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

Six-month changes in spirituality, religiousness, and heavy drinking in a treatment-seeking sample.

OBJECTIVE: This descriptive and exploratory study investigated change in alcoholics’ spirituality and/or religiousness (S/R) from treatment entry to 6 months later and whether those changes were associated with drinking outcomes.

METHOD: Longitudinal survey data were collected from 123 outpatients with alcohol use disorders (66% male; mean age = 39; 83% white) on 10 measures of S/R, covering behaviors, beliefs, and experiences, including the Daily Spiritual Experiences and Purpose in Life scales. Drinking behaviors were assessed with the Timeline Followback interview. Alcoholics Anonymous (AA) participation and attendance were also measured.

RESULTS: Over 6 months, there were statistically significant increases in half of the S/R measures, specifically the Daily Spiritual Experiences scale, the Purpose in Life scale, S/R practices scale, Forgiveness scale, and the Positive Religious Coping scale.

There were also clinically and statistically significant decreases in alcohol use.

• Multiple logistic regression analyses showed that increases in Daily Spiritual Experiences and in Purpose in Life scores were associated with increased odds of no heavy drinking at 6 months, even after controlling for AA involvement and gender.

CONCLUSIONS: In the first 6 months of recovery, many dimensions of S/R increased, particularly those associated with behaviors and experiences. Values, beliefs, self-assessed religiousness, perceptions of a Higher Power, and the use of negative religious coping did not change.

Increases in day-to-day experiences of spirituality and sense of purpose/meaning in life were associated with absence of heavy drinking at 6 months, regardless of gender and AA involvement.

The results of this descriptive study support the perspective of many clinicians and recovering individuals that changes in alcoholics’ S/R occur in recovery and that such changes are important to sobriety.

Robinson EA, Cranford JA, Webb JR, Brower KJ. Six month changes in spirituality religiousness and heavy drinking in a treatment-seeking sample. J Stud Alcohol Drugs. 2007 Mar;68(2):282-90.

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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.

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-centredness 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.

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 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

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.

Under diagnosis of alcohol misuse in the older adult population

Alcohol abuse in older adults is common, yet it is often under detected and misdiagnosed, and as a result associated with considerable morbidity.

There is growing concern that as the population ages, there will be a substantial increase in the number of older adults needing treatment for alcohol misuse and currently, little is done to identify and address this situation.

Factors contributing to under diagnosis include, but are not limited to,

• depression,
• dementia,
• physical changes associated with age,
• life events,
• late onset of alcoholism and
• lack of screening.

A case report is presented and existing research findings are discussed in the article cited below.

• The importance of assessment,
• the use of screening tools,
• treatment issues and
• identification of other comorbidities are presented.

The focus on increased awareness among clinicians as well as their role in identifying and addressing alcohol abuse issues in the older adult population is explored.

Loukissa D. Under diagnosis of alcohol misuse in the older adult population Br J Nurs. 2007 Nov 8-21;16(20):1254-8.

Brief-TSF can assist patients cease alcohol consumption.

Concept of Alcoholism

In TSF and Brief-TSF alcoholism is considered an illness that affects individuals both mentally and physically in such a way that they are unable to control their use of alcohol. Viewed from this perspective, the concept of controlled use of alcohol amounts to denial of the primary problem, that is, loss of control. Specific causative factors (ie, stress) are of less relevance in recovery than is acceptance of both the loss of control and the need for abstinence and a willingness to follow the pathway laid out in the 12-steps.

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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