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NIDA-CTN-0031 Version 3.

0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009

National Institute on Drug Abuse


Clinical Trial Network

STAGE-12
Stimulant Abuser Groups to
Engage in 12-Step Programs

A Combined Group and Individual


Treatment Program

Version Number: 3.0


April 2009
Stuart Baker, M.A.
Dennis C. Daley, PhD
Dennis M. Donovan, PhD
Anthony S. Floyd, PhD

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Table of Contents

1.0 INTRODUCTION ....................................................................................................... 4

2.0 OVERVIEW OF STAGE-12 MODEL......................................................................... 8

3.0 STIMULANT DRUGS................................................................................................ 9

4.0 APA CLASSIFICATION OF SUBSTANCE USE DISORDERS .............................. 15

5.0 CONTEXT OF STAGE-12 RESEARCH PROTOCOL............................................. 17

6.0 DEVELOPMENT OF STAGE-12 MODEL............................................................... 19

7.0 GOALS AND OBJECTIVES OF STAGE-12 PROGRAM ....................................... 22

8.0 RECOVERY GOALS............................................................................................... 22

9.0 RESEARCH ON 12-STEP INTERVENTIONS......................................................... 24

10.0 ROLE OF 12-STEP PROGRAMS IN TREATMENT AND RECOVERY ............... 26

11.0 EFFECTIVENESS AND EFFICACY OF 12-STEP MUTUAL SUPPORT


PROGRAMS......................................................................................................... 27

12.0 EFFICACY OF INTERVENTIONS TARGETING INCREASED 12-STEP


INVOLVEMENT .................................................................................................... 30

13.0 INTENSIVE REFERRAL (THE “BUDDY” SYSTEM) ........................................... 34

14.0 STAGE-12 AND OTHER TREATMENTS FOR ADDICTION ............................... 37

15.0 STAGE-12 MODEL .............................................................................................. 38

16.0 STAGE-12 IN CONTRAST TO OTHER TREATMENTS ...................................... 41

17.0 APPROACHES MOST DISSIMILAR TO STAGE-12 ........................................... 41

18.0 STAGE-12 INDIVIDUAL SESSIONS.................................................................... 47

19.0 STAGE-12 GROUP TREATMENT SESSIONS .................................................... 56

20.0 STAGE-12 GROUP TOPIC #1: ACCEPTANCE (STEP 1)................................... 63

21.0 STAGE-12 GROUP SESSION #1: FIRST STEP WORKSHEET ......................... 69

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22.0 STAGE-12 GROUP TOPIC #2: PEOPLE, PLACES, & THINGS ......................... 72

23.0 STAGE-12 GROUP TOPIC #3: SURRENDER .................................................... 78

24.0 STAGE-12 RECOVERY ACTIVITY: SPIRITUALITY WORKSHEET ................... 84

25.0 STAGE-12 GROUP TOPIC #4: GETTING ACTIVE ............................................. 85

26.0 STAGE-12 GROUP TOPIC 5: MANAGING EMOTIONS OBJECTIVES.............. 93

27.0 STAGE-12 COUNSELOR SELECTION, TRAINING AND SUPERVISION........ 103

References ........................................................................................................ 111

Appendix ........................................................................................................... 120

COUNSELOR’S SELF-RATING STAGE-12 ADHERENCE SCALES ....................... 130

STAGE-12 ADHERENCE SCALES ......................................................................... 1355

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1.0 INTRODUCTION

1.1 About this Manual


This manual was adapted from: Baker, S. (1998). Twelve-Step Facilitation
Therapy for Drug Abuse. New Haven, CT: Yale Psychotherapy Research
Center, which was adapted from other TSF manuals including Nowinski, J.,
Baker, S., & Carroll, K.M. (1992). Twelve Step Facilitation Therapy Manual: A
Clinical Research Guide for Counselors Treating Individuals with Alcohol
Abuse and Dependence. NIAAA Project MATCH Monograph Series, Volume 1,
DHHS Publication No. (ADM) 92-1893. Rockville, MD: National Institute on
Alcohol Abuse and Alcoholism.
1.2 About STAGE-12
STAGE-12 refers to Stimulant Abuser Groups to Engage in 12-Step Programs.
This is a combined individual and group intervention targeted toward individuals
who have primary or secondary diagnoses of abuse or dependence on
methamphetamine, cocaine, or other stimulant drugs. It incorporates core
treatment sessions from the Twelve-Step Facilitation Therapy for Drug Abuse
and the procedures of the intensive referral process developed and evaluated by
Timko and colleagues (Timko, DeBenedetti, & Billow, 2006; Timko &
DeBenedetti, 2007) that uses members from community-based 123-Step groups
to serve as “buddies” or temporary sponsors. The STAGE-12 intervention has
been designed to be incorporated into intensive outpatient settings; however, it
could equally well be incorporated into other treatment settings such as
outpatient or residential. It could also be useful for clients with substance use
disorders other than or in addition to stimulant abuse or dependence. The
primary goals of STAGE-12 are to increase participants’ attendance at 12-Step
meetings and to increase their active involvement in 12-Step activities. This
increased attendance and engagement is thought to mediate subsequent
reductions in substance use and to facilitate recovery.

1.3 About the Authors


Stuart M. Baker, MA, LADC is the Assistant Director of the Legion Clinic and a
consultant to the Yale University School of Medicine Substance Abuse
Psychotherapy Research Center. Mr. Baker’s research and clinical interests lie
in the area of developing, specifying, evaluating and training behavioral
treatments for substance users and evaluating combinations of psychotherapy
and medications to enhance treatment outcome in the addictions. He has
considerable experience as a clinician, supervisor, consultant, educator and
administrator. Mr. Baker has authored or co-authored several treatment manuals
including the Twelve-Step Facilitation Therapy (TSF) manual used in Project
MATCH and Twelve-Step Facilitation Therapy for Drug Abuse used in a clinical
trial for opiate dependent patients. He has provided numerous training programs
on TSF throughout the U.S. and Canada.

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Dennis C. Daley, Ph.D. is Professor of Psychiatry and Chief of Addiction


Medicine Services (AMS) at Western Psychiatric Institute and Clinic (WPIC) of
the University of Pittsburgh Medical Center. Dr. Daley has been involved in
providing services to individuals with addiction and co-occurring disorders and
their families for nearly 30 years. He has been a researcher, consultant or trainer
in over twelve studies funded by the National Institute on Drug Abuse and the
National Institute on Alcohol Abuse and Alcoholism. Dr. Daley has over 250
publications including books, workbooks and journals on recovery from addiction,
mental illness, co-occurring disorders, relapse prevention, anger management,
and family recovery. He has co-authored several books and treatment manuals
for professionals including one of NIDA’s “Therapy Manuals for Drug Abuse” on
group counseling. He has written materials for children and adolescents as well
as adults. Dr. Daley has written books, guides and videos for families. His
materials are used throughout the U.S. and other countries, and several of his
works have been translated to foreign languages. He and Dr. Donovan co-
authored the interactive guide for individuals in recovery entitled Using 12-Step
Programs in Recovery: For Individuals with Alcohol or Drug Addiction.
Dennis M. Donovan, Ph.D. is the Director of the Alcohol and Drug Abuse Institute,
Professor in the Department of Psychiatry and Behavioral Sciences, and Adjunct
Professor in the Department of Psychology at the University of Washington in
Seattle. He was affiliated with the Addictions Treatment Center at the Seattle
Department of Veterans Affairs Medical Center for over 20 years, involved in
clinical, administrative, training and research activities, most recently serving as
the Associate and Acting Director of the first Center of Excellence in Substance
Abuse Treatment and Education (CESATE) within the Department of Veterans
Affairs. He has over 150 publications in the area of substance abuse and
addictive behaviors and has co-edited and co-authored a number of books. Dr.
Donovan has served as an associate editor and/or as a member of the editorial
boards for professional journals, and as an external peer reviewer for a number
of journals in the area of addictions, psychology, and behavioral sciences. He
has also been a member of the Clinical and Treatment Research Review
Committee of NIAAA and the Behavioral AIDs Research Review Committee of
NIDA. He is a member of a number of national professional organizations and
served as President of the Society of Psychologists in Addictive Behaviors. He is
a Fellow in the Division on Addictions of the American Psychological Association.
Anthony S. Floyd, Ph.D., is a Research Scientist at the Alcohol and Drug Abuse
Institute, University of Washington. He completed pre-doctoral fellowships in
Health Care and Health Policy in the Department of Health Research and Policy,
Stanford University, and in Health Services Research and Development at the
Department of Veterans Affairs, VA Palo Alto Health Care System, and Menlo
Park, CA. He also completed a post-doctoral fellowship in substance abuse
treatment research at the Center for Alcohol and Addiction Studies, Brown
University, Providence, RI. He currently serves as the National Project Director
for the STAGE-12 protocol in the NIDA Clinical Trials Network. He has written
about enhancing alcohol treatment outcomes through aftercare and self-help
groups and has also noted that AA and continuing care services deserve greater

