Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychiatric Practitioners and Patients

 

 

Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychiatric

Practitioners and Patients

TWELVE-STEP FACILITATION: INTRODUCTION

The goal of this chapter is to help clinicians better engage and support patients who have

co-occurring or primary alcohol or drug problems through use of 12-step programs to enhance

treatment outcomes and recovery. Twelve-step facilitation (TSF) is an evidence-based practice with

a large research base, a therapy manual (Nowinski et al. 1995), and a Web-based training site

(Sholomskas and Carroll 2006). It is a valuable technique easily available to the practicing

psychiatrist and other mental health professionals. The research base of TSF is reviewed in other

chapters of this book. This chapter is a condensed presentation of some of the key techniques and

concepts of TSF, with some special adaptations for psychiatric practice. An important concept to

recognize at the outset is that TSF is a therapist’s technique to help patients engage in and

maximize their response to 12-step meetings, such as Alcoholics Anonymous (AA). (TSF is not AA,

nor is it, as far as we know, officially endorsed by AA or other 12-step programs.) TSF can also be

applied to treat individuals who are dependent on substances other than alcohol, such as narcotics.

Such individuals can be encouraged to go to Narcotics Anonymous (NA) meetings, where the 12

steps are applied as well.

It should be noted that there are many approaches to self-help that clinicians can promote through

TSF that have parallels to group mutual help. Norcross (2006), for example, describes a variety of

self-help techniques and available resources, including meditation, readings, and film.

This chapter was developed in conjunction with the American Academy of Addiction Psychiatry at their

December 2006 annual meeting. Support for the workshop was provided by the National Institute on Alcohol

Abuse and Alcoholism and the National Institute on Drug Abuse.

DEFINING THE PROBLEM

Why should one be interested in this technique? Fifteen percent of the general population may be

diagnosed with a substance use disorder (13% with alcohol abuse, with or without other drug

abuse) at some time in their lives (Kessler et al. 2005), and somewhere between 20% and 50% of

typical psychiatric inpatients or outpatients will have a current, episodic, or past history of a

substance use disorder (Center for Substance Abuse Treatment 2005). For example, approximately

50% of patients with bipolar disorder will experience alcohol or drug problems, and research has

shown that those with active substance use are more likely to be medication nonadherent and

experience a wide variety of other problems, including suicide attempts and more frequent

decompensations (Comtois et al. 2004). Other research shows that these problems improve with

sobriety (Weiss et al. 2005). When treating a patient with bipolar disorder who has relapsed to or

developed substance dependence, the clinician is faced with several options: try to manage the

patient on his or her own, refer the patient for outside substance use treatment while continuing to

treat him or her, or refer the patient to another service or an addiction specialist for management

of both the bipolar disorder and substance use problems. In our experience, many clinicians would

rather continue with most of their patients; however, many assess their weekly, biweekly, or

monthly visits as just not potent enough to deal with active addiction as well as the bipolar issues.

For patients who have developed major addiction, have lost control, and are at serious risk for

adverse consequences, referral to a specialized inpatient or outpatient program may be the best

choice. However, many patients may not be so out of control, or they may not want addiction

treatment to show up on their insurance or health records. Furthermore, participating in

concurrent, outside professional treatment may present other problems, including problems withPrint: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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cost, location, transportation, time, and potentially conflicting treatment messages. Even if outside

referral is made but the patient returns when stable, there is a good chance that 12-step programs

will be part of his or her ongoing treatment plan. In any case, almost all residential treatment

programs in the United States have a strong 12-step orientation and are oriented to continuation

with 12-step attendance after discharge. Thus, knowing about TSF would likely be helpful.

ADDING TSF TO ONGOING TREATMENT

A typical treatment plan would be to integrate the patient’s usual therapy and medications with the

principles, content, and support offered in 12-step meetings. TSF is a method for helping the

patient both get to and productively use 12-step meetings, as well as a method for the clinician to

learn and utilize key concepts about 12-step meetings as part of overall therapy. This integrated

treatment plan, though not indicated or possible for all patients, has some significant advantages in

terms of its addictions impact: no or low cost, ready availability in most communities, anonymity to

insurance and others, long-term support that will not go away with a change or end in insurance

benefits, and importantly, the ongoing relationship of the treating clinician. Patients with alcohol

dependence and psychiatric disorders may have become socially isolated and will benefit from

12-step meetings’ social support, particularly support that does not endorse substance use. For

example, research has shown that nondrinking support from other 12-step meeting participants is

associated with abstinence over three times more than support from the patient’s own family

(Kaskutas et al. 2002). Addiction treatment programs that are 12-step based have been shown to

yield reduced cost in continuing care (Humphreys and Moos 2007). Further evidence of the benefit

of 12-step–oriented approaches in treatment programs was provided by Morgenstern (2004) who

found that promotion of a 12-step orientation was associated with a greater decrease in substance

use at 6 months posttreatment than was the orientation of cognitive-behavioral therapy.

Furthermore, 12-step programs endorse personal responsibility for recovery behavior, loss of

denial of illness (denial of illness also occurs for many psychiatric disorders), and helping others to

recover (thus developing both empathy and self-esteem). These elements of 12-step recovery are

applicable to the treatment of and recovery from psychiatric disorders, in addition to addiction

recovery (Minkoff 1989). Nevertheless, patients and physicians may resist this approach due to

some common misperceptions, such as that 12-step programs are antimedication and require

certain religious beliefs. These issues will be addressed in later sections.

AA is most appropriate for alcohol-dependent individuals, not alcohol abusers. That is to say, many

people who meet DSM-IV-TR criteria (American Psychiatric Association 2000) for alcohol abuse

(not dependence) can learn to drink in a controlled manner. For such individuals, alcohol may be

associated with certain social situations or even mood states and can be limited; such people may

be managed in a psychotherapy situation where they learn to moderate their drinking. It should be

noted, however, that most alcoholics can stop drinking for a period of time before they fall into

problematic use again; what they cannot do is moderate their consumption in a consistent manner

over the long term. Clinicians must therefore clarify the distinction between the two patterns of

consumption in deciding whether AA membership is indicated.

