This document outlines a presentation on applying 12-step facilitation approaches in clinical settings. It discusses key principles like increasing AA/NA attendance, obtaining a sponsor, and developing spirituality and social support. Two models are described: inpatient treatment lasting 14-28 days and intensive outpatient programs. The 12-step facilitation approach emphasizes accepting addiction, surrendering to a higher power, and getting active in 12-step groups. Elective topics like family dynamics and triggers are also addressed. Evidence-based treatment programs in Puerto Rico would incorporate these levels and principles of care.

1. Applying Research In Clinical
Settings: The 12 Step Facilitation
Approach: Two models of
Addictions Treatment: Inpatient
and Intensive Outpatient (IOP)
Radka Toscova PhD
03/20/13 1
March 15, 2013

2. Organization of Presentation
 Applying Research Findings to clinical
Settings
 Twelve Step Facilitation Group (TSF)
 Evidence-Based Substance Abuse
Treatment Program
– Outpatient
– Intensive Outpatient
– Inpatient
03/20/13 2

3. Applying Research Findings in
Clinical Programs: Four Guiding
Principles/ Objectives
 AA/NA Attendance
 Having a Sponsor
 Increased Spiritual Practices
 Social Support (For Not Drinking):
– From AA/NA
– Family
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4. Attending Meetings
 Attend AA/NA 4-5 / week minimum before
treatment ends results in continued
engagement in AA/NA highest abstinence
rates.
 Treatment Programs should prioritize
AA/NA and encourage a high rate of
Attendance, Prior to the End of treatment,
i.e. before Patients are discharged.
03/20/13 4

5. Having a Sponsor
 Drug/Alcohol Treatment Should help
Patients Learn how to Seek and Obtain a
SPONSOR.
 What is the role of the SPONSOR?
Valid Expectations vs. Fantasies.
 Didactic practice/ rehearsal in treatment
group, feedback from group members
 Practice in AA/NA
 Follow-up in group,
 Keep Going (persist in the search for
SPONSOR)
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6. Increasing Spirituality…
 Prayer
 Meditation /Mindfulness
 Therapist Assigned Reading
Homework: The Big Book, How it
works, One Day at a Time, Slogans,
Daily Meditative Guides.
 Therapist Led Group Discussion of
Readings.
03/20/13 6

7. Increasing Spirituality
 Cognitive Changes (Restructuring)
– Occur as a Result of the Spiritual Practices
 The concept of Delayed Discounting
– The Addictive Bran: A bird in The Hand is Worth Two
in the Bush!
– Thus, One Day at a Time, Concept
– Treatment is Oriented to Here and Now and Short
term Goals.
 EmotionalChanges: People Instructed to
Engage in Wide Variety of Spiritual Practices to
Cope with Negative Emotional States/Traits
03/20/13 7

8. Social Support
 NA/AA Provides Support and an
Environment For Not Using drugs Or
Drinking.
 Family Support that Encourages
Abstinence from Drugs and Alcohol.
 Thus the Need to Include the Family in
Treatment, and Reinforce Abstinence and
Any issues which may Undermine
treatment goals (Not Enabling, Detaching)
03/20/13 8

9. Other Research Findings: The
Community Reinforcement Approach
(Cession & Azrin
 Marital/Family Therapy
 Job Club
 Improving / Developing
Communication Skill
 Social/Recreational Skills
 Other Behavioral Skills/Life Skills
 Relapse Prevention
03/20/13 9

10. Cognitive Behavioral Skills Therapy
One of The Match Treatment
Comparison Models
 Similar Outcome as TSF, but lacked
the longevity and Abstinence
Associated with TSF.
 Skills Based approach
 Role play/skill rehearsal
 Communications Skills
03/20/13 10

11. Motivational Enhancement Therapy
(MET) Third MATCH Treatment Type
 Based on Stages of Change Model
(Prochaska and DiClemente Wheel of
Change)
Action
Determination
Lapse/Relapse
Contemplation
Precontemplation
Try Again
03/20/13 11

