Approaches to Drug Abuse Counseling U.S. Department of Health and Human Services, National Institutes of Health Joseph Nowinski 1. OVERVIEW, DESCRIPTION, AND RATIONALE 1.1 General Description of Approach
Twelve-Step Facilitation (TSF) consists of a brief, structured, and manual-driven approach to facilitating early recovery from alcohol abuse/alcoholism and other drug abuse/addiction. It is intended to be implemented on an individual basis in 12 to 15 sessions and is based in behavioral, spiritual, and cognitive principles that form the core of 12-step fellowships such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). It is suitable for problem drinkers and other drug users and for those who are alcohol or other drug dependent.
1.2 Goals and Objectives of Approach
TSF seeks to facilitate two general goals in individuals with alcohol or other drug problems: acceptance (of the need for abstinence from alcohol or other drug use) and surrender, or the willingness to participate actively in 12-step fellowships as a means of sustaining sobriety. These goals are in turn broken down into a series of cognitive, emotional, relationship, behavioral, social, and spiritual objectives.
1.3 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 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 as the locus of change in one’s life.
1.4 Agent of Change
The facilitator in the TSF treatment model is more truly a facilitator of change than an agent of change. The true agent of change (i.e., sustained sobriety) lies in active participation in 12-step fellowships like AA and NA along with the principles set forth in the 12 steps and 12 traditions that guide these fellowships.
1.5 Conception of Drug Abuse/Addiction, Causative Factors
Alcoholism and other drug addiction are considered illnesses that affect individuals both mentally and physically in such a way that they are unable to control their use of alcohol or other drugs. Viewed from this perspective, the concept of controlled use of alcohol or other drugs amounts to denial of the primary problem, that is, loss of control. Specific causative factors 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.
2. CONTRAST TO OTHER COUNSELING APPROACHES 2.1 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 Tucson 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.
2.2 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-behavioral 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 problemsolving 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).
3. FORMAT 3.1 Modalities of Treatment
TSF was designed to be used in the context of short-term individual counseling but has been adapted for use in a group format. One part of TSF (the conjoint program) is specifically intended to be implemented through sessions with a significant other (SO).
3.2 Ideal Treatment Setting
To date, TSF has been implemented exclusively in the context of outpatient treatment, although it has been used with both individuals who have never sought treatment before (true outpatients) and those who had previous inpatient treatment (aftercare clients). The model is flexible enough, consisting of both core and elective programs, to accommodate both of these client groups. However, since TSF relies heavily on client involvement in community-based 12-step meetings, it would be less ideally implemented in an inpatient setting. TSF can easily be integrated into a general mental health outpatient clinic setting.
3.3 Duration of Treatment
TSF is manual guided and time limited. It is intended to be implemented in 12 to 15 sessions spread over approximately 12 weeks. For nonalcohol drug addiction, it is recommended that clients be seen twice a week for the first 3 weeks. The initial assessment session runs 1-1/2 hours, and regular sessions are intended to last 1 hour.
3.4 Compatibility With Other Treatments
TSF may be utilized in combination with supportive pharmacotherapy for both alcoholism and other drug addiction. While recognizing the existence of multiple problems of adjustment in most problem drinkers and other drug users (e.g., marital conflict, family dysfunction), 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 debilitating depression or other major affective disorder, or a psychotic disorder, which would take precedence over TSF. TSF is not compatible with treatments based on notions of controlled use.
3.5 Role of Self-Help Programs
Participation in self-help groups is central to TSF and is regarded as the primary agent of change. Specific objectives within TSF include attending 90 AA or NA meetings in 90 days, getting and using members’ phone numbers, getting a sponsor, and assuming responsibilities within a meeting.
4. COUNSELOR CHARACTERISTICS AND TRAINING 4.1 Educational Requirements
Although it is manual guided, TSF requires considerable clinical skill to implement properly. Issues in implementation include the ability to stay focused, maintain structure within each session, and engage in constructive confrontation. Accordingly, it is recommended that prospective facilitators have a minimum of a master’s degree (or equivalent) in a counseling field and a minimum of 1,000 hours of supervised counseling experience as prerequisites for competence in TSF.
