888 PDF
888 PDF
888 PDF
0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
STAGE-12
Stimulant Abuser Groups to
Engage in 12-Step Programs
1
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Table of Contents
2
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
22.0 STAGE-12 GROUP TOPIC #2: PEOPLE, PLACES, & THINGS ......................... 72
3
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
1.0 INTRODUCTION
4
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
5
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
1.4 Forward
This manual reflects and extends prior work at the Yale University Psychotherapy
Development Center to understand and improve drug abuse treatment by
specifying and evaluating innovative psychotherapies. Twelve Step Facilitation
(TSF) treatment manuals for alcoholism (NIAAA, 1995) and drug dependence
(Baker, 1998), serve as the primary basis of the present manual. These TSF
manuals reflect the work of numerous individuals who have contributed to the
series of clinical trials conducted at the Yale Substance Abuse Treatment Unit
that have evaluated TSF in comparison to other treatments. These include
Stuart Baker, Art Woodard, Dr. Joseph Nowinski, and Dr. Kathleen Carroll, who,
as counselors, supervisors, trainers, and authors, have fostered this exciting and
promising treatment approach.
1.5 Research Support
Although approaches similar to the treatment described here are in wide use in
the clinical community, there was, until recently, very little empirical evidence
supporting their use (Holder et al., 1991; Miller et al., 1995). This occurred,
primarily, because this type of approach had not been described in a form (i.e., a
detailed treatment manual) necessary for evaluation in controlled clinical trials.
This, and previous TSF manuals, is thus an important contribution to both the
treatment and research communities. Now that this approach has been
manualized and we can train counselors to use it consistently, a number of
important studies have been completed that suggest this manualized TSF
approach is very effective:
First, in the NIAAA-supported Project MATCH (Project MATCH Research Group,
1993, 1997), the largest alcohol treatment trial ever done, involving over 1700
alcohol dependent individuals in 9 clinical research units across the United
States, TSF was associated with excellent retention and very good drinking
outcomes. Moreover, TSF was found to be comparable in effectiveness to
Cognitive-Behavioral Therapy (CBT) and Motivational Enhancement Therapy
(MET) two forms of treatment with strong records of empirical support (Project
MATCH Research Group, 1997). Furthermore, in the few instances where there
were differences in outcome on some variables (such as in rates of complete
abstinence and negative consequences of drinking), these tended to favor the
Twelve Step Facilitation approach over CBT and MET (Project MATCH Research
Group, 1997). Although Project MATCH was designed to detect patient-
treatment interactions (matching effects), only two significant matching effect was
seen, both of which also favored TSF. First, in the outpatient arm of the study,
patients low in psychiatric severity (as measured by the Addiction Severity Index)
had more abstinent days after TSF treatment than CBT; neither treatment was
6
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
clearly superior for patients higher in psychiatric severity. Second, at the 3 year
follow-up TSF was more effective than MET for outpatient clients with social
networks that were supportive of drinking (Longabaugh, Wirtz, Zweben, & Stout,
1998). This latter finding was mediated in part by AA involvement. Clients with
networks supportive of drinking assigned to TSF were more likely to be involved
in AA, and AA involvement was associated with better 3-year drinking outcomes
for such clients.
Second, TSF has also been used in a trial of psychotherapy and medication for
cocaine-dependent patients who also abuse alcohol (Carroll et al., 1998). This
twelve-week randomized clinical trial of disulfiram and three forms of manual-
guided psychotherapy (TSF, CBT, and Clinical Management) indicated the
following: The two active psychotherapies, Cognitive-Behavioral Coping Skills
Therapy and Twelve-Step Facilitation, were more effective than Clinical
Management, a psychotherapy control condition, in fostering longer periods of
consecutive abstinence from cocaine, abstinence from both cocaine and alcohol
simultaneously, as well as a higher percentage of cocaine-free urine specimens.
Moreover, the benefits of TSF and CBT compared with the minimal treatment
were sustained through a one-year follow-up (Carroll, et al., 2000).
To date the Twelve Step Facilitation therapy that has been evaluated has been
delivered as individual counseling. However, the modal method treatment
delivery is group therapy. A group-based adaptation of TSF has been developed
and evaluated (Brown, et al., 2002a, 2002b). It was found that clients who
received the group-delivered TSF as aftercare had substance use outcomes
comparable to those of clients who had received a group-delivered relapse
prevention (RP) aftercare intervention. Further, a number of client-treatment
matches were found. Females and individuals with a multiple substance abuse
profile had better alcohol outcomes with TSF aftercare than with RP aftercare.
Individuals with high psychological distress at treatment entry had longer periods
of post-treatment abstinence with TSF aftercare than with RP aftercare.
The therapeutic approach underlying this manual is grounded in the principles
and twelve steps of Narcotics Anonymous (NA), Cocaine Anonymous (CA),
Crystal Meth Anonymous (CMA), and Alcoholics Anonymous (AA). It is important
to note, however, that this manual has no official relationship with, or sanction
from, any 12-Step program. The fellowships of NA, CA, CMA and AA are
described in official 12-Step program literature and are realized through their
worldwide meetings. NA, CA, CMA and AA do not sponsor or conduct research
into drug dependence or its treatment or endorse any treatment program. While
intended to be consistent with 12-Step principles, this treatment program is
designed for delivery in research protocols and in clinical settings by trained and
supervised counselors. Its goals are to educate patients regarding the NA, CA,
CMA and AA view of drug dependence and to facilitate their active participation
in NA, CA, CMA or AA.
7
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
1.6 Cautions
This manual, like any other, should not be used without appropriate training and
ongoing supervision. It may not be applicable to all patient types, or compatible
with all clinical programs or treatment approaches. This manual may
supplement, but does not replace or substitute for the need for adequate
assessment of each patient, careful case formulation, ongoing monitoring of
patients' clinical status, or clinical judgment.
8
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
9
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
People who abuse or are addicted to cocaine are also at increased risk to
contract HIV/AIDS and hepatitis B or C, especially those who inject cocaine with
needles.
3.2 Methamphetamine (meth, fire, speed, chalk, ice, crystal, crank,
Tina, glass)
This is another powerful and addicting stimulant drug that affects the brain. It
may be injected with a needle, swallowed in pill or capsule form, smoked in
crystallized “chunks” that look like frozen ice water, or snorted in a powder form.
The high, which is often described as an intense “rush,” lasts from 8-24 hours,
which is substantially longer than the high produced by cocaine. Unlike cocaine,
which is derived from a plant, methamphetamine is made in laboratories, which
sometimes leads to explosions and fires.
Short-term effects include the initial “rush” or high as well as an increase in
wakefulness or alertness, an increase in heart rate, and a rise in body
temperature. Other short-term effects include paranoia, hallucinations,
convulsions, insomnia, dry, itchy skin, loss of appetite, acne or sores, and
numbness.
Effects of methamphetamine on psychological functioning include an increase in
excitability, anxiety, irritability, depression, delusions, aggressiveness, and panic.
In addition, motivation and interest in work, friends, sex or food may actually
decrease.
Long-term effects of methamphetamine use include damage to nerve endings in
the brain, kidney or lung disorders, hallucinations, malnutrition, insomnia, weight
loss, psychological problems, and difficulty functioning at work, in the family or in
society. In some instances, the effects can make the user appear to have
paranoid schizophrenia. Brain imaging studies suggest that chronic users may
experience severe structural and functional changes in areas of the brain, which
can lead to problems with learning, memory and controlling emotions.
10
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
11
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
12
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Drug withdrawal occurs after the brain (and body) has adapted to the drug being
present by making changes in its own physiology, but the amount of the drug
present is reduced or removed completely. The brain then has to undo all of the
adaptive changes it had previously made. The symptoms produced by this
“undoing” of changes are what patients experience as “withdrawal syndrome.”
Tolerance and withdrawal comprise two elements of what DSM-IV-TR describes
as physical dependence on drugs.
13
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Drug addiction, like all chronic illnesses, has predictable effects on an individual
(symptoms) and a predictable course. As noted above, in addition to the
physical aspects of addiction, the individual suffers psychologically, socially, and
spiritually. Addiction to mood-altering substances is characterized by denial, or
refusing to accept the limitations of the addiction.
“Many of us did not think that we had a problem with drugs until
the drugs ran out. Even when others told us that we had a
problem, we were convinced that we were right and the world was
wrong. We used this belief to justify our self destructive behavior.”
(Narcotics Anonymous, 1988, p. 5)
Twelve-Step Recovery programs such as NA, CA, CMA and AA are not a
treatment method, but a fellowship of peers connected by their common
addiction and guided by the principles of the 12-Steps of recovery. The only
requirement to join one of these fellowships is a desire to stop using mood-
altering drugs or alcohol.
These 12-Step programs make no commitment to a particular causal model of
addiction. They limit the concepts to those of loss of control and denial from their
roots in AA, 12-Step programs emphasize two themes:
1. Spirituality: a belief in a “power greater than ourselves,” which is defined
individually, by each person, and which represents faith and hope for
recovery.
14
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
15
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
a. Fatigue
b. Vivid, unpleasant dreams
c. Insomnia (an inability to sleep) or hypersomnia (sleeping for an
excessively long time)
d. Increased appetite
e. Psychomotor retardation or agitation
f. These symptoms are not due to a general medical condition or
better accounted for by another mental disorder.
4.3 Stimulant Induced Disorders
These disorders involve psychiatric symptoms that are thought to be caused by
the effects of stimulants. DSM-IV-TR recognizes cocaine-induced psychotic,
mood, anxiety, sleep and sexual dysfunction disorders (American Psychiatric
Association, 2005).
4.4 Stimulant Abuse
These symptoms must have persisted for at least one month or have occurred
repeatedly over a longer period of time. A diagnosis of psychoactive substance
abuse is used if the individual does not meet the criteria for dependence but still
shows a maladaptive pattern of substance use, as indicated by one or both of the
following:
1. Recurrent use leading to the patient’s failure to fulfill major role
obligations at work, school or home.
2. Recurrent use in situations in which use is physically hazardous (e.g.,
driving while intoxicated).
3. Recurrent substance related legal problems. The patient continues to
use despite knowledge of having a persistent or recurrent social,
occupational, psychological, or physical problem that is caused or
exacerbated by use of the psychoactive substance.