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attention in the treatment of substance abuse disorders, particularly as cost-


effective additions to primary treatment. He is also a co-author with Dr. Donovan
on a chapter, entitled “Facilitating involvement in 12-Step programs,” in Volume
18 of Recent Developments in Alcoholism.

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

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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.

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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.

2.0 OVERVIEW OF STAGE-12 MODEL

2.1 Structure of Treatment Manual


This introductory chapter will provide a review of stimulant drugs and their effects
on patients and families, causes of addiction, and summarize DSM IV symptoms
of stimulant abuse and dependence. Other topics presented in this chapter
include a brief introduction to the National Institute on Drug Abuse’s National
Drug Abuse Treatment Clinical Trials Network (CTN), which is supporting the
research of this model in nine treatment sites throughout the United States; a
description of how we adapted this protocol from Twelve-Step Facilitation
Therapy (TSF) and the Intensive Referral Program (IRP), and details on the
process of developing this protocol as well as goals and objectives of STAGE-12.
For clinicians interested in the research basis of 12-Step interventions, Chapter
Two provides an extensive review of the literature, summarizing results from
multi-site and single site studies. Issues regarding the effectiveness and efficacy
and 12-step programs are discussed as well as the importance of sustainability
once this research project is completed.
Subsequent chapters will describe the format and focus of the three STAGE-12
individual treatment sessions, the five STAGE-12 group treatment sessions, how
clinicians are chosen and trained, and the adherence scale used to rate tapes of
treatment sessions to insure that clinicians are delivering the treatment as it is
intended.
An extensive bibliography and list of readings and other resources are included.
These resources will provide clinicians with pertinent clinical and research
literature as well as other resources related to 12-Step programs.
2.2 Stimulant Problems Significance to Public Health
Abuse and addiction to stimulants such as cocaine or methamphetamine
represent a significant health problem in the United States. Problems with
cocaine became more common in the 1990’s when many individuals became
addicted to crack cocaine, an inexpensive form of cocaine with high addiction
potential. In the past decade, methamphetamine use has increased, which has
also led to more people becoming addicted to this drug. These stimulant drugs
cause much harm for addicted individuals, their families, and society.
Many individuals with stimulant abuse or dependence disorders have other
substance use disorders, medical problems, psychiatric disorders, and

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psychosocial problems. Because of the public health significance of stimulant


problems, this STAGE-12 treatment model has been developed for use in a
multi-site clinical trial throughout the United States. Our belief is that this model
will enable community treatment programs to systematically prepare addicted
patients for “active” participation in 12-Step programs, which in turn will improve
their outcomes regarding drug use and lifestyle change.

3.0 STIMULANT DRUGS


Stimulants are drugs that stimulate the central nervous system (CNS) to produce
an increase in energy, psychomotor activity, a heightened sense of sensory
arousal, pleasure, and euphoria, and a decrease in appetite and the need for
sleep. Like all drugs, stimulant drugs affect judgment, emotions and behavior.
Following is a brief review of cocaine and methamphetamine, two of the most
common stimulants used.
3.1 Cocaine (C, coke, snow, flake, blow, crack)
Cocaine is a very addictive and strong central nervous system stimulant drug that
directly affects the brain. This drug is derived from the coca bush, which grows
primarily in South America. Cocaine is usually sold on the street as a fine, white,
crystalline powder, which can be snorted, sniffed, dissolved in water and injected
with a needle, or converted and smoked in the forms of “freebase” or “crack.”
“Crack” is a cheap form of cocaine that made this drug available to more people.
Crack is a smokable form of cocaine that has been processed with ammonia or
baking soda and water, and heated to remove the hydrochloride from cocaine to
make it smokable. It’s also smoked in combination with marijuana or tobacco.
Street cocaine is often diluted with cornstarch, talcum powder, sugar, procaine (a
local anesthetic) or other stimulants such as amphetamines. Some users mix
cocaine powder with heroin to create a “speedball,” which can be a dangerous
combination of drugs.
The initial high from smoking freebase or crack cocaine may last only 5-10
minutes while the high from snorting may last about 20-30 minutes. The high
from cocaine is characterized by feelings of euphoria, an increase in energy, a
decrease in fatigue, mental alertness or hyper stimulation. The user may also
feel more talkative or sexual, or feel a decrease in appetite or the need for sleep.
Short-term effects of small or moderate amounts of cocaine can lead to
constricted blood vessels, dilated pupils, as well as increased heart rate, blood
pressure and temperature. Some users feel restless, irritable and anxious.
Large amounts can lead to bizarre, unpredictable, erratic or violent behaviors.
Those who use the drug repeatedly may experience tremors, vertigo, muscle
twitches, paranoia or a toxic reaction. Occasionally, death can occur from
cardiac arrest or seizures followed by respiratory arrest.
Long-term effects of use can lead to addiction, restlessness, irritability, mood
disturbances, paranoia, auditory hallucinations, severe cardiovascular effects
(disturbances in heart rhythm or heart attacks), respiratory effects (chest pain or

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respiratory failure), neurological effects (seizures, strokes, or headaches), and


abdominal pain or nausea.

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.

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3.3 Summary of Effects of Stimulants on Functioning


Following is a summary of physical, psychological and social problems that are
common among those with stimulant use disorders:
Physical: withdrawal symptoms may be experienced such as severe craving,
insomnia, restlessness, mental confusion, and depression. Other physical or
medical problems include cardiovascular (e.g., hypertension, arrhythmia’s,
cardiomyopathy, myocarditis, myocardial ischemia, myocardial infarction), head
and neck (erosion of dental enamel, rhinitis, perforation of nasal septum), CNS
(headache, seizures), lung damage, pneumonia, chronic cough, acute renal
failure, sexual dysfunction, spontaneous abortion in the pregnant woman, and
infections (HIV, hepatitis B or C, tetanus) from sharing needles.
Psychological: poor judgment, anxiety, depression, suicidal feelings and
behaviors, insomnia, emotional liability, irritability, aggressive behavior, and
psychotic symptoms. Symptoms of psychiatric disorders such as schizophrenia,
panic disorder, depression, or mania can be triggered or exacerbated by
stimulant use or withdrawal. The neurotoxic effects of methamphetamine include
cognitive impairments and the early onset of movement disorders associated
with aging.
Social/family: damaged or lost relationships, increased risk of child abuse or
neglect, lost jobs, accidents, prostitution, spread of infections, criminal behaviors,
violent behaviors, homicide, and high-risk sexual behaviors (unprotected sex, sex
with strangers, or sex with multiple partners).
As a result of the significant health and social problems caused or exacerbated
by stimulant abuse and dependence, the National Institute of Drug Abuse (NIDA)
is sponsoring a multi-site study of STAGE-12 (STimulant Abuser Groups to
Engage in 12-Step Programs), a psychosocial intervention that integrates group
sessions from Twelve-Step Facilitation Therapy (TSF) with individual sessions
adapted from the Intensive Referral Program (IRP). STAGE-12 is one of the
evidence-based psychosocial treatments whose efficacy is supported by NIAAA
and NIDA clinical trials. Studies also show that addictive individuals who
received IRP reduce substance use more than patients receiving standard care.
Patients receiving IRP also showed higher rates of engagement in 12-step
recovery activities. Chapter 2 of this manual summarizes the research on TSF
and IRP, as well as other 12-step counseling and facilitative interventions that
serve as the basis for STAGE-12.
STAGE-12 is designed to be integrated into an existing ambulatory treatment
program that offers a minimum of 5 hours of addiction treatment per week.
Rather than offer this treatment as an “add-on” to current treatments offered in
these programs, STAGE-12 “replaces” five group and three individuals sessions,
which makes it easy to implement in community treatment programs that offer
Intensive Outpatient, Day Treatment, Partial Hospital, or Evening programs that
offer group treatments. This protocol was developed to help Community

