Mechanisms of behavior change in alcoholics anonymous: does Alcoholics Anonymous lead to better alcohol use outcomes by reducing depression symptoms?

Rationale  Indices of negative affect, such as depression, have been implicated in stress-induced pathways to alcohol relapse. Empirically supported continuing care resources, such as Alcoholics Anonymous (AA), emphasize reducing negative affect to reduce relapse risk, but little research has been conducted to examine putative affective mechanisms of AA’s effects.

Methods  Using lagged, controlled, hierarchical linear modelling and meditational analyses this study investigated whether AA participation mobilized changes in depression symptoms and whether such changes explained subsequent reductions in alcohol use. Alcohol-dependent adults (n = 1706), receiving treatment as part of a clinical trial, were assessed at intake, 3, 6, 9, 12 and 15 months.

Results  Findings revealed elevated levels of depression compared to the general population, which decreased during treatment and then remained stable over follow-up. Greater AA attendance was associated with better subsequent alcohol use outcomes and decreased depression. Greater depression was associated with heavier and more frequent drinking. Lagged mediation analyses revealed that the effects of AA on alcohol use was mediated partially by reductions in depression symptoms. However, this salutary effect on depression itself appeared to be explained by AA’s proximal effect on reducing concurrent drinking.

Conclusions  AA attendance was associated both concurrently and predictively with improved alcohol outcomes. Although AA attendance was associated additionally with subsequent improvements in depression, it did not predict such improvements over and above concurrent alcohol use. AA appears to lead both to improvements in alcohol use and psychological and emotional wellbeing which, in turn, may reinforce further abstinence and recovery-related change.

Research; John F. Kelly, Robert L. Stout, Molly Magill, J. Scott Tonigan & Maria E. Pagano, Addiction, Volume 105 Issue 4, Pages 626 – 636

• See also
• Disturbing Denial
• Strategies for Dealing With Denial
• Addiction & Recovery Books
• The Dual Disorders Recovery Book
• Acceptance and Surrender

There is a long-recognized association between alcohol consumption and aggressive behavior. But does aggression and hostility continue into sobriety?

This study was designed to examine aggression in a group of socially well-adapted recovered alcoholics.

The question addressed was whether the treatment, together with long-term abstinence from alcohol, could reduce aggression and hostility in recovered alcoholics.

Sixty four male stable alcoholics with at least 3 years sobriety were compared with 69 non-alcoholics. Neither group had any other psychological problems.

Both groups were given a questionnaire on general characteristics as well as aggressive and hostility traits.

After a 3-year abstinence, men from the recovering alcoholics group displayed greater signs of hostility and covert aggression. They were different from non-alcoholics on measures for indirect aggression, irritability, negativism, suspicion, resentment, and guilt.

Research report; Ziherl S, Cebasek Travnik Z, Kores Plesnicar B, Tomori M, Zalar B. Trait aggression and hostility in recovered alcoholics. Eur Addict Res 2007; 13(2): 89-93.

Compatibility With Other Treatments

Brief-TSF may be utilised in combination with supportive pharmacotherapy; for example, craving reduction medications.

While recognising the existence of multiple problems of adjustment in most problem drinkers (e.g., marital conflict, family dysfunction), Brief-TSF advocates pursuing the goal of early recovery as primary, delaying most other therapies if necessary, until the client has achieved approximately 6 months of sobriety.

The primary exceptions to this recommendation would be emergency or incapacitating medical treatment, debilitating depression or other major affective disorder, or a psychotic disorder, which would take precedence over Brief-TSF.

Brief-TSF is not compatible with treatments based on notions of controlled use.

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Alcoholics and Loss of control of drinking

Alcoholics and addicts can attest to their countless attempts to stop or cut back on their drinking or drugging. They learn but cannot really accept that they have no power over alcohol or drugs.

The following research of the 1970’s began to explore this phenomenon and in the process confirming a basic tenet of Alcoholics Anonymous.

We alcoholics are men and women who have lost the ability to control our drinking. We know that no real alcoholic ever recovers control. All of us felt at times that we were regaining control, but such intervals – usually brief – were inevitably followed by still less control, which led in time to pitiful and incomprehensible demoralization. We are convinced to a man that alcoholics of our type are in the grip of a progressive illness. Over any considerable period we get worse, never better. Alcoholics Anonymous, pp 30.