4.5 Stimulant Dependence
According to DSM-IV-TR, the group of substance abuse and dependence
disorders "deals with symptoms and maladaptive behavioral changes associated
with more or less regular use of psychoactive substances that affect the central
nervous system. These behavioral changes would be viewed as extremely
undesirable in almost all cultures." Diagnostic criteria for psychoactive substance
dependence include at least three of the following symptoms, some of which
have persisted for at least one month, or have occurred repeatedly over a longer
period of time:
1. A substance is often taken in larger amounts or over a longer period than
the person intended.
2. There is a persistent desire or one or more unsuccessful efforts to cut
down or control substance use.
16
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
17
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
18
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
19
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
20
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
body, and spirit, for which the only effective remedy is abstinence from mood-
altering substances, one day at a time. STAGE-12 adheres to the concepts set
forth in the Twelve Steps and Twelve Traditions (Alcoholics Anonymous, 1981) of
NA, CA or AA.
The overall goal of this treatment is to promote abstinence from stimulants and
other substances by facilitating patients’ active involvement and participation in
the fellowship of 12-Step recovery programs (NA, CA, AA, CMA). Active
involvement in 12-Step programs is regarded as the single most important factor
responsible in maintaining sustained recovery from drug abuse or dependence,
and therefore, is the desired outcome of participation in this treatment.
21
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
22
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
3. Patients should see the connection between their drug use and negative
consequences that result from it. These consequences may be physical,
social, legal, psychological, financial, or spiritual.
8.2 Emotional Aspects of Recovery
1. Patients should understand the NA, CA, CMA, and AA view of emotions
and how certain emotional states (anger, loneliness) can lead to drug
use.
2. Patients should be informed regarding some of the practical ways 12-
Step programs suggest for dealing with emotions so as to minimize the
risks of using drugs.
3. STAGE-12 attempts to introduce and guide the individual in the use of
12-Step program tools for dealing with such emotions as anger,
loneliness, and grief. These tools include making use of the program
slogan “Don’t let yourself get too hungry, angry, lonely, or tired”
(H.A.L.T.).
8.3 Interpersonal Aspects of Recovery
1. Addiction has been described as a “disease of isolation.”
2. STAGE-12 provides support for patients to become connected to 12-Step
programs by going to meetings, participating in meetings and
establishing a relationship with a sponsor.
8.4 Behavioral Aspects of Recovery
1. Patients should understand how the powerful and cunning illness of drug
addiction has affected their whole lives and how many of their existing or
old habits (people, places and things) have supported their continued
drug use.
2. Patients should replace people, places and things that threaten their
abstinence with people, places and things that support their recovery.
3. Patients should turn to the fellowship of NA, CA, CMA or AA and to make
use of its resources and practical wisdom in order to change their
addictive behavior.
4. Patients should “get active” in NA, CA, CMA or AA as a means of
sustaining their abstinence.
8.5 Social Aspects of Recovery
1. Patients should attend and participate regularly in 12-Step meetings of
various kinds, including NA, CA, CMA or AA sponsored social activities.
2. Patients should access NA, CA, CMA or AA whenever they experience
the urge to use or when they slip or relapse.
3. Patients should re-evaluate their relationships with “enablers” and fellow
drug users.
23
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
24
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
25
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
establishing a support system; managing feelings; coping with guilt and shame;
warning signs of relapse; coping with high-risk relapse factors; and maintaining
recovery over the long-term. Phase 2 involved 12 weekly problem solving
groups during which time the patients comprising the group discussed their
personal problems and concerns related to addiction and recovery. Many of the
issues reviewed in Phase 1 were revisited as well as other problems or issues.
26
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
recovery, take a moral inventory of themselves, admit the nature of their wrongs,
make a list of individuals whom they have harmed, and make amends to those
people. Individuals who establish significant periods of recovery may then “take
the message” to others, which is the focus of Step 12.
Involvement in such mutual support programs is meant to provide participants
with support for remaining substance free, a social network (“fellowship”) with
which to affiliate, and a set of 12 guiding principles to facilitate change in various
areas of life (the 12 “Steps”) to be followed in the recovery process (Kaskutas,
Bond et al. 2002). Caldwell and Cutter (1998) described the general guidelines
for recovery based on this philosophy as the “12-step‘six pack”: don’t drink or use
drugs, go to meetings, ask for help, get a sponsor, join a group, and get active
27
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
28
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Cutter 1998) suggest that individuals who are attending AA but are having
difficulty embracing key aspects of the program may need professional
assistance that focuses more on 12-step practices and tenets and less on
meeting attendance.
11.2 Low Rates of 12-Step Attendance and Involvement Following
Treatment As Usual
Despite the potential benefits associated with 12-step involvement and
attendance, 60-70% of substance abusers have never attended a 12-step
meeting. Kelly and Moos (2003) found that approximately 40% of a cohort of
nearly 3,000 individuals who had attended 12-step meetings in the 90 days prior
to or during treatment had dropped out over the following year.
Among drug abusers, Fiorentine found that higher levels of post treatment
attendance at 12-Step meetings were associated with higher rates of abstinence
from both drugs and alcohol. Fiorentine also found that those who participated
concurrently in both treatment and 12-Step programs had higher rates of
abstinence than those who participated only in treatment or in 12-step programs
(Fiorentine and Hillhouse 2000).
Moos and Moos (2004) found that individuals with alcohol use disorders who
participated in AA for 4 months or longer in the first year after seeking help had
better 1-year and 8-year alcohol-related outcomes than individuals who did not
participate in AA. Individuals who sustained their participation in AA in Years 2–8
had better 8-year outcomes than did individuals who did not continue to
participate or who participated for a shorter interval. Individuals who delayed
participation in AA had no better outcomes than those who never participated.
Early engagement during and/or shortly after treatment and sustained
involvement in 12-Step programs contribute positively to substance use
outcomes. However, such low rates of attendance during or after treatment are
found despite the fact that most treatment programs incorporate a 12-step
philosophy and that professional staff report a high rate of referral to 12-step
programs (Humphreys 1997). However, referral by professionals is not always
introduced to patients in a manner that fosters acceptance of 12-Step programs
(Caldwell 1999). This is of concern since substance abusers appear less likely to
become involved in 12-step activities if left to do so on their own than if more
active encouragement and referral are provided in treatment (Sisson and
Mallams 1981; Humphreys 1999; Weiss, Griffin et al. 2000; Timko, DeBenedetti,
et al. 2006). Even if patients initially attend meetings, there typically are high
rates of attrition, which prevents them from receiving the maximum benefit from
12-step involvement (Godlaski, Leukefeld et al. 1997). Caldwell and Cutter
(Caldwell and Cutter 1998) suggest that early attrition from attending meetings
may, in part, be due to individuals’ inability to embrace or utilize other aspects of
the 12-step program.
In a study of inpatient substance abuse treatment within the Department of
Veterans Affairs (DVA), researchers found that individuals treated in 12-step
29
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
30
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
With the exception of one study by Maude-Griffin, et al. (1998), the results from
these clinical studies indicate that interventions designed to facilitate involvement
in 12-Step programs, whether delivered as individual or group therapies, result in
significant and substantial reductions of substance use comparable to and not
different from the outcomes of more established, evidence-based treatments
such as cognitive behavioral therapy and relapse prevention.
12.2 Multi-Site Studies
Two large-scale multi-site clinical trials support the conclusions that it is possible
to enhance the attendance at and involvement in 12-step self-help groups
particularly when involved in a formal treatment program that has a strong 12-
step orientation, and, in doing so, improve outcomes. Project MATCH (1993 &
1997) evaluated three manually guided, individually delivered treatments for
alcohol dependence: Cognitive-Behavioral Therapy (CBT), brief Motivational
Enhancement Therapy (MET), and Twelve Step Facilitation Therapy (TSF)
(Donovan, Kadden et al. 1994; Donovan, Carroll et al. 2003). The content of
TSF therapy was designed to be consistent with AA and other 12-step programs,
and with treatment programs based on the Minnesota Model (Nowinski and
Baker 1992; Nowinski, Baker et al. 1992). The primary goal of TSF is to promote
abstinence by facilitating the patient’s acceptance of the addiction, surrender to a
Higher Power, and active involvement in 12-Step meetings and related activities.
While participants in all three Project MATCH therapies demonstrated significant
and comparable reductions in the number of drinks per drinking day and
increases in the percent days abstinent, those participants who received TSF
had significantly higher rates of continuous abstinence when compared to the
other two treatments at a 1-year follow-up. This differential benefit for the TSF
group appears to have been related to differences in the treatments’ ability to
engage patients in 12-step activities. Participants in the outpatient TSF also
reported significantly more involvement in 12-step activities than those in either
CBT or MET. AA participation, in turn, positively predicted the frequency of
abstinent days in the post treatment period (Connors, Tonigan et al. 2001).
Compared to CBT or MET, TSF resulted in a greater awareness of a higher
power, endorsement of total abstinence, and engagement in AA practices. Two
of these active ingredients, emphasis on abstinence and commitment to AA
practices, were predictive of greater abstinence, and commitment to AA practices
mediated or explained why TSF patients reported significantly higher abstinence
rates 6 months after treatment relative to CBT and MET.
In a multi-site study of cocaine addiction, Crits-Christoph and colleagues (1997 &
1999) found that patients who received Individual Group Counseling (IDC) and
Group Drug Counseling (GDC) combined did better than those who received
GDC combined with Supportive Expressive (SE) or Cognitive Behavioral Therapy
(CBT). IDC (Mercer & Woody, 1999) and GDC (Daley, Mercer & Carpenter,
1999; 2002) emphasized the 12-step philosophy, focused on the disease concept
of addiction, advocated healthy behavioral and lifestyle changes, and strongly
encouraged and reiterated the importance of self-help group attendance as well
31
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
32
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
33
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
34
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
35
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
36
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
37
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
38
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
39
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
40
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
and couple therapy, vocational counseling, parenting skills, and so on. When
STAGE-12 is provided as part of a larger treatment package, it is essential for
the STAGE-12 counselor to maintain close and regular contact with other
treatment providers.
41
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
42
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) January 2009
43
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
44
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
45
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
46
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
47
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
48
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
49
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
50
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
51
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
52
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
client may have about asking for and working with a sponsor. If no meetings
were attended, or if the client seems reluctant to attend meetings, the counselor
explores this with the client in an attempt to understand this resistance, identify
perceived and/or actual barriers, and problem solve ways of dealing with or
overcoming these barriers. The counselor repeats the procedure of contacting a
12-Step volunteer to arrange to take the participant to a 12-Step meeting.