THE BACKGROUND OF TSF

Just as with most manualized, evidence-based practices for psychotherapies, the elements of TSF

come from good clinicians working with astute academics to put together a manual that is based on

their experiences with 12-step treatment. In this case, Kathleen Carroll, Ph.D., from Yale worked

with two talented addictions counselors, Joseph Nowinski, Ph.D., and Stuart Baker, M.A., to develop

a manual for use as a treatment condition in Project MATCH (Mattson et al. 1998), the largest

addictions treatment trial of the early 1990s, which compared outcomes of motivational

interviewing, cognitive-behavioral therapy, and TSF. What follows is based on this manual but has

substantial input from several other sources, including clinician focus groups organized by the

American Academy of Addiction Psychiatry and other referenced sources. We also write from

experience teaching psychiatry residents to do a psychiatric version of TSF with patients, using the

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STARTING OUT

The first step in helping your patients go to 12-step meetings is to work on a simple program to

enhance your own familiarity with meetings as well as 12-step content. There are three easy ways

to do this:

Read AA material. First, go to the AA Web site (http://www.alcoholics-anonymous.org) and read

through the introductory material, or read printed material. You will be in a much stronger position with

your patients in referring them to AA, and to this site, if you can talk to them about your actual

experience with this material and with this site. Basic orientation requires 15–30 minutes. Other

material is on the Web site, including Alcoholics Anonymous, the “big book” of AA. Printed materials can

be obtained by calling your local AA phone number. This same approach applies to NA materials

(http://www.na.org/). An additional resource is available in a brief course on AA on the Web site

http://www.med.nyu.edu.

1.  

Read the TSF manual. This manual can be obtained in print from the National Institute on Alcohol Abuse

and Alcoholism, Publications Distribution Center, P.O. Box 10686, Rockville, MD, 20849-0686. The

manual is about 120 pages long.

2.  

Go to a meeting as a professional guest. There is no better way to learn about AA than by going to an

actual AA (or other 12-step) meeting as a professional guest. This can be easily accomplished by calling

the AA phone number in virtually any directory throughout the United States (and many other countries)

and identifying yourself as a doctor or other health care provider who would like a guide to take him or

her to a local AA meeting as a professional guest. Most AA communities have standing committees of

members whose job it is to do this, and not uncommonly some of them are recovering health care

professionals themselves. It works best to meet with one or two of these guides for half an hour before

the meeting to hear their views and get oriented to what happens in meetings. Attend the meeting (an

open meeting is one where guests [i.e., nonalcoholic individuals] are allowed), then meet with the

guides afterward to talk about what you heard and ask questions you may have about what went on.

Meetings typically run for an hour or an hour and a half. If you find this meeting interesting and helpful,

you might want to talk to your guides about attending a meeting of a different socioeconomic, cultural,

racial, or other group—AA meetings reflect the general communities from which they spring. Matching

patients to the right AA meeting, where they feel more familiar with others, is often key to their

becoming regular members. It is hard to appreciate these differences without experiencing them. It also

substantially strengthens your suggestion to your patients to attend if you can invoke your experience

with attending AA meetings as a professional guest, and, therefore, you know that one meeting can feel

quite different from another.

3.  

CORE ELEMENTS OF THE TSF MANUAL

All of the exerpts that follow are quoted from the TSF manual (Nowinski et al. 1995, pp. ix –18);

however, because of space limitations, this chapter does not review the manual in full. What is

offered might be considered a primer for the manual, with editorial comments and additions for

psychiatrists regarding treating patients with co-occurring psychiatric issues. In Project MATCH,

TSF was designed to be accomplished in 12 sequential sessions over about 3 months. However, for

the practicing clinician, it is more likely that real-world TSF will occur off and on over the course of

treatment, which for some may be weeks or months and for others could be many years.

The following material set in block text is direct or paraphrased copy from the Project MATCH

Twelve-Step Facilitation Therapy Manual and is primarily from the introductory material and

therapist guidelines. The text set in italics is our edits to this material, with our discussion about

TSF materials and our edits in regular paragraph type. Our comments may help the psychiatrist

starting out with TSF by adding material and approaches that harmonize with psychiatric practice

and psychiatric patients. For the sake of brevity, we have used the psychiatric example of bipolar

disorder in most cases, rather than invoking many different diagnostic examples.

TSF Treatment Goals

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Acceptance by patients that they suffer from the chronic and progressive illness of alcoholism

It is very important that clinicians who refer patients to AA or other 12-step programs make sure

that the message given to patients about their addictions harmonizes with what patients hear at

12-step meetings, because receiving conflicting information is not a good way to make a productive

integration. A pharmacological analogy would be that one should not prescribe medications that

negatively interact. Some clinicians will have a hard time swallowing the acceptance phrase above

as it is written; however, if you add at the end, if they continue to drink abusively, and do not

participate in recovery activities, then most clinicians can endorse this. The corollary for psychiatric

patients can be useful: for example, in the case of bipolar disorder it would read, acceptance by

patients that they suffer from bipolar disorder and that their disease will likely become chronic and

progressive if they do not take their medications or participate in recovery (therapeutic) activities.

Dual Recovery Anonymous (DRA), or “Double Trouble,” is a 12-step program created by persons

with both psychiatric and addiction disorders (see http://www.draonline.org/dra_steps.html). The

first of DRA’s 12 steps is “We admitted we were powerless over our dual illness of chemical

dependency and emotional or psychiatric illness—that our lives had become unmanageable.”

Importantly, this means that individuals are

Powerless over being born with the illnesses or managing them without help, and

Powerless to predict behavior once drinking, in a manic episode, or both; but

Not powerless to get to meetings or therapy appointments;

Not powerless to take medications regularly and avoid bars; and

Not powerless to participate in recovery from both disorders.