12. The 12 Step Facilitation Model
 Originally Conducted Individually, in the
MATCH study, for research comparison
with the other treatment modalities.
 Manual Driven
 In Clinical Setting, Group Therapy.
– The Group acts as Support and Gives Reality
Based Feedback about Aspects of their Actions
which they do not see.
– Cost Effective
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13. Distinctions:
 12 Step Facilitation Model TSF: One of the
Three Comparison Treatment Groups In Project
MATCH. (CBT Skills an MET)
 12 Step Treatment “The Minnesota Model”
(OLD), Based on AA Principles
 12 Stop Treatment “ The Evidence Based
Minnesota Model” (NEW) and other major
Treatment Programs.
 “Detox” (medical Stabilization )
 “Treatment” Primarily Behavioral Early
– Recovery, Engage in NA/AA
 “Therapy” Later Recovery
03/20/13 13

14. 12 Step Facilitation Overview
Objectives of Treatment
To help Addicts/Alcoholics learn About NA/AA,
their view of being Drug Free/Sober,
attend Meetings and engage in Mutual Help
programs, by attending a minimum of 4-5
meetings/ week before the end of Treatment.
To address Acceptance and Surrender, i.e the
First three Steps of NA/AA
Role of Therapist, preferably a Member of
NA/AA is to Educate, Advise, and Support;
To be a resource person about NA/AA
03/20/13 14

15. 12 Step Facilitation Overview
Responsibilities of the Patients
NA/AA: “The Only requirement for membership
is the desire to stop drinking/using drugs.”
1. To Attend all sessions
2. Come to meetings sober
3. Keep a Journal
4. Be Honest even if he/she has slips
5. Be willing to share and give feedback
6. Be willing to attend NA/AA meetings
03/20/13 15

16. 12 Step Facilitation Model
 Core Program
– Assessment
– Acceptance
– Surrender
– Getting Active in NA/AA
 Elective Components
– Genograms
– Enabling
– People places, Routines
– Emotions (hungry, angry, lonely, tired)
– Moral inventories (step 4 and 5)
– Relationships /Living Sober
Conjoint Program : Enabling, Detaching
03/20/13 16

17. 03/20/13 17

18. Assessment and Feedback
 Introduction
 Administer the Alcoholics Anonymous
Affiliation Scale (AAAS)
 Complete The Substance Abuse History
 Review the Consequences of Substance
Abuse
 Assess Tolerance and Loss of Control
 Diagnosis
 Program Overview
 Recovery Tasks
03/20/13 18

19. 03/20/13 19

20. Topic 2: Acceptance
 Readings from the 12 Step
Facilitation Handbook are Discussed
 Step One
– I Have a Problem with Drugs/Alcohol
– Drugs/Alcohol have been my life more
and more UNMANAGEABLE
– My inability to manage my use
Drugs/Alcohol means that I have
become POWERLESS over them.
03/20/13 20

21. Acceptance
 Motivation Assessed on a scale of 1 being least
motivated 10 being most motivated
– Location or contact name/phone
 Discuss DENIAL as a normal human reaction to
loss of control over substance use, like a step in
the normal GIEF process.
– REFUSING to face facts (not talking or thinking)
– MINIMIZING the problems (highlighting the good times)
– EXAGGERATING others’ problems to see self as mild
– BARGAINING (trying to control substance use)
ACCEPTANCE : The end of the grief process
Recovery Tasks: Discuss which SPECIFIC MEETINGS
each group member will commit to attend. NEW
READINGS, JOURNAL about reactions to
meetings/readings, meeting new people.
03/20/13 21