4.2 Training, Credentials, and Experience Required
A master’s degree in marriage and family counseling, a master’s degree in social work, or a doctoral degree in clinical psychology would represent appropriate professional prerequisites for conducting TSF. Having certification as an alcohol or other drug abuse counselor is desirable but cannot substitute for basic clinical credentials. In addition, it is recommended that facilitators treat a minimum of two complete cases (minimum of eight sessions each) under supervision prior to attempting to conduct TSF unsupervised.
4.3 Counselor’s Recovery Status
TSF facilitators need not be in recovery personally. Any serious TSF facilitator, however, should have read all AA/NA literature that clients will be asked to read and should be familiar with at least AA and Al-Anon meetings from personal experience (minimum of six meetings each). In addition, it is not recommended that a facilitator whose own views are unsympathetic to the primary goals of TSF (e.g., abstinence, active involvement in 12-step fellowships) seek to implement this model, for obvious reasons.
4.4 Ideal Personal Characteristics of Counselor
The best TSF facilitators have a good working grasp of basic Rogerian nonspecific, client-centered therapeutic skills, including unconditional positive regard and good active listening skills, combined with a good working knowledge of 12-step philosophy and the practicalities of getting active in 12-step fellowships. The ideal TSF facilitator is able to maintain session focus without excessive drift while also maintaining rapport. The TSF facilitator establishes a collaborative relationship with the client and utilizes confrontation in a constructive, nonpunitive manner.
4.5 Counselor’s Behaviors Prescribed
The TSF facilitator will help the client:
- Assess his or her alcohol or other drug use and advocate abstinence.
- Explain basic 12-step concepts (e.g., surrender, higher power).
- Advocate and actively support and facilitate initial involvement in AA/NA.
- Facilitate ongoing participation (e.g., getting a sponsor).
- Suggest and discuss specific readings from AA/NA literature.
- Conduct two conjoint sessions if the client has an SO.
- Help the client learn to use AA/NA as resources in times of crisis and to support and celebrate sobriety.
- Help the client (time permitting) develop an initial understanding of more advanced concepts such as moral inventories.
- Conduct a termination session that helps the client assess critically his or her progress in the program.
4.6 Counselor’s Behaviors Proscribed
The TSF facilitator does not:
- Conduct sessions with an intoxicated client.
- Attend AA or NA meetings with the client.
- Act as a sponsor.
- Threaten reprisals for noncompliance.
- Advocate controlled drinking or other drug use.
- Allow therapy to drift excessively onto collateral issues, such as marital or job conflict.
4.7 Recommended Supervision
Because TSF requires a relatively high level of clinical skill and the capacity to maintain focus, it is recommended that aside from the basic clinical training cited earlier, the facilitator actively participate in ongoing collegial supervision that includes observation of audiotaped or videotaped sessions. Broadly speaking, the goals of such supervision should be to:
- Provide support for the facilitator.
- Clarify treatment objectives and content (e.g., core versus elective topics).
- Help the facilitator minimize drift.
Supervisors should have a minimum of 2 years of prior general therapy supervisory experience, should be comfortable with TSF and AA philosophy in general, should have conducted TSF and other manual-guided therapies personally, and should be thoroughly familiar with all aspects of the model.
5. CLIENT-COUNSELOR RELATIONSHIP 5.1 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.
5.2 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.
5.3 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.
5.4 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 break down 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.
6. TARGET POPULATIONS 6.1 Clients Best Suited for?This?Counseling Approach
TSF has been utilized in controlled outcome studies with alcohol abusers and alcoholics and with persons who have concurrent alcohol-cocaine abuse and dependency. It has been used with clients of diverse socioeconomic, educational, and cultural backgrounds and a range of maladjustment.