In addition, the following topics/issues should be reviewed. Review of Drug
Urges and “Slips” or Episodes of Use
During individual session 2 (and also during session 3), the counselor reviews
the patient’s attempts at maintaining abstinence, any strong drug cravings or
thoughts about using substances since the last session, and any actual lapses or
relapses to drug or alcohol use. Lapses and relapses are handled by examining
the antecedents to the drug use, then suggesting appropriate 12-Step tools that
might have been employed to avoid using drugs (meetings, contacting
sponsor/peers, reading of recovery materials, writing in a journal, etc) Episodes
of use are treated non-judgmentally and interpreted to be times when the power
of the illness of drug dependence overcomes the patient’s coping abilities.
18.5 NA, CA, CMA or AA Meetings All headings need to be 18.4.2,
18.4.3 etc until “Third Individual Session/Termination from
STAGE-12 Program”
The counselor congratulates the patient for any periods of drug
abstinence/sobriety, and for efforts to remain abstinent one day at a time. The
counselor explores the patient’s reactions to any 12-Step meetings attended. If
no meetings were attended, or the patient seems reluctant to attend meetings,
the counselor explores this with the patient in an attempt to understand this
resistance.
18.6 Readings and Journal
A review of the patient’s reaction to assigned readings or journal give the
counselor an opening to assist the patient in working through barriers that he or
she may be experiencing in becoming actively involved in 12-Step programs.
18.7 Recovery Tasks
The counselor follows up on any other suggested recovery tasks such as
contacting a sponsor or taking on service work at a meeting. This review of the
week provides the patient a chance to talk about day-to-day life and provides the
counselor with an opportunity to teach and encourage the use of the tools of 12-
Step programs for dealing with life situations.
18.8 Wrap-Up
The counselor discusses strategies for staying sober during the coming week (or
period between sessions). The counselor and patient discuss suggested
recovery tasks, which may include readings from recovery literature, listening to
recovery tapes, or performing recovery related activities such as contacting
53
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
54
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
time regarding changing people, places and things in order to reduce the
risk of a lapse or relapse?
5. Readings: what recovery material is being read by the patient? What are
the patient’s reactions to these readings? What questions does the
patient have about addiction, recovery, or the use of mutual support
programs from his or her readings?
6. Getting a sponsor: what progress is being made with a sponsor? If the
patient has a sponsor, how has this aided recovery? How is the patient
using a sponsor? If the patient has not obtained a sponsor yet, what is
the basis of any resistance to getting one? What suggestions can the
counselor make, and what commitments will the patient make regarding
getting a sponsor?
7. Telephone therapy: how is the patient doing in regards to getting phone
numbers of other members of NA, CA, CMA or AA, and calling them on
the phone to get support for recovery?
8. Evaluation of STAGE-12 experience: how has the patient’s views on the
following changed since starting treatment in STAGE 12:
a. Addiction to stimulant drugs.
b. Addiction as an illness vs. a character defect.
c. The “addict” part of personality, and how this controls drug use.
d. NA, CA, CMA or AA as a support to ongoing recovery from
addiction (meetings, sponsor, getting active, calling 12-Step
friends).
e. Being dependent on drugs.
f. Negative consequences of continued use.
g. Most helpful parts of STAGE-12.
h. Least helpful parts of STAGE-12.
i. Treatment for addiction.
j. The need for ongoing participation in 12-Step programs.
k. Keeping a journal as part of ongoing recovery.
In helping patients evaluate their experiences with STAGE-12, the counselor
needs to encourage honesty. Most likely different patients will have found
different parts of the program more or less helpful in their recovery.
Regardless of the patient’s view of success in STAGE-12 treatment in regards to
drug free days vs. lapses or relapses, treatment should end on a respectful note.
The patient should be reminded how to contact and use 12-Step programs,
which are available every day.
55
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
56
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
to help integrate the new members into the group membership and process as
they join.
To supplement learning from the group sessions, patients are asked to keep a
personal journal, and recovery tasks are suggested each week to complete
between sessions. Central to this approach is strong encouragement to attend
several different kinds of 12-Step meetings per week and to read the 12-Step
program literature throughout the course of treatment.
19.3 Written Journal
Each program participant will be asked to maintain a “personal journal,” which is
summarized in group at the beginning of each session. In this journal, the patient
records the following:
1. All meetings attending since the last group sessions (dates, times,
places)
2. Personal reactions to the meetings (thoughts, feelings, experiences)
3. Reactions to suggested readings
4. Any actual episodes of drug or alcohol use (lapses or relapses)
5. Reactions to recovery tasks
6. Strong cravings or urges to use drugs and how the patient managed
these
When offering patients advice or giving them recovery tasks from the point of
view of a 12-Step oriented program like STAGE-12, it is important to remember
that 12-Step programs prefer the word suggestion to the word rule. Specific
strategies for staying clean are as varied as the number of people who are in the
12-Step fellowship. It is important for each individual drug abuser to do what
works for them to maintain abstinence.
19.4 Technical Problems
In keeping with the spirit of 12-Step programs, counselors using this manual are
advised to avoid making assignments, in the sense of telling patients what they
should do. The 12-Step tradition tells us that it is better to share “some things
that other addicts have found helpful in your situation” without pressing for the
kind of commitment that other therapies might.
Suggestions made by the 12-Step counselor should be consistent with what is
found in 12-Step publications. Examples of strategies for dealing with urges and
slips that are consistent with 12-Step programs include:
1. Calling a friend
2. Going to an NA, CA, CMA or AA meeting
3. Going to a 12-Step social event
4. Calling your sponsor
5. Calling the NA, CA, CMA or AA Hotline
6. Changing a habit pattern
57
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
7. Distracting yourself
Aside from being consistent with 12-Step traditions, recovery tasks should be
specific, and the counselor should make a point of following up on them at the
beginning of each session.
Finally, the counselor should be familiar with 12-Step literature, as well as with
the locations, times, and types of meetings that may be available in the area.
When dealing with technical problems like those described below, the goal is to
determine if the patient is still interested in and capable of participating in
therapy.
19.5 Troubleshooting-Lateness/Cancellations
Patient is consistently late, cancels or fails to show for group or individual
sessions. In individual sessions, the counselor can explore the reason why the
patient was late, missed, or rescheduled a therapy session. Listen for evidence
of denial. “I can do this on my own,” “I don’t think my problem is as bad as you
seen to think it is,” “I don’t believe I’ve lost control of my drug use,” “I was busy
and forgot about our session,” and so on.
Group sessions can also discuss the issue of missed sessions or lateness, which
provides a learning opportunity for other patients present. Often, they will offer
their ideas on why other members miss or come late to group sessions.
When denial is the issue, the counselor should identify and interpret it as part of
the illness of addiction. Remember that denial is not necessarily verbalized, but
may be acted out through behavior or through various excuses for not going to
meetings, not completing suggested readings, missing group or individual
sessions and not following through with agreements made in group sessions
(e.g., seeking a sponsor or going to specific NA meetings). One form that denial
often takes is chronic lateness and cancellations. If this pattern emerges, but
patients refuse to “own up to it” as resistance, try to engage them in a frank and
non-judgmental discussion of their reservations about treatment. If the pattern
continues, a more open discussion about motivation for treatment may be
helpful. Eliciting feedback from other groups members can help as well (e.g.,
“What do other group members think about what Lisa said was the reason she
missed the past two group sessions”).
Keep in mind that this form of resistance does not invariably reflect denial of the
addiction. In some cases, it may be due to a fear of failure or social anxiety or
shyness. Help resistant patients clarify their reasons for resisting active
involvement in 12-Step programs and work from there.
19.6 Patient Comes to Group Session High on Drugs or Alcohol.
Do not proceed with a session if a patient shows up under the influence of drugs
or alcohol. Ask the patient to call the NA, CA, CMA or AA Hotline, a 12-Step
program friend, or a sponsor. If the person is not willing to do this, encourage
him to call a significant other to arrange for transportation home. Other treatment
58
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
program staff may have to help should this occur so that group sessions are
conducted on time.
19.7 Patient Resists Going to NA, CA, AA or CMA Meetings
This common resistance can take many forms, from making excuses to criticizing
the 12-Step meetings or their members. Interpret this respectfully as denial, as
evidence of the patient’s refusal to accept loss of control and the fact that drugs
are making life progressively more unmanageable (Step 1). It is appropriate to
coach patients regarding how to go to a meeting and what to expect. The
counselor should not offer to take patients to a meeting but may do anything
reasonable short of that, such as role-playing or arranging for an escort through
various 12-Step program contacts the counselor has developed, following the
procedures of the intensive referral process used in the STAGE-12 individual
counseling sessions.
If a patient continues to resist going to meetings, patiently persist in trying to get
this person to make definite commitments to meetings, using the NA, CA, CMA
or AA meeting schedules to identify specific meetings to attend. However, a
STAGE-12 counselor should never terminate a patient for refusing to go to
meetings, as this would be inconsistent with 12-Step program philosophy of
recovery.
19.8 Patient Uses Other Types of Drugs or Alcohol
Substance substitution is one symptom of addiction and should be interpreted as
such if the patient appears to be using a substitute for their primary drug of
choice. Addicted individuals cannot be allowed to believe that they can safely
use other substances, for two reasons. First, use of another substance will
reduce resistance to use of the patient’s substance of choice. Second, there is a
risk of cross-addiction (multiple addiction) if the patient turns to a substitute
mood-altering substance
19.9 Response to Emergencies
When working with patients who may be actively using drugs or alcohol, or
whose abstinence is compromised by lapses or relapses, it is not uncommon for
counselors to be confronted by various emergencies. Typical examples of such
emergencies include:
1. Getting arrested for drug related charges.
2. Having a serious family dispute as a result of drug use.
3. Feeling depressed about being dependent on drugs.
4. Getting into trouble on the job as a consequence of drug use.
5. Needing medical detoxification as a consequence of a binge.
6. Re-awakening of intense urges to use drugs and fear of full blown
relapse.
Usually, in times of crisis, the STAGE-12 counselor should consistently
encourage patients to turn to the resources of 12-Step programs as the basis for
59
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
their recovery. The counselor may offer specific advice and help in this regard,
such as assisting the patient in contacting the NA Hotline or the patient’s
sponsor.
