Cost-Effectiveness of Home Visits in the Outpatient Treatment of Patients with Alcohol Dependence

The purpose of this study was to compare the cost-effectiveness of conventional outpatient treatment for alcoholic patients (CT) with this same conventional treatment plus home visits (HV), a new proposal for intervention within the Brazilian outpatient treatment system.

A cost-effectiveness evaluation alongside a 12-week randomized clinical trial was performed. We identified the resources utilized by each intervention, as well as the cost according to National Health System (SUS), Brazilian Medical Association (AMB) tables of fees, and others based on 2005 data. The incremental cost-effectiveness ratio (ICER) was estimated as the main outcome measure – abstinent cases at the end of treatment.

• There were 51.8% abstinent cases for HV and 43.1% for CT, a clinically relevant finding.
• Other outcome measures, such as quality of life, also showed significant improvements that favored HV.

The baseline scenario presented an ICER of USD 1,852. Sensitivity analysis showed an ICER of USD 689 (scenario favoring HV) and USD 2,334 (scenario favoring CT).

The HV treatment was found to be cost-effective according to the WHO Commission on Macroeconomics and Health.

Research; Edilaine Moraesa, Geraldo M. Camposa, Neliana B. Figliea, Ronaldo Laranjeiraa, Marcos B. Ferrazb. Eur Addict Res 2010;16:69-77 (DOI: 10.1159/000268107)

• See also
• Psychology Books
• 12 Steps and Post Traumatic Stress
• AA & NA Work for Teens Too
• Stools and Bottles
• Brief-TSF can assist patients cease alcohol consumption.

CONTRAST TO OTHER COUNSELING APPROACHES

Most Similar Counseling Approaches

TSF has its roots in the Minnesota Model first described by Daniel J. Anderson and as implemented in most AA-oriented treatment programs (e.g.,the Hazelden Foundation, the Betty Ford Foundation, the Sierra Tuscan Center, and others). These models assume addiction can be arrested but not cured, ascribe to the AA/NA philosophy as described in AA/NA literature that relies heavily on a combination of spirituality and pragmatism, and advocate peer support as the primary means for achieving sustained sobriety.

Most Dissimilar Counseling Approaches

Any approach that advocates controlled use of alcohol or other drugs (as compared with abstinence) is fundamentally dissimilar to TSF with respect to basic treatment goals. Cognitive-behavioural approaches that are based on the idea that problem drinking and other drug use stem primarily from inadequate stress management skills and that aim to enhance problem solving and coping skills differ from TSF with respect to the assumption of peer support as fundamental to recovery. TSF also assumes that alcoholism and other drug addiction are primary diagnoses and not symptoms of another diagnosis (e.g., depression, antisocial personality).

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.

TSF & 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-centeredness 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.

Subscribe to regular updates

TSF ASSESSMENT

The assessment session in TSF runs 1-1/2 hours. The goals are to:

• Establish client-facilitator rapport.
• Conduct a collaborative assessment of alcohol and other drug abuse(history).
• Discuss the client’s prior efforts to stop or control use.
• Discuss negative consequences associated with use.
• Share a diagnosis with the client and attempt to have it be a collaborative decision.
• Outline the TSF program.
• Attempt to get a commitment from the client to give TSF and AA/NA and try and to keep an open mind.

Assessment within the TSF model has both an informational and a motivational goal.

It is recommended that periodic alcohol tests be done either randomly or when the facilitator suspects that the client may have been drinking or using.

Consistent with 12-step philosophy, no client is excluded from treatment as a consequence of drinking or using, although with some clients it may become appropriate to discuss inpatient treatment. Sessions with clients who are found to be (or who admit to being) drunk or high are terminated, and arrangements are made to get the client home safely.

TSF CLIENT-COUNSELOR RELATIONSHIP

What Is the Counselor’s Role?

The facilitator’s role in TSF is broadly defined as including education and advocacy, guidance and advice, and empathy and motivation. Each of these broad goals is broken down further into a series of specific guidelines or objectives. For example, guidance and support include monitoring client involvement in AA/NA, encouraging clients to volunteer for basic service work, identifying appropriate social events the client might participate in, locating appropriate meetings, and clarifying the role of a sponsor.

Who Talks More?

Clients and facilitators talk about equally in effective TSF sessions. Since TSF is an active intervention, facilitators who are passive may not succeed in maintaining focus or accomplishing basic goals. At the same time, success in TSF is dependent on monitoring client activity and reactions, which requires soliciting active client involvement in sessions.

How Directive Is the Counselor?