Acceptance by patients that they have lost the ability to control their drinking

Research has shown that persons with more severe dependence do better in AA than those with

episodic abuse (Tonigan et al. 2006) because of the concept of loss of control stated above, as well

as other issues. This means that if your patient has only mild abuse and can control his or her

drinking most of the time with your support, then he or she is probably not the most likely AA

candidate. In terms of bipolar behavior, the correlate would be acceptance by patients that they

have lost the ability to control their behavior when manic or severely depressed. In talking to

patients about this concept or phrase excerpted above, one can add the word reliably just before

“control their drinking.” For example, with the alcohol-dependent bipolar patient the clinician

would ask, “Can you reliably control your drinking well enough that you are willing to take the risk

of decompensating with both your alcohol and manic behavior and ending up in the hospital, jail, or

both again? Can you reliably control your manic behavior (if you stop your medications) such that

you are willing to take the risk of decompensating, or going back to drinking, or both?”

Acceptance by patients that since there is no effective cure for alcoholism, the only viable alternative is

complete abstinence from the use of alcohol

If patients with major mental illness can reliably control their drinking to one small glass of wine a

day, then by definition, they do not have dependence and TSF is not for them. However, if they do

have dependence with episodic or regular dyscontrol if they drink, it is much easier for them to not

drink at all than to prime the pump with attempts at controlled drinking. The analogy here is

acceptance by patients that since there is no effective cure for bipolar or schizophrenic disorder,

the only viable alternative is to take daily medications and participate in healthy recovery

behaviors (such as seeing their psychiatrist and attending 12-step meetings if they have substance

dependence).

Surrender

Acknowledgment on the part of the patient that there is hope for recovery, but only through accepting

the reality of loss of control (from alcohol dependence/major mental illness) and by having faith that Print: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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some higher power (AA meetings, the psychiatrist, medications, support groups for the mentally ill, a

spiritual higher power) can help the individual whose own willpower has been defeated by alcohol/major

mental illness

Most psychiatrists are unfortunately familiar with the mentally ill patient who understands his or

her disorder one month, accepts it, and does everything in his or her power to stay well, but over

time comes to believe that he or she no longer has a disorder and then decreases or stops taking

medications and receiving therapy and decompensates to depression or mania. The same process

can hold for addictions. Clinical experience shows that relapsing back into denial of illness happens

for both psychiatric and addiction disorders and is not something that is dealt with once and for all.

Quite often denial can creep back intermittently and lead to serious problems. By continually

concentrating on acceptance of illness, 12-step members reinoculate themselves against denial. For

example, each time AA, DRA, or other 12-step program members speak in meetings, they introduce

themselves by saying, “Hi, my name is Rick, and I am a recovering alcoholic.” In dual disorder AA

or DRA meetings, the speaker might say, “Hi, my name is Rick, and I am a recovering bipolar

alcoholic.” The power in this phrase is the direct challenge to denial; 12-step meetings strongly

promote that denial can reemerge if it is not actively and regularly challenged.

Acknowledgment by the patient that the fellowship of AA has helped millions of alcoholics to sustain their

sobriety and that the patient’s best chances for success are to follow the AA path. Furthermore, the

12-step approach can be a valuable approach to dealing with any other potentially chronic and relapsing

condition, such as most psychiatric disorders.

There are two key issues here. First, by merely examining a schedule book of meetings in any

community and going to a meeting or two, it becomes clear that many, many people go to AA

meetings. For example, in Seattle there are about 1,200 meetings per week, and an average

meeting has 15–100 attendees. Observing this mass of people all going in the same healthy

direction has a potency that cannot be captured by the academic discussion of a research finding.

Second, sustain is a key word in the excerpt above. That is, while our research shows that most

psychiatric and addiction disorders are chronic and relapsing in nature, most treatment structures

are short-term or episodic (e.g., limits on study lengths, limits on payment for an episode of

treatment, managed care limits on number of sessions). Twelve-step meetings are available

without cost, without end, and almost without boundary, as they are now easily available almost

anywhere in the United States and are becoming more available throughout much of the world. As

Mark Twain reportedly said, “Stopping smoking is easy. I’ve done it hundreds of times.”

In this regard, it is useful to explain to the patient how the speakers’ presentations

(“qualifications”) are useful in putting the illness into context. It is increasingly understood that

the narratives and personal stories that one hears at meetings have an important psychological role

in promoting both the speakers’ and listeners’ recovery (Mankowski et al. 2001). But their

relevance often needs to be clarified for the new attendee.

Objectives

The two major treatment goals of acceptance and surrender are reflected in a series of specific

objectives that are congruent with the AA view of individuals with alcoholism. These specific

objectives are cognitive, emotional, behavioral, social, and spiritual in nature.

Cognitive

Patients need to understand some of the ways in which their thinking has been affected by alcohol, other

drugs, or mental disorders.

Clinicians who conclude that TSF might be helpful to their patients are likely driven by observing

behaviors and negative consequences due to alcohol or drug use. At times the patients themselves

may conclude they have an addiction problem, but it is more likely that it is the clinician who will

be led to such a conclusion based on the patient’s substance-related problems and consequences.Print: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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In such cases, although the patient may have sought treatment for a psychiatric problem alone, the

clinician may decide that the patient also has a co-occurring problem with addiction, which needs

clinical focus.

Patients need to understand how their thinking may reflect denial and thereby contribute to continued

drinking (or psychiatric relapse) and resistance to acceptance (Step 1), which can lead to

decompensation of addiction, psychiatric, or both conditions.

The therapist remains vigilant for signs of denial of either disorder, patient accounts of slips, and

medication nonadherence or missing appointments, and explains these slips in terms of denial.

The therapist suggests recovery tasks that will enhance patient’s understanding of addiction and his or

her psychiatric disorder, as well as how both of these can benefit from the fellowship of AA.

