Foundation of Addiction Medicine 2019

651 CASE FORMULATION

The case formulation helps to answer:
1. Why did the client start using drugs?
2. How did using drugs lead to abuse and dependency?
3. Why has the client not been able to stop on his/her own?
4. How did key beliefs develop?
5. How did the client function prior to using drugs?
6. What interpretations can we make about high-risk
circumstances related to using drugs?

652 COGNITIVE TECHNIQUES

1. Addressing ambivalence and enhancing motivation
• An exploration of the client’s ambivalence and motivation
• Addressed as necessary throughout the treatment
• Aims to work with the client’s perception of substance use rather

than imposing the therapist’s external view of reality
• The aim is to lead clients to the point where they propose goals

to change their substance use by developing discrepancy

653 SOCRATIC QUESTIONING:

• Through the Socratic method, clients are guided through a
process of discovering their distorted patterns of thinking and
behavior

• Promotes insight and rational decision-making by making the
client aware of important information

• This process shapes thinking through active questioning and
selective reflecting

654 EXAMPLE

• Client: It makes me feel sad when I think I’ll never get better.
• Therapist: Of course you’ll get better, all the evidence tells us so.
A more productive approach:
• T: How would you feel if you thought you would get better?
• C: I’d feel happier.
• T: What is it that makes you think you’ll never get better, why do you think

that?
Then go on to examine the evidence and follow this up with linking the thought

about not getting better with the sad emotion, and how the emotion will
change depending on the type and nature of the thoughts the client has

65 DISTRACTION

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Used to help clients to refocus their attention
• Internal (emotional states, automatic thoughts, craving)
• External drug-related stimuli
Distraction can be either
• Cognitive (changing the focus of attention)
• Behavioral (engaging in physical activity, housework, gardening)

656 ADVANTAGE-DISADVANTAGE
ANALYSIS

• Maintain beliefs that minimize the disadvantages and maximize the
advantages of using substance

• In the A-D analysis, the patient is guided through the process of
listing and re-evaluating the advantages and disadvantages of drug
use

657 IDENTIFYING AND MODIFYING
DRUG-RELATED BELIEFS

• Clients who abuse substances are likely to have drug-related
belies such as: “Smoking relaxes me”

• Clients are typically not attentive to their drug-related beliefs,
often viewing their drug use as a function of extrinsic factors

• In cognitive therapy, the drug user is taught about these beliefs as
they apply to his or her drug-use patterns

658 BEHAVIORAL TECHNIQUES

Activity Monitoring and Scheduling
• Useful basic strategies for understanding and modifying

drug-related behaviors and for increasing productive behaviors
• For a period of 1 week the client records daily activities and the

degree to which he or she felt a sense of pleasure or mastery
from participating in each activity
• Pleasure and mastery, recorded on a scale from zero (none) to
ten (extreme), provide an indication of the client’s mood and the
level of reward or satisfaction derived from each activity

659 BEHAVIORAL EXPERIMENTS

• Used to test the validity of clients’ drug-related beliefs and core
beliefs

• E.g., consider the client who believes “I would lose all my friends
if I didn’t smoke pot”

A behavioral experiment might involve having this client participate
in “usual activities” with friends, without using marijuana (The client
would be encouraged to fully participate in all non-drug related
activities)
• Subsequently, this will be discussed in the sessions with the

therapist irrespective of the result

660 BEHAVIORAL REHEARSAL (ROLE PLAY
AND REVERSE ROLE PLAY)

• People with substance abuse problems have concurrent problems
with interpersonal communication (e.g., assertiveness, active
listening)

• Therapist may initiate role-playing to teach the client effective
interpersonal skills

• Repeated role playing helps clients develop new, mature, effective
repertoires of social behavior in a safe environment where errors
can be corrected without actual consequences

661 RELAPSE PREVENTION

• Substance abuse and dependence are characterized by both
remission and relapse

• Most people who quit using drugs have a lapse or a relapse most
likely within 90 days of the initiation of abstinence (Mackay,
Donovan, & Marlatt, 1991)