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Treatment Providers (CTPs) offer a systematic approach to facilitate patients’


involvement in 12-Step programs such as NA, CA, CMA or AA.
3.4 Causes of Addiction
Addiction to drugs including stimulants is caused by the interaction of many
factors. No one factor in and of itself can explain why a given individual develops
an addiction to these or other drugs. A biopsychosocial framework takes into
account physical, psychological and social factors that contribute to both the
development, and the maintenance of an addiction to drugs. Factors involved in
the development of an addiction may vary from those that account for the
continuation of an addiction over time.
Addictive drugs and alcohol work on the mesolimbic dopamine pathway or
“reward pathway” of the brain, which is the part of the brain involved in making
food, sex and social interactions pleasurable. This pathway runs from the base
of the brain to the very front of the brain behind the eyes. This pathway
developed to make eating food and engaging in sex rewarding so that these
become important in our lives and we engage in them repeatedly. Regular food
consumption is needed for our health. Sex is needed for reproduction to ensure
continuation of our species.
Drugs such as alcohol, nicotine, cocaine, methamphetamine, morphine, heroin
and marijuana stimulate this same brain system. It is the stimulation of this
reward pathway that makes these drugs “habituating” and causes the addicted
individual to repeat drug use despite negative consequences. The more
frequently this brain system is stimulated by drugs, the more the use of drugs
assumes a central importance in the person’s life, and the more a person “wants”
or “needs” these drugs. With repeated drug use over time, a pattern of behavior
develops in which the use of the drug becomes of central importance in the life of
the addicted person. Friends, family, loved ones, sex, food, work, sports,
hobbies, and other natural rewards then become less important. In a sense, the
brain’s reward pathway gets “hijacked” by drugs, which results in dependence on
drugs. This is why it is so difficult for those addicted to drugs to stop using them
once they exhibit dependency. With abstinence over time in recovery, the brain
has to “reset” itself, so that the natural rewards once again stimulate the reward
pathway as strongly as drugs did in the past. Since this process takes time,
many addicted individuals relapse before their brains have adjusted to living
without drugs.
Another issue is what happens to the normal functioning of the brain when it is
exposed repeatedly and continuously to addictive drugs. The brain engages in
delicate biological processes, which are thrown out of balance by the effects of
drugs used repeatedly. But the brain adjusts itself, so that it gradually returns to
a normal level of functioning despite the impact of the drugs on its natural
physiology. This process of adjustment or adaptation to exposure to drugs is
called “tolerance.” Tolerance involves either a reduction in the effect of drugs
over time, or the need for higher doses of drugs to achieve the same effect.

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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.

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3.5 Narcotics Anonymous (NA) View of Drug Addiction


Mutual support programs such as Narcotics Anonymous (NA) or Alcoholics
Anonymous (AA) view addiction as a chronic, progressive illness, which if not
arrested, may lead to insanity or death. Addiction is characterized by loss of the
ability to control (limit) the use of drugs. Drug addiction is described in the “Basic
Text” of Narcotics Anonymous (1988).

“At first, we were using in a manner that seemed to be social or at


least controllable. We had little indication of the disaster that the
future held for us. At some point, our using became uncontrollable
and anti-social. This began when things were going well, and we
were in situations that allowed us to use frequently. This was
usually the end of the good times. We may have tried to moderate,
substitute or even stop using, but we went from a state of drugged
success and well-being to complete spiritual, mental and emotional
bankruptcy. This rate of decline varies from addict to addict.
Whether it occurs in years or days, it is all downhill. Those of us
who don’t die from the disease will go to prison, mental institutions
or complete demoralization as the disease progresses” (pp. 6–7).

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.

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2. Pragmatism: a belief in doing “what works” for the individual, meaning


doing what ever it takes in order to avoid using the first drug.

4.0 APA CLASSIFICATION OF SUBSTANCE USE DISORDERS


In the DSM-IV-TR, the American Psychiatric Association delineates symptoms
for the following classifications of substance use disorders: intoxication,
withdrawal, abuse, dependence, and substance induced disorders. Each type of
disorder has specific symptoms.
4.1 Intoxication
This refers to a reversible syndrome due to recent ingestion or exposure to
cocaine or methamphetamine. Symptoms of stimulant intoxication include:
1. Clinically significant maladaptive behavioral or psychological changes
that developed during or shortly after the use of stimulants.
2. Two or more the following symptoms develop during or shortly after the
use of stimulants.
a. Tachycardia (an excessively rapid heartbeat) or bradycardia (an
abnormally slow heartbeat rate).
b. Pupillary dilation.
c. Elevated or lowered blood pressure.
d. Perspiration or chills.
e. Nausea or vomiting.
f. Evidence of weight loss.
g. Psychomotor agitation or retardation.
h. Muscular weakness, respiratory depression, chest pain, or cardiac
arrhythmias (abnormal or irregular heartbeats).
i. Confusion, seizures, dyskinesias (an impairment in the ability to
control movements, characterized by spasmodic or repetitive
motions or lack of coordination), dystonias (an abnormal muscle
tone, characterized by prolonged, repetitive muscle contractions
that may cause twitching or jerking movements of the body or a
body parts), or coma.
These symptoms are not due to a general medical condition or better accounted
for by another mental disorder.
4.2 Withdrawal
This is caused by stopping stimulant use after a heavy and prolonged period of
use.
1. It involves a dysphoric mood (e.g., an emotional state characterized by
anxiety, depression, unease, or distress) and two or more of the following
physiological changes within a few hours to several days after stopping
stimulant use:

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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.

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3. A great deal of time is spent in activities necessary to get the substance,


taking the substance, or recovering from its effects.
4. The patient experiences frequent intoxication or withdrawal symptoms
when he or she is expected to fulfill major role obligations at work,
school, or home, or the patient persists in substance use when it is
physically hazardous.
5. Important social, occupational, or recreational activities are given up or
reduced because of substance use.
6. The patient continues substance use despite knowledge of having a
persistent or recurrent social, psychological, or physical problem that is
caused or exacerbated by the use of the substance.
7. The patient develops a marked tolerance--that is, a need for markedly
increased amounts of the substance (at least a 50 percent increase) in
order to achieve intoxication or desired effect--or a markedly diminished
effect with continued use of the same amount.
8. The patient manifests characteristic withdrawal symptoms related to
types of substances used.
9. A substance is often taken to relieve or avoid withdrawal symptoms

5.0 CONTEXT OF STAGE-12 RESEARCH PROTOCOL

5.1 NIDA’s Clinical Trials Network


The current STAGE-12 treatment protocol and clinician manual were developed
for a multi-site clinical trial as part of NIDA’s National Drug Abuse Treatment
Clinical Trials Network (CTN) to help patients with stimulant abuse or
dependence. The CTN comprises 16 Nodes across the United States. Each
Node consists of a Regional Research and Training Center (RRTCs), typically at
an academic research center, which is affiliated with a number of Community
Treatment Providers (CTPs) that serve as sites for the research trials. The CTN
currently has approximately 240 CTP sites representing all types of programs
and levels of care for addiction treatment.
The overall mission of the CTN is to improve the quality of care and outcomes of
drug abuse treatment in community treatment programs throughout the country
using science as the vehicle. Within this context, the CTN has two primary goals:
1. Conduct studies of treatment interventions in rigorous, multi-site clinical
trials to determine effectiveness across a broad range of community-
based treatment settings and diversified patient populations.
2. Transfer the research results to physicians, counselors, other providers
and their patients to improve the quality of drug abuse treatment through
the implementation of evidence-based practices. .

