with says as much about us as it does about them.” Earnie Tucker (quoted by Melody Beattie)

Codependency is not something to make light of, it’s as much (if not more) the codependent’s problem as the dependent’s. As Caroline Casey humorously noted in “Making the Gods Work for You” (Harmony Books NY 1998), on page 72:
“What do codependents see when they die? Someone else’s life flashes before their eyes.”

This is literally a life-changing book for codependents.

Reviewer: A reader

Once Melody Beattie’s Codependent No More has been “digested”, Beyond Codependency helps to move the recovering codependent past the hurt and on to the business of literally changing behaviors and making a better life. I absolutely recommend this book above any others to recovering codependents.

Mutual-aid support groups play a vital role in substance abuse treatment.

In 2005, a national survey of participants in mutual-aid support groups for addiction was conducted to identify key differences between participants in various recovery groups. Extensive data was collected from survey respondents on many aspects of recovery.

In their recently published article, researchers focus on the impact of survey respondents’ level of spirituality on their recovery and their participation in mutual-aid support groups.

Key findings include:

• Active involvement in groups significantly improves the chances of remaining clean and sober, regardless of the group (Save Our Souls, SMART, Women For Sobriety, and 12-step such as Alcoholics Anonymous) in which one participates.
• Respondents whose individual beliefs better matched those of their primary support groups showed greater levels of group participation, resulting in better outcomes as measured by increased number of days clean and sober.
• Spiritual respondents were more likely to actively participate in 12-Step groups and WFS, both of which have spiritual components in their programs.
• Non-religious respondents were significantly less likely to participate in 12-Step groups.
• Respondents with low levels of spirituality were more likely to actively participate in groups with secular programs, such as SOS and SMART Recovery.

This study provides more evidence that in recovery “one size does not fit all.” These results have important implications for treatment planning and implementation, indicating that matching clients to appropriate support groups according to their individual beliefs can have a positive impact on their program involvement and, ultimately, on their treatment outcomes.

When participants in recovery groups feel more comfortable with the philosophies of the groups they attend, they are more likely to become actively involved in these groups, which often results in longer periods of remaining abstinent from the use of alcohol and other drugs.

This research was funded by a grant from the National Institute on Drug Abuse. The survey was conducted with the assistance of The Center for Survey Research at the University of Virginia, Secular Organizations for Sobriety (SOS), SMART Recovery, and Women for Sobriety (WFS).

Reference: Atkins, R.G., Hawdon, J.E. (2007) Religiosity and participation in mutual-aid support groups for addiction. Journal of Substance Abuse Treatment, 33(3): 321-331.

The Spirituality of Imperfection: Storytelling and the Search for Meaning by Ernest Kurtz, Katherine Ketcham Read more about this title…

Self-help groups: A referral resource for professional therapists

This article discusses the nature, structure, limitations, and potential of self-help organizations. 

The effective utilization of self-help organizations requires the referring therapist’s awareness of the

• goals,
• methods, and
• services
• provided by the group and evaluation of the unique needs of potential group members.

The value of self-help groups may depend on appropriate referral by psychotherapists.

Research; Self-help groups: A referral resource for professional therapists. Professional Psychology: Research and Practice, Volume 13, Issue 3, June 1982, Pages 345-353. Emil R. Rodolfa and Lynn Hungerford

See also;

• Brief-TSF professional training is complimentary to all these courses.
• Twelve Step Facilitation

Beyond the Influence: Understanding and Defeating Alcoholism by Katherine Ketcham, William F. Asbury, Mel Schulstad, Arthur P. Ciaramicoli Read more about this title…

This study analyzed the Alcoholics Anonymous (AA) participation of 55 patients during the 3 months after their discharge from structured treatment, when dropout is high.

Three levels of meeting attendance were discerned:

• low,
• mid-level, and
• “90 meetings in 90 days.”

Of greatest interest, the mid-level group showed mixed interest in AA practices despite substantial meeting attendance, that is,

• they admitted powerlessness over alcohol, but had less enthusiasm for the higher power concept, and relapsed significantly;
• they were likely to have a sponsor, but were less involved with other AA members; and
• they reported working the 12 Steps, but were less interested in the AA literature.