Denial of illness in a previously substance-dependent person usually leads to experimentation,

which may then lead to increased use (in an effort to match previous effects as tolerance to the

substance builds), which may lead fairly rapidly to problematic and dependent use. In the case of

relapse, this process may start with a drop-off in attendance at 12-step meetings, even before the

actual substance use begins. The clinician should therefore be attentive to a patient’s attendance at

12-step meetings and view a decline in attendance as an indication both to encourage renewed

attendance on the part of the patient and to look for circumstances potentially associated with

relapse.

For individuals with a psychiatric disorder, denial of illness may lead to a refusal to initiate

treatment. Similarly, individuals in denial of their relapse to substance use may begin canceling

treatment appointments or decreasing or stopping medications—either of which may occur before

recurrence of major psychiatric symptoms.

Certain psychiatric conditions display denial in different manners. For example, grandiosity in

mania leads the patient to believe that he or she knows better and can handle anything; nihilism in

depression leads the patient to believe that he or she is not worth treatment and nothing matters

anyway; posttraumatic stress disorder leads the patient to believe that his or her symptoms are

worse than they actually may be because he or she is seeing a specialist and concentrating on the

memories; delusions in schizophrenia may tell the patient that it is the medications that are

causing, for example, electric rays from the sky that torture him or her.

Patients need to see the connection between their alcohol abuse and negative consequences that result. .

.which may be physical, social, legal, psychological, financial, or spiritual; and, further, patients need to

analyze in detail how their co-occurring psychiatric problems have been affected by their addictions and

vice versa. Common problems include aggravated symptoms, decompensations, medication adherence

problems, suicide attempts, monetary problems, and the other problems named above.

Emotional

Patients need to understand the AA view of emotions and how certain emotional states (e.g., anger and

loneliness) or a relapsing psychiatric disorder can lead to drinking.

A version of the AA view of emotions and how to deal with them is described in Topic 8 of the

Twelve-Step Facilitation Therapy Manual (p. 79) but is too lengthy to fully review here. It may be

surprising to the reader to find that many elements of Marlatt’s relapse prevention (Marlatt and

Gordon 1985) and Linehan’s dialectical behavioral therapy (Linehan 1993) have a good deal of

overlap with AA content and principles, in terms of analyzing how certain emotions lead to certain

behaviors and how to handle them.

HALT (Hungry, Angry, Lonely, Tired) is an AA mnemonic and slogan that not only captures common

emotional relapse states but suggests action, as in “HALT before you do something you do not

really want to do.” Interestingly, this model is quite compatible with the cognitive-behavioralPrint: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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approach that many therapists apply in treating addictive disorders. Feelings such as anxiety and

depression may regularly lead to the self-administration of a drug of abuse; these feelings may

then become conditioned stimuli that produce a response experienced as craving, thereby

precipitating drug taking without a conscious decision on the part of the addict. The same is true

for a particular setting in which alcohol or drugs were repeatedly taken; it may become a

conditioned stimulus for drug-seeking behavior on subsequent occasions of exposure. For this

reason, the recovering alcoholic individual is warned in 12-step groups to watch out for negative

feelings and avoid bars and drug-related social situations; these have become conditioned stimuli

for alcohol-seeking behavior, leaving the alcoholic person more vulnerable to “needing” a drink.

When reviewing psychiatric symptoms or substance use or craving since the last visit, the

psychiatrist might integrate TSF by asking, “Have there been any episodes of feeling hungry, angry,

lonely, or tired since your last visit, and if so, how did you handle them?” By using the AA verbiage,

the psychiatrist is telling the patient that he or she supports AA and that the psychiatrist’s therapy

is meant to be integrated with what the patient is getting through AA.

Patients need to be informed regarding some of the practical ways AA suggests for dealing with emotions

so as to minimize the risks of drinking.

The most common and obvious way for a patient to become informed of these methods is to attend

AA meetings. In fact, the methods by which a patient learns how to deal with emotions are so

numerous that they are included in almost every story, vignette, step description, or other

literature that AA publishes (Topic 8 [pp. 79–86] from the Twelve-Step Facilitation Therapy Manual

has very practical materials in a workbook format). For individuals who are seeing a therapist, AA

methods present a way to deal with problematic emotions other than taking medication.

Behavioral

Patients need to understand how the powerful and cunning illness of alcoholism has affected their whole

lives and how many of their existing or old habits have supported their continued drinking. They further

need to understand how their addiction and psychiatric conditions have interacted and adversely affected

each other.

The behavioral approach associated with conditioned stimuli is a useful cognitive-behavioral

technique for addiction treatment to frame changes in the activities associated with drug use

(Carroll 2004). The issue of self-medication may emerge and has the potential to confuse both the

psychiatrist and the patient.

Virtually all research conducted on the matter shows that dependent use of substances makes

major psychiatric disorders worse, resulting in increased symptoms, decompensations, emergency

room visits, homelessness, and suicide, among other problems (Center for Substance Abuse

Treatment 2005). Furthermore, patients who invoke the term self-medication have an increased

likelihood of suicidal ideation and suicide attempts (Bolton et al. 2006). To equate this with what

our medications are supposed to do is like equating electricity used for home heating to electricity

in a lightning bolt that destroys someone’s house. Research has shown that when an individual

with bipolar disorder who is in a manic state claims to be self-medicating, he or she is most likely

aiming to get even more euphoric, and that patients who use the term self-medication have worse

prognoses for recovery (Weiss 2004). Using the term self-medication when addiction or abuse of

substances is more accurately meant can be confusing to both the patient and psychiatrist. Such

use allows concrete-thinking patients to think, “Well, the psychiatrist said I self-medicated, so I

guess I will take his medications [lithium, antipsychotics, etc.] on Monday through Friday and my

medications [crack and alcohol] on the weekend. After all, it’s all medication.”

We will deal with this topic more below when giving concrete examples of how to talk to patients

about meetings.

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Patients need to turn to the fellowship of AA and make use of its resources and practical wisdom in order

to change their alcohol behavior.

Patients need to “get active” in AA as a means of sustaining their sobriety.