22. Topic 3: SURRENDER
 Introduction to 12 Step Groups
– View DVD
– Review material and willingness to Attend NA/AA Scale of 1 – 10.
– Discuss any fears and concerns which may interfere with
willingness to Attend NA/AA
– Discussion about the different kinds of meetings e.g. speaker…
 Discuss readings about the Surrender Chapter in the 12 Step
Facilitation Handbook.
– Read and discuss Step Two and Three ; Willpower not enough.
– Discuss the concept of Higher Power, leap of Faith.
– Who does the individual trust, who has been helpful in the past
– On a scale of 1-10, how willing is the individual to turn to OTHERS,
for help with his/her drug /alcohol Problems. Asking for help in
NA/AA
 Discuss which meetings the Individual will commit to attend
– Plan /Discuss readings and the use of the journal e.g. Read Bill’s
Story. Always review if any slips occurred.
03/20/13 22

23. Topic 4: Getting Active in NA/AA
 Review:
– Journal re: meetings attended, meeting people
– Number of Sober days; SOBER ONE DAY AT A TIME
– Urges to drink (When, Where, What did the patient do?
How was it handled? How can he/she use NA/AA to deal
with future urges?
– Review slips, when, where, with whom?
– AA Concept of People, Places, Things
– EASY DOES IT
– FIRST THINGS FIRST
 Getting active: Access help from NA/AA members
 Use the Telephone.
 Getting a Sponsor, Temporary Sponsor
 Readings: Living Sober, The “Big Book”
03/20/13 23

24. Elective Topics
 Elective Components
– Genograms
– Enabling
– People places, things/ Routines
– Emotions (hungry, angry, lonely, tired)
– Moral inventories (step 4 and 5)
– Relationships
– Living Sober
Conjoint Program : Enabling, Detaching
03/20/13 24

25. Genogram: Addiction is a Disease
Betty 64 Bob 65
36 42 44
Steve
Drugs
03/20/13
14 16 18 25

26. Primary Focus of the Facilitation
Program
 Going to AA Meeting
 Getting Active in AA
 Getting and Using a Sponsor
 Therapist Provides Ongoing
Troubleshooting
03/20/13 26

27. Evidence-Based Substance Abuse
Treatment Model in Puerto Rico
03/20/13 27

28. Evidence Based Treatment Program
in Puerto Rico: Proposed Model
Levels of Care:
 Inpatient 28 days (multimodal)
 Inpatient 21 days (multimodal)
 Inpatient 14 days (multimodal)
 Inpatient 7 days (multimodal)
 Intensive Outpatient 3-4 hours/daily 12-14 weeks
(Group format with individual therapy as indicated)
– Day Program
– Evening program
 Outpatient 12-14 weeks (Group utilizes The 12 Step
Facilitation Model, Individual Therapy as Indicated
03/20/13 28

29. Levels Of Care
 LENGTH of treatment is a better predictor
of positive outcome than INTENSITY.
 Treatment can be SEQUENCED, from More
Intensive early on in treatment, to less
intensive as the patient stabilizes.
 They can go from INPATIENT to IOP,
followed by OUTPATIENT TREATMENT, as
indicated based on Clinical Criteria of
Severity and Risk Factors
 Engagement in NA/AA is stable .
03/20/13 29

30. Initial Levels of Care Determination
 Initial
Triage/Assessment Evaluates
Severity and Risk Factors:
– Problem Severity/ Drug of Choice
– Relapse Proneness/History of Relapse
– Treatment History
– Social Support for Abstinence
– Impulsivity
– Safety Issues/ violence potential
– Other Mental Health/Health Issues
03/20/13 30

31. Flow of Patients
Levels of Care: Triage/Evaluation
Inpatient 28 IOP Day
12-14 NA/
Inpatient 21 weeks Outpatient AA
Treatment Other
TSF Group Community
IOP
Inpatient 14 Resources
Evening
12-14
Inpatient 7 weeks
03/20/13 31

32. Treatment Components of IOP 12
Weeks/3 days/week 4 Hrs/day
 12 Step Facilitation Group (TSF) (12 weeks)
 Interpersonal Skills: Coping with Triggers
and Pressures to Use Drugs/Drink (6
weeks)
 SelfRegulation Skills: Coping with Negative
Mood States (emphasis on Hungry, Angry,
Lonely, Tired, Resentful, Jealous (6 weeks).
 Skill Based Groups 6 weeks: Anger
Management, Communication/
Assertiveness skills, Job Club, Family
Education/Therapy, Individual Therapy, as
03/20/13 32
Indicated/Requested, Stress Management.