Findings suggest that individuals who are attending AA but having difficulty embracing key aspects of the program need professional assistance that focuses more on AA practices and tenets and meeting attendance.

Barriers to affiliation can also serve as opportunities for furthering both counselling goals and affiliation.

Research; Paul Elliott Caldwell and Henry S.G. Cutter. Journal of Substance Abuse Treatment. Volume 15, Issue 3, May-June 1998, Pages 221-228

• See also:
• Twelve Step Facilitation
• Brief-TSF Description
• AA and Treatment Work Better Together
• Alcohol Related Brain Injury
• THE TWELVE REWARDS OF RECOVERY

Self-help for substance-use disorders: history, effectiveness, knowledge gaps, and research opportunities

Scientific evidence suggests substance-use disorder (SUD)-focused self-help group involvement is a helpful adjunct to SUD treatment, yet significant knowledge gaps remain.

The principal aim of this review is to highlight areas of knowledge deficit and their implications for research and practice. To accomplish this, evidence regarding whether self-help group involvement is effective, for whom, and why, is reviewed.

The appropriateness of self-help groups for certain subpopulations is considered with respect to

• psychiatric comorbidity,
• religious orientation,
• gender, and
• age.

Results;

• An increasingly rigorous body of evidence suggests consistent benefits of self-help group involvement.
• Regarding subpopulations, current evidence suggests non- or less-religious individuals benefit as much from self-help groups as more religious individuals and
• women become as involved and benefit as much as men.
• However, participation in, and effects from, traditional self-help groups for dually diagnosed patients may be moderated by type of psychiatric comorbidity.
• Some youth appear to benefit, but remain largely unstudied.
• Dropout and nonattendance rates are high, despite clinical recommendations to attend.

Clinicians can significantly influence the effectiveness of self-help, but optimal methods and duration of facilitation efforts need testing.

Greater understanding of the reasons why many do not attend or drop out would benefit facilitation efforts.

Self-help for substance-use disorders: history, effectiveness, knowledge gaps, and research opportunities. Clinical Psychology Review, Volume 23, Issue 5, October 2003, Pages 639-663. John F. Kelly

See also;

• Brief-TSF is designed to address these issues.
• What About This Spiritual Awakening Thing?

The Twelve-Step Facilitation Handbook: A Systematic Approach to Early Recovery from Alcoholism and Addiction by Joseph Nowinski, Stuart Baker Read more about this title…

Adolescents’ participation in Alcoholics Anonymous and Narcotics Anonymous: review, implications and future directions.

Youth treatment programs frequently employ 12-Step concepts and encourage participation in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).

Since AA/NA groups are easily accessible at no charge and provide flexible support at times of high relapse risk they hold promise as a treatment adjunct in an increasingly cost-constricting economic climate.

Yet, due to concerns related to adolescents’ developmental status, skepticism exists regarding the utility of AA/NA for youth.

This review evaluates the empirical evidence in this regard, identifies and discusses knowledge gaps, and recommends areas for future research.

Findings suggest youth may benefit from AA/NA participation following treatment, but conclusions are limited by four important factors:

• a small number of studies;
• no studies with outpatients;
• existing evidence is solely observational; and
• only partial measurement of the 12-Step construct.

While surveys of adolescent SUD treatment programs indicate widespread clinical interest and application of adult-derived 12-Step approaches this level of enthusiasm has not been reflected in the research community.

Qualitative research is needed to improve our understanding of youth-specific AA/NA barriers, and efficacy, comparative effectiveness, and process studies are still needed to inform clinical practice guidelines for youth providers.

Research; Kelly JF, Myers MG. Adolescents’ participation in Alcoholics Anonymous and Narcotics Anonymous: review, implications and future directions. J Psychoactive Drugs. 2007 Sep;39(3):259-69.

See also;

• Brief-TSF is designed to address these issues.
• Twelve Step Facilitation