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5.2 Adaptation of Twelve-Step Facilitation Therapy (TSF)


STAGE-12 is a manual-guided brief treatment that adapts interventions from TSF
initially developed for use in psychotherapy research protocols for the treatment
of alcohol abuse and dependence. The initial TSF protocol involved 12-15
individual sessions with an additional 2-3 conjoint sessions if the patient was
married. In the Project MATCH study of alcoholics, TSF was reduced to 8-12
individual sessions, including “Core” sessions that all patients received (e.g.,
Introduction to 12-Step Programs; Step 1, Steps 2 and 3; Getting Active; and
Termination) as well as “Elective” sessions based on each patient’s individual
needs (e.g., The Genogram; Enabling; People, Places and Things; HALT; Steps
4 and 5; and Sober Living). In addition, two “Conjoint” sessions were provided to
patients married or involved in a significant relationship (e.g., Enabling;
Detaching).
Since its initial development, the TSF model has been adapted for the treatment
of drug abuse and dependence, including patients with cocaine and opiate
problems. The content of the sessions was similar to that outlined above with the
addition of two sessions. One session addresses “HIV Risk Reduction” since
patients with drug abuse or dependence may engage in high-risk behaviors
increasing the chances of transmitting or acquiring HIV infection (e.g., sharing
needles or drug paraphernalia or engaging in unprotected sex or sex with
multiple partners). Another session addresses the need to identify and manage
feelings to reduce relapse risk as the inability to manage negative emotional
states is one of the highest relapse risk factors. Emotions addressed include but
are not limited to loneliness, anger, grief, anxiety, resentment and self-pity.
The TSF model has also been adapted for use with families to facilitate their
participation and use of mutual support programs such as Al-Anon or Nar-Anon.
More recently, the TSF protocol has also been adapted for use in group as well
as individual treatment.
TSF is designed for use in early recovery and has two primary goals:
1. Acceptance: help patients accept their addiction as a chronic disease
and accept that this had led to unmanageability.
2. Surrender: help patients surrender and engage in a recovery process
involving a willingness to go beyond oneself and follow a 12-step
program.
5.3 Intensive Referral Program
The Intensive Referral Program (IRP) model was developed primarily to facilitate
addicted patients’ active involvement in 12-Step programs such as AA, NA and
others. While TSF attempts to provide patients with a better understanding of the
principles of 12-step programs, with the expectation that this will increase the
likelihood of attending meetings and getting involved in 12-step activities, the
Intensive Referral Program goes about it in the opposite direction. That is, it
attempts to get patients to attend meetings and get actively involved, with the
expectation that over time they will gain a better understanding of and

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appreciation for the principles of 12-step approaches. The IRP component of


STAGE-12 is provided in three individual sessions, each of which focuses on
helping the patient become involved in 12-Step programs through meeting
attendance, finding a “home” group, getting a sponsor, and “working” the 12-
Steps. These sessions also focus on the patients’ concerns about 12-Step
programs as well as their experiences during participation in IRP sessions. In
addition to reviewing aspects of the 12-step approach and providing the patient
with a list of meetings and their locations and times, the primary method of
facilitating getting patients to attend meetings is the counselor and patient calling
a volunteer from a community-based 12-step program and arranging for the
volunteer to take the patient to a meeting. This individual serves as a temporary
sponsor for the patient, supports their efforts at recovery, explains the purpose
and function of 12-step meetings, and helps them take the initial steps to attend a
meeting. Subsequent sessions with the counselor either explore the patient’s
experiences at the meetings or, if the patient did not attend, the barriers to
attendance. If the patient did not attend, another call is made to a volunteer to
again arrange for the volunteer to take the patient to a meeting. This approach
has been shown to lead to increased attendance and a significantly greater level
of engagement in 12-step activities than standard referral methods by
counselors.

6.0 DEVELOPMENT OF STAGE-12 MODEL


6.1 Protocol Development Team
The current protocol for which this manual has been adapted was developed by
the CTN 0031 (STAGE-12) Protocol Executive Committee (EC), which included
broad representation of the CTN. Members of the CTN 0031 EC included those
from:
1. Regional Research and Training Centers
2. Community Treatment Providers
3. NIDA Center for the Clinical Trials Network (CCTN)
4. The CTN Clinical Coordinating Center (EMMES Corporation)
5. The CTN Data and Statistics Center (Duke Clinical Research Institute)
Conference calls were held among the EC Committee and workgroups weekly or
more often to review in great detail all aspects of the protocol including
background and significance, prior research, various 12-Step interventions (both
counseling and facilitative), assessment batteries, outcome measures, CTP
acceptance of the STAGE-12 protocol, informed consent procedures, budgets,
training, data analysis, and operating procedures.
6.2 STAGE-12 Protocol Development
We developed the STAGE-12 approach based upon an extensive review of the
empirical literature on 12-Step interventions and a survey of Community
Treatment Providers (CTPs) involved in the CTN that offer outpatient

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psychosocial treatment. Research indicates that while most addiction treatment


programs incorporate 12-Step related interventions (education, counseling or
both); this is typically not done in a consistent or systematic manner. The
committee believed that the protocol could easily be adapted in community
treatment settings, which would enable more patients to receive systematic
preparation for active participation in 12-Step programs.
Most of the work done on TSF has used an individual counseling format;
however, the bulk of treatment provided in CTPs is delivered in group settings.
The majority of the 67 CTPs responding to the survey from the Protocol
Executive Committee preferred a treatment protocol that could be provided in
ambulatory treatment groups with several individual sessions added. A protocol
combining individual and group approaches was seen as the most acceptable
approach to use, particularly since most CTPs utilize group treatment as a major
modality of treatment for addicted patients. Our decision was also informed from
findings of the cocaine collaborative multi-site clinical trial, which found superior
outcomes for patients receiving a combination of individual and group sessions
that incorporated the 12-step philosophy of recovery.
The protocol team considered the importance of sustaining the implementation of
this protocol upon completion of the trial. This led to the decision to integrate the
8-session protocol into an existing ambulatory program rather than attempt to
“add” it on to current services. Five STAGE-12 group sessions replace five other
existing group sessions, and three individual STAGE-12 sessions: (one for the
initial session, one at about week three, and one at termination from the STAGE-
12 protocol) will replace three individual counseling sessions from the standard
treatment program. A unique feature of this program is teaming each patient up
with a person in recovery who accompanies the patient to NA or other 12-Step
meetings in the community.
This protocol is designed to be integrated into an existing intensive outpatient,
partial hospital, day or evening primary treatment program for patients with any
type of stimulant abuse or dependence. Therefore, it can easily be incorporated
into an existing program as it is not an “add on” but a “replacement” for select
current group and individuals sessions offered. The rationale of the STAGE-12
group sessions is to provide a systematic review of certain aspects of NA and AA
in order to increase patient understanding, acceptance, and use of these mutual
support programs in their ongoing recovery. The individual IRP sessions also
aim to help the patient become active in NA or other 12-Step programs.
This treatment protocol is appropriate for patients who may have previously
participated in Twelve Step programs such as NA or AA, patients who have
never been exposed to 12-Step programs, and/or patients who may or may not
have had previous treatment for a substance abuse or dependence problem.
The program described in this manual is intended to be consistent with active
involvement in 12-Step recovery programs such as Narcotics Anonymous (NA),
Cocaine Anonymous (CA), Alcoholics Anonymous (AA), and Crystal Meth
Anonymous (CMA). It assumes that addiction is a progressive disease of mind,

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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.