Serious psychiatric (suicidality, psychosis, violence, self-injury) or medical
emergencies (need for detoxification from addictive substances) require either an
emergency session with the counselor, a referral to an emergency mental health
service, or to a hospital emergency room for evaluation and possible intervention.
In such instances, patients’ continued participation in the STAGE-12 program
may require review.
19.10 Group Process Issues
In addition to problems experienced in recovery or participation in 12-Step
programs, problems are also commonly encountered in the group “process.”
These problems may require the Group Counselor to intervene to help the group
address them. Following is a discussion of some of the more common group
process problems and some suggested strategies for the Group Counselor.
19.11 A group member dominates the discussion or always brings
the discussion back to himself
The Group Counselor can thank the member for the contributions and then elicit
opinions and experiences from other group members. If the group member
persistently tries to dominate group discussions or always turns the discussion
back to his own problems or issues, this behavior pattern can be pointed out by
the Group Counselor to make this member and other group members aware of
the behavior. The other members can be asked how they feel about the
member’s dominating the discussion, and how they want to deal with this in a
way that is satisfying to everyone in the group. Even though this creates a
problem on one level, on another level some group members find that it creates a
safety net for them because they may believe they don’t have to self-disclose
personal problems or feelings as long as another member is taking up the group
time. For example, if Levon is dominating the discussion of people, places, and
things, the Group Counselor could say to the group “Levon has shared his
experiences with people, places and things. Now, let’s hear from some others.
Megan, what are your experiences with people, places, and things in relation to
your cocaine addiction?”
60
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
61
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
62
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
63
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
5. State that the five group sessions will focus to a large extent on helping
members understand and get actively involved in the 12-Step program.
Today’s discussion will focus on Step 1.
6. Step 1: Ask a group member to write this Step on a board or flip chart and
then read it aloud. “We admitted that we were powerless over our
addiction and that our lives had become unmanageable.”
7. Ask the group what this Step means to them. Some patients may respond
that they think it means that they are helpless over their addiction and
insist that they are still in control, or that they cannot change. Others may
not see any connection between their use and the unmanageability in their
lives. Break the Step down into three key words: we, powerless,
unmanageability.
a. We: the 12-Step program works on inter-dependence among
members. People get better by helping each other. One slogan
that reflects this is: “You alone can do it, but you can’t do it alone.”
Each recovering person is responsible to make the efforts to stay
sober, but they have the support of other recovering persons.
Remind the group that recovery works best when it is seen as a
“we” process rather than an “I” process.
b. Powerless: rephrase this concept to accepting a “limitation.”
Everyone is faced with accepting limitations of one kind or another
in their lives. Ask the group members what kind of limitations they
have had to face in their lives. Most will come up with several
examples In this case, the limitation is that the patients can no
longer use drugs safely. Most patients are experts on how to use
drugs; however, they can no longer use safely. Do the patients
believe that they can still control their drug use? This concept
seems easily grasped by most patients. While they are powerless
over the fact that they can no longer use safely, they have the
power to do something about it. This is the paradox of accepting
“powerlessness.” How does it feel to be powerless? Anger and
sadness are common responses. Ask the patients if they have
ever accepted a limitation in another part of their life. What was
that like? What were their thoughts and feelings about that
experience?
c. Unmanageability: ask the group what this term means to them,
and to give personal examples of “unmanageability” in their life
related to drug use. For those patients who resist the idea of their
lives becoming unmanageable, suggest that they think about the
history of their drug use and the effects on them and their family.
Unmanageability is all of the negative consequences that have
occurred throughout the patient’s substance use.
8. Grief Process: explain to the group that the natural human response to
facing a limitation (powerlessness and unmanageability) is grief. The first
64
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
stage of the grief process is denial. As one moves through the process of
acceptance of being “powerless” the stages that one experiences are
similar to those of accepting loss. Some patients may experience a “loss”
related to addiction as well as their lifestyle. This explanation helps to
humanize the experience of denial with the patients. Outline the stages of
grieving and assure the patients that this is a process with movement back
and forth among the stages, and that 12-Step programs help with this
process.
a. Stages of Grief: these include 1) denial; 2) anger; 3) sadness,
sorrow or depression; 4) bargaining; and 5) acceptance.
b. Denial: explore with the patients how they have used denial in
relation to their disease of addiction. Review some examples of
denial:
• Simple Denial: refusing to discuss drug use; resisting doing
a serious drug use history; refusing to acknowledge the
real consequences of using; rejecting clear evidence of
tolerance; and refusing to attend 12-Step meetings.
• Minimizing one’s own use and maximizing others’ use.
• Avoidance through sleep, isolation, other compulsive
behavior, work.
• Rationalizing or finding excuses to use
• Distracting or changing the topic away from one’s drug
use.
• Contrasting self with others, believing, “I’m different.”
• Pseudo choice or “I really wanted to experience those
negative consequences!”
• Bargaining to placate self or others.
9. Ask the group members for personal examples of denial. This is a good
point to talk about the dual nature of addiction. Drawing a rough outline of
a person, indicate one “healthy” part, a small part, that wants recovery
today, then indicate another “addicted” part, much larger, that pulls the
person to want to use drugs. This much larger part is composed of many
voices that talk to the patient or the Anti-recovery Committee. Ask the
patients what messages that they give themselves about using. Note
these next to the figure on the using side. This is a catalog of the patients’
denial. The Anti-recovery Committee never completely goes away. An
NA slogan is that “While I am in the room getting recovery, my disease is
in the parking lot doing push-ups!” The job of recovery is to strengthen the
recovering part, the human part. Ask the patients how they can do this.
Suggest that 12-Step programs offer support and positive messages
about recovery and living.
10. Review the stages of acceptance and ask the patient to pick where they
fit relative to these stages and to identify where they are in the process of
denial versus acceptance.
65
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
66
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
2. “You slipped because you fooled yourself into thinking you were safe. So
you met with your old friends, thinking you could do that and not use.”
3. “The part of you that wants to deny your addiction tells you that you can
control your use that it was okay for you to use at a party. You fooled
yourself into believing that you could limit your use, because you wanted
to believe that.”
4. “I know you don’t like to hear this, but I see your denial at work again.
The part of you that still wants to use — that doesn’t want to let go of
drugs was telling you that you could use just a little, and that you would
be able to stop there, even though experience proves you can’t.”
A second way of conceptualizing denial is to think of it as “insanity” as that word
is used in 12-Step programs. Addiction as a form of insanity is implied in Step 2
(“Came to believe that a Power greater than ourselves could restore us to
sanity"). The form of insanity involved in addiction is the addict’s belief
(delusional because it flies in the face of experience) that they can use safely.
Addiction has been described as an illness of the mind as much as an illness of
the body. The addict rationalizes using and creates an illusion of choice when, in
fact, using is an obsession that leaves no room for free will or conscious
(rational) choice. From this perspective, resistance to accepting a diagnosis of
addiction or of continuing to think and act in ways that promote using are aspects
of addiction itself, just as much as physical tolerance is. The counselor can
interpret resistance in these terms as follows:
“Addiction is in fact an illness — an illness of the mind and of the
body. It affects you physically — for example, you’ve had heart
palpitations from cocaine. It also affects you mentally — in the
way you think, even when you’re clean. When you went to that
party last weekend, you convinced yourself that it would be okay
to use as long as you used only at the party. Then you went
home and continued using until you passed out. That’s the
illness at work. It’s called ‘stinking thinking’ in 12-Step programs.”
“From the 12-Step point of view, that fact that you don’t want to
go to meetings is just another symptom of the illness. You know
from experience that once you start using you can’t stop until you
run out of money or pass out, but you continue to convince
yourself that you really don’t have this obsession or that you can
control it in some way when the facts speak to the contrary.”
Finally, some counselors may find it helpful to approach denial by viewing it as
an internal conflict. The addicted individual can be thought of as someone who
has a “dual personality”: the part of the self that wants to stay clean and enjoys
clean and sober consciousness and clean and sober living (the recovering
personality) versus the part that resists the idea of limitation, craves drugs, and
will do anything to get them (the addict personality). Recovery represents an
ongoing struggle between these two forces within the drug dependent patient.
The counselor needs to ally with the recovering personality and assist the patient
67
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
in strengthening it, while confronting the addict personality consistently but with
respect and compassion. Keep this phrase in mind throughout treatment: Denial
never sleeps. Recovery demands eternal vigilance, which is what active
involvement in a 12-Step recovery program can provide.
In order to align effectively with the recovering personality within the patient, the
counselor must understand that:
1. Addiction is more powerful than the patient’s individual willpower alone,
so the addictive personality and denial will inevitably win out if the patient
chooses to fight them without help in the form of a 12-Step program.
2. It is normal human tendency to resist accepting limitation and to test
limitation. This is deadly to the addict in the long run.
The addicted person’s personality is cunning and clever and will make every
effort to lower the defenses of the recovering personality by trying to convince the
addict that s/he is safe (no longer needs NA, CA, CMA OR AA or can use safely).
Some have compared being in recovery to walking up a down escalator: As soon
as addicts stop working a recovery program, the illness will begin bringing them
down. Alternatively, it could be said that recovery requires eternal vigilance.
68
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
The first thing is to admit powerlessness, or, in other words, to say “I can't control
my use of drugs, or the consequences of my use of drugs.”
1. How have drugs placed your life, or the lives of others, in jeopardy?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
69
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
5. How do you feel about yourself for having a drug abuse or dependence
problem?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Take an honest look at how the consequences of your drug use has affected you
and others. This is “connecting the dots.” Looking back over your drug use
answer the following questions.
1. What health problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. What family/personal problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. What sexual problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. What legal problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
_________________________________________________________________
5. What financial problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
70
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
6. What work problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
71
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
72
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
3. Drug Cravings: Ask the patients if they experienced any thoughts about
using or cravings to use. In early recovery from drug addiction strong
cravings are common.
a. How do patients experience drug cravings (e.g., physical signs,
thoughts, and feelings)? How did the patients manage their
cravings? Did they use any 12-Step tools?
b. Offer support for all positive efforts made to avoid that first use of
drugs.
c. If needed, suggest other 12-Step tools such as calling other
recovering peers, keeping to a routine schedule of meetings,
putting off using and getting busy with safe activities, etc.
4. Slips (lapses or relapses): If any patients used drugs and had a lapse
or relapsed, review the events that occurred prior to re-starting their drug
use.
a. What set off this behavior to use drugs?
b. Review the role that the patient’s denial may have played in
continued use or their lapse or relapse.
c. If necessary, encourage them to return to review Step 1 and focus
on “acceptance.” At any time in the treatment process, it is
reasonable to review the first Step with the patient.