• A lapse, or a “slip”, is defined as the initial use of a substance after
an individual has made a commitment to abstain from that
substance

• A relapse, on the other hand, is a full return to the maladaptive
behaviors originally associated with use of the substance

662 RELAPSE PREVENTION

Focus on the maintenance stage of addictive behavior change has
two main goals:
• To prevent the occurrence of initial lapses after a commitment to

change has been made
• This initial use might result in an Abstinence Violation Effect

(AVE; i.e., perceived loss of control) and an ultimately increased
probability of relapse
• To prevent any lapse that does occur from escalating into a
full-blown relapse (Witkiewitz et al., Relapse prevention for
alcohol and drug problems, 2004)

663 THE ABSTINENCE VIOLATION EFFECT

• To reframe their perception of lapses-to view them not as
failures-but as mistakes-need for increased planning to cope more
effectively in similar situations in the future

• Reframing: “I used alcohol last night, but I had been sober for 30
days before. So in the past 31 days, I have been sober for 30.
That’s better than I have done for 10 years.”

664 LIFESTYLE CHANGES

• Learn more effective coping skills (Meditation, anger
management, and positive self-talk)

• Relaxation training, stress-management, and time management
• Balanced Lifestyle
• Pursue again pleasurable activities replaced by drinking
• Develop “positive addictions”, e.g., meditation, exercise, or yoga

665

THANK YOU

12 STEP FACILITATION (TSF)

Ms. Karishma Khan
Psychiatric Social Worker

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Educational Objectives:

▷ Understanding origin of 12 step
Facilitation

▷ Knowing more about the Program of
Recovery (the 12 Steps) and the Twelve
traditions

▷ How to start a new AA group, types of
meetings and procedure

▷ Effectiveness

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Introduction

Twelve-step facilitation therapy is an active
engagement strategy designed to increase the
likelihood of a substance abuser becoming affiliated
with and actively involved in 12-step self-help
groups, thereby promoting abstinence.

(Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition); 12-Step
Facilitation Therapy, NIDA)

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Cont...

● Set of guiding principles- for recovery from Addiction,
Compulsion or other Behavioural problems.

● Originally proposed by Alcoholics Anonymous
(Alcoholics Anonymous: The Story of How More Than
One Hundred Men Have Recovered from Alcoholism,
1939).

● The method was adopted and became the foundation
of other twelve step programmes

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The process involves the following:
● Admitting that one cannot control one's alcoholism,

addiction or compulsion;
● Recognizing a higher power that can give strength;
● Examining past errors with the help of a sponsor

(experienced member);
● Making amends for these errors;
● Learning to live a new life with a new code of behavior;
● Helping others who suffer from the same alcoholism,

addictions or compulsions

( American Psychological Association)

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Three key ideas predominate

(1) Acceptance
(2) Surrender
(3) Active involvement in 12-step meetings
and related activities.

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HISTORY

• A.A. had its beginnings in Historic Home of AA cofounder
1935 at Akron, Ohio, as the Bill Wilson
outcome of a meeting
between Bill W., a New York
stockbroker, and Dr. Bob S., a
surgeon.

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History- Bill and Bob’s meeting

• Met during a business trip in Akron,
Ohio.

• Dr.Bob was so impressed with Bill’s
knowledge of alcoholism and ability
to share from his own experience

• Discussion lasted for six hours

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• William Griffith Wilson (November 26,
1895 to January 24, 1971)

• Ruined Promising Career, Failed to graduate
in law, Damaged his marriage, Hospitalized
for Alcoholism at Town’s Hospital four times

• Robert Holbrook Smith(August 8, 1879 –
November 16, 1950)

• Almost failed to graduate from medical
school because of Alcohol,

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History

1930’s : Oxford Group - Dr.Franklin ➢ Miracles are again possible

Nathaniel ➢ The change must change others

Philosophy : ➢ FOUR ABSOLUTES
➢ All people are sinners

➢ Sinners can be changed • Absolute-Honesty,
➢ Confession is a prerequisite for • Absolute-Purity
• Absolute-Unselfishness,
change

