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Applying Research In Clinical Applying Research In Clinical Settings: The 12 Step Facilitation Settings: The 12 Step Facilitation Approach: Two models of Approach: Two models of Addictions Treatment: Inpatient Addictions Treatment: Inpatient and Intensive Outpatient (IOP)and Intensive Outpatient (IOP)

Radka Toscova PhDRadka Toscova PhDMarch 15, 2013March 15, 2013

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Organization of PresentationOrganization of Presentation

Applying Research Findings to clinical Settings

Twelve Step Facilitation Group (TSF)

Evidence-Based Substance Abuse Treatment Program – Outpatient – Intensive Outpatient– Inpatient

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Applying Research Findings in Applying Research Findings in Clinical ProgramsClinical Programs: Four Guiding : Four Guiding Principles/ ObjectivesPrinciples/ Objectives

AA/NA AttendanceHaving a SponsorIncreased Spiritual Practices Social Support (For Not Drinking):– From AA/NA – Family

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AttendiAttending Meetingsng Meetings

Attend AA/NA 4-5 / week minimum before treatment ends results in continued engagement in AA/NA highest abstinence rates.

Treatment Programs should prioritize AA/NA and encourage a high rate of Attendance, Prior to the End of treatment, i.e. before Patients are discharged.

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Having a SponsorHaving a Sponsor

Drug/Alcohol Treatment Should help Patients Learn how to Seek and Obtain a SPONSOR.

What is the role of the SPONSOR? Valid Expectations vs. Fantasies.

Didactic practice/ rehearsal in treatment group, feedback from group members

Practice in AA/NA Follow-up in group, Keep Going (persist in the search for

SPONSOR)

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Increasing Spirituality…

Prayer Meditation /MindfulnessTherapist Assigned Reading

Homework: The Big Book, How it works, One Day at a Time, Slogans, Daily Meditative Guides.

Therapist Led Group Discussion of Readings.

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Increasing SpiritualityIncreasing Spirituality Cognitive Changes (Restructuring)– Occur as a Result of the Spiritual Practices

The concept of Delayed Discounting– The Addictive Bran: A bird in The Hand is Worth Two

in the Bush! – Thus, One Day at a Time, Concept– Treatment is Oriented to Here and Now and Short

term Goals.

Emotional Changes: People Instructed to Engage in Wide Variety of Spiritual Practices to Cope with Negative Emotional States/Traits

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Social SupportSocial Support

NA/AA Provides Support and an Environment For Not Using drugs Or Drinking.

Family Support that Encourages Abstinence from Drugs and Alcohol.

Thus the Need to Include the Family in Treatment, and Reinforce Abstinence and Any issues which may Undermine treatment goals (Not Enabling, Detaching)

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Other Research Findings: The Other Research Findings: The Community Reinforcement Approach Community Reinforcement Approach (Cession & Azrin(Cession & Azrin

Marital /Family TherapyJob ClubImproving / Developing

Communication SkillSocial/Recreational SkillsOther Behavioral Skills/Life SkillsRelapse Prevention

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Cognitive Behavioral Skills Therapy Cognitive Behavioral Skills Therapy One of The Match Treatment One of The Match Treatment

Comparison ModelsComparison ModelsSimilar Outcome as TSF, but lacked

the longevity and Abstinence Associated with TSF.

Skills Based approachRole play/skill rehearsalCommunications Skills

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Motivational Enhancement Therapy Motivational Enhancement Therapy (MET) Third MATCH Treatment Type(MET) Third MATCH Treatment TypeBased on Stages of Change Model

(Prochaska and DiClemente Wheel of Change)

Contemplation

Determination

Action

Lapse/Relapse

Try AgainPrecontemplation

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The 12 Step Facilitation ModelThe 12 Step Facilitation Model Originally Conducted Individually, in the

MATCH study, for research comparison with the other treatment modalities.

Manual Driven

In Clinical Setting, Group Therapy. – The Group acts as Support and Gives Reality

Based Feedback about Aspects of their Actions which they do not see.

– Cost Effective

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Distinctions:Distinctions: 12 Step Facilitation Model TSF: One of the

Three Comparison Treatment Groups In Project MATCH. (CBT Skills an MET)

12 Step Treatment “The Minnesota Model” (OLD), Based on AA Principles

12 Stop Treatment “ The Evidence Based Minnesota Model” (NEW) and other major Treatment Programs.

“Detox” (medical Stabilization ) “Treatment” Primarily Behavioral Early – Recovery, Engage in NA/AA

“Therapy” Later Recovery

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12 Step Facilitation Overview12 Step Facilitation Overview Objectives of Treatment

To help Addicts/Alcoholics learn About NA/AA, their view of being Drug Free/Sober,attend Meetings and engage in Mutual Help programs, by attending a minimum of 4-5 meetings/ week before the end of Treatment.