Abstract of research report; This study evaluates the ability of alcoholics to regulate their blood alcohol levels (BAL) within a designated range by relying primarily on interoceptive (internal) cues. Forty male alcoholics and 20 control subjects were exposed to an initial training session in which they received sufficient ethanol to maintain them within a designated BAL range over a 2 1/2-hour period.

They were then exposed to two experimental sessions, one providing "overfeedback" and one "underfeedback." During each session, subjects had ten drinking decisions to make with respect to regulation of their BAL.

The results indicated that alcoholics displayed greater "loss-of-control" than control subjects.

This finding supported the hypothesis that alcoholics may possess a neurophysiologic feedback dysfunction that contributes to their relative inability to regulate ethanol intake.

A. M. Ludwig, F. Bendfeldt, A. Wikler and R. B. Cain. Loss of control in alcoholics. Archives of General Psychiatry. Vol. 35 No. 3, March 1978.

Research Evidence for Twelve Step Facilitation

Tonigan, J. Scott1. (2001). Benefits of Alcoholics Anonymous attendance: Replication of findings between clinical research sites in Project MATCH. Alcoholism Treatment Quarterly. Vol 19(1), , US: Haworth Press Inc. 2001, 67-77.

Project MATCH Research Group. (1998). Matching alcoholism treatments to client heterogeneity: Project MATCH three year drinking outcomes. Alcoholism: Clinical and Experimental Research. Vol. 22. No. 6.

“At three years follow-up, . . . , a significantly higher abstinence rate was found with TSF clients. Among TSF clients 36% were abstinent, compared with 27% of Motivational Enhancement Therapy and 24% of Cognitive Behavioural Therapy clients (p< 0.007).”

Patient-Treatment Matching, National Institute on Alcohol Abuse and Alcoholism, Alcohol Alert No. 36, April 1997

“. . . in the outpatient group, 10 percent more patients who received TSF achieved continuous abstinence compared with those who received the other two treatments (24 percent for TSF as opposed to 15 percent for CBT and 14 percent for MET).”

Tonigan, J. Scott: Miller, William R: Connors, Gerard J. (2000), Project MATCH client impressions about Alcoholics Anonymous: Measurement issues and relationship to treatment outcome. Alcoholism Treatment Quarterly. Vol 18(1), 2000, 25-41.

Saunders, John B. The efficacy of treatment for drinking problems. International Review of Psychiatry. Vol 1(1-2), Mar 1989, 121-137.

National Drug and Alcohol Research Centre (NDARC) Commonwealth Department of Health and Ageing. Guidelines for the Treatment of Alcohol Problems. June 2003.

Blondell RD.Looney SW. Northington AP. Lasch ME. Rhodes SB. McDaniels RL. Using recovering alcoholics to help hospitalized patients with alcohol problems. Journal of Family Practice, 50(5):E1, 2001 May.

CONCLUSIONS: Among trauma victims with injuries severe enough to require hospital admission, brief advice from a physician followed by a visit with a recovering alcoholic appears to be an effective intervention. Although further study is needed to confirm these findings, in the meantime physicians can request that members of Alcoholics Anonymous (AA) visit their hospitalized patients who have alcohol use disorders. Interventions by recovering alcoholics are part of their twelfth-step work (an essential part of the AA program) and are simple, practical, involve no costs, and pose little patient risk. They can be arranged from the patient’s bedside telephone. Some patients will show a dramatic response to these peer visits.

Riordan, Richard J.; Walsh, Lani. Guidelines for professional referral to alcoholics anonymous and other twelve step groups. Journal of Counseling & Development, Mar/Apr94, Vol. 72 Issue 4, p351.

Sisson Rw & Mullams JH. (1981) The use of systematic encouragement and community access procedures to increase attendance at AA and Alanon meetings. American J of Drug & Alcohol Abuse. V8(3), 371-6.

Participation in Alcoholics Anonymous: Intended and Unintended Change Mechanisms. (Proceedings of Symposium at the 2001 RSA Meeting) Alcoholism: Clinical & Experimental Research, Volume 27(3)., March 2003, pp 524-532. 2003Research Society on Alcoholism.

Summary:

• AA cannot be ignored in understanding treatment outcomes.
• It is possible to facilitate AA attendance.
• Treatment is the time to do it.
• Attendance is not involvement.
• AA participation predicts better outcomes.
• Continuous abstinence is the outcome most likely to be affected by AA.
• The abstinence message of AA does not seem to be deleterious.