5. Getting Active: Ask about what efforts group members made in
becoming actively involved with 12-Step programs.
a. What efforts have they made at obtaining a sponsor?
b. Have they committed to any service work, participated in any
social activities, obtained any new phone numbers or called any
recovering peers? Be sure to congratulate the patient for each
clean day since the last session.
22.2 Methods and Points for Group Discussion of New Material
1. Use a brief presentation and an interactive discussion format to
review the content of this group session. Elicit experiences and
example from group members related to the content as it is
reviewed in group.
2. State that material for this group session deals with the pragmatic
details of changing one’s lifestyle.
a. Adages in 12-Step programs are that “if nothing changes,
nothing changes” and “avoid slippery people, slippery
places, and slippery things, unless you want to slip.”
b. There are often powerful people, places, and things (habits
and routines) connected with drug use. By identifying
those people, places and things (habits or routines) that
are dangerous to recovery and exploring new people,
places and things that can be put in place that support
73
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
74
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
22.4 Troubleshooting
An issue that may arise doing this exercise is the patient’s resistance to letting go
of some of those things listed on the dangerous side of the chart. Be sensitive to
the process of letting go and grieving the past. Even though, for example, some
people may be dangerous to a person’s recovery, they have also been a source
of companionship. Some individuals, like spouses and lovers, may straddle the
chart. Take time to explore what about the patient’s relationship with these
people makes recovery difficult or what about it supports recovery? If the
patient’s own home is dangerous to recovery, what can the patient do to change
this? Does the patient need to leave this situation? Often, drug dependent
patients live in toxic situations with cohorts who are also addicted or abusive.
This exercise heightens the awareness of this conflict for some patients. What
achievable goal can the patient work on to shift the balance towards recovery?
75
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Places
Things
(rituals/routines)
76
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Things (rituals I got rid of my pipe and NA meetings I feel good about
and routines) feel it was the right thing Brother’s house staying connected
Crack pipe to do. Dances at recovery to positive people.
Friday and I’m going to meetings club Hanging with others
Saturday nights at and NA sponsored in recovery is the
bars and parties dances on weekends. only way for me to
feel I can recover.
77
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
78
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
79
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
80
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
81
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
5. Turn our will and our lives over: discuss what is meant in 12-Step
programs by “turning it over.”
a. What have been the patients’ experiences trusting others? Have
they ever followed another’s advice? How did that turn out? How
do patients decide who is trustworthy and who is not?
b. What does the idea of “turning over” your will mean to the patients?
Ask them if they believe that the experience of other addicts and
alcoholics can have any relevance for them.
c. Part of recovery may involve following a “common wisdom” such as
that found in the 12 Steps. Working this Step means setting aside
one’s will as it applies to using, and being open to following the
suggestions of others about staying clean and sober.
d. Some patients have major therapeutic issues around trust due to
past traumas and may require more time and care with this Step
(Baker and Triffleman, 1998).
6. Care of God, as we understood Him: The final key phrase is that
one’s will is turned over to the, “care of God, as we understood Him”.
Depending on personal experience, some people have a more caring
concept of God than others. One suggestion for newcomers is to
consider the possibility that the 12-Step recovery groups act as their
“higher power” at first.
23.3 Readings and Recovery Tasks
1. Recovery tasks for this topic include readings from:
a. It Works: How and Why (Narcotics Anonymous) pp. 17-35.
b. Basic Text (Narcotics Anonymous, 1988) pp. 22–26.
c. Living Sober (Alcoholics Anonymous, 1975) pp. 77–87.
2. Ask group members what 12-Step group meetings they will attend
between sessions, remind them to keep their journal and assign
appropriate readings.
3. Instruct group members to complete the written handout “ Thinking
about a Spiritual vs. a Non-spiritual Way of Living” and bring to the
session next week
Ask the group members to summarize the session and contract to follow through
on their commitment to complete the agreed upon recovery tasks.
23.4 Troubleshooting
Again, when presenting material in Steps 1, 2 and 3, the best therapeutic stance
is frank but non-judgmental. The counselor must believe in the illness model of
addiction: that drug addiction is an illness affecting the body, mind, and spirit.
The counselor must be prepared, however, for the patient to resist these ideas.
Patients may criticize or demean NA, CA, CMA or AA and the 12 Steps or may
attempt to draw the counselor into a discussion (or argument or debate) about
whether addiction is really an illness or whether or not controlled use is possible.
82
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
They may attempt to change the agenda of this program, for example, to make it
into marital therapy or psychodynamic psychotherapy. The counselor is advised
not to enter into such debates, not to react defensively to criticism, and not to get
off the track of the program. Keep the following in mind:
1. The objective of this STAGE-12 treatment is facilitation of the patient’s
active involvement with 12-Step programs.
2. The counselor does not need to defend NA, CA, CMA or AA--it does
very well on its own and will continue to whether or not this particular
patient believes in it.
3. Believing that the 12 Steps can help, or in a Higher Power may be less
important than simply going to meetings, which should be the first goal.
4. Addiction is a powerful and cunning illness, and patients may just insist
on doing it their way for now.
5. Every clean and sober day (and sometimes every clean and sober
hour) is important and should be recognized. Whenever you are
confronted with a slip, think about now many clean and sober days
(hours) the patient has had since seeing you last.
Addiction is an illness that defeats the will and causes addicts to regress,
becoming more and more infantile (impulsive, self-centered) and difficult to deal
with over time. It is important to separate the illness from the person it affects.
83
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Competing and
GET THE GOOD LIFE BY… Caring and Giving
Getting
GET SELF-WORTH Doing Being
THROUGH…. Being Perfect (Who I am as a person)
Success Being Human
(Accepting my limits and
dependences)
Faithfulness
84
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
85
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
86
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
87
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
88
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
89
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
90
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
91
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
With this situation the counselor may want to suggest that the patient give 12-
Step programs a fair chance. We are not asking that people join NA, CA, AA or
CMA, but that they go to meetings, sit, listen, and process their experience with
their groups to share their experiences.
Some addicted patients with co-occurring psychiatric disorders who have strong
anxiety and fears about group meetings may need encouragement to gradually
approach and experience meetings. For example, a patient was encouraged to
first drive by the meeting site, then enter the parking lot, peek in the window of
the meeting room, and finally enter the meeting. This process took several
weeks.
Other patients may have fears of disclosing too much about themselves to
strangers. In these cases encourage the patient to not share at first, but to sit
and listen at meetings. If possible, encourage them to return to the same
12-Step group meetings on a regular basis. What the patient will discover is that
what was once a room full of strangers has become a room full of friends.
As you process their experience at meetings in group sessions, explore in depth
their feelings and thoughts about what was said and if any of the people in the
meeting room seemed trustworthy. How might they begin to relate to these
people? What might they have in common with some others in the meeting, etc?
More typically, patients may attend one to two meetings per week at first. With
the “Getting Active” topic, the goal is to increase the patient’s level of
participation. This may include increasing the number of meetings attended
during the week. The target goal is to attend daily 12-Step meetings for ninety
days (90 in 90). If a person is attending only one meeting per week, a
reasonable goal might be to push for three meetings per week.
Looking for a sponsor can be a daunting task for some patients. Some of our
patients have been hurt by past personal relationships and are very slow to trust
others. One helpful strategy is to ask the patient what qualifications s/he would
look for or want in a sponsor. The purpose of this topic is to introduce the
concept of sponsorship and encourage the patient to begin looking for a
temporary sponsor. Temporary sponsors may or may not turn into permanent
sponsors. The idea is that the relationship is on a trial basis for both parties.
This may help alleviate some fears for patients.
92
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
93
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
94
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
95
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
96
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
97
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Resentment Worksheet
WHAT HOW I FELT WHAT I DID WHAT I SHOULD DO
HAPPENED DIFFERENTLY USING
PROGRAM TOOLS
98
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Resentment Worksheet
Example of Melissa
99
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
8. Emotions: grief
a. Grief is as important a subject as anger and resentment in the 12-
Step literature.
b. In the course of addiction (and often before drug abuse begins),
addicted individuals may experience losses that have gone
ungrieved. The counselor should be familiar with the stages of
grief.
• Denial: minimizing the importance of what was lost,
including denying its importance.
• Bargaining: attempting to replace the lost things with
something else without acknowledging this loss.
• Anger: the breakdown of denial and the natural reaction to
loss.
• Sadness: the true expression of a loss that has been
denied.
• Acceptance: this comes slow as denial breaks down and
the individual feels able to come to terms with the reality of
the loss (or limitation) and is ready to move on.
c. Ask group members to identify one loss in their lives that they
have worked through in terms of these stages.
d. Then ask them to identify one loss that they have not worked
through, about which they may be in denial.
• Drug addicted individuals need to come to terms with the
loss of drugs (and the related lifestyle), which is
experienced in recovery.
• Another perspective is that group members need to accept
their limitation, which is that they cannot control their use of
drugs and have to give them up
e. Ask group members to write a “good-bye letter” to drugs and
addiction in their journals.
• Dependency on drugs needs to be conceptualized as a
relationship that must be broken and grieved in the interest
of recovery.
• This requires sensitivity and respect on the part of the
counselor, along with an appreciation for the grief process
and an ability to work with patients in a sympathetic
manner through their grief over the loss of drugs.
26.3 Recovery Tasks
Meetings
1. Ask group members to make a list of meetings they will attend in their
ongoing recovery.
2. Suggest other kinds of meetings the patient might attend.
100
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
3. Discuss how group members can become more active in NA, CA, CMA or
AA.
Telephone Therapy and Sponsor
1. Ask group members to continue to collect new numbers of AA, NA, CA, or
CMA members.
2. Ask group members to commit to call program friends.
3. Ask group members how often they plan to contact their sponsors.
4. For those who do not have a sponsor, discuss plans to obtain one in the
near future.
Readings
a. Continue reading Narcotics Anonymous (Narcotics Anonymous,
1988)
b. Living Sober (Alcoholics Anonymous, 1975) we suggest:
• “Fending Off Loneliness” (pages 33 – 37)
• “Watching Out for Anger and Resentments” (pages 37 – 41)
• “Looking Out for Over-relation” (pages 43 – 44)
• “Being Grateful” (pages 47 – 51)
• “Eliminating Self-pity” (pages 56 – 59)
• Other program literature (e.g., meditation books, pamphlets, etc.)