Patients need to attend and participate regularly in meetings of various kinds, including AA-sponsored

social activities.

Patients need to obtain and develop a relationship with an AA sponsor.

Patients need to access AA whenever they experience the urge to drink or suffer a relapse.

Patients need to reevaluate their relationships with “enablers” and fellow alcoholics.

It is easy to understand the need for an individual who is trying to stay sober to avoid spending

time with friends who are still drinking/using substances. This type of reasoning is also applicable

to individuals who are receiving treatment for psychiatric disorders—it is not unusual for a

well-meaning but uninformed friend or relative to suggest that a patient stop taking his or her

medications because they are chemicals and not natural. Identifying persons who are supportive of

recovery and avoiding or working to change those who are not are important elements of TSF. This

is especially important in choosing certain AA meetings that may be more supportive of

co-occurring issues and in choosing a sponsor. The sponsor should either have co-occurring

disorders him- or herself or should be supportive and understanding of these issues.

Spiritual

Patients need to experience hope that they can arrest their alcoholism and manage and recover from

their psychiatric disorder(s).

Patients need to develop a belief and trust in a power greater than their own willpower.

The above statements hold for both addictions and psychiatric disorders. If the willpower of the

individual seeking treatment were adequate, he or she would not need to see the psychiatrist, take

medications, or use the 12-step programs. These types of “power greater than oneself” are pretty

concrete; however, what about the role of spirituality or God?

The issue of God in TSF

Spirituality has been defined as “that which gives people meaning and purpose in life” (Puchalski

et al. 2004, p. 689). The element of spirituality is what distinguishes AA from orientations that

approach addiction recovery on the basis of physical and behavioral consequences of disease alone

as well as from formal religious practices. Alcoholics Anonymous repeatedly mentions a “program

of recovery” and associates it with terms such as spiritual experience and spiritual awakening

(Alcoholics Anonymous 1976). A spiritual orientation is inherent in four of the steps, which include

the word God. However, both key AA texts (Alcoholics Anonymous 1976, 1984) dedicate great

effort to differentiating traditional concepts of God from the AA spiritual concept of a higher power.

Both spirituality and God can have many different meanings, and a patient who balks at

interpretation of these terms might be open to working under another interpretation—either word

can attract or repel individuals, depending on their associations. During discussions of previous

experiences with 12-step programs with a patient (or simply what he or she might have heard

about them), the issue of the spiritual element in these programs is raised quickly. (Special care

needs to be taken here for psychotic patients with religious delusions.) One should try to explore

the person’s associations to key words with open questions.

What do you know or think about the term spirituality? How do you think it is used in AA [or another

12-step program the individual may have attended or heard about]?

How about the term higher power? Was this concept helpful to you? If not, let’s see if we can figure out

how it might be.

Your dependence on alcohol/drugs, by definition, is clearly stronger than your own willpower. Do youPrint: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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recognize your dependence as a power greater than yourself? If so, then what are some examples of

this?

Recovery from this dependence can also be seen as greater than yourself; what does this mean

to you?

The wisdom and experience from those in 12-step meetings with successful long-term recovery

are clearly greater than your own; are you willing to use this help?

How do you feel about the term God?

What does this term mean to you?

When speaking with an individual who seems resistant to discuss God, one may find it helpful to

explain that the use of this term is not a requirement for membership in AA or other 12-step

programs and that others prefer the terms my higher power or the power of my AA group. Most

larger AA communities even have agnostic and atheist groups, for those for whom hearing the term

God is too disruptive. In the context of the 12-step process, spirituality can be thought of as the

willingness to change. It can also be defined as connectedness with other people and what is

meaningful in someone’s life.

How is the discomfort with the use of God addressed in AA? First, the issue of God is qualified

(Alcoholics Anonymous 1976, pp. 44–57; 1984, pp. 25–33, 34–41) with “as we understood him.”

Second, flexibility on the concept of God is made clear in one chapter of Alcoholics Anonymous that

addresses any alcoholic person “who feels he is an atheist or agnostic,” encouraging his or her

membership. The text points out for these potential members that “We Agnostics. . .had to face the

fact that we must find a spiritual basis for life” in order to achieve recovery, thereby implying AA’s

distinction between spirituality and theistic religion.

Universality of spirituality

All people across cultures have had exposure to spirituality. Encourage patients to reflect on past

spiritual experiences and to build on them. Also, encourage patients to find comfort in spiritual

experiences.

Resistance to religion or spirituality

For patients who express resistance to religion or spirituality, talk to them after they have been to

a few 12-step meetings in order to determine if there is anything they can connect with.

Spirituality from a different perspective

For patients who are not inclined to look at the spiritual aspects of AA, the doctor can suggest that

they do some other things that have similar spiritual foundations. For example, patients can

volunteer for the Salvation Army to experience spirituality from another perspective.

Spirituality and morality

Patients need to acknowledge character defects including specific immoral or unethical acts, and harm

done to others as a result of the patients’ alcoholism or psychiatric disorders.

The moral tone of this statement may cause discomfort for many psychiatrists; however, looking at

the “wreckage of the past”—a typical AA phrase—is something that should be done as part of taking

any good history. This task helps to challenge denial. While it is clear that the cocaine-abusing

patient who sold his or her parents’ television should acknowledge substance use problems and

make restitution, what about the manic patient who by choice cuts down medications to “get an

edge,” then spends the entire limit of the family’s credit cards on unnecessary, impulsive items? Is

this an illness issue, a moral issue, or both? The AA approach says that although an individual may

not be responsible for having the illness, he or she is very responsible for managing its recovery.

Facing up to the wreckage of the past, whether from addictions, psychiatric illness, or both, is a

basic part of recovery. While restitution of money or other concrete objects can be made,

self-forgiveness for hurting others, such as in the examples above, is more difficult. Both the

individual and the therapist must work together on this task.Print: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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ROLE OF THE THERAPIST

The primary role of the therapist is as a facilitator of patients’ acceptance of their alcoholism and of a

commitment to the fellowship of Alcoholics Anonymous as the preferred path of recovery. However, when

the facilitator is also a pyschiatric practitioner (and often a prescriber), explaining the nature of

co-occurring psychiatric illnesses, medications, and other therapies are also key facilitation issues.