33. IOP Day/ Evening Program 3 days/wk
TSF Group (12 weeks ) 1 hr /day/2 days/week
Anger Communication
Interpersonal Skills: Coping with Management
1 hr/1/week/6 weeks
Pressures to Use: 6 weeks 1hr 6weeks
1hr/day Recreation/ Family
Hobbies: Therapy
Job Club 1 hr/1/week
Self- Regulation Skills: 6 weeks/2hrs/
1 hr/
Negative Mood States /6 weeks 1/week
6 weeks
6 weeks 1hr/day
Relapse
Prevention
Stress Management/Mindfulness/Meditation Exercise
03/20/13 33

34. IOP (Continued)
The Proposed IOP will be on Monday, Wednesday and
Thursday, of each week, for 12 weeks, 4 hours/day,
including 2/ 15 minute breaks per day.
 Relapse prevention group will be offered during the
second half of treatment.
 Family Therapy/Conjoint/ Marital therapy will be offered
during the second ½ of the IOP program, after
patients are more stable.
 2 hours will be allocated for the Family component,
the first 45 minutes will be didactic/educational, based
on a topic, after which there can be a break up into
about 4 smaller groups, depending on the number of
counselors allocated.
 Offer a 6 week Smoking Cessation Module.
03/20/13 34

35. IOP Continued
 Priorto Starting IOP, Patients will need to
agree, to Attend Clean and Sober.
 If
they appear to be high or intoxicated, they
may be drug tested. If they are high, they
would have made arrangements to get a ride
home, due to safety Issues.
 They will be encouraged to return on the next
treatment day, prepared to discuss the slip.
Therapist will not guilt or shame the patient.
03/20/13 35

36. IOP Continued
 The only requirement to be a member of
NA/AA is The Desire to Stop Using/
Drinking.
 However, IOP requires members to attend
clean and sober because the program is 4
hours long and patients need to be clear
headed and oriented to the demands of
discussion and other treatment activities.
03/20/13 36

37. Inpatient Program
 Initial
Triage/Assessment Evaluates
Severity and Risk Factors; Assigns
to 28 day, 21 day, 14 day or 7 day:
– Problem Severity/ Drug of Choice
– Relapse Proneness/History of Relapse
– Treatment History
– Social Support for Abstinence
– Impulsivity
– Safety Issues/ violence potential
– Other Mental Health/Health Issues
– HIV, Hepatitis
03/20/13 37

38. Inpatient Program (Continuation)
Daily Schedule
6:30-7:00 am Wake Up
7:00 am Breakfast
– Therapeutic Duty Assignment
– 8:00 Morning Meditation
 8:15 Morning Lecture
 9:00 Group Discussion of Lecture
 10: 00 Break
 10:30 Small Group Coping Skills
 11:30 Walking Meditation/ Mindfulness
 12:00 Lunch
03/20/13 38

39. Inpatient Schedule
 1:00 pm group
– Monday and Wednesday: Managing Negative
Emotions:
– Self Regulation
 2:00 Break/ Work on Assignments
– Arts Crafts, Orchid Greenhouse
– 2:45 Light Snack
 3:00 Lead meditation/ Mindfulness
 3:30 Fitness/ Exercise
 4:30 Free Time
 5:00 Group: Coping Skills:
03/20/13 39

40.  6:30 Dinner
 7:30 Newcomer Meeting
 8:00 12 Step meeting (community
member led)
 9:00 Guided Social hour Monday
(games, tea, music. reading )
 10:00 Free Time … Sleep
03/20/13 40