➢ The change can access God • Absolute-Love

directly

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1939- BIG BOOK

• The first edition released in 1939
• Six steps initially – later divided into 12 steps
• Latest Version – Fourth edition -2001
• Consists of 11 chapters
• Personal Stories- Part 1,

Part 2 and Part 3

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Over 80 years of Growth

1935 : Joining the fold 1964- Beginning in Sri Lanka

1942 : AA Prison Groups 1975- AA’s first public information film
AA: An Inside View

1947: First Official Group in England 1995: Planted seed in China

1950: First International Convention in 2000: 11th International Convention in
Cleveland (3,000 people attended ) Minnesota, 47,000 people celebrated freedom
Adoption of Twelve Traditions from Bondage. Theme: Pass It On-Into the 21st
Century
1952: Arrival of Al-Anon Group 2009: Co-Founders Bill and Bob were honored
by Points of light Institute , Washington D.C
1955: Three legacies of AA – Recovery, for pioneering a volunteer movement
Unity, Service
2010: 75th year Anniversary, Theme: Vision for
You

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AA in India

• Harold.M, School Teacher- The first person in India to
stop drinking through spiritual principles of AA

• 5th May 1957- Founder’s day in India
• 1967- Formation of the Intergroup
• 1986- General Service Office in Mumbai
• 1991- Charters, Bye laws
• Books printed in Regional Languages (9)

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Twelve Step Facilitation Approach

• Concept: Alcoholism – 679
Spiritual and Medical
Disease

• Active Participation in
meetings for sustained
sobriety

• Not a method of
treatment- but a
FELLOWSHIP

• Commonality –
Addiction

• Criteria to Join: Desire
to Quit

12 steps –Program of Recovery

★ We admitted that we were powerless over Alcohol- that
our lives had become unmanageable

★ Came to believe that a Power greater than ourselves could
restore us to sanity

★ Made a decision to turn our will and our lives over to the
care of God as we understood him

★ Made a searching and fearless moral inventory of ourselves

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Cont...

★ Admitted to God, to ourselves, and to another human being
the exact nature of our wrongs

★ Were entirely ready to have God remove all these defects
of character

★ Humbly asked him to remove our shortcomings
★ Made a list of all persons we had harmed , and became

willing to make amends to them all

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Cont...

★ Made a direct amends to such people wherever possible,
except when to do so would injure them or others.

★ Continued to take personal inventory and when we are
wrong promptly admitted to it

★ Sought through prayer and meditation to improve our
conscious contact with God as we understood him, praying
only for knowledge of His will for us and the power to carry
that out

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Cont...

★ Having had a spiritual awakening as the result of these
steps, we tried to carry this message to alcoholics, and to
practice these principles in all our affairs.

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The man takes a drink; Slogans The 7t's ---take
the drink takes a time to think the
One day at a
drink; the drink takes time! thing through
the man

This too shall Sobriety is a journey ..........
pass! not a destination

But for the Grace of God!

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Starting a New AA Group

• 2-3 people can start a group
• Can inform to the neighboring groups / local

intergroup central office (district or area
committee)
• General Service Office – New group form-
Complimentary handbook & Small supply of
literature

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Twelve Steps/AA Group

• Any two or three people with substance use who

wants to achieve sobriety can call themselves as A.A

No Penalty for not conforming to the No fees/ dues to be levied
principles of AA

Attending AA is a choice , no members Internal affairs of each group can be

can be expelled conducted as they wish

Group gathered for the purpose of There is no formal application required
quitting substance can be AA provided to join in AA
they do not have purpose otherwise

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Types of Meetings

• Open Meetings
• Closed Meetings
• Discussion meetings
• Big book study meetings
• Step study meetings
• Speaker meetings

No two AA meetings are alike

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Suggested AA meeting procedure

• Opens the meeting with AA preamble and introduction “My name is___________and
I am an alcoholic and your Secretary.”