Grieving
1. Suggest that group members write a good-bye letter to drugs as if it were
a relationship that they have decided to end.
2. Instruct them to write in their journal about losses that they have not
adequately acknowledged and grieved, including losses in each of these
areas:
• Relationships
• Self-esteem
• People, pets, or things
• Goals
H.A.L.T.
What lifestyle changes is the patient willing to make to address fatigue and
nutrition?
26.4 Wrap-Up
What was the gist of today’s session?
Do you understand and are you willing to follow through with the Recovery
Tasks?
101
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
26.5 Troubleshooting
The importance of going to meetings, getting involved in them, and developing
relationships with other recovering addicts cannot be overstated. The patient can
use the fellowship of recovering addicts as a source of support, advice, and
comfort. By now, going to meetings should be a part of the patient’s lifestyle; if it
is not, the counselor should spend more time uncovering and working through
the patient’s resistance to this. A contracting approach can be a useful technique
wherein the counselor and patient agree that the patient will try out a certain
number of 12-Step meetings or experiment with some form of participation.
Patients’ experiences at meetings, like their reactions to the Narcotics
Anonymous Basic Text (Narcotics Anonymous, 1988), need to be processed at
each session.
Role-playing can be another effective technique to help the shy or shameful
patient overcome internal barriers to going to meetings or participating in them.
Have patients practice, for example, saying their names out loud, as if they were
doing so at a meeting. Assure the patients that they will not be pressured at
meetings to say more than they feel comfortable with.
Once patients have become regular in their attendance, the next step is to
encourage them to talk. Meetings and subsequent contacts with fellow 12-Step
program members can be used as opportunities to talk about ongoing sources of
resentment and grief. Patients who merely attend 12-Step meetings and do not
participate or develop communicative relationships with other recovering people
are handicapped in their ability to resist denial and are apt to slip into drug use as
a means of drowning those emotions.
102
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
103
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
104
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
105
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
The didactic seminar usually lasts 2-3 days, depending on the experience level of
the counselors. The seminar includes a review of basic 12-Step principles, topic-
by-topic review of the manual, watching videotaped examples of counselors
implementing the treatment, several role play and practice exercises, discussion
of case examples, and rehearsing strategies for difficult or challenging group
sessions.
27.8 Supervised Groups and Training Cases
The supervised group and individual sessions training cases provide an
opportunity for the counselor to try this approach and adapt their usual approach
to conform more closely to manual guidelines. The number of training group
sessions and individual cases varies according to the experience and skill level
of the counselor. Generally, we find that more experienced counselors require
only a few group sessions and one or two training cases to achieve high levels of
competence. Less experienced counselors generally require more supervised
group and individual sessions.
For supervision of training cases, each group and individual session is audio
taped, then forwarded to the supervisor. The supervisor reviews each session,
completes a rating form (described below) evaluating the counselor’s adherence
and competence in implementing the treatment session, and provides one hour
of individual supervision to the counselor. Supervision sessions are structured
around the supervisor’s ratings of adherence and competence, with the
supervisor noting areas in which the counselor delivered the treatment
effectively, as well as areas in need of improvement. Frequency of supervision
can decrease as the counselor gains more experience and demonstrates
competence in group and individual sessions.
27.9 Rating and Assessment of Counselor Adherence and
Competence
To have a concrete basis on which to evaluate counselor implementation of
STAGE-12, both counselors and supervisors complete parallel adherence rating
forms after each session conducted or viewed. The rating forms are provided in
the appendix. They consist of Likert-type items covering a range of key
interventions (presentation of content of group sessions, review of recovery
tasks, exploration of the patient’s use of denial, encouragement to make use of
12-Step programs, etc.).
The counselor version of the form, called the STAGE-12 Counselor Checklist
(adapted from Carroll et al., 1998), asks the counselor to rate what strategies and
interventions were implemented in a given group or individual session, and how
much the intervention was used. The STAGE-12 Checklist has a variety of
purposes. First, it is intended to remind the counselor, at each session, of the
key ingredients of STAGE-12. Second, the STAGE-12 Checklist is intended to
foster a greater adherence to the manual through self monitoring of adherence.
Third, it can organize and provide the basis for supervision, as the counselor can
more readily note and explore with the supervisor the strategies and
106
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
107
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
108
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
teaching about 12-Step program tools, which requires considerable activity and
commitment from the patient, with patients who are still highly ambivalent or even
resistant to treatment. It is important to remind such counselors that the manual
is a blueprint, or a set of guidelines for treatment, to be used to provide a clear
set of goals and overall structure to the treatment, but manuals are by no means
scripts for treatment. This often entails considerable sufficient familiarity by the
counselor with the didactic material, so the counselor can alter the material to
adapt to each individual patient or group, and the material can be presented in a
way that sounds fresh and dynamic, not manual-generated. Patients should
never be aware that the counselor is following a manual.
27.14 Balancing Adherence and Competence
There is an important distinction between adherence and competence, that is,
the degree to which the counselor follows the guidelines laid out in the therapy
manual, and counselor competence, which refers to the counselor’s level of skill
in delivering that treatment (Carroll & Nuro, 1997). Several investigators have
noted that a counselor’s adherence and competence are not necessarily closely
related (Shaw & Dobson, 1988; Waltz, Addis, Koerner, & Jacobson, 1993). That
is, a counselor can follow a treatment manual virtually word-for-word and not
deliver that treatment competently or skillfully (i.e., with an appropriate level of
flexibility and understanding of a particular group or individual patient, using
appropriate timing and language). In some cases extremely high adherence
(e.g., a wooden, mechanistic, rote repetition of material in the manual) indicates
very low competence in a counselor. High adherence and low skillfulness may
also occur in cases where a counselor delivers a technique competently, but at
an inappropriate level during a session that is insensitive to the needs of a
particular patient. Conversely, there are cases of high skillfulness and low
adherence, for example, where a counselor empathetically responds to the
patient and provides incisive interpretations at the precise moment they are most
likely to be helpful, but rarely touches on material described in the manual
(Carroll & Nuro, 1997). Achieving a high level of adherence to the STAGE-12
manual and fostering a positive therapeutic alliance should be seen as
complementary, not contradictory, processes.
27.15 Going Through the Material Too Quickly
Many of the 12-Step recovery concepts, while seemingly simple and based on
common sense, are in fact quite complex, particularly for patients with cognitive
impairment, those with dual diagnoses, and those who have a low baseline of
coping skills. Thus, a common error made by many counselors is to fail to check
back with the patients in group to make sure they understand the material and
think through how it might be applied to their current concerns. When this
occurs, it often takes the form of presentation of 12-Step recovery material as a
lecture, rather than an interactive dialogue between the group members and the
counselor. Ideally, for each idea or concept presented by the counselor, the
counselor should stop and ask group members to provide an example or to
describe the idea in their own words before presenting the next idea. Because
109
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
group sessions cover a large amount of content, some areas will be discussed
more briefly than others.
27.16 Overwhelming the Group or Individual Patient
For each group session topic, a range of ideas and 12-Step recovery tools are
presented. Another problem that arises is that some counselors try to present all
of the material, in the order presented in the manual, to each group. For many
patients, it is overwhelming. Learning and feeling comfortable with one or two
recovery tools is far preferable to having only a surface understanding of several.
Similarly, if too much material is presented, the time that can be devoted to
practicing particular recovery tools is limited. Introduction of new material can be
spread out over several sessions. The topic of “Hungry, Angry, Lonely, Tired”,
which contains several 12-Step techniques for managing stressful situations, for
example, can be spread out over several sessions.
27.17 Letting Recovery Tasks Slide
Although process data from clinical trials suggests that the majority of patients
carry out recovery tasks and those who follow through with recovery tasks have
better substance use outcomes, a number of counselors do not sufficiently attend
to recovery tasks. This takes the form of a brief and cursory review of completion
of recovery tasks in the beginning of group session in which specific examples or
details are not elicited. Of course, each group member cannot respond to every
question raised during check-in, but it is helpful to elicit examples when a specific
issue is discussed. For example, when discussing resistance of a patient to
getting an NA, CA, AA or CMA sponsor, the group counselor may ask a member
to share his beliefs about asking for help, what he believes are the real reasons
he has not done this, and how he feels about asking another person for help with
recovery.
27.18 Abandoning the Manual with Difficult Patients or Groups
Many patients present with a range of complex and severe co-morbid problems
including relapse to drug use, family problems or mood problems (depression or
anxiety). Some counselors become overwhelmed by relapses or concurrent
problems and drift from use of the manual in an attempt to address these “other”
problems. In such cases, the counselor often takes a less, rather than the more
structured approach needed to conduct the group. Generally, if patients are
sufficiently stable for outpatient therapy in a structured partial hospital, IOP or
day or evening program, we have found that the manual, which provides
guidelines for a highly structured approach to treatment, prioritizing of concurrent
problems, offering limited case management, and focusing primarily on achieving
initial abstinence through participation in 12-Step programs, is adequate to
contain even fairly disturbed patients.
110
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
References
Alcoholics Anonymous (1976). Alcoholics Anonymous: The Story of How Many
Thousands of Men and Women Have Recovered from Alcoholism. New York:
Alcoholics Anonymous World Services, Inc.
Alcoholics Anonymous (1981). Twelve Steps and Twelve Traditions. New York:
Alcoholics Anonymous World Services, Inc.
Alcoholics Anonymous (1975). Living Sober. New York: Alcoholics Anonymous
World Services, Inc.
Baker, S. (1998). Twelve Step Facilitation for Drug Dependence. New Haven,
CT: Psychotherapy Development Center, Department of Psychiatry, Yale
University.
Baker, S. & Triffleman, E. (1998). The Modification of Twelve Step Facilitation
Therapy for Use with Civilian Patients with PTSD and Substance Abuse.
(source???)
Barber, J.P., Luborsky, L., Gallop, R., Crits-Christoph, P., Frank, A., Weiss, R.D.,
Thase, M.E., Connolly, M.B., Gladis, M., Foltz, C., & Siqueland, L. (2001).
Therapeutic alliance as a predictor of outcome and retention in the National
Institute on Drug Abuse Collaborative Cocaine Treatment Study. Journal of
Consulting and Clinical Psychology, 69(1), 119-124.