Humphreys, Keith. Professional interventions that facilitate 12-step self-help group involvement. Alcohol Research & Health. Vol 23(2), 1999, 93-98.

It is concluded that health care professionals can influence participation in TSF groups.

Caldwell PE. (1999) Fostering client connections with Alcoholics Anonymous; A framework for Social Workers in various practice settings. Social Work in Health Care, V28(4), 45-61.

Parker J & Guest DL, (1999) The clinicians guide to 12-step programs; How, when and why to refer a client. Auburn House; Westport.

TSF shows good effect on behaviors that are generally accepted outcomes.

Robert F. Forman, PhD, Charles Dackis, MD, Rick Rawson, PhD. (2004). Substance abuse: 12 principles to more effective outpatient treatment.

Patients who participate in 12-step programs and treatments have better outcomes than those who do not.

Sheeren. Journal of Studies on Alcohol, 49:104, 1988.

• AA Should be considered essential in treatment of addictive disorders and
• AA reduces relapse

Humphreys, Keith; Moos, Rudolf. Volume 25(5) May 2001 pp 711-716. Can Encouraging Substance Abuse Patients to Participate in Self-Help Groups Reduce Demand for Health Care?

Conclusion; “Professional treatment programs that emphasize self-help approaches increase their patients’ reliance on cost-free self-help groups and thereby lower subsequent health care costs. Such programs therefore represent a cost-effective approach to promoting recovery from substance abuse.”

Riordan, Richard J.; Walsh, Lani. Guidelines for professional referral to alcoholics anonymous and other twelve step groups. Journal of Counseling & Development, Mar/Apr94, Vol. 72 Issue 4, p351.

“ . . . support groups such as AA can serve several adjunctive goals in a counselor’s treatment plan. In the early phases, clients may be very needy as they work through the denial, guilt, and shame, as well as the craving. They may need almost constant support. The counselor cannot realistically be available on a 7-days-a-week basis; AA, however, is. Likewise, in a long-term counseling relationship, AA can be an ally to the counselor, providing extra foundation and support as the client works through more deeply seated issues.”

Smart, Reginald G; Mann, Robert E. Recent liver cirrhosis declines: Estimates of the impact of alcohol abuse treatment and Alcoholics Anonymous. Addiction. Vol 88(2), Feb 1993, 193-198.

• AA has been found to be a significant contributor to reductions in cirrhosis mortality & morbidity.
• An increase of 1.0% in AA membership reduces cirrhosis mortality by 0.06%.

Kaner EF, Wutzke S, Saunders JB, Powell A, Morawski J, Bouix JC; WHO Brief Intervention Study Group. Impact of alcohol education and training on general practitioners’ diagnostic and management skills: findings from a World Health Organization collaborative study. J Stud Alcohol. 2001 Sep;62(5):621-7

CONCLUSIONS: Greater exposure to alcohol-related Continuing Medical Education (CME) appears to result in better diagnosis and more appropriate management of alcohol-related problems by GPs.

Longabaugh R, Wirtz PW, Zweben A, Stout RL. Network support for drinking, Alcoholics Anonymous and long-term matching effects. Addiction. 1998 Sep;93(9):1313-33.

“CONCLUSIONS:

• In the long-term TSF may be the treatment of choice for alcohol-dependent clients with networks supportive of drinking;
• Involvement in AA should be given special consideration for clients with networks supportive of drinking, irrespective of the therapy they will receive.”

There is a need for best practice education in alcoholism intervention

Walsh, R A; Sanson-Fisher, R W; Low, A; Roche, A M. Teaching medical students alcohol intervention skills: results of a controlled trial. Volume 33(8) August 1999 pp 559-565

“Conclusions: Training can improve medical student performance in alcohol intervention”

Peter Anderson, Eileen Kaner, Sonia Wutzke, Michel Wensing, Richard Grol1, Nick Heather and John Saunders. ATTITUDES AND MANAGEMENT OF ALCOHOL PROBLEMS IN GENERAL PRACTICE: Alcohol & Alcoholism Vol. 38, No. 6, pp. 597-601, 2003

Conclusion: Both education and support in the working environment need to be provided to enhance the involvement of GPs in the management of alcohol problems.