Education

The therapist acts as a resource and advocate of the 12-step approach to recovery.

The 12-step therapist explains the AA view of alcoholism and interprets slips and resistance to AA in

terms of the power of alcoholism and the dynamics of denial.

The 12-step therapist introduces several of the 12 steps and their related concepts and helps the patient

to understand key AA themes and concepts (e.g., denial, powerlessness) by identifying the patient’s

personal experiences that illustrate them.

And for those with comorbid disorders, the therapist adds the context of the patient’s psychiatric disorder

to these same conditions (for example, the role of denial in bipolar illness; how a slip with drinking and

psychiatric medication nonadherence might be similar).

Introduction of steps is probably best done in actual meetings or by the patient’s sponsor, unless

the psychiatrist wants to get much more involved. Table 26–1 lists the DRA steps.

Introduces, explains, and advocates reliance on the fellowship of AA as the foundation for recovery,

which should be thought of as an ongoing process of “arrest” (as opposed to cure). The concepts of

arrest and recovery versus cure hold for most psychiatric disorders.

TABLE 26–1. The 12 Steps of Dual Recovery Anonymous

1. We admitted we were powerless over our dual illness of chemical dependency and emotional or psychiatric

illness—that our lives had become unmanageable.

2. We came to believe that a Higher Power of our understanding could restore us to sanity.
3. We made a decision to turn our will and our lives over to the care of our Higher Power, to help us to

rebuild our lives in a positive and caring way.

4. We made a searching and fearless personal inventory of ourselves.
5. We admitted to our Higher Power, to ourselves, and to another human being, the exact nature of our

liabilities and our assets.

6. We were entirely ready to have our Higher Power remove all our liabilities.
7. We humbly asked our Higher Power to remove these liabilities and to help us to strengthen our assets for

recovery.

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 to such people wherever possible, except when to do so would injure them or

others.

10. We continued to take personal inventory, and when wrong promptly admitted it, while continuing to

recognize our progress in dual recovery.

11. We sought through prayer and meditation to improve our conscious contact with our Higher Power,

praying only for knowledge of our Higher Power’s will for us 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 others who

experience dual disorders and to practice these principles in all our affairs.

Source. Reprinted from Dual Recovery Anonymous 1993–2004.Print: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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In the clinical context, recovery is based on an individual’s behavior and medical status, which can

be assessed by recourse to diagnostic criteria in DSM-IV-TR. Some of these criteria are also given

in the items listed in the Addiction Severity Index (McLellan et al. 1992), which is used widely in

research to evaluate recovery. Behavior and medical status can be assessed relatively easily

because they are premised on observable behavior or symptoms described by the patient, family

member, or clinician. But a spiritually grounded definition of recovery can be useful as well. A

different set of criteria can be used to diagnose addiction and describe the spiritual aspects of

recovery associated with the 12-step experience, such as relief of guilt and shame, expression of

gratitude, and finding purpose in life (Galanter 2007). These are particularly relevant in helping the

patient understand what is meant by recovery from the broader perspective of the 12-step

experience.

Explains the role of a sponsor and helps patients identify what they would most benefit from in a

sponsor.

Answers questions about material found in the Big Book, The Twelve and Twelve, and other readings.

Again, it is possible for a psychiatrist to help his or her patients to attend AA meetings and get

something out of them without having to read the big book in its entirety. However, reading it can

be both helpful and interesting and can help the psychiatrist to better understand addiction and the

AA model of recovery. Most of this type of more concrete AA work is best done by the patient’s

sponsor.

Facilitation

The therapist uses patients’ reports of their experience between sessions to actively facilitate their

involvement in AA. The 12-step therapist. . .encourages attendance at AA meetings, monitors patient

involvement in AA, and actively promotes a progression toward greater involvement in AA, for example

in going to meetings that require more personal involvement, such as “step” meetings and “discussion”

meetings. The psychiatric practitioner can productively use his or her patient’s behavior and

understanding of meeting discussions as therapeutic material for both disorders.

One can spend a great deal of time on the issue of active involvement in AA. It is important for

patients to understand that participation is necessary for recovery. On the other hand, for first-time

attendees or patients with social anxiety, it may be understandable that they are reluctant to speak

or meet with other members. When it is clear that this is the case for a particular patient, it should

be addressed in a supportive way. For that patient, the idea that if he or she keeps going back, he

or she will feel more comfortable in time should be emphasized. Sitting in the back of the meeting

room and not speaking is an acceptable first step toward later involvement.

Some basic meeting involvement coaching might include asking such questions as, What meetings

did you attend since last session? Did you arrive early, on time, or late for meetings? Where exactly

were the meetings, where did you sit, did you stay for the whole meeting, and were you able to pay

attention the whole time?

Discussing answers to these questions uncovers resistance and nonattendance as well as

psychiatric problems that might be interfering with attendance, such as paranoia or social phobia.

Dealing with the causes of nonattendance and resistance then becomes part of therapeutic work,

involving medications, motivational interviewing, cognitive-behavioral techniques, or other specific

cognitive approaches. Initiating discussion about AA involvement using such approaches is briefly

illustrated here.

Motivational interviewing: “So you thought about going to a meeting last night, but didn’t quite get

there. . .What do you think you might have gained if you had gone? What would have been the

downside of going?”

Cognitive-behavioral therapies and AA facilitation: “So you thought about going to a meeting last night,

but didn’t quite get there. . .Let’s examine what you said to yourself to convince yourself not to go,Print: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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then work out a strategy to get you there.”

Twelve-step disease model facilitation: “So you thought about going to a meeting last night, but didn’t

quite get there. . .What was responsible for not getting there—was it you or was it your disease? That

kind of experience is the illness at work; it’s the disease that tells you that you don’t have a disease.