6.2 Clients Poorly Suited for?This?Counseling Approach
Individuals who have severe symptoms of addiction to cocaine or opiates, who are unemployed, and who also have no source of spousal or other family support appear to have the poorest prognosis. That is not to say that alternative treatments have proven effective with that group of individuals. When treating addiction to cocaine, it is recommended that sessions be scheduled twice a week for the first 3?weeks.
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 a 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.
8. SESSION FORMAT AND CONTENT 8.1 Format for a Typical Session
Regular TSF sessions follow the format described below. The assessment and termination sessions and the first conjoint session follow slightly different formats.
The facilitator devotes about 10?minutes to a specific discussion of the client’s so-called recovery week, including any drinking or using that occurred, any urges to drink or use that the client experienced, reactions to recovery tasks and other specific suggestions made at the end of the prior session, reactions to meeting attended, and overall progress in getting active in AA or NA.
8.1.2 New Material.
The topic for each session is tentatively decided on in advance and may include a core topic, such as acceptance or surrender, or an elective topic like genograms or moral inventories. The presentation of new material often follows suggestions for reading and includes both didactic material and probing discussion to ensure that the client truly understands concepts.
Summary and Recovery Tasks. The facilitator asks the client to summarize what he or she got out of each session and ends with several specific suggestions (recovery tasks) that typically include reading (or listening to tape-recorded books), attending meetings, getting involved in meetings, and keeping a journal.
8.2 Several Typical Session Topics or Themes
Core topics include the assessment plus acceptance, surrender, and getting active. Acceptance has to do with discussing and illustrating Step 1 of AA and NA, which concerns accepting (as opposed to denying) one’s loss of control over alcohol or other drug use. Examples of loss of control in general, and in the client’s experience in particular, and the normal human reactions to it are discussed in some detail. The AA/NA view of powerlessness is discussed along with the concept of denial and the forms it commonly takes. The client is asked to identify with denial and to describe his or her own reactions to the concept of powerlessness and personal experiences with acceptance of limitation.
Elective topics include subjects such as genograms, which are used in TSF to illustrate how alcoholism and addiction are often family illnesses that continue to claim victims across generations. The client is guided in constructing a detailed alcohol-oriented and other-drug-oriented genogram, followed by a discussion of the notion of addiction as an illness. The goals are to reinforce acceptance and reduce shame.
8.3 Session Structure
As described earlier, TSF is a manual-guided treatment and as such is relatively structured. The facilitator largely determines the focus of sessions and provides specific advice from a consistent conceptual framework (i.e., the 12-step approach). The facilitator must also solicit feedback from the client, assign recovery tasks that are tailored to the individual client, and keep the focus of treatment from drifting.
8.4 Strategies for Dealing With Common Clinical Problems
Each topic within the TSF treatment manual includes a section on troubleshooting, which helps the facilitator anticipate and plan for common problems such as lateness, coming to sessions under the influence, and client resistance to new material. Most often these strategies are consistent with AA/NA philosophy and encourage the client to utilize the resources of 12-step fellowships. For example, the client who arrives drunk or high is asked how he or she will “not drink/use again for the rest of today.” Clients are never punished, rejected, or scolded within the TSF model for drinking or using, since it is accepted that loss of control is the essence of their illness. However, sessions are cut short if the client is drunk/high. He or she will be strongly encouraged to call an AA or NA hotline or a recovering friend and to go to a meeting immediately. Chronic lateness or cancellations are dealt with as denial.
As a rule, the TSF facilitator places ultimate responsibility for recovery on the client. The facilitator is a guide and a source of support, but the key to recovery is always seen as active involvement in one or more 12-step fellowships. A common strategy for dealing with resistance in TSF is to ask the client to keep an open mind or just give it an honest try. The facilitator maintains a position of unconditional positive regard and acceptance of the client’s illness, regardless of whatever resistance emerges.
