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Mental health: 12 step facilitation

As more complex clients – with substance use problems and accompanying mental disorders – increasingly present for treatment, we offer a timely facilitator guide

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12 step facilitation for co-occurring disorders is evidence-based treatment that, like cognitive behavioural therapy (CBT) and motivational enhancement therapy (MET), has proven to be successful in treating people with substance use disorders, be they alcohol or drugs. 12 step facilitation for co-occurring disorders is an adaptation of TSF for people diagnosed with both a substance use disorder and a mental health disorder, such as anxiety, depression, schizophrenia or post-traumatic stress disorder.

The TSF-COD programme can be used by adults and adolescents, in group and individual settings. It does not depend on previous exposure to 12 step fellowships. It offers a systemised and consistent approach to addiction treatment in community-based, criminal justice, private practice and mental health settings. It is recommended that facilitation be collaborative between a trained professional and one or more peer counsellors. The trained professional should have indepth understanding of both substance-use and mental-health disorders, as TSF-COD is best conceptualised as psychotherapy-assisted
recovery. Facilitators can also coordinate efforts with prescribers.

Facilitators of TSF-COD have two main goals:

  • to facilitate active involvement in a 12 step fellowship such as Alcoholics Anonymous, Narcotics Anonymous or Double Winners
  • to facilitate active involvement in mental-health treatment.

TSF-COD facilitators seek to accomplish these through a combination of education, coaching and promoting action.

What is the research behind TSF and TSF-COD?

The largest psychotherapy outcome study to date remains Project Match: matching alcoholism treatments to client heterogeneity. It spanned seven years across nine treatment sites in the US. All three treatment modalities used – CBT, MET and TSF – proved effective at reducing alcohol use. Perhaps the biggest surprise, for those unfamiliar with TSF, was that TSF was sometimes superior to both CBT and MET. “On at least one other time-honoured outcome measure – the percentage of patients maintaining complete abstinence – those in TSF fared significantly better at all followup points than did patients in the other two conditions,” the principal developer of MET, Dr William Miller, concluded.

Subsequent randomised clinical trials by other researchers confirmed Project Match findings. Studies have shown that engagement in AA or other 12 step fellowships after treatment for a substance use disorder increases abstinence rates by about 33% and decreases healthcare costs by about 64% when compared to CBT.

The National Institute on Alcohol Abuse and Alcoholism funded a survey on alcohol use and its relation to mental illness, designed to reflect the entire US population. It found that people with severe alcohol use disorder were 3.9 times more likely to suffer from depression, 3.8 times from schizophrenia, 2.6 times from anxiety and 2.2 times from post-traumatic stress disorder. The higher the severity of a person’s alcohol use, the more likely it is that s/he has a co-occurring mental health disorder. In a catch-22, people with a mental health disorder often turn to alcohol or drugs to self-medicate – but the substances worsen the mental illness. People with co-occurring disorders can have a more successful recovery if both conditions are treated at the same time.

So recent research has focused on how 12 step recovery improves mental health. It is worth reading three of these studies: Mechanisms of action in integrated cognitive-behavioral treatment versus twelve-step facilitation for substance-dependent adults with comorbid major depression, Mechanisms of behavior change in alcoholics anonymous: does Alcoholics Anonymous lead to better alcohol use outcomes by reducing depression symptoms? and Gender Differences in a Controlled Pilot Study of Psychosocial Treatments in Substance Dependent Patients with Post-Traumatic Stress Disorder.

What are the specific objectives of TSF-COD?

Treatment and recovery for co-occurring disorders can be understood as a process of change in three key dimensions of a person’s life: social/behavioural, cognitive and spiritual – people can make changes at different rates in each dimension. These major goals can be broken down into specific objectives, as follows.

Social objectives:

  • Participants recognise any link between their co-occurring disorders and how their current social network – friends, family, significant others – supports continuation of both disorders
  • Participants understand how research proves that fellowship participation (attending meetings, getting a sponsor early) provides an alternative social network which supports recovery from co-occurring disorders
  • Participants come to believe how essential building a supportive social network is
  • Participants come to believe they will need to either replace their enablers with supporters or encourage them to change
  • Participants seek the social support they need including professional appointments if needed with, say, a psychiatrist, counsellor, case manager.

Behavioural objectives:

  • Participants appreciate how they altered their lifestyle over time to accommodate their co-occurring disorders, sacrificing other activities
  • Participants learn how to pursue alternative habits and routines for a more resilient recovery
  • Participants commit to take medications as prescribed and to work with their psychiatrist
    to address any uncomfortable side effects
  • Participants learn how to create a balanced lifestyle that supports healthy recovery.

Relationship objectives:

  • Participants understand how a substance-use disorder constitutes a “relationship” that has taken precedence over relationships with people including family, friends and significant others
  • Participants recognise that they might have encouraged significant others to enable their drug or alcohol use – eg, by helping to obtain them or by minimising negative consequences
  • Participants recognise how their mental health disorder impacted their relationships with others, and are encouraged to address those issues to strengthen healthy relationships
  • Participants learn not to feel ashamed to talk about their mental health disorder with support people in their lives.

Cognitive objectives:

  • Participants understand ways in which their thinking has been affected by their co-occurring disorders. For example, drinking and using often lead to rationalising and lying, as much to oneself as others. This includes denying the reality of negative consequences – medical, physical, social, legal, psychological, financial – so they can continue to drink or use drugs
  • Participants recognise their thinking errors and how to challenge them. This extends to more optimistic thinking for people with depression.

Emotional objectives:

  • Participants understand how some emotional states – like anger, resentment, loneliness, shame – can lead to an urge to use alcohol or other drugs or can ‘set off’ a mental health relapse
  • Participants develop strategies for alternative ways of coping with these emotional states.

Spiritual objectives:

  • Participants experience hope that they can halt their co-occurring disorders
  • Participants develop a belief and trust in some power greater than their own willpower – eg, a fellowship of peers or a psychiatrist
  • Participants believe in the power of honesty, connection to others and altruism as alternatives to isolation and alienation
  • Participants build on the spiritual dimension of recovery, such as meditation or prayer, communing with art or nature, committing to community service, reading recovery materials.

People with dual disorders can become double winners – research shows how you can help.

Joseph Nowinski PhD is an internationally recognised clinical psychologist and author and is assistant professor at the Hazelden Betty Ford Graduate School of Addiction Studies, where he teaches Advanced Twelve Step Facilitation.
His books include The Twelve Step Facilitation Handbook: A guide to recovery from substance abuse and co-occurring disorders
If You Work it, It Works: the science behind 12 step recovery
Hard To Love: Understanding and overcoming male borderline personality disorder
Almost Alcoholic: Is my (or my loved one’s) drinking a problem?

Joseph Nowinski was assistant professor of psychiatry at the University of California San Francisco School of Medicine, and associate adjunct professor of psychology at the University of Connecticut.  For further information visit http://www.josephnowinski.com.