Mark A. Perini, MD, Alcoholics Anonymous and Drug Therapy in the Treatment of Alcohol Abuse and Dependence. Wake Forest University Baptist Medical Center, Internal Medicine Residency Program, September 26, 2000.

In summary,

• There is evidence supporting a recommendation to attend Alcoholics Anonymous in the literature. One can feel comfortable in stating the following learning points:
• Alcoholics Anonymous (AA) is a safe, low cost, widely available tool of behavioral change that strives to capitalize on the patient’s inner motivation and spirituality.
• AA should be part of any attempt at treatment of alcohol abuse or dependence.
• Success with AA can be enhanced by a twelve-step facilitation treatment implemented concomitantly with AA attendance.
• Referring patients to AA groups composed of individuals of similar age, cultural, and occupational status may improve attendance and outcomes as well.

A World Health Organization Working Group has listed the competencies needed by primary health care doctors and teams for the successful management of potential or established alcohol-related problems:

• a knowledge of the prevalence of hazardous and harmful alcohol consumption and related physical, psychological and social problems;
• a knowledge and appreciation of the effects of patients’ alcohol problems on their partners and families;
• an awareness of the patients’ personal attitudes to alcohol;
• the ability to identify the various physical, psychological and social indications of a drinking problem;
• the ability to communicate accurate information on alcohol and alcohol-related problems, in an appropriate context, to patients and their relatives;
• the ability to distinguish between low-risk, harmful and dependent levels of alcohol consumption;
• the ability to manage the physical consequences and complications of acute intoxication;
• the ability to take an accurate drinking history;
• the ability to recognise signs of alcohol-related disease;
• the ability to interpret laboratory tests accurately;
• the ability to choose an appropriate management plan (brief intervention or referral to appropriate colleagues or clinics);
• and the ability to direct and manage the detoxification of patients at home.

TSF and Alcoholics Anonymous are well accepted by providers and clients.

Twelve-Step Orientated Residential Treatment Programs: A Review. (March 2000) Richard Csiernik, Ph.D. School of Social Work, King’s College, University of Western Ontario, London, Ontario

The treatment modality with the longest successful history of rehabilitating alcoholics is a mutual aid/self-help program, Alcoholics Anonymous(A.A.). From A.A. has germinated a network of similar twelve-step approaches that are the most readily accessible means for maintaining abstinence. Individuals with an addiction problem may join a twelve step group on their own or may be introduced to the idea and the process through participation in a formal treatment program.

Vaillant, G. E. (1983). The natural history of alcoholism. Cambridge, MA: Harvard University Press.

Conclusion: that there are many alcohol-dependent individuals regardless of social or psychological make-up who find help for alcoholism through AA. It seems prudent to consider a referral to AA for all alcoholic clients except for those with significant pathology.

Friedmann PD, McCullough D, Chin MH, Saitz R Screening and intervention for alcohol problems a national survey of primary care physicians and psychiatrists. Journal of General Internal Medicine 2000, 15.~4-91, 2000.

The majority of physicians said that they usually or always recommended 12 Step groups to problem drinking patients

Chang, Grace; Astrachan, Boris M; Bryant, Kendall J. Emergency physicians’ ratings of alcoholism treaters. Journal of Substance Abuse Treatment. Vol 11(2), Mar-Apr 1994, 131-135.

Physician agreement on the efficacy of alcoholism treaters was greatest for AA (87%), moderate for mental health professionals (including psychiatrists and psychologists, 55%) and least for physicians and surgeons (excluding psychiatrists, 23%).

Roche AM, Parle MD, Stubbs JM, Hall W, Saunders JB. Management and treatment efficacy of drug and alcohol problems: What do doctors believe. Addiction. 1995;90:1357-66.

A majority of post graduate doctors believed Alcoholics Anonymous to be the referral of choice for alcoholism.

Norman Swan. Naltrexone and Alcohol Dependence. The Health Report, ABC Radio National. Broadcast Monday 1 July 2002

Professor John Saunders: “Some of the alcohol-dependent patients that I have seen over the years have achieved the most stable and rewarding recovery through regular attendance at Alcoholics Anonymous. For example, of the 300,000 to 400,000 alcohol-dependent people in Australia, only 20,000 are regular attenders of AA. I wish more people did attend regularly because I do think it provides very considerable benefit.”