To address Acceptance and Surrender, i.e the First three Steps of NA/AA

Role of Therapist, preferably a Member of NA/AA is to Educate, Advise, and Support;To be a resource person about NA/AA

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12 Step Facilitation Overview12 Step Facilitation Overview Responsibilities of the Patients

NA/AA: “The Only requirement for membership is the desire to stop drinking/using drugs.”

1. To Attend all sessions

2. Come to meetings sober

3. Keep a Journal

4. Be Honest even if he/she has slips

5. Be willing to share and give feedback

6. Be willing to attend NA/AA meetings

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12 Step Facilitation Model12 Step Facilitation Model Core Program– Assessment– Acceptance– Surrender– Getting Active in NA/AA

Elective Components– Genograms– Enabling– People places, Routines– Emotions (hungry, angry, lonely, tired)– Moral inventories (step 4 and 5)– Relationships /Living SoberConjoint Program : Enabling, Detaching

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Assessment and FeedbackAssessment and Feedback

Introduction Administer the Alcoholics Anonymous

Affiliation Scale (AAAS) Complete The Substance Abuse History Review the Consequences of Substance

Abuse Assess Tolerance and Loss of Control Diagnosis Program Overview Recovery Tasks

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NA and AA Readings

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Topic 2: AcceptanceTopic 2: Acceptance

Readings from the 12 Step Facilitation Handbook are Discussed

Step One– I Have a Problem with Drugs/Alcohol– Drugs/Alcohol have been my life more

and more UNMANAGEABLE–My inability to manage my use

Drugs/Alcohol means that I have become POWERLESS over them.

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AcceptanceAcceptance Motivation Assessed on a scale of 1 being least

motivated 10 being most motivated– Location or contact name/phone

Discuss DENIAL as a normal human reaction to loss of control over substance use, like a step in the normal GIEF process.– REFUSING to face facts (not talking or thinking)– MINIMIZING the problems (highlighting the good times)– EXAGGERATING others’ problems to see self as mild– BARGAINING (trying to control substance use)ACCEPTANCE : The end of the grief processRecovery Tasks: Discuss which SPECIFIC MEETINGS

each group member will commit to attend. NEW READINGS, JOURNAL about reactions to meetings/readings, meeting new people.

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Topic 3: SURRENDERTopic 3: SURRENDER Introduction to 12 Step Groups

– View DVD– Review material and willingness to Attend NA/AA Scale of 1 – 10.– Discuss any fears and concerns which may interfere with

willingness to Attend NA/AA– Discussion about the different kinds of meetings e.g. speaker…

Discuss readings about the Surrender Chapter in the 12 Step Facilitation Handbook.– Read and discuss Step Two and Three ; Willpower not enough.– Discuss the concept of Higher Power, leap of Faith.– Who does the individual trust, who has been helpful in the past– On a scale of 1-10, how willing is the individual to turn to OTHERS,

for help with his/her drug /alcohol Problems. Asking for help in NA/AA

Discuss which meetings the Individual will commit to attend– Plan /Discuss readings and the use of the journal e.g. Read Bill’s

Story. Always review if any slips occurred.

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Topic 4: Getting Active in NA/AATopic 4: Getting Active in NA/AA Review:

– Journal re: meetings attended, meeting people– Number of Sober days; SOBER ONE DAY AT A TIME– Urges to drink (When, Where, What did the patient do?

How was it handled? How can he/she use NA/AA to deal with future urges?

– Review slips, when, where, with whom?– AA Concept of People, Places, Things – EASY DOES IT– FIRST THINGS FIRST

Getting active: Access help from NA/AA members Use the Telephone. Getting a Sponsor, Temporary Sponsor Readings: Living Sober, The “Big Book”

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Elective TopicsElective Topics

Elective Components– Genograms

– Enabling– People places, things/ Routines– Emotions (hungry, angry, lonely, tired)– Moral inventories (step 4 and 5)

– Relationships

– Living Sober

Conjoint Program : Enabling, Detaching

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Genogram: Addiction is a DiseaseGenogram: Addiction is a Disease

36 44

Betty 64 Bob 65Bob 65

14 16 1814 16 18

SteveSteveDrugsDrugs

42

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Primary Focus of the Facilitation Program

Going to AA Meeting Getting Active in AAGetting and Using a SponsorTherapist Provides Ongoing

Troubleshooting

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Evidence-Based Substance Abuse Evidence-Based Substance Abuse Treatment Model in Puerto RicoTreatment Model in Puerto Rico

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Evidence Based Treatment Program in Puerto Rico: Proposed Model: Proposed ModelLevels of Care:

Inpatient 28 days (multimodal) Inpatient 21 days (multimodal) Inpatient 14 days (multimodal) Inpatient 7 days (multimodal) Intensive Outpatient 3-4 hours/daily 12-14 weeks

(Group format with individual therapy as indicated)– Day Program– Evening program

Outpatient 12-14 weeks (Group utilizes The 12 Step Facilitation Model, Individual Therapy as Indicated

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Levels OfLevels Of CareCare LENGTH of treatment is a better predictor

of positive outcome than INTENSITY.