TSF is similar to many cognitive-behavioral therapies in that it is focused and requires the facilitator to be fairly directive while still maintaining good rapport. The TSF facilitator is directive in the following ways:

• The focus of therapy is on early recovery. The facilitator does not allow the focus to drift onto other issues (e.g., relationship or work problems) even if these are significant. The facilitator validates other concerns and helps the client develop an overall treatment plan to deal with them but maintains the focus of TSF.
• The client’s reactions to assignments and meetings are considered very important. In TSF the facilitator needs to solicit specific feedback from the client.
• Each TSF session has a specific topic (core, elective, or conjoint) that includes a specific agenda to be covered. Although a given topic may require more than one session to cover, and while the facilitator needs to be somewhat flexible in his or her agenda, the facilitator must also take responsibility for controlling the content and flow of sessions.
• Each TSF session follows a set format that the facilitator is responsible for following. Again, there is some flexibility, but the facilitator does not simply follow the client’s agenda.
• Every TSF session ends with the facilitator making specific suggestions to the client (recovery tasks). In addition, the facilitator is expected to make specific suggestions (e.g., which meetings to attend, how to ask for a sponsor) throughout treatment.

Therapeutic Alliance

In TSF, the facilitator is seen as an expert in interpersonal counseling techniques and as knowledgeable in the principles and practicalities of 12-step fellowships.

However, in TSF the facilitator is not regarded as the primary agent of change; rather, it is the 12-step fellowship (AA or NA) that is seen as the agent of change.

Accordingly, the TSF facilitator needs to conceptualize treatment as the product of a collaborative relationship and should assume responsibility for doing the best he or she can to establish that collaborative relationship.

However, it is not the facilitator’s goal to breakdown the client’s denial, to provide all support needed to stay sober, to take the client to meetings, and so forth. Even in emergencies, the facilitator’s role and responsibilities are limited in the TSF model. For this reason the word "facilitator" was chosen rather than therapist or counselor, as it seems to describe the role better than those labels.

Slogans for everyday life and the ethical practices of Alcoholics Anonymous

Alcoholics Anonymous has developed an oral tradition for teaching people to alter their relation to their own desires and their own freedom fundamentally, teaching that is done through practice rather than through ideas.

Our study of AA’s innovative organisational tools for building long-lasting mutual-help groups shows that the same tools that build the organisation also exemplify and embody the organisation’s ethical worldview.

To that extent, AA’s group practices are worth studying not only from the point of view of learning about bottom-up, non-expert-led networks but also to shed light on the development of a popular pragmatist ethics in which little techniques – anonymity, the focus on the 24-hour cycle, etc. – deconstruct the Kantian distinction between means and ends.

This study of the everyday ethics of AA members argues that AA’s unique role in the history of popular ethical practices can be traced to several original features.

• First, AA incorporates elements of the disease model of alcoholism while remaining fundamentally a spiritual programme, thus mapping an important hybrid terrain often ignored by students of medicalisation.
• Secondly, AA was able to steer away from the political controversies about temperance, prohibition, and control of alcoholic beverages that had made the old temperance movement founder.
• Thirdly and most importantly, AA uniquely managed to combine the once-in-a-lifetime experience of total transformation that is characteristic of religious conversion with the development of a series of slogans and mental techniques for dealing with the ‘trivial’ details of life.

This paper first outlines the hybrid terrain of AA, between medicine and religion, and then examines a few of the techniques that are at the core of AA’s success, including anonymity, the Higher Power, and the twenty-four hour cycle.

Valverde M. & White-Mair K. (1999), One Day At A Time and other Slogans for Everyday Life the Ethical Practices of Alcoholics Anonymous. Sociology (1999), 33:393-410

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.

Stages of Affiliation with Alcoholics Anonymous

 How do alcoholics get to AA?¹

AA has grown to over 100,000 groups with more than two million members simply on word-of-mouth recommendation. Often the recommendation has come from friends, family, employers, healthcare workers or law courts.

People progress through stages of affiliation with others and with Alcoholics Anonymous in pursuit of solutions to their problems. Two paths are identified; Direct Affiliation and Facilitated Affiliation².

The stages are not necessarily discrete where a person moves in clear progression from one stage to the next. A person is more likely to move up and down, sometimes jumping a stage in regression or progression. However, AA reports that 51% of current members stayed sober from their first meeting.

Facilitation plays a significant part in the process of AA affiliation as approximately 60%³ of AA members seek help from the helping professions prior to attending AA.

These stages of affiliation generally follow Prochaska and DiClemente Stages of Change model and are;

• Pre-contemplation,
• Contemplation,
• Preparation,
• Non-affiliation,
• Affiliation,
• Misaffiliation,
• Affiliation-mandated,
• Supra-affiliation,
• Altruistic affiliation,
• Ambivalent affiliation,
• Disaffiliation,
• Re-affiliation.