• The Alcoholics Anonymous 2001 Membership Survey reveals a wide cross section of demographics. Age of members ranging from teenagers to over 70 years, of both genders, varied ethnic groups and from all occupations. Only a third of members self-referred to AA with the majority being referred by professionals (38%), family or friends. Sixty one percent attended some form of treatment before attending AA and 64% received some form of treatment after joining.
• Current global membership of AA is estimated to be 2 million people with some 30,000 in Australia.
• The participation rate in AA in the USA and most westernized countries is approximately 5 per 1000 of the adult population (age 15 yrs plus). The Australian AA participation rate is approximately 2 per 1000 adult population. There is room for growth.
• By comparison the participation rate in formal treatment services for alcohol in Australia is approximately 1.9 per 1000 population.

AIHW: Alcohol and other drug treatment services in Australia: Findings from the National Minimum Data Set 2000-01. AIHW Cat. No. AUS 30. Canberra: AIHW.

TSF is based on a clear and well-articulated theory.

Joseph Nowinski, Twelve-Step Facilitation, Approaches to Drug Abuse Counseling. U.S. Department of Health and Human Services, National Institutes of Health. Dual Diagnosis Recovery Network.

Wallace J. (1996) Chapter 1; Theory of 12-step oriented treatment. IN, Roger F, Keller DS & Morgenstern J. Treating substance abuse; theory and technique. The Guilford Press, New York.

Miller WR & Kurtz E. (1994) Models of alcoholism used in treatment; contrasting AA and other perspectives with which it is often confused. J of Studies on Alcohol. V55, 159-66.

Khantzian EJ, Mack JE. (1994) How AA works and why it’s important for clinicians to understand. J of Substance Abuse Treatment. V11(2), 77-92.

Chappel JN. (1997) Spirituality and addiction psychiatry. IN – Miller NS The principles and practices of addictions in psychiatry. WB Saunders; Philadelphia.

Burkhardt MA & Nagai-Jacobson MG. (1997) Spirituality and Healing. IN, Dossey BM (Ed) Core Curriculum for Holistic Nursing. Aspen Publishers, American Holistic Nurses Association, Maryland.

Steffen V. (1997) Life stories and shared experience. Soc Sci Med. V45(1), 99-111.

Bradley, A. M. (1988). Keep coming back: The case for a valuation of Alcoholics Anonymous. Alcohol Health and Research World,12, 192-199.

Tonigan, J.S., Connors, G.J. & Miller, W.R. (1996) The Alcoholics Anonymous Involvement (AAI) Scale: Reliability and norms. Psychology of Addictive Behaviors, 10(2), 75-80.

Alcoholics Anonymous shows good retention rates for clients.

William W (1994) The society of AA; 1949. (Classic reprint) Am J Psychiatry. V151(6), 259-62.

Humphreys K; Huebsch PD; Finney JW; Moos RH. A comparative evaluation of substance abuse treatment: V. Substance abuse treatment can enhance the effectiveness of self-help groups. Alcoholism: Clinical and Experimental Research 23(3): 558-563, 1999.

“Affiliation with Alcoholics Anonymous (AA) and other 12-Step self-help groups is becoming more common at the same time as professional substance abuse treatment services are becoming less available and of shorter duration. As a result of these two trends, patients’ outcomes may be increasingly influenced by the degree to which professional treatment programs help patients take maximum advantage of self-help groups.”

Moos RH; Finney JW; Ouimette PC; Suchinsky RT. A comparative evaluation of substance abuse treatment: I. Treatment orientation, amount of care, and 1-year outcomes. Alcoholism: Clinical and Experimental Research 23(3): 529-536, 1999.

“The study was conducted among 3018 patients from 15 Veterans Affairs 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. 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”

TSF addresses cultural diversity and different populations.

Gabriele Bardazzi, Andrea Quartini, Grazia Filippini, Maria Luisi Marcias, Alberto Centurioni, Ginetta Fusi, Allaman Allamani (1999) Cost-effectiveness in the treatment of alcohol abuse: a treatment program experience. Journal For Drug Addiction And Alcoholism. 22nd year: 1999 no 4.

Tonigan JS. Miller WR. Schermer C. Atheists, agnostics and Alcoholics Anonymous. Journal of Studies on Alcohol. 63(5):534-41, 2002 Sep.

Timko, Christine; Moos, Rudolf H.; Finney, John W.; Connell, Ellen G. Gender differences in help-utilization and the 8-year course of alcohol abuse. Addiction, Volume 97(7) July 2002 p 877-889.