• Serenity Prayer
• Reading from the Big book
• If custom of the group- Introducing new members of the group
• Introducing the chairperson or secretary
• Regular announcements
• Passing the basket
• Close the meeting with Lord’s prayer or any other prayer decided by group/ moments

of silence

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Effectiveness

• Emerged from Divine Inspiration and Personal Experience
• AA Proponents say “ Rarely have we seen a person fail who has

thoroughly followed our path”- Bill W, 1939
• Carl Jung was convinced about the role of spirituality in Addiction

Recovery
• Various studies have proved that the 12 step program was efficacious

in helping people to maintain abstinence. Humphreys, K., & Moos, R.
H. (2007), Widbrodt et.al., (2014). Chi, F. W, et.al., (2013).

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Effectiveness

• Dr. Patrick Carnes , a world known therapist in treating sexual
addiction in his book “A Gentle Path through the Twelve
Steps”- “The Twelve Steps have been so useful and
translatable because they tap into the essential human process
of change and make that process more explicit, more
understandable, and more sustainable”

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Effectiveness

• A randomized , Placebo controlled , double blinded study with
people of cocaine dependence found patients who are assigned
to 12 step programme had 20% higher abstinent rates than
those assigned to treatment as usual- regardless of whether
they are simultaneously given medication to reduce cocaine
use or simply a placebo (Carroll et. al., 2012)

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Effectiveness- Project MATCH

• One of the largest and widely quoted studies to support
“AA Works” philosophy in 1998

• It compared three kinds of treatment – each delivered in
out-patient through individual therapy

• 806 clients- five outpatient treatment centers -randomly
assigned.

• Researchers also interviewed and assessed clients to rate
them on relevant attributes

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Effectiveness- Project MATCH

• 30 %of these clients were abstinent three years after treatment
• Those who drank during those three years abstained, on

average, two-thirds of the time.
• Most powerful predictors of long-term drinking outcome:

readiness-to-change and self-efficacy (clients' confidence in
their ability to abstain).
• Twelve Step Facilitation offered a statistically significant
advantage when total abstinence was the desired outcome

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Conclusion

While the efficacy of 12-step programs (and 12-step
facilitation) in treating alcohol dependence has
been established, the research on its usefulness for
other forms of substance abuse is more preliminary,
but the treatment appears promising for helping
drug abusers sustain recovery.

(Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition), NIDA)

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Alcoholics Anonymous India

http://www.aagsoindia.org/

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THANK YOU

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References

• Alcoholics Anonymous World Services (1984). Pass it on: The story of Bill Wilson and how
the A.A. message reached the world. New York, NY: Alcoholics Anonymous World Services,
Inc.

• Carnes, P. (2012). A gentle path through the Twelve Steps. Center City, MN: Hazelden.
• Chi, F. W., Sterling, S., Campbell, C. I., &Weisner, C. (2013). 12-Step participation and

outcomes over 7 years among adolescent substance use patients with and without psychiatric
comorbidity. Substance Abuse, 34, 33-42.
• Carroll, K. M., Nich, C., Shi, J. M., Eagan, D., & Ball, S. A. (2012). Efficacy of disulfiram and
Twelve-Step Facilitation in cocaine-dependent individuals maintained on methadone: A
randomized placebo-controlled trial. Drug and Alcohol Dependence, 126, 224-231.
• Humphreys, K., & Moos, R. H. (2007). Encouraging posttreatment self-help group
involvement to reduce demand for continuing care services: Two-year clinical and utilization
outcomes. Alcoholism: Clinical and Experimental Research, 31, 64-68.

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References

• Jung, C. G., Adler, G., & Hull, R. F. C. (eds.) (1977). Collected works of C.
G. Jung, Volume 18: The symbolic life: Miscellaneous writings. Princeton,
NJ: Princeton University Press.

• Project MATCH Research Group (1998). Matching alcoholism treatment to
client heterogeneity: Project MATCH three-year drinking outcomes.
Alcoholism: Clinical and Experimental Research, 22, 6, 1300-1311.

• Smith, B., & Wilson, B. (1939). The Big Book of Alcoholics Anonymous.
New York, NY: Alcoholics Anonymous World Services, Inc.

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