Department of Professional Education, Training and Research 3 Models of Intervention: Cognitive-Behavioural Motivational Interviewing 12 Step Facilitation

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Theory practice concepts underlying treatment
12 step and Minnesota method                    
     Tim Leighton, Director of Professional
Education and Research, Action on
Addiction                             
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12 Step Facilitation Approach
FACTORS COMMONLY ASSOCIATED WITH 12 STEP
APPROACH Aims at abstinence A programme of 12
Steps Acceptance of Powerlessness Fellowship of
recovering (i.e. abstinent) people Meetings Member
s identify themselves as alcoholics or
addicts Addiction seen as a disease
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12 Step Facilitation Approach
HISTORY AA founded 1935 AA develops national
profile in US 1940-1960 NA founded 1952 origins
of Minnesota Model 1950 MM arrives in
UK 1975
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12 Step Facilitation Approach
THE BASICS Anyone with a desire to stop using
can attend meetings Meetings are widely available
in UK, usually for 90 mins in the evenings, but
lunchtime and even breakfast time meetings are
available There are no dues or fees. There is a
voluntary collection for coffee, room rent and
literature, but no pressure to contribute There
is usually a main speaker who shares their own
experience, followed by open sharing There is
a lot of informal help and support available
(lifts to meetings, company, telephone support,
organised social activities) Clean/sober time is
recognised and celebrated Explicitly welcoming of
diversity
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12 Step Facilitation Approach

• The 12 Step approach
• is holistic a threefold illness physical,
  mental, spiritual
• emphasises the importance of the spiritual
• recognises that addiction is not just about
  taking drugs
• helps a recovering person to structure her life
  to reduce anxiety
• encourages people to keep going with their
  recovery if you feel you are cured you are in
  danger of losing what you have gained
• keeps it simple
• can act as a healthy substitute addiction

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12 Step Facilitation Approach

• properly practised (according to the literature,
  especially the traditions) a 12 Step programme is
• non-directive, simply suggesting that people try
  what has worked for others
• non-authoritarian
• tolerant of different beliefs and personal
  spirituality
• not based on a cult of personality
• welcoming of newcomers

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12 Step Facilitation Approach

• 12 Step fellowships can (like many organisations)
  be
• dogmatic
• over rigid
• intimidating for some newcomers
• unable to integrate events which dont accord
  with the philosophy
• but, as Bill W said, the 12 Step fellowships do
  and should evolve and change

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12 Step Facilitation Approach
The 12 Steps of Narcotics Anonymous 1. We
admitted that we were powerless over our
addiction, that our lives had become
unmanageable 2. We came to believe that a Power
greater than ourselves could restore us to
sanity. 3. We made a decision to turn our will
and our lives over to the care of God as we
understood him. 4. We made a searching and
fearless moral inventory of ourselves. 5. We
admitted to God, to ourselves, and to another
human being the exact nature of our wrongs. 6.
We were entirely ready to have God remove all
these defects of character. 7. We humbly asked
him to remove our shortcomings. 8. We made a
list of all persons we had harmed, and became
willing to make amends to them all. 9. We made
direct amends wherever possible, except when to
do so would injure them or others. 10. We
continued to take personal inventory and when we
were wrong promptly admitted it. 11. We sought
through prayer and meditation to improve our
conscious contact with God as we understood him,
praying only for knowledge of his will and the
power to carry that out. 12. Having had a
spiritual awakening as a result of these steps,
we tried to carry this message to addicts, and to
practise these principles in all our affairs.
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12 Step Facilitation Approach

• Potential benefits of affiliation with NA or AA
• The therapeutic value of one addict helping
  another is without parallel (Narcotics
  Anonymous Basic Text p18)
• Social support for goal of abstinence
• New friends
• Improved confidence and self-esteem
• Opportunity for spiritual development
• Suggested programme for living (12 Steps)
• Meeting as focal point for day or week
• Social activities (e.g. coffee, eating, hanging
  out, football, NA dances and parties)
• Active role at meeting (helping with tea/coffee,
  greeting, leading the meeting, group treasurer)
• Learning valuable organisational and
  interpersonal skills on NA committees
• Sponsorship

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12 Step Facilitation Approach

• A selection of AA/NA slogans (unofficial)
• Easy does it (but do it!)
• One day at a time
• Just for today
• We didnt get sick in one day, we dont get well
  overnight
• Let go, let God
• Turn it over
• Together we can
• Live and let live
• First things first!
• This too shall pass
• Stick with the winners!
• Keep it simple!
• It works if you work it!
• Keep coming back!
• Think . . . think . . . think!