Treatment can be SEQUENCED, from More Intensive early on in treatment, to less intensive as the patient stabilizes.

They can go from INPATIENT to IOP, followed by OUTPATIENT TREATMENT, as indicated based on Clinical Criteria of Severity and Risk Factors

Engagement in NA/AA is stable .

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Initial Levels of Care DeterminationInitial Levels of Care Determination

Initial Triage/Assessment Evaluates Severity and Risk Factors:– Problem Severity/ Drug of Choice– Relapse Proneness/History of Relapse– Treatment History– Social Support for Abstinence– Impulsivity– Safety Issues/ violence potential– Other Mental Health/Health Issues

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Flow of PatientsFlow of Patients

Inpatient 28

Inpatient 21

Inpatient 14

Inpatient 7

IOP Day 12-14 weeks

IOPEvening12-14 weeks

OutpatientOutpatientTreatmentTreatmentTSF GroupTSF Group

Levels of Care: Triage/EvaluationLevels of Care: Triage/Evaluation

NA/AA

OtherCommunityResources

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Treatment Components of IOP 12 12 Weeks/3 days/week 4 Hrs/dayWeeks/3 days/week 4 Hrs/day

12 Step Facilitation Group (TSF) (12 weeks) Interpersonal Skills: Coping with Triggers

and Pressures to Use Drugs/Drink (6 weeks)

Self Regulation Skills: Coping with Negative Mood States (emphasis on Hungry, Angry, Lonely, Tired, Resentful, Jealous (6 weeks).

Skill Based Groups 6 weeks: Anger Management, Communication/ Assertiveness skills, Job Club, Family Education/Therapy, Individual Therapy, as Indicated/Requested, Stress Management.

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IOP Day/ Evening Program 3 days/wk

TSF Group (12 weeks ) 1 hr /day/2 days/week

Interpersonal Skills: Coping withPressures to Use: 6 weeks

1hr/day

Self- Regulation Skills: Negative Mood States

6 weeks 1hr/day

Anger Management1hr 6weeks

Job Club1 hr/

6 weeks

Communication1 hr/1/week/6 weeks

Family Therapy

6 weeks/2hrs/1/week

Recreation/Hobbies:

1 hr/1/week/6 weeks

Relapse Prevention

Stress Management/Mindfulness/Meditation Exercise

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IOP (Continued)IOP (Continued)The Proposed IOP will be on Monday, Wednesday and

Thursday, of each week, for 12 weeks, 4 hours/day, including 2/ 15 minute breaks per day.

Relapse prevention group will be offered during the second half of treatment.

Family Therapy/Conjoint/ Marital therapy will be offered during the second ½ of the IOP program, after patients are more stable.

2 hours will be allocated for the Family component, the first 45 minutes will be didactic/educational, based on a topic, after which there can be a break up into about 4 smaller groups, depending on the number of counselors allocated.

Offer a 6 week Smoking Cessation Module.

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IOP ContinuedIOP Continued

Prior to Starting IOP, Patients will need to agree, to Attend Clean and Sober.

If they appear to be high or intoxicated, they may be drug tested. If they are high, they would have made arrangements to get a ride home, due to safety Issues.

They will be encouraged to return on the next treatment day, prepared to discuss the slip. Therapist will not guilt or shame the patient.

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IOP ContinuedIOP Continued

The only requirement to be a member of NA/AA is The Desire to Stop Using/ Drinking.

However, IOP requires members to attend clean and sober because the program is 4 hours long and patients need to be clear headed and oriented to the demands of discussion and other treatment activities.

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Inpatient ProgramInpatient ProgramInitial Triage/Assessment Evaluates

Severity and Risk Factors; Assigns to 28 day, 21 day, 14 day or 7 day:– Problem Severity/ Drug of Choice– Relapse Proneness/History of Relapse– Treatment History– Social Support for Abstinence– Impulsivity– Safety Issues/ violence potential– Other Mental Health/Health Issues– HIV, Hepatitis

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Inpatient Program (Continuation)Daily Schedule

6:30-7:00 am Wake Up7:00 am Breakfast– Therapeutic Duty Assignment – 8:00 Morning Meditation

8:15 Morning Lecture 9:00 Group Discussion of Lecture 10: 00 Break 10:30 Small Group Coping Skills 11:30 Walking Meditation/ Mindfulness 12:00 Lunch

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Inpatient ScheduleInpatient Schedule

1:00 pm group– Monday and Wednesday: Managing Negative

Emotions: – Self Regulation

2:00 Break/ Work on Assignments– Arts Crafts, Orchid Greenhouse– 2:45 Light Snack

3:00 Lead meditation/ Mindfulness 3:30 Fitness/ Exercise 4:30 Free Time 5:00 Group: Coping Skills:

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6:30 Dinner7:30 Newcomer Meeting8:00 12 Step meeting (community

member led)9:00 Guided Social hour Monday

(games, tea, music. reading )10:00 Free Time … Sleep