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7.0 GOALS AND OBJECTIVES OF STAGE-12 PROGRAM


The STAGE-12 program has two primary goals, which generally correspond to
the first three Steps of NA, CA, CMA or AA: acceptance of addiction and
surrender.
7.1 Acceptance of Addiction
The breakdown of the illusion that the individual through willpower alone can
effectively and reliably control or limit his/her use of mood-altering substances.
1. Acceptance by patients that they suffer from the chronic and progressive
illness of drug addiction.
2. Acceptance by patients that they have lost the ability to control their use
of mood-altering substances.
3. Acceptance by patients that since there is no effective “cure” for
addiction, the only viable alternative is complete abstinence from all
mood-altering substances.
7.2 Surrender
1. This involves a willingness to reach out beyond oneself and to follow the
twelve steps presented in 12-Step programs.
2. Acknowledgment on the part of the patient that there is HOPE for
Recovery (sustained abstinence), but only through accepting the reality
of the loss of control and by having faith that some HIGHER POWER can
help the individual whose own willpower has been defeated by addiction
to mood-altering substances.
3. Acknowledgement by the patient that the fellowship of NA, CA, CMA or
AA has helped millions of addicts to sustain their recovery, therefore, the
patient’s best chance for success is to follow the path of NA, CA, CMA or
AA.

8.0 RECOVERY GOALS


Recovery is the process of managing the stimulant addiction over time, and
making changes in oneself and one’s lifestyle to support abstinence from drugs.
The two major goals of STAGE-12 are reflected in the following objectives which
are congruent with the NA, CA, CMA and AA view of drug addiction or
alcoholism. These objectives address all major domains of functioning and show
that change is needed in addition to abstinence from substances.
8.1 Cognitive Aspects of Recovery
1. Patients should understand some of the ways in which their thinking has
been affected by drug addiction.
2. Patients should understand how their thinking may reflect denial
(“stinking thinking”) and thereby contribute to continued drug use and
resistance to acceptance (Step 1).

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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.

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8.6 Spiritual Aspects of Recovery


1. Patients should experience hope that they can recover from their drug
addiction.
2. Patients should develop a belief and trust in a power greater than their
own willpower.
3. Patients should explore and re-evaluate their purpose in life.
4. Patients should make a commitment to ethical and moral behavior, and
acknowledge specific immoral or unethical acts, and harm done to others
as a result of their drug addiction.

9.0 RESEARCH ON 12-STEP INTERVENTIONS

9.1 Types of 12-Step Interventions


There are two types of interventions related to 12-Step programs provided in
addiction programs. These include: (1) 12-Step oriented counseling or therapy,
and (2) facilitation of active involvement in 12-Step programs such as NA, CA,
CMA or AA. The main difference between the two is that the latter facilitative
intervention focuses primarily on helping patients engage and actively use 12-
Step programs in the community while the 12-Step counseling or therapy
approaches also deal with many of the common issues facing addicted
individuals in recovery. These issues include, but are not limited to the impact of
addiction on the family, managing social pressures to engage in substance use,
identifying early warning signs of relapse as well as high-risk relapse factors,
addressing other addictions (gambling, sex, internet), or changing lifestyle.
Counseling approaches may also entail helping patients develop specific
recovery “skills” to manage these challenges of recovery. Following is a brief
review of several twelve-step counseling approaches that are described in
treatment manuals.
9.2 Twelve-Step Facilitation Therapy for Alcohol Problems (TSF)
This original version of TSF was developed as a brief, structured treatment by
Nowinski and Baker for use with alcohol problems. This model involved 12-15
individual sessions with single patients, with 2-3 additional sessions with the
patient’s partner for those patients who were married or involved with a
significant other. This TSF model was based on the 12-Step program of
Alcoholics Anonymous (AA). It was subsequently adapted and a manual was
developed by Nowinski, Baker and Carroll for use in Project MATCH, a large,
multi-site clinical trial in the treatment of alcoholism in which TSF was compared
with Cognitive-Behavior Therapy and Motivational Enhancement Therapy. In this
revised version, TSF was delivered in 12 individual sessions, or 10 individual and
2 conjoint sessions for patients with a partner. The goals, structure and content
of TSF were similar in these two variations of TSF.

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9.3 Twelve-Step Facilitation Therapy for Drug Abuse


This model was adapted by Baker and colleagues at the Yale University
Psychotherapy Development Center for use with drug abuse and dependence.
Minor changes were made to reflect recovery needs and issues of patients with
drug use disorders. This TSF approach involved 12 individual sessions and 2
conjoint sessions for patients with partners. Variations of this approach have
been used with cocaine and opioid addiction.
9.4 Twelve-Step Facilitation Therapy for Families (TSF-F)
Nowinski also adapted this model for use with families to address their needs in
recovery since they are often adversely affected by a loved one’s alcoholism or
drug addiction. TSF-F for families was also a brief, structured treatment based
on the 12-Step program of Al-Anon.
9.5 Individual Drug Counseling (IDC)
This model was developed by Mercer and Woody, and used in a large, multi-site
clinical trial of treatment of cocaine use disorders. Three individual treatments
(IDC, Supportive-Expressive Psychotherapy and Cognitive-Behavioral Therapy)
combined with Group Drug Counseling (GDC) were compared to GDC combined
with brief case-management sessions (GDC plus case management was the
control condition for this study).
IDC involved individual sessions twice per week for 3 months, weekly for 3
months, and monthly for 3 months for a total of 42 sessions over a 9-month
period of time. Although IDC was rooted in the philosophy of NA and the 12-Step
recovery model, it addressed many early and middle recovery issues and
focused on learning recovery skills in addition to engaging in 12-Step programs
of recovery. IDC sessions covered a range of topics and issues based on the
individual patient’s problems and concerns. These topics include post-acute
withdrawal symptoms, the use of other drugs and alcohol, managing cravings,
social pressures to use drugs and other high-risk situations, compulsive sexual
behaviors, relationships, relapse prevention, drug-free lifestyle, spirituality,
shame and guilt, personal inventory, character defects, anger management,
relaxation and use of leisure time, employment issues, money management and
the transfer of addiction to “other” behaviors. In this clinical trial, IDC was
combined with weekly Group Drug Counseling (GDC) sessions to provide a
comprehensive outpatient program to patients with cocaine problems.
9.6 Group Drug Counseling (GDC)
This model, developed by Daley, Mercer, and Carpenter for the multi-site cocaine
treatment trial, was also grounded in NA and the 12-Step program of recovery.
GDC involved 24 weekly group sessions. Phase I involved 12 weekly, structured
psycho educational sessions, each focusing on a specific issue or topic related to
addiction or recovery. Issues addressed during these weekly group sessions
included: causes and symptoms of addiction; the process of recovery; managing
cravings, people, places and things; relationships in recovery; self-help groups;

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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.