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12 Step Facilitation Approach

• Treatment outcomes for 12 Step facilitation
• Increased acceptance of impact of addiction
  (reduced denial)
• Increased identification as a recovering
  addict/alcoholic
• Understanding of meaning and relevance of Steps
• Exposure to 12 Step meetings
• Increased motivation for 12 Step behaviours
  (attending meetings, reading literature, getting
  a sponsor etc)
• Decreased attribution of drug use to external
  situations and personal inadequacy
• Increased interest in developing personal meaning
  and purpose
• See for example
• FINNEY, J., NOYES, C., COUTTS, A. MOOS, R.
  (1998) Evaluating Substance Abuse Treatment
  Process Models I. Changes on Proximal Outcome
  Variables during 12-Step and Cognitive-Behavioral
  Treatment. Journal of Studies on Alcohol, 59/4.

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12 Step Facilitation Approach
Counselling style 12 Step counselling was often
associated with a tough, confrontational style.
Not a single research study has ever shown this
style to be effective. (White, W. L., Miller,
W. R. (2007). The use of confrontation in
addiction treatment History, science and time
for change. Counselor, 8(4), 12-30.) Not much in
evidence in treatment centres these days 12 Step
counsellors (especially those in recovery) can
tend towards pushing a rather rigid agenda and
find it hard to hear clients who are genuinely
different (from themselves or from the typical
client) 12 Step literature advises against
preaching, is often rather open-minded, and
advocates self-discovery through honesty and
identification, rather than telling the newcomer
how it is and labelling him/her as
alcoholic/addict
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12 Step Facilitation Approach

• Best counselling style for 12 Step facilitation
• Similar skills and qualities as for a good MI or
  CBT counsellor
• Excellent LISTENING skills
• Able to be active in helping client explore and
  understand
• Able to tolerate clients doubts, concerns or
  stumbling blocks without dismissing or
  immediately countering them
• Excellent knowledge of and positive attitude
  towards 12 Step recovery
• Collaborative, respectful, believing in the
  client
• Understands there are many ways to achieve
  successful recovery
• Able to keep a focus
• BUT see WALITZER, K. S., DERMEN, K. H. BARRICK,
  C. (2009) Facilitating involvement in Alcoholics
  Anonymous during out-patient treatment a
  randomized clinical trial. Addiction, 104/3,
  391-401.

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12 Step Facilitation Approach
WALITZER, K. S., DERMEN, K. H. BARRICK, C.
(2009) Facilitating involvement in Alcoholics
Anonymous during out-patient treatment a
randomized clinical trial. Addiction, 104/3,
391-401. TIMKO, C., BILLOW, R. DEBENEDETTI,
A. (2006) Determinants of 12-step group
affiliation and moderators of the
affiliationabstinence relationship. Drug and
Alcohol Dependence, 83/2, 111-121. TIMKO, C.,
DEBENEDETTI, A. BILLOW, R. (2006) Intensive
referral to 12-Step self-help groups and 6-month
substance use disorder outcomes. Addiction,
101/5, 678-688. KASKUTAS, L. A., SUBBARAMAN, M.
S., WITBRODT, J. ZEMORE, S. E. (2009)
Effectiveness of Making Alcoholics Anonymous
Easier A group format 12-step facilitation
approach. Journal of Substance Abuse Treatment,
37/3, 228-239.
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12 Step Facilitation Approach

• POTENTIAL STUMBLING BLOCKS
• Aversion to religious or spiritual ideas
• Unready for complete abstinence
• Very anxious or fearful in groups
• Fear of losing all personal control and choice
• Cultural difference
• Vulnerability to abuse or exploitation
• Need for psychotropic medication