“Conclusions: The results suggest that although alcoholism interventions were designed primarily for men, they are currently delivered in ways that are also useful to women. Problem-drinking women appear to benefit from sustained participation in AA, which emphasizes bonding with supportive peers to maintain abstinence.”

Gabhainn, S.N. Assessing sobriety and successful membership of Alcoholics Anonymous. Journal of Substance Use, 8(1):55-61, 2003. (168538)

“There were few differences across sociodemographic groups in perceived successful membership.”

Humphreys K. (196) Worldview change in adult children of Alcoholics/ Alanon self-help groups; reconstructing the alcoholic family. Int J of Group Psychotherapy. V46(2), 255-63.

Kramer TH & Hoisington D. (1992) Use of AA & NA in the treatment of chemical dependencies of traumatic brain injury survivors. Brain Injury. V6(1), 81-8.

Kus RJ (1988) “Working the Program”; The Alcoholics Anonymous experience and gay American men. Holistic Nursing Practice. August, pp 62-74.

Obuchwsky M & Zweben JE. (1987) Bridging the gap; The methadone client in 12-step programs. J of Psychoactive Drugs. V19(3), 301-2.

McGonagle D. (1994) Methadone Anonymous; A 12-STEP PROGRAM. Reducing the stigma of methadone use. J Psychosoc Nurs Ment Health V32(10), 5-12.

Cermak TL. Al-Anon and recovery. Recent Dev Alcohol 1989;7:91-104

Humphreys K; Ribisl KM. The case for a partnership with self-help groups. (editorial). Public Health Reports. V114(4): 322-329, 1999.

“This essay discusses the origins and nature of self-help groups. The authors note three ways they can be effective in addressing public health issues: (1) By offering accessible and effective interventions for specific problems; (2) By enhancing profesionally run health promotion and health care programs; and (3) By enriching community life and building a base for public health advocacy. An organization the American Self-Help Clearinghouse is noted.”

Vaughn C; Long W. Surrender to win: How adolescent drug and alcohol users change their lives. Adolescence, 34(133): 9-24, 1999.

This paper offers a phenomenological analysis of seven young adults who managed to surrender their addictions and, for anywhere from five to fifteen years, construct sober identities. The participants came from highly dysfunctional homes, began substance use as children, and were polydrug users. A series of catastrophic life events led them to Alcoholics Anonymous, where they were exposed to self-reflective prayer, a cadre of recovering adolescents and, in particular, adults who offered detached nurturing. This provided the support they needed to confront their addictions through the Twelve Steps of Alcoholics Anonymous.

TSF can be used by staff with a wide diversity of backgrounds and training.

Riessman F. (1965) The ‘Helper’ therapy principle. Social Work. April.

Borkman T (1976) Experiential knowledge; a new concept for the analysis of self-help groups. Social Service Review. (Sep), 445-56.

Davis DR & Jansen GG. (1998) Making meaning of Alcoholics Anonymous for social workers; Myths, metaphors and realities. Social Work. V43(2), 169-82.

Nowinski J, Baker S, Carroll KM. Twelve-Step facilitation therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. NIAAA Project MATCH Monograph Series, vol. 1. DHHS Pub. No. (ADM)92-1893. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1992.

Nowinski J. (1996) Chapter 2; Facilitating 12-step recovery from substance abuse and addiction. IN, Roger F, Keller DS & Morgenstern J. Treating Substance Abuse; Theory and Technique.

Thompson DL & Thompson JA. (1993) Working the 12 steps of Alcoholics Anonymous with a client; a counselling opportunity. Alcoholism Treatment Quarterly. V10(1/2), 49-61.

Borman LD. (1976) “Self-help and the professional.” Social Policy. V7(2), 46-7.

Wheeler, Sue; Turner, Linda. Counselling problem drinkers: The realm of specialists, Alcoholics Anonymous or generic counsellors. British Journal of Guidance & Counselling, Aug97, Vol. 25 Issue 3, p313.

Counsellors usually had some knowledge of AA but had little understanding of the 12-step programme that forms the basis of recovery for alcoholics as described by AA. They were, however, in favour of clients attending AA as an adjunct to individual counselling.