Who could you have called?”

More detailed attendance questions: “Did you offer to help with setup or cleanup at the meeting? Did

you talk to anyone before or after the meeting? What were some key issues you heard discussed at the

meeting? How did these issues apply to you? Did you say something in the meeting? What was it like to

talk, or want to talk, but be unable or afraid to talk? Let’s rehearse right here what you could say.”

An example of a specific co-occurring disorders intervention (panic disorder and social phobia): “So you

thought about going to a meeting last night, but were afraid you would panic if you were called on, so

you didn’t go. Let’s work out a strategy.”

Prescribe medications for social phobia (e.g., selective serotonin reuptake inhibitor, gabapentin.

Note that an alcoholic patient should not receive benzodiazepines; see Alcoholics Anonymous

1984).

Rehearse something very simple to say in meetings (in the patient’s words) with visualization,

such as “Hi, I’m Rick and I’m glad to be here.” Have the patient carry a written card or have

this phrase written on his or her hand. Rehearse this again and again in session and have the

patient do this at home. Let the patient know that there is no requirement for individuals to say

anything during meetings; even if called on, he or she can just pass.

For highly anxious performance-challenged patients, a 10- to 20-mg dose of propranolol before

meetings may help, until the patient is more comfortable.

Clarifies the role of therapist versus sponsor and refuses to become a sponsor while helping the patient

to find one.

Naturally, a number of other types of issues can arise with respect to initiating AA treatment. Table

26–2 presents some common problems and offers solutions that may guide a clinician in his or her

facilitation of AA participation. Table 26–3 provides specific questions and topics whose discussion

can further help to facilitate involvement in treatment.

TABLE 26–2. Engaging those with Alcoholics Anonymous (AA) resistance

Problem

Solution

The patient has had previous bad experiences with

treatment for alcohol dependence, and AA is guilty by

association.

Explore these issues and interpret the resistance

of guilt by association.

The patient has had a previous bad experience with AA

directly (e.g., he or she might have met someone at a

meeting and then drunk with him or her; the patient

might have gone to a meeting and felt that he or she did

not fit with the other attendees).

Explore what happened and the patient’s role in

this.

Talk about matching meetings to the patient.

The patient has had a previous bad experience due to

symptoms of co-occurring psychiatric problems (e.g.,

social phobia, paranoia).

Explore this, and explain that you will develop a

strategy to deal with these symptoms.

Explain to the patient that an AA meeting is about

the safest place there is to exhibit symptoms

publicly because it is a supportive and

nonconfrontational environment.

The patient has had very little previous experience with

AA, but stopped attending meetings, used alcohol or

drugs, and concluded that meetings “don’t work.”

Explain that the patient’s previous attendance and

involvement wasn’t an adequate “dose.”

Illustrate this point with the following analogies,

selecting the analogy that the patient is most

likely to hear or understand, given their clinicalPrint: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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Problem

Solution

history:

Antibiotic model: Would it be safe to conclude

that an antibiotic was ineffective after only taking

one-third of the dose for only one-third of the

time prescribed?

Diabetes model: Would it be safe to conclude

that a diabetes treatment was ineffective after

taking the medicine only half the time and eating

chocolate cake in between doses?

Bipolar model: Would it be safe to conclude that

a bipolar medication was ineffective after taking

just one-third of the prescribed dose or skipping

doses altogether for weeks at a time?

TABLE 26–3. Examples of working with patients

Examine the patient’s previous experiences with the following core topics

Sobriety

“Tell me about the times you have been abstinent of both drugs and alcohol.”

“What seemed to work and what did not work for 1) addictions, 2) psychiatric problems, and 3) both

problems.”

Treatment

“Tell me about times you have stopped or cut down use in the past.”

“Tell me about your previous treatments? What seemed to work and what didn’t?”

Twelve-step meetings

“What have been your experiences with Alcoholics Anonymous (AA)?”

“Have you ever gone to meetings? If so, when?”

“How involved and committed were you? Did you ever try ’90 in 90′ (90 meetings in 90 days)?”

“Did you go to the same meeting regularly (e.g., weekly for several months)? Tell me about these meetings

and the people you met there.”

“Did you get a sponsor? If so, how, and what was he or she like? Did he or she help, and if so, how? If not,

why not—what got in the way? Did this sponsor know you had a dual disorder or that you were also on

medications?”

“Did you ever work the steps? If so, which steps?”

“How fully ‘plugged-in’ did you ever get with AA? Did people know you? Did you know them? Did you ever

do any ‘service’? If so, tell me about your service.”

– If the patient answers mostly yes to the above 12-step questions, analyze what happened to the patient’s

12-step relationship.

– If the patient answers mostly no to the above 12-step questions, make your position clear on why you are

a strong advocate of AA by stating, “Most people with more than a few months of sobriety are regularly using

AA” and “The more involved with AA you are, the more likely it is you will have a positive outcome and the

more likely your pyschiatric disorder will improve.”

Not focused so much on illness as previous attempts at quitting, treatment, and AA

Some clinicians may choose to meet a patient’s sponsor so that both the sponsor and clinician both

know they are on the same side and are providing consistent information to the individual seekingPrint: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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treatment. This is only done with the patient’s approval and during a session with the patient

present. Other clinicians prefer to not meet the patient’s sponsor but still encourage a constructive

relationship between patient and sponsor. A patient may not feel comfortable with the initial choice

of sponsor and may discuss this in therapy. If this takes place, the therapist can explore the

patient’s concern. This may help the patient relate more comfortably to his or her sponsor. AA

members may decide to get a new sponsor if they feel that would be best for them.

Some patients are resistant to the idea of getting a sponsor, and this can be a problem. For those

with more serious psychiatric disorders, it is best, but not absolutely necessary, that their sponsors

also have co-occurring disorders. This way, problems around psychiatric diagnosis, symptoms, and

treatments, especially medications, are avoided, and psychiatric treatments are reinforced rather

than resisted by the sponsor. Patients are more likely to meet such sponsors by going to DRA, dual

diagnosis AA meetings, or other variants of 12-step meetings that focus on persons with

co-occurring disorders. Many AA schedules in larger communities even list dual diagnosis as a

qualifier for certain meetings.