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12 Step Facilitation Approach
The evidence base for 12 Step approaches is
growing In reviews and meta-analyses of studies
(e.g. Mesa Grande) AA and alcoholism
counselling usually do not do very well.
Lectures and client education do disastrously
badly However there is a growing body of studies
(often focusing on treatment process) which give
a different picture e.g. Project MATCH, George
Christos research, Finney et al, Toumbourou et
al, Caldwell Cutter
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12 Step Facilitation Approach
Interesting findings Involvement is more
important than attendance (Montgomery, Miller
Tonigan 1995) People entering 12 Step treatment
(especially residential) are markedly
psychologically distressed and take years to
normalise (Christo 199) Spiritual beliefs,
external locus of control, disease model beliefs
do not predict retention in NA. History of
problematic alcohol involvement does (Christo
Franey 1995) NA attendance is associated with a
range of good outcomes (Tombourou et al 2002) TSF
may be treatment of choice for clients with
network support for drinking (Longabaugh et al
1998)
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12 Step Facilitation Approach
Interesting findings continued Depressed
patients may not benefit as much from 12 step
involvement (although substance use outcomes did
not differ) They tend to stay depressed (Kelly et
al 2003) Those who have difficulty embracing key
aspects may need professional assistance to
overcome barriers (Caldwell Cutter
1998) Changes in social networks mediate AA
effect. Specific AA social support seems to
support abstinence better than non-AA support
(Kaskutas et al 2002) Latest series of papers
from John Kelly colleagues re-analysing Project
MATCH dataset, using lagged mediational analysis.
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12 Step Facilitation Approach
PILLARS OF THE 12 STEP PHILOSOPHY? ABSTINENCE
DISEASE MODEL HIGHER POWER RECOVERY IS FOR
LIFE POWERLESSNESS I CANT, WE CAN GIVE IT AWAY
TO KEEP IT (12th STEP)
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12 Step Facilitation Approach
DISEASE MODEL Traditional Medical Model
AA Research Big Book 1975-2003 Alco
holism is a distinct, unitary entity ?
? Alcoholics and pre-alcoholics are different ?
? Irresistible craving or compulsion ?
? Loss of control ? ? Permanent and
irreversible condition ? ? Progressive
disease which inexorably progresses ?
? through distinct phases
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12 Step Facilitation Approach
DISEASE MODEL AA has described a THREEFOLD
ILLNESS based on the opinion of Dr Silkworth
(1935) that alcoholics seemed to suffer
from PHYSICAL an allergy of the body MENTAL an
obsession of the mind Bill W stressed a 3rd
dimension SPIRITUAL a spiritual malady driven by
resentment Recent Research (Christo Franey
1995) showed that 50 of a sample of UK NA
members did not view their addiction as a
disease
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12 Step Facilitation Approach
HIGHER POWER
Religious beliefs in AA/NA range from explicit
acceptance of God as the Higher Power to
straightforward atheism. Choice of Higher Power
is personal - this is clearer in the NA
literature which suggests only that the HP should
be loving, caring and greater than
ourselves Some critics argue the spiritual, not
religious line is a semantic confidence trick
and the language of the Steps and literature
reveal an unambiguously religious organisation.
The Supreme Courts of several US States have
agreed with this. Christo Franeys 1995
research showed that spiritual beliefs in a
sample of UK NA members did not predict continued
involvement. West et als London based research
showed that God steps were often experienced as
off-putting by clients in NHS drug/alcohol
treatment
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12 Step Facilitation Approach
POWERLESSNESS Does the 12 Step doctrine of
Powerlessness tend to

• Teach people they are helpless?
• Undermine personal responsibility?
• Foster dependence on others
• Disempower people and teach them to mistrust
  themselves?
• Well, it can do all that, but clearly it
  shouldnt! How should we help clients to
  understand powerlessness?

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12 Step Facilitation Approach
Traditional Modern
more MI style disease notion may or may not be
useful encourages individual exploration,
interested in clients questions open-minded
means the counsellor is as well stresses
understanding how can you use these ideas and
practices? informed re mood-altering
medication wants to work with difference
denial bashing stresses disease notion stresses
surrender, interprets questioning as denial
open-minded means open to what we are telling
you stresses attendance go to meetings, read
the book, dont pick up rigid about mood-altering
medication uncomfortable with difference