10.0 ROLE OF 12-STEP PROGRAMS IN TREATMENT AND RECOVERY


Twelve-step oriented mutual support programs such as NA, CA, CMA and AA
represent an important, readily available, and pervasive resource in recovery
from substance use disorders, whether associated with formal treatment or not
(Room and Greenfield 1993; Humphreys 1999; Kelly 2003). Individuals with
substance use disorders can become involved with 12-Step programs before
entering professional treatment, as part of their professional treatment, as
aftercare following professional treatment, or instead of professional treatment
(Fuller and Hiller-Sturmhofel 1999). These mutual support programs, which
include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine
Anonymous (CA), Crystal Meth Anonymous (CMA) and a number of others, are
highly accessible and are available at no cost in communities throughout the
world. For some individuals with substance use disorders 12-Step programs are
the only resource ever used to recover from an alcohol or drug problem (Room
and Greenfield 1993; Hasin and Grant 1995; Kaskutas, Weisner et al. 1997).
Although initiated with alcohol as its primary focus, this philosophy has also been
integrated into the treatment of drug dependence, and there is increasing
evidence to support the potential utility of 12-Step groups with stimulant abusers
(Donovan & Wells, 2006), as in the Group Drug Counseling (GDC) and Individual
Drug Counseling (IDC) approaches developed for treatment of cocaine addicts
(Crits-Christoph, Siqueland et al. 1997; Crits-Christoph, Siqueland et al. 1999;
Daley, Mercer et al. 1999; Mercer and Woody 1999). Participation in 12-Step
programs is also a recommended component in the Matrix Model used in the
treatment of both cocaine and methamphetamine dependence (Shoptaw,
Rawson et al. 1994; Rawson, Shoptaw et al. 1995; Obert, McCann et al. 2000).
Many residential and outpatient treatment programs include 12-Step meetings
on-site and encourage patients to become involved in community-based 12-Step
meetings and activities as part of their ongoing recovery (Fuller and Hiller-
Sturmhofel 1999).
The 12-step philosophy refers to a particular view of the recovery process. It
emphasizes the importance of accepting addiction as a disease that can be
arrested but never eliminated, enhancing individual maturity and spiritual growth,
minimizing self-centeredness, and providing help to other addicted individuals
(e.g., sharing recovery stories in group meetings, sponsoring new members)
(Humphreys, Wing et al. 2004). Self-help programs based on this philosophy
outline 12 Steps those individuals with substance use disorders can use to guide
their recovery process. These Steps specify that addicted individuals must admit
their powerlessness over alcohol and drugs, rely on a Higher Power for help in

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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

11.0 EFFECTIVENESS AND EFFICACY OF 12-STEP MUTUAL SUPPORT


PROGRAMS
There has been an increased focus on 12-step self-help groups by clinicians,
policy makers, and researchers over the recent past. Given cutbacks in funding
for professional treatment, 12-Step programs are seen as an inexpensive and
readily available complement to formal treatment and as a source of support
following treatment (Etheridge, Craddock et al. 1999; Florentine 1999;
Humphreys 1999; Humphreys 2003). Recent efficacy and effectiveness studies
provide support for the effectiveness of 12-Step oriented approaches (Donovan
1999). Generally, these studies have found a positive relationship between 12-
Step involvement and improvement on substance use outcomes for both
alcoholics and drug abusers, even over extended periods of time ranging up to
16 years (Emrick, Tonigan et al. 1993; Montgomery, Miller et al. 1995; Timko,
Finney et al. 1995; Morgenstern, Labouvie et al. 1997; Project Match Research
Group 1997; Watson 1997; Ouimette, Moos et al. 1998; Fiorentine and Hillhouse
2000; Fiorentine and Hillhouse 2000; Weiss, Griffin et al. 2000; McKay, Merikle
et al. 2001; Tonigan 2001; Kaskutas, Bond et al. 2002; Morgenstern, Bux et al.
2003; Moos and Moos 2004; Kaskutas, Ammon et al. 2005; Moos and Moos
2005; Moos and Moos 2006).
Weiss and colleagues found that active involvement in self-help activities (as
opposed to meeting attendance) in a given month predicted fewer days of
cocaine use in the next month (2001; 2005). Patients who increased their
involvement in self-help activities during the first three months of treatment had
significantly fewer days of subsequent cocaine use. The best outcomes were
found among those individuals who received both the 12-step oriented Individual
Drug Counseling (IDC) and Group Drug Counseling (GDC). The combined
effects of being involved in a treatment approach that emphasizes 12-step
involvement plus actual engagement in self-help activities were associated with
the best outcomes.
McKellar and colleagues (2003) reported that research provides increasingly
supportive evidence that 12-step involvement “works;” that is; increased 12-step
meeting attendance and/or involvement lead to a decrease in subsequent alcohol

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and drug use. Attendance at 12-step meetings, whether independent of formal


treatment or as an adjunct to treatment, has also been found to be associated
with reductions in health care costs, particularly those related to subsequent
substance abuse treatment (Humphreys and Moos 1996, 2001, 2007).
Treatment approaches or interventions that are meant to increase engagement in
12-step activities appear to be effective in doing so and, thus, contribute to
positive substance use outcomes through their impact on increasing 12-step
activities and attendance (Carroll, Nich et al. 1998; Humphreys 1999;
Morgenstern, Bux et al. 2003; Weiss, Griffin et al. 2005).
11.1 Meeting Attendance and Engagement in 12-Step Activities
Involvement, rather than attendance, appears to be the better predictor of
substance use outcomes. The greater the level of involvement in 12-Step
activities, the better the outcome for alcoholics and cocaine abusers (Gilbert
1991; Montgomery, Miller et al. 1995; Caldwell and Cutter 1998; Weiss, Griffin et
al. 2000; Weiss, Griffin et al. 2001; Weiss, Griffin et al. 2005). While more people
are attending than are getting involved in the 12-Step programs, regular
attendance may be a precursor for involvement for many of these individuals.
Caldwell and Cutter (1998) found that individuals who attend AA daily in early
recovery are more likely to embrace both the program and fellowship dimensions
of AA, and that those who have dropped out or who attend meetings infrequently
or erratically tend to be less accepting of all aspects of AA. This latter group also
appears to do less well than those who have frequent and consistent attendance
(Morgenstern, Kahler et al. 1996; Weiss, Griffin et al. 2000; Moos and Moos
2004; Kaskutas, Ammon et al. 2005; Moos and Moos 2005). Fiorentine (1999)
found that weekly or more frequent meeting attendance was associated with drug
and alcohol abstinence among patients at outpatient drug treatment programs.
Similarly, Moos (2004) found that more frequent participation in AA (e.g.,
attending two or more meetings per week) during the first year after seeking help
was associated with a higher likelihood of subsequent abstinence at 1- and 8-
year follow-ups. Furthermore, the timing of this attendance was crucial. Early
involvement was important; individuals who delayed participation for a year or
more and then eventually entered AA had outcomes that were no better than
those of individuals who never entered AA. Continued attendance and the
duration of involvement in 12-step activities over time were also important and
were predictive of a broader range of substance use and psychosocial outcomes
than was attendance. Participation in AA had a positive influence on alcohol-
related outcomes over and above the effects attributable to professional
treatment.
These findings suggest that it is important not only to get patients to attend 12-
step meetings, but to do so early after they have sought treatment and to
encourage consistent attendance over time. It is also important to have patients
become actively involved in the 12-step process beyond meeting attendance.
However, interventions that are effective in increasing attendance may be
insufficient to ensure active involvement. Caldwell and Cutter (Caldwell and

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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

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oriented programs had significantly higher rates of substance abstinence at the


follow-up than did those in cognitive-behaviorally oriented programs (Ouimette,
Finney et al. 1997), a finding consistent with Project MATCH (Project Match
Research Group 1997; Donovan 1999). The greater a program’s emphasis on
12-step approaches, the stronger the positive relationship between 12-step
participation and better substance use outcomes. Also, 12-step oriented
programs and those having a higher percentage of staff in recovery were more
likely to make referrals to 12-Step programs than were cognitive-behavioral or
eclectic programs (Humphreys 1997). Thus, it appears possible to enhance the
attendance at and effectiveness of 12-step self-help groups, particularly when
involved in a formal treatment program that has a strong 12-step orientation
(Humphreys, Huebsch et al. 1999; Fiorentine and Hillhouse 2000; Fiorentine and
Hillhouse 2000). This finding is consistent with that of Weiss, et al. (Weiss 2005)
who reported that the combined effects of being involved in a treatment that
emphasized 12-step involvement plus actual engagement in self-help activities
was associated with the best clinical outcomes for cocaine addiction.