Tobie L Sacks and Nicholas A Keks. (No date) Medical Journal of Australia, Practice Essentials, Mental Health #14, Alcohol and drug dependence: diagnosis and management

The Process of Reconnecting: Recovery from the Perspective of Addicted Women

This study examined women’s experiences with addiction to drugs and/or alcohol and their process of recovery. The techniques of in-depth interviews and participant observations were employed to elicit the perspectives of the women. The study consisted of 12 participants, 6 who were currently involved in a 90-day community-based drug and alcohol treatment program and 6 who had more than five years of recovery.

Grounded theory method guided data collection and analysis. The women in this study described experiences of connectedness and disconnectedness throughout their lives, their addiction, and their recovery. The researcher constructed a substantive theory and model to explain this process of connectedness and disconnectedness.

The findings support that making connections and establishing healthy relationships play a significant role for women in achieving sobriety and maintaining recovery.

Research; The Process of Reconnecting: Recovery from the Perspective of Addicted Women. Carolynn Masters & Dorothy S. Carlson. Journal of Addictions Nursing, Volume 17, Issue 4 December 2006 , pages 205 – 210

TSF for Dual Diagnosis

The role of 12-step programs and 12-step-oriented treatments for dually diagnosed individuals (DDI) remains unclear. Here are presented the results of a pilot study in a target population of 10 seriously mentally ill patients received an adjunctive modified 12-step facilitation (TSF) therapy emphasizing engagement of DDI in a specialized 12-step program for DDI.

Participants significantly increased their 12-step attendance and decreased their substance use during the 12 weeks of treatment.

Larger and longer-term studies are needed to assess the efficacy of modified TSF for DDI relative to other treatments, and to determine what forms of TSF are most effective in this population.

Research; Bogenschutz MP. Tucker NE Specialized 12-step programs and 12-step facilitation for the dually diagnosed. Community Ment Health J. 2005 Feb;41(1):7-20.

Brief-TSF can be adapted to serve these people.

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.

The impact of Alcoholics Anonymous (AA) on non-professional substance abuse recovery programs and sober living houses.

In addition to being a widely used and effective approach for alcohol problems, AA has been central to the development of several types of nonprofessional recovery programs.

Known as “social model recovery,” these programs were staffed by individuals in recovery and they encouraged program participants to become involved in AA as a way to address their drinking problems. In addition, they relied on the traditions, beliefs, and recovery practices of AA as a guide for managing and operating programs (e.g., democratic group processes, shared and rotated leadership, and experiential knowledge).

This chapter reviews the philosophy, history, and recent changes in several types of these programs, along with a depiction of AA’s influence on them.

Programs examined include neighborhood recovery centers, residential social model recovery programs, and two types of sober living houses: California Sober Living Houses and Oxford Houses. Recent outcome evaluations on both types of sober living houses are presented.

Polcin DL, Borkman T. The impact of Alcoholics Anonymous (AA) on non-professional substance abuse recovery programs and sober living houses. Recent Dev Alcohol. 2008;18:91-108.

See also;

• Brief-TSF ASSESSMENT
• AA and Treatment Work Better Together
• If you have healthcare training this manual may help.
• The Most Effective Form of Harm Reduction

Group Treatment for Substance Abuse: A Stages-of-Change Therapy Manual

The author of this article describes a psychological model, based on studies he and his colleagues have conducted, to clarify the operation of Alcoholics Anonymous (AA) and other movements that operate through social and ideologically grounded support and can be characterized as “spiritual recovery movements.”

Taken together, the findings from the cited studies make evident that peer-led ideologically oriented self-help programs illustrate the value of combining intense mutual support with the psychology of commitment to a health-related ideology.

Although peer-led self-help programs are not among the approaches employed by traditional psychiatrically grounded providers of care, their success underlines their potential value to mental health professionals who can make use of these programs to complement conventional treatment.

This would require the introduction of certain elements in professional curriculums, such as;

• an understanding of the psychology underlying these programs,
• an openness to the contribution of such programs to recovery from illness, and
• competency in referral to and even collaboration with these programs.

The current practice of psychiatrists and general medical caregivers does not reflect acceptance of these programs, however.

The author recommends that physicians in psychiatric residency programs should, as part of their standard curriculum, attend AA meetings, visit drug-free therapeutic community programs, and serve as co-leaders of peer-led therapy groups on ambulatory services.

Research report; Galanter, M. Alcohol and drug abuse: Healing through social and spiritual affiliation. Psychiatric Services, 53(9):1072-1074, 2002.

Brief-TSF is designed to address these issues.