Desired Therapist Characteristics

Twelve-step therapists, being professionals whose goal is to facilitate and encourage active participation

in AA, need not be personally in recovery; however, they must be knowledgeable of and comfortable with

the foundation of 12-step recovery as described in AA-approved literature. Therapist self-disclosure of

recovery status is to some extent a clinical issue, but generally speaking the authors encourage honesty

in the therapeutic relationship.

If they are not in recovery, it is strongly recommended for therapists to attend at least 10 open AA

meetings and an equal number of Al-Anon or Families Anonymous meetings, and to be thoroughly

familiar with AA reading materials.

In addition, to be maximally effective as a facilitator, the therapist is advised to develop a network of AA

contacts—men and women—who are active in AA and who could be called on to assist in getting a shy or

ambivalent patient to their first meetings, giving advice about particular meetings, providing directions,

and so forth. Persons who have been sober and active in AA for at least a year are candidates for doing

this type of 12-step work as part of their own recovery. Therapists can develop working relationships

with these people by going to AA meetings on some regular basis, or by talking with recovering persons

they know. First-hand knowledge of such contact people is desirable.

Active, Supportive, and Involved: 12-step therapists are expected to be interactionally active and

nonjudgmentally confrontational during therapy sessions, as opposed to merely reflective. This does not

mean that the therapist lectures the patient, does more talking than the patient, or chastises the patient

for slips. Rather, the therapist utilizing this approach should be prepared to identify denial and confront

the patient consistently in a frank but respectful manner regarding the patient’s attitudes or behaviors, to

actively encourage the patient to get involved in the fellowship of AA, and to help the patient understand

key AA concepts as they are reflected in the patient’s actual experience.

Patients can be expected to interpret the AA concepts presented here in light of their own experience.

This is consistent with the AA approach, which allows for a great deal of individuality of interpretation

within broad guidelines. For example, the 12 steps specifically allow for individuality in conceptualizing a

higher power (“God as we understand him”). Similarly, what represents unmanageability (Step 1) for one

patient may not be meaningful to another. What is most important is not whether patients interpret

these concepts in the same way; rather, what counts is the end result: active involvement in the

fellowship of Alcoholics Anonymous.

Confrontation: In the context of this program, confrontation is something that therapists can think of as

helpful and honest mirroring. The most appropriate form of confrontation is to share frankly but

respectfully what you see the patient doing. Most often this involves confronting the patient about some

form of denial. Confrontation that is patronizing or harsh or implies that the patient has a characterPrint: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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problem as opposed to a powerful and cunning illness is likely to be counterproductive.

We have discussed therapist preparation earlier in this chapter, in the section titled “Starting Out.”

Realistically, we doubt that many practicing clinicians will go to 10 meetings and it is our

experience that many residents have become at least moderately 12-step adept by attending a

couple of meetings, reading the TSF manual, and working intensively with a few patients who go to

12-step meetings, making sure to spend a good deal of each session talking about what went on at

meetings. This review of meetings brings up psychiatric symptoms, relationship matters, and

cognitive challenges, providing ample material for a therapist to attend to during a session. This

concentration on what goes on at meetings also conveys the idea that meetings are important.

KEY POINTS

Co-occurring and substance-induced disorders are common in psychiatric patients, and mental health

practitioners can enhance outcomes from both disorders by applying 12-step facilitation (TSF).

TSF is not Alcoholics Anonymous (AA) nor is it endorsed by AA. It is an evidence-based therapy performed

by the clinician to help a patient begin to attend and benefit from 12-step meetings, including AA.

Co-occurring disorders (COD) TSF is a practical enhancement of TSF that includes typical psychiatric issues

and treatment but has not been separately tested.

Twelve-step approaches and meetings are ubiquitous, inexpensive, and evidence based and provide

long-term, recovery-based help with patients with substance use disorders.

Twelve-step approaches to acceptance and denial for the chronic and often relapsing illness of addiction are

appropriate for and benefit most psychiatric disorders.

The official policy of AA is supportive to seeing psychiatrists and taking psychiatric medications for mental

disorders. However, a good deal of variability exists with many 12-step communities having COD 12-step

meetings and others being neutral or even hostile toward the idea.

Developing COD TSF skills is an effective way for the mental health practitioner to stay productively

involved with his or her COD patient, provides a good model of integrated care, and provides a great deal of

low-cost but high-frequency psychosocial support to the patient.

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at: http://www.draonline.org/dra_steps.html. Accessed January 20, 2008.Print: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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Galanter M: Spirituality and recovery in twelve-step programs: an empirical model. J Subst Abuse

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SUGGESTED READING

Bogenschutz MP: Specialized 12-step programs and 12-step facilitation for the dually diagnosed. Community

Ment Health J 41:7–20, 2005Print: Chapter 26. Twelve-Step Facilitation: An Adaptation for Psychia… http://www.psychiatryonline.com/popup.aspx?aID=353402&print=yes…

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Double Trouble in Recovery: Double Trouble in Recovery. Available at:

http://www.doubletroubleinrecovery.org/index.htm. Accessed September 5, 2007.

Nowinski J: The Twelve Step Facilitation Outpatient Program Facilitator Guide. Center City, MN, Hazelden,

2006

Nowinski J, Baker S: The Twelve Step Facilitation Handbook: A Systematic Approach to Early Recovery From

Alcoholism and Addiction. Center City, MN, Hazelden, 2003

Nowinski J, Baker S, Carroll K: Twelve Step Facilitation Therapy Manual. Rockville, MD, National Institute on

Alcohol Abuse and Alcoholism, 1995

Copyright © 2008 American Psychiatric Publishing, Inc. All Rights Reserved.