8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation
Strategies for dealing with resistance within the TSF model all begin with an assumption that the client has an illness that is characterized by loss of control over alcohol or other drug use, which leads him or her to want to resist accepting that loss of control. Though the only viable treatment goal from the TSF and 12-step perspective is abstinence from all alcohol or other drug use, it is expected that the client will have a hard time accepting this limitation, as anyone has difficulty accepting limitation. Viewed in this light, resistance is seen as a natural part of the course of early recovery. Indeed, the TSF facilitator should be suspicious if too little resistance is encountered (a phenomenon known as compliance).
The TSF facilitator seeks to deal with resistance through open discussion and through a process of shaping the client’s behavior and attitudes. The methods employed for this shaping include consistent reinforcement of progress, acceptance of resistance, reframing of 12-step concepts (which are not dogmatically set), and compromise. The client is often asked to keep an open mind, to listen, and to try to identify with one or more of the people they hear at meetings. This is then discussed in the review part of each TSF session. The client is consistently told that he or she can accept or reject an aspect of 12-step philosophy and that the fellowship can still be a vital source of support for early recovery.
8.6 Strategies for Dealing With Crises
In TSF, the facilitator is given specific guidelines for dealing with crises ranging from suicidal ideation to spouse abuse to divorce. As a rule, only psychiatric emergencies and acute intoxication or overdose are grounds for suspending TSF. Otherwise, crises are assessed and triaged. In many instances the facilitator will direct the client to the resources of 12-step fellowships (including Al-Anon and Alateen for partners and children of clients) as a means of coping with acute stressors. Clients are encouraged to discover how ubiquitous their own problems are among people who have alcohol or other drug problems and how such issues are common topics of discussion at meetings. Indeed, the facilitator may very well be a less useful resource in this regard than the support of fellow recovering persons, many of whom have dealt with or are actively dealing with similar problems. If an emergency session is deemed necessary, the TSF manual includes specific facilitator guidelines.
8.7 Counselor’s Response to Slips and Relapses
Slips and relapses are considered normal and even expected parts of early recovery, as are frequent urges to drink or use. The 12-step model regards addiction as an illness characterized by compulsion that overwhelms individual willpower. Until the client is solidly connected to a 12-step fellowship, he or she is expected to experience difficulty sustaining sobriety even with the best of intentions. The primary purpose of the review part of the TSF session is to assess the client’s recovery week and to evaluate urges and slips and how the client dealt with them. This material becomes an important context in which the facilitator gradually shapes greater involvement in AA/NA. Typically, a pattern is discerned in slips. For example, it is common for a client to stay clean and sober for 1?or 2 days after a meeting and then to slip. Identifying this pattern (often with the aid of a calendar) can help to reinforce the importance of active involvement in AA/NA. In some circumstances a pattern of frequent slips despite attendance at meetings will lead the facilitator to recommend inpatient treatment.
9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT
TSF includes a two-session conjoint program to be used whenever possible when a client is in a relationship with an SO. Like other aspects of TSF, the conjoint sessions are focused and aim to meet specific goals. They are not intended to be used as brief marital or relationship counseling, although one objective of these sessions is to help the couple assess the impact of drug abuse on the relationship. Marital therapy may be briefly discussed, and SOs’ concerns, frustrations, and grievances are validated, but the facilitator also suggests that intensive relationship counseling (along with other therapies such as family therapy or sex therapy) be deferred, at least until the client has completed TSF and, preferably, 6?months of sobriety.
The two conjoint sessions deal with the subjects of enabling and detaching. Both of these concepts have their origins in Al-Anon, a 12-step program similar to AA and NA but for the affected rather than the addicted. A primary goal of the TSF conjoint program is to encourage and briefly facilitate the partner’s use of Al-Anon as a resource for coping with being in a relationship with an addict and also for healing personal wounds that typically derive from that kind of relationship. Another goal is to assess initially the partner’s use of alcohol or other drugs and make an appropriate referral if necessary. Finally, the goals and objectives of TSF itself and 12-step programs are outlined.
TSF includes guidelines for handling emergency calls from a partner. The approach emphasizes support and efforts to facilitate the partner’s use of Al-Anon.
Joseph Nowinski, Ph.D.P.O. Box 15Tolland, CT 06084
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