Blondell, R. D., Looney, S. W., Northington, A. P., Lasch, M. E., Rhodes, S. B., &
McDaniels, R. L. (2001). Can recovering alcoholics help hospitalized patients
with alcohol problems? Journal of Family Practice, 50(5), 447.
Brook, D. W., & Spitz, H. I. (Eds.). (2002). The group therapy off substance
abuse. New York, NY: The Haworth Medical Press.
Brown, T. G., Seraganian, P., Tremblay, J., & Annis, H. (2002). Matching
substance abuse aftercare treatments to client characteristics. Addictive
Behaviors, 27(4), 585-604.
Brown, T. G., Seraganian, P., Tremblay, J., & Annis, H. (2002). Process and
outcome changes with relapse prevention versus 12-Step aftercare programs
for substance abusers. Addiction, 97, 677-689.
Caldwell, P. E. (1999). Fostering client connections with Alcoholics Anonymous:
a framework for social workers in various practice settings. Social Work in
Health Care, 28(4), 45-61.
Caldwell, P. E., & Cutter, H. S. (1998). Alcoholics Anonymous affiliation during
early recovery. Journal of Substance Abuse Treatment, 15(3), 221-228.
Carroll, K.M. (1998). A Cognitive-Behavioral Approach: Treating Cocaine
Addiction. NIH Publication 98-4308. Rockville, MN: National Institute on Drug
Abuse.
Carroll, K.M., Cooney, N.L., Donovan, D.M., Longabaugh, R.L., Wirtz, P.W.,
Connors, G.J., DiClemente, C.C., Kadden, R.R., Rounsaville, B.J., & Zweben,
A. (1998). Internal validity of Project MATCH treatments: Discriminability and
integrity. Journal of Consulting and Clinical Psychology, 66(2), 209-303.
111
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Carroll, K. M., Nich, C., Ball, S. A., McCance, E., Frankforter, T. L., &
Rounsaville, B. J. (2000). One-year follow-up of disulfiram and psychotherapy
for cocaine-alcohol users: Sustained effects of treatment. Addiction, 95(9),
1335-1349.
Carroll, K. M., Nich, C., Ball, S. A., McCance, E., & Rounsavile, B. J. (1998).
Treatment of cocaine and alcohol dependence with psychotherapy and
disulfiram. Addiction, 93(5), 713-727.
Carroll, K.M., Nich, C., & Rounsaville, B.J. (1997). Contribution of the
therapeutic alliance to outcome in active versus control psychotherapies.
Journal of Consulting and Clinical Psychology, 65, 510-514.
Carroll, K.M., Nich, C., & Rounsaville, B. (1998). Utility of Counselor Session
Checklists to Monitor Delivery of Coping Skills Treatment for Cocaine
Abusers. Psychotherapy Research, 8(3), 307-320.
Carroll, K.M. & Nuro, K.F. (1997). The Use and Development of Treatment
Manuals. In: Carroll, K.M. (ed.) (1997) Improving compliance with alcoholism
treatment. NIAAA Project MATCH Monograph Series.
Castonquay, L.G. (1993). “Common factors” and “nonspecific variables”:
Clarification of the two concepts and recommendations for research. Journal
of Psychotherapy Integration, 3, 267-286.
Chappel, J. N., & DuPont, R. L. (1999). Twelve-step and mutual-help programs
for addictive disorders. Psychiatric Clinics of North America, 22(2), 425-446.
Cocaine Anonymous (1993). Hope, Faith & Courage. Cocaine Anonymous
World Services, Inc. Los Angeles, California.
Collins, G. B., & Barth, J. (1979). Using the resources of AA in treating alcoholics
in a general hospital. Hospital and Community Psychiatry, 30(7), 480-482.
Connors, G.J., Carroll, K.M., DiClemente, C.C., Longabaugh, R., Donovan, D.M.
(1997). The therapeutic alliance and its relationship to alcoholism treatment
participation and outcome. Journal of Consulting and Clinical Psychology,
65(4), 588-598.
Connors, G. J., Tonigan, J. S., Miller, W. R., & the Project MATCH Research
Group. (2001). A longitudinal model of intake symptomatology, AA
participation and outcome: retrospective study of the Project MATCH
outpatient and aftercare samples. Journal of Studies on Alcohol, 62(6), 817-
825.
Crits-Christoph, P., Siqueland, L., Blaine, J., Frank, A., Luborsky, L., Onken, L.
S., et al. (1997). The National Institute on Drug Abuse Collaborative Cocaine
Treatment Study. Rationale and methods. Archives of General Psychiatry,
54(8), 721-726.
Crits-Christoph, P., Siqueland, L., Blaine, J., Frank, A., Luborsky, L., Onken, L.
S., et al. (1999). Psychosocial treatments for cocaine dependence: National
Institute on Drug Abuse Collaborative Cocaine Treatment Study. Archives of
General Psychiatry, 56(6), 493-502.
112
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Daley, D. C., Mercer, D. E., & Carpenter, G. (1999). Drug Counseling for Cocaine
Addiction: The Collaborative Cocaine Treatment Study Model (Vol. 4).
Bethesda, MD: National Institute on Drug Abuse.
Daley, D.C. & Marlatt, G.A. (2006). Overcoming Your Alcohol or Drug Problem:
Therapist Manual. NY: Oxford University Press
Donovan, D. M. (1999). Efficacy and effectiveness: Complementary findings from
two multisided trials evaluating outcomes of alcohol treatments differing in
theoretical orientations. Alcoholism: Clinical and Experimental Research,
23(3), 564-572.
Donovan, D. M., Carroll, K. M., Kadden, R. M., DiClemente, C. C., & Rounsavile,
B. J. (2003). Therapies for matching: Selection, development,
implementation, and costs. In T. F. Babor & F. K. Del Boca (Eds.), Treatment
matching in alcoholism (pp. 42-61). New York: Cambridge University Press.
Donovan, D. M., Kadden, R. M., DiClemente, C. C., Carroll, K. M., Longabaugh,
R., Zweben, A., et al. (1994). Issues in the selection and development of
therapies in alcoholism treatment matching research. Journal of Studies on
Alcohol, Supplement No.12, 138-148.
Donovan, D. M., & Wells, E. A. (2007). "Tweaking 12-Step": The potential role of
12-step self-help group involvement in methamphetamine recovery.
Addiction, 102(Supplement 1), 120-128.
Emrick, C. D., Tonigan, J. S., Montgomery, H., & Little, L. (1993). Alcoholics
Anonymous: What is currently known? In B. S. McGrady & W. R. Miller
(Eds.), Research on Alcoholics Anonymous: Opportunities and Alternatives
(pp. 41-76). New Brunswick, NJ: Rutgers Center of Alcohol Studies.
Etheridge, R. M., Craddock, S. G., Hubbard, R. L., & Rounds-Bryant, J. L.
(1999). The relationship of counseling and self-help participation to patient
outcomes in DATOS. Drug and Alcohol Dependence, 57.(2), 99-112.
Fiorentine, R. (1999). After drug treatment: are 12-step programs effective in
maintaining abstinence? American Journal of Drug and Alcohol Abuse, 25(1),
93-116.
Fiorentine, R., & Hillhouse, M. P. (2000a). Drug treatment and 12-step program
participation: the additive effects of integrated recovery activities. Journal of
Substance Abuse Treatment, 18(1), 65-74.
Fiorentine, R., & Hillhouse, M. P. (2000b). Exploring the additive effects of drug
misuse treatment and Twelve-Step involvement: does Twelve-Step ideology
matter? Substance Use and Misuse, 35(3), 367-397.
Flores, P. J., & Georgi, J. M. (2005). Substance abuse treatment: Group therapy
(TIP 41 (DHHS Publication No. (SMA) 05-3991)). Rockville, MD: Center for
Substance Abuse Treatment, Substance Abuse and Mental Health Services
Administration.
Fuller, R. K., & Hiller-Sturmhofel, S. (1999). Alcoholism treatment in the United
States. An overview. Alcohol Health & Research World, 23(2), 69-77.
113
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Galloway, G. P., Marinelli-Casey, P., Stalcup, J., Lord, R., Christian, D., Cohen,
J., et al. (2000). Treatment-as-usual in the methamphetamine treatment
project. Journal of Psychoactive Drugs, 32(2), 165-175.
Gilbert, F. S. (1991). Development of a "Steps Questionnaire". Journal of Studies
on Alcohol, 52(4), 353-360.
Godlaski, T. M., Leukefeld, C., & Cloud, R. (1997). Recovery: with and without
self-help. Substance Use and Misuse, 32(5), 621-627.
Hasin, D. S., & Grant, B. F. (1995). AA and other help seeking for alcohol
problems: Former drinkers in the U.S. general population. Journal of
Substance Abuse, 7(3), 281-292.
Horvath, A.O. & Luborsky, L. (1993). The role of the therapeutic alliance in
psychotherapy. Journal of Consulting and Clinical Psychology, 61, 561-573.
Humphreys, K. (1997). Clinicians' referral and matching of substance abuse
patients to self-help groups after treatment. Psychiatric Services, 48(11),
1445-1449.
Humphreys, K. (1999). Professional interventions that facilitate 12-step self-help
group involvement. Alcohol Research and Health, 23(2), 93-98.
Humphreys, K. (2003). Alcoholics Anonymous and 12-step alcoholism treatment
programs. Recent Developments in Alcoholism, 16, 149-164.
Humphreys, K. & Moos, R. H. (2001). Can encouraging substance abuse
patients to participate in self-help groups reduce demand for health care? A
quasi-experimental study. Alcoholism: Clinical and Experimental Research,
25(5), 71-716.
Humphreys, K., Huebsch, P. D., Finney, J. W., & Moos, R. H. (1999). A
comparative evaluation of substance abuse treatment: V. Substance abuse
treatment can enhance the effectiveness of self-help groups. Alcohol: Clinical
and Experimental Research, 23(3), 558-563.
Humphreys, K., & Moos, R. H. (1996). Reduced substance-abuse-related health
care costs among voluntary participants in Alcoholic Anonymous. Psychiatric
Services, 47, 709-713.
Humphreys, K., & Moos, R. H. (2007). Encouraging post treatment self-help
group involvement to reduce demand for continuing care services: Two-year
clinical and utilization outcomes. Alcoholism: Clinical & Experimental
Research, 31(1), 64-68.
Humphreys, K., Wing, S., McCarty, D., Chappel, J., Gallant, L., Haberle, B., et al.