12.0 EFFICACY OF INTERVENTIONS TARGETING INCREASED 12-STEP


INVOLVEMENT

12.1 Single Site Studies


Results of single-site trials have been equivocal related to the relative efficacy of
interventions targeting 12-step engagement compared to other types of treatment
such as cognitive-behavioral therapy with respect to substance use outcomes.
Wells et al. (1994) found that an outpatient "recovery support group" for cocaine
addicts that was based on the 12-steps of AA and focused on the first three of
the 12 steps (acceptance, higher power, and surrender) had substance use
outcomes both during the treatment period or at a 6-month follow-up that were
comparable to those in a group-based relapse prevention intervention. Given
similar findings that the outcomes of TSF were equal to or better than those seen
with relapse prevention in an aftercare setting, Brown et al. (2002) concluded that
the adoption of well-supervised and structured TSF inspired programs seems a
reasonable strategy for most patients.
Carroll and colleagues (1998) found that self-help involvement during treatment
was significantly higher for patients assigned to TSF compared to those assigned
to CBT or clinical management. Furthermore, 58% of all participants reported
attending at least one AA or self-help meeting over the follow-up period. Both
TSF and CBT were associated with substantial and significant reductions in
alcohol and cocaine use over the course of the 12-week treatment period
compared to the clinical management condition. Carroll and colleagues (1998;
2000) also found that participants who attended any self-help groups, regardless
of treatment condition, had significantly better cocaine outcomes during follow-up
than those who did not attend these programs.

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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

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as getting and using a sponsor. Overall, patients in all treatment conditions


reduced their cocaine use significantly; however, those in the combined
GDC+IDC conditions reduced their cocaine use significantly more and did so
more rapidly than those in the other conditions (Crits-Christoph, Siqueland et al.
1999). The combined GDC+IDC condition had the highest rates of 12-step
attendance and involvement. The incremental benefit of adding Individual Drug
Counseling to Group Drug Counseling was notable. Patients in the GDC-only
condition reported attending fewer 12-Step meetings compared to the combined
GDC+IDC condition.
12.3 Treatment as Usual and Twelve Step Facilitation Are Not the
Same
The fact that a program or a counselor indicates that treatment is guided by 12-
step philosophy does not necessarily mean that 12-step practices, let alone 12-
step facilitation practices, are actually being employed. STAGE-12 therapy is
quite different from 12-step referral methods typically found in substance abuse
programs.
Humphreys and colleagues (2004) report that there are few “pure” 12-step
treatment programs or practitioners. Rather, most are likely to incorporate an
eclectic perspective, blending 12-step, cognitive-behavioral, and other
philosophies and techniques. Even practitioners who describe themselves as
“12-step oriented” typically consider only a subset of 12-step processes important
for patients. Thus, even having treatment with a 12-step program philosophy and
counselors that encourage 12-step involvement may not be sufficient to increase
12-step involvement and activities; a systematic, manually guided 12-step
facilitative intervention and treatment-as-usual are not equivalent.
Morgenstern and colleagues (2001) studied community-based intensive
outpatient treatment programs (IOP). The programs were described as having a
12-step orientation, a focus on overcoming denial, an emphasis on facilitating
involvement with self-help groups, the provision of education about the disease
of addiction, and an emphasis on the need for abstinence. All of these are
viewed as 12-step-oriented treatment components. However, based on
monitoring of program content, only one of these treatment elements,
encouraging involvement with self-help groups, was observed to be occurring.
Other 12-step activities, including discussing the disease concept of addiction,
encouraging 12-step recovery, invoking the concepts of spirituality and higher
power, and exploring the patient’s denial, were even less frequently employed.
Galloway and colleagues (2000) found a high degree of variability in the extent to
which attendance at 12-step meetings was required as part of treatment by
community-based programs involved in the CSAT-funded multi-site trial of
treatment for methamphetamine abuse.
One of the recommendations of an expert consensus panel (Humphreys, Wing et
al. 2004) is that community-based treatment programs, even those that label and
represent themselves as “12-step oriented,” should evaluate whether their

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current program practices actively support involvement in 12-step self-help


groups. Further, they also should examine the methods employed by their
counselors in this regard. Typically, they noted, when counselors do attempt to
support 12-step self-help group involvement in TAU, they rarely use empirically
supported methods. When clinicians use empirically validated techniques to
support mutual help group involvement, it is far more likely to occur (Humphreys
1999).

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12.4 Briefer 12-Step Interventions to Fit Current Practice Issues of


Sustainability
Humphreys believes that in order to make 12-step facilitative interventions more
useful in clinical practice, researchers and clinicians should develop and evaluate
briefer forms of such interventions. The current STAGE-12 protocol was
developed as a briefer intervention that can easily be sustained in community
treatment programs that offer levels of care such as intensive outpatient or partial
hospital programs. This protocol can easily be integrated into an existing
program’s structure without requiring significant changes that would create a
burden for clinical staff.

13.0 INTENSIVE REFERRAL (THE “BUDDY” SYSTEM)


An approach that is both consistent with the recommendation for developing
briefer 12-step facilitative interventions and related to the 12-step recovery model
involves the use of 12-step members serving as a “bridge” between formal
treatment and individuals’ entrance into a 12-step program. It has been a
common practice in many treatment programs to use AA or NA members who
serve as volunteers in a “buddy system” or as temporary sponsors (Blondell,
Looney et al. 2001; Collins and Barth 1979; Chappel and DuPont 1999). This is
consistent with the pamphlet, available on-line from Alcoholics Anonymous
(http://www.alcoholics-anonymous.org/en_pdfs/p-49_BridgingTheGap.pdf),
entitled “Bridging the Gap between Treatment & AA through Temporary Contact
Programs.” It provides guidelines for 12-step community members to serve as
the temporary “buddy” or sponsor to help facilitate the transition of clients from
treatment into the community. Patients who have engaged in 12-step activities
through the efforts of such volunteers have credited the peer intervention as
being the most important factor that motivated them to seek help for their
substance use disorder. When recovering alcoholics and drug addicts provide
help to a substance-abusing patient, they are also furthering their own 12th-step
work. Furthermore, such interventions are relatively simple, practical, involve
little or no costs, and pose little patient risk (Blondell, Looney et al. 2001).
One form of such a voluntary “buddy system” intervention is “Systematic
Encouragement and Community Access” (SECA), an intensive referral procedure
developed by Sisson and Mallams (Sisson and Mallams 1981). In addition to
suggesting that the patient attend 12-step meetings and providing a printed list of
meeting times and locations, the counselor arranges an in-session telephone call
to a current member of a 12-step group, who talks to the patient briefly and
arranges to attend a meeting with him or her. The 12-step group member
contacts the patient with a reminder telephone call the night before the meeting,
and drives the patient to the meeting. Timko and colleagues (Timko,
DeBenedetti et al. 2006; Timko and DeBenedetti, 2007) have recently completed
a large randomized trial evaluating a manualized 3- session version of this
intensive 12-step referral procedure with individuals entering outpatient
substance abuse treatment. In comparison to the two participating clinics’