(2004). Self-help organizations for alcohol and drug problems: toward
evidence-based practice and policy. Journal of Substance Abuse Treatment,
26(3), 151-158.
Kaskutas, L. A., Ammon, L., Delucchi, K., Room, R., Bond, J., & Weisner, C.
(2005). Alcoholics anonymous careers: patterns of AA involvement five years
after treatment entry. Alcoholism: Clinical and Experimental Research,
29(11), 1983-1990.
Kaskutas, L. A., Bond, J., & Humphreys, K. (2002). Social networks as mediators
of the effect of Alcoholics Anonymous. Addiction, 97(7), 891-900.
114
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Kaskutas, L. A., Weisner, C., & Caetano, R. (1997). Predictors of help seeking
among a longitudinal sample of the general public, 1984-1992. Journal of
Studies on Alcohol, 58(2), 155-161.
Kassel, J. D., & Wagner, E. F. (1993). Processes of change in Alcoholics
Anonymous: A review of possible mechanisms. Psychotherapy, 30, 222-234.
Kelly, J. F. (2003). Self-help for substance-use disorders: History, effectiveness,
knowledge gaps, and research opportunities. Clinical Psychology Review,
23(5), 639-663.
Kelly, J. F., & Moos, R. (2003). Dropout from 12-step self-help groups:
prevalence, predictors, and counteracting treatment influences. Journal of
Substance Abuse Treatment, 24(3), 241-250.
Lamb, S., Greenlick, M. R., & McCarty, D. (Eds.). (1998). Bridging the gap
between practice and research: Forging partnerships with community-based
drug and alcohol treatment. Washington, DC: National Academy Press.
Longabaugh, R., Wirtz, P.W., Zweben, A., & Stout, R.L. (1998). Network support
for drinking, Alcoholics Anonymous and long-term matching effects.
Addiction, 93(9), 1313-1333.
Luborsky, L., McLellan, A.T., Woody, G.E., O’Brien, C.P., & Auerbach, A. (1985).
Therapies success and its determinants. Archives of General Psychiatry, 42,
602-611.
Luborsky, L. & DeRubeis, R.J. (1984). The use of psychotherapy treatment
manuals: A small revolution in psychotherapy research style. Clinical
Psychology Review, 4, 5-15.
Maude-Griffin, P. M., Hohenstein, J.M., Humfleet, G.L., Reilly, P.M., Tusel, D.J.,
& Hall, S.M. (1998). Superior efficacy of cognitive-behavioral therapy for
urban crack cocaine abusers: Main and matching effects. Journal of
Consulting and Clinical Psychology, 66(5), 832-837.
McCrady, B. S. (1994). Alcoholics Anonymous and behavior therapy: Can habits
be treated as diseases? Can diseases be treated as habits. Journal of
Consulting and Clinical Psychology, 62(6), 1159-1166.
McKay, J. R., Merikle, E., Mulvaney, F. D., Weiss, R. V., & Koppenhaver, J. M.
(2001). Factors accounting for cocaine use two years following initiation of
continuing care. Addiction, 96(2), 213-225.
McKellar, J., Stewart, E., & Humphreys, K. (2003). Alcoholics anonymous
involvement and positive alcohol-related outcomes: Consequence, or just a
correlate? A prospective 2-year study of 2,319 alcohol-dependent men.
Journal of Consulting and Clinical Psychology, 71(2), 302-308.
Mercer, D. E., & Woody, G. E. (1999). An individual drug counseling approach to
treat cocaine addiction: The Collaborative Cocaine Treatment Study Model.
(Vol. Manual 3). Bethesda, MD: National Institute on Drug Abuse.
Metzger, D.S., DePhillippis, D., Druley, P., O’Brien, C.P., NcLellan, A.T.,
Williams, J., Navaline, H., Dyanick, S., & Woody, G.E. (1992). The Impact of
HIV Testing on Risk for AIDS Behaviors. In: L. Harris (ed.) Problems of Drug
115
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
116
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Nowinski, J., & Baker, S. (1992). The Twelve Step Facilitation Handbook: A
systematic approach to early recovery from alcoholism and addiction. New
York: Lexington Books.
Nowinski, J. & Baker, S. (1998). The Twelve Step Facilitation Handbook. San
Francisco: Jossey Bass.
Nowinski, J., Baker, S., & Carroll, K. (1992). Twelve step facilitation therapy
manual: A clinical research guide for therapists treating individuals with
alcohol abuse and dependence (Vol. 1). Rockville, MD: National Institute on
Alcohol Abuse and Alcoholism.
Obert, J. L., McCann, M. J., Marinelli-Casey, P., Weiner, A., Minsky, S., Brethen,
P., et al. (2000). The matrix model of outpatient stimulant abuse treatment:
History and description. Journal of Psychoactive Drugs, 32(2), 157-164.
Ouimette, P. C., Moos, R. H., & Finney, J. W. (1998). Influence of outpatient
treatment and 12-step group involvement on one-year substance abuse
treatment outcomes. Journal of Studies on Alcohol, 59(5), 513-522.
Owen, P. L., Slaymaker, V., Tonigan, J. S., McCrady, B. S., Epstein, E. E.,
Kaskutas, L. A., et al. (2003). Participation in alcoholics anonymous: intended
and unintended change mechanisms. Alcoholism: Clinical and Experimental
Research, 27(3), 524-532.
Project MATCH Research Group. (1993). Project MATCH: Rationale and
methods for a multisite clinical trial matching patients to alcoholism treatment.
Alcoholism: Clinical & Experimental Research, 17, 1130-1145.
Project Match Research Group. (1997). Matching alcoholism treatments to client
heterogeneity: Project MATCH post treatment drinking outcomes. Journal of
Studies on Alcohol, 58, 7-29.
Rawson, R. A., Shoptaw, S. J., Obert, J. L., McCann, M. J., Hasson, A. L.,
Marinelli-Casey, P. J., et al. (1995). An intensive outpatient approach for
cocaine abuse treatment. The Matrix model. Journal of Substance Abuse
Treatment, 12(2), 117-127.
Room, R., & Greenfield, T. (1993). Alcoholics Anonymous, other 12-step
movements and psychotherapy in the US population, 1990. Addiction, 88(4),
555-562.
Rounsaville, B.J. & Carroll, K.M. (1993). Interpersonal Psychotherapy for drug
users. In: Klerman, G.L. & Weissman, M.M. (eds.) New Applications of
Interpersonal Psychotherapy, 319-352. Washington, DC: American
Psychiatric Association Press.
Rounsaville, B.J., Chevron, E., Weissman, M.M., Prusoff, B.A., & Frank, E.
(1986). Training counselors to perform interpersonal psychotherapy in clinical
trials. Comprehensive Psychiatry, 27, 364-371.
Rozenzweig, S. (1936). Some implicit common factors in diverse methods of
psychotherapy. American Journal of Orthopsychiatry, 6, 412-415.
Shoptaw, S., Rawson, R. A., McCann, M. J., & Obert, J. L. (1994). The Matrix
model of outpatient stimulant abuse treatment: evidence of efficacy. Journal
of Addictive Disease, 13(4), 129-141.
117
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
118
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
119
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009
Appendix
People
Places
Things
(Habits and
Routines)
120
STAGE 12: Recovery Tasks Report
You are responsible for following through on the recovery tasks that
are suggested at the end of our counseling session. Complete this
“Recovery Tasks Report” and bring it to the next session so that we
can review your recovery tasks activity.
1. Mutually agreed upon list of CA, CMA, AA, and NA group meetings to
be attended this week:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
121
Date: __________
B. Twelve Step Recovery (CA, CMA, AA, and NA) meetings attended:
Type of meeting/Topic:____________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Type of meeting/Topic:____________________________________________
What I heard/saw:________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
122
Date:__________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
123
Date: __________
____________________________________________________________
____________________________________________________________
D. “Slips” (Dates that I used drugs or drank alcohol; how much; what I
did about it):
___________________________________________________________
___________________________________________________________
____________________________________________________________
______________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
124
STAGE-12 Recovery Activity: Spirituality Worksheet
Thinking about a Spiritual vs. Non-Spiritual Way of Living
Spirituality has to do with meaning and purpose in life; what it means to be
human, who we are, and why we are here.
It is NOT a set of rules about what is good and bad, right and wrong.
NON-
SPIRITUAL
SPIRITUAL
Competing and
GET THE GOOD LIFE BY…………. Caring and Giving
Getting
Being
Doing
(Who I am as a person)
Being Human
GET SELF-WORTH THROUGH…
(Accepting my limits
Being Perfect
and dependences)
Faithfulness
Success
125
STAGE-12 Resentment Worksheet
WHAT I SHOULD DO
WHAT
HOW I FELT WHAT I DID DIFFERENTLY USING
HAPPENED
PROGRAM TOOLS
126
STAGE-12 Group Session #1
First Step Worksheet
The first step of NA, CA, CMA or AA states “We admitted we were powerless over our
addiction, that our lives had become unmanageable.” Experience has shown that people
who have been able to remain clean and sober have come to terms with this statement as
it applies to their lives. In order to assist you in taking this step, try honestly answering
the following questions in your written journal. After that, discuss these with your
sponsor (if you have one) or your counselor.
The first thing is to admit powerlessness, or, in other words, to say “I can't control my use
of drugs, or the consequences of my use of drugs.”
1. How have drugs placed your life, or the lives of others, in jeopardy?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. What types of physical abuse have happened to you, or others, as a result of your
drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
127
5. How do you feel about yourself for having a drug abuse or dependence problem?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Take an honest look at how the consequences of your drug use has affected you and
others. This is “connecting the dots.” Looking back over your drug use answer the
following questions.
1. What health problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. What family/personal problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. What sexual problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. What legal problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
5. What financial problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
128
6. What work problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
129
COUNSELOR’S SELF RATING ADHERENCE SCALE
FOR STAGE-12 GROUP SESSIONS
130
131
COUNSELOR SELF-RATING ADHERENCE SCALE
FOR STAGE-12 INDIVIDUAL SESSIONS
Self-Rating Individual Session #1
132
Self-Rating Individual Session #2
133
Self-Rating Individual Session #3
134
ADHERENCE SCALE FOR STAGE-12 GROUP SESSIONS
135
136
ADHERENCE SCALE FOR STAGE-12 INDIVIDUAL SESSIONS
Individual Session #1
137
Individual Session #2
138
Individual Session #3
139