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standard referral procedure (e.g., encouraging meeting attendance and providing


list of meetings and times), the intensive referral to 12-step meetings resulted in
significantly greater engagement in 12-step activities (doing service work, having
experienced a spiritual awakening, and overall involvement), greater reductions
on the alcohol and drug use composite scores of the Addiction Severity Index,
and higher rates of abstinence from drugs over a 6-month follow-up period.
13.1 12-Step Interventions Delivered in Group Format
One approach that may be more sustainable with respect to both clinical service
delivery and reimbursement models than individually administered STAGE-12 is
the provision of 12-step facilitative interventions in a group setting. Group
formats represent the modal form of delivery of addiction treatment services
(Stinchfield, Owen et al. 1994; Brook and Spitz 2002; Weiss, Jaffee et al. 2004;
Flores and Georgi 2005). Treatment programs provide group treatment because
of its cost-efficiency and perceived effectiveness at engaging patients and
bringing about abstinence or reduced drug use. Further, groups may involve a
number of “curative factors” that facilitate behavior change and the acquisition
and maintenance of abstinence. Such factors include knowing that one is not
alone, giving and receiving support, instilling hope, learning from others’
experiences and from interacting with others; learning to communicate feelings
and needs more effectively, making sense of one’s own experience through
interaction with similar others, and confronting problematic behaviors, such as
denial, manipulativeness and grandiosity (Stinchfield, Owen et al. 1994; Flores
and Georgi 2005).
These mechanisms of change associated with group therapy may well be
operative in 12-Step programs (Kassel and Wagner 1993). However, for a
number of logistical, methodological, and statistical reasons, addiction
researchers have not focused on evaluating group treatment to the extent that it
has been studied in other areas of behavioral health (National Institute on Drug
Abuse 2003). This constitutes a major gap between addiction research and
clinical practice (Lamb, Greenlick et al. 1998).
The results of controlled trials of group therapy with substance abusers, in
general, have been equivocal (Weiss, Jaffee et al. 2004). However, as noted
above, the results of Wells and colleagues (1994) and Brown and colleagues
(Brown, Seraganian et al. 2002a, 2002b) indicated that 12-step oriented
interventions delivered in a group format were comparable to more well-
established, empirically supported relapse prevention groups with respect to
substance use outcomes. These findings suggest the viability of group-based
approaches to 12-step facilitative interventions. Further, the results of the NIDA
Collaborative Cocaine Treatment Study suggest that group based 12-step
approaches may be enhanced further by the addition of individual sessions that
reinforce and augment the 12-step emphasis provided in groups.

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13.2 Summary and Rationale


William Miller, serving as a discussant for a symposium on AA involvement and
change mechanisms (Owen, Slaymaker et al. 2003), provided the following
conclusions about the current status and future direction of research and clinical
practice in this area (p.531):
• AA cannot be ignored in understanding treatment outcomes. At the very
least, studies should carefully inquire about AA involvement, to examine
its relationship to treatments and outcomes.
• It is possible to facilitate AA attendance. Without question, there are
counseling procedures that significantly increase AA attendance, at least
during and often after treatment. TSF therapy clearly did this in Project
MATCH. Systematic encouragement can significantly increase
attendance.
• Treatment is the time to initiate AA attendance. If AA attendance is not
initiated during the period of treatment, it is quite unlikely to happen.
Treatment, then, is a good time to encourage sampling of the program and
meetings of AA.
• Attendance is not involvement. When frequency of AA meeting attendance
is measured separately from behavioral indicators of involvement in the
program and fellowship of AA, the two measures are moderately
correlated. In fact, among more frequent AA attendees during Project
MATCH treatment, AA attendance declined over the course of follow-up
while AA involvement remained steady or increased. This suggests a
gradual process of internalization of the AA program and surely indicates
that conclusions cannot be drawn from attendance alone.
• AA involvement predicts better outcomes. Longitudinal studies usually,
although not always, find that AA involvement after treatment is
associated with higher rates of abstinence regardless of the kind of
treatment received. When AA attendance and AA involvement are both
measured, the latter tends to be the stronger predictor of outcome.
Miller’s conclusions about AA, as well as the empirical findings on which they are
based, have helped shape the present protocol that will focus on a broader range
of 12-Step programs. It will evaluate the impact on substance use of a combined
group and individual treatment approach for stimulant abusers. Specifically, the
present approach is based on the TSF therapy from Project MATCH as modified
for use with drug abusers (Baker 1998) and delivered in a group format (Brown,
Seraganian et al. 2002; Brown, Seraganian et al. 2002). These group sessions
will be augmented by three individual sessions, two of which are drawn from the
STAGE-12 manual, into which are integrated action-oriented interventions
derived from the intensive referral procedure of Timko, et al. (2006) as a means
of increasing involvement in 12-step activities and meeting attendance. This
combined group plus individual approach is named STAGE-12 (STimulant
Abuser Groups to Engage in 12-Step programs).

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Twelve-step programs serve as cost-effective resources that complement,


support, and extend the cognitive and behavior changes made in treatment
(McCrady 1994). However, given the low rates of involvement in and high rates
of attrition from 12-step programs, it is necessary to evaluate methods to help
substance abusers and treatment programs take full advantage of self-help
groups (Humphreys 1999). Implementation of systematic, structured, and
manual-guided 12-step programs, integrated within treatment, represents one
such method to increase engagement and retention in professional treatment.

14.0 STAGE-12 AND OTHER TREATMENTS FOR ADDICTION


14.1 Treatment for Addiction
Many efficacy and effectiveness studies sponsored by the National Institute on
Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism
(NIAAAA) have been conducted on psychosocial, pharmacotherapy and
combined treatment approaches for drug abuse or dependence and alcohol
abuse or dependence. This research has led to the establishment of a significant
evidence-base for effective treatment of drug or alcohol abuse and dependence.
Many of the psychosocial treatments for drug addiction are described in NIDA’s
Therapy Manuals for Drug Addiction series, and effective treatments for
alcohol problems are described in the NIAAA’s Clinical Research Guides for
Counselors. Several treatment approaches such as Twelve-Step Facilitation
Therapy and Motivational Interviewing have been used with both drug and
alcohol use disorders.
These evidence-based psychosocial treatment approaches include:
1. Cognitive and behavioral therapies
2. Coping and social skills training
3. Community reinforcement approach
4. Integrated treatment for substance use and co-occurring psychiatric
disorders
5. Family and marital therapies
6. Individual drug counseling
7. Group drug counseling
8. MATRIX model of recovery from cocaine and methamphetamine
disorders
9. Motivational enhancement therapy
10. Motivational interviewing
11. Twelve-step facilitation therapy
In addition, there are many effective pharmacotherapies for alcohol, nicotine and
opioid addiction. These include medications used to manage withdrawal
syndromes, as “replacement” medications for addiction to drugs like heroin or
other opioid, and to reduce cravings and relapse risk. Medications are usually

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used in conjunction with psychosocial therapies in the treatment of drug or


alcohol addiction. Following are the most common medicines used to help
individuals in recovery manage their addiction:
1. Alcohol: Disulfiram (Antabuse), Acamprosate (Campral), Naltrexone oral
(ReVia) and injections (Vivitrol).
2. Opioids: Methadone, Naltrexone, Buprenorphine (Buprenex, Suboxone
and Subutex).
3. Nicotine: Buproprion SR (Zyban), nicotine replacement therapy,
Clonidine (Catapres), Varenicline (Chantese).
4. Cocaine: Disulfiram (Antabuse), Topiramate, Modafinil (Provigil),
Propranolol (Inderal), Naltrexone, Baclofen (Lioresal), TA CD (Cocaine
Vaccine).

15.0 STAGE-12 MODEL


15.1 Active Ingredients: Counselor Behaviors Prescribed and
Proscribed
All behavioral or psychosocial treatments include common factors as well as
unique factors or active ingredients (Strupp & Hadley, 1979). Common factors
refer to dimensions of treatment that are shared across most psychotherapies.
These common factors include the provision of education, a convincing rationale
for the treatment, enhancing expectations of improvement, provision of support
and encouragement, and in particular, the quality of the therapeutic relationship
(Rozenzweig, 1936; Castonquay, 1993). A positive therapeutic relationship, or
alliance, has repeatedly been associated with better outcome in a range of
psychotherapies (Horvath & Luborsky, 1993), including substance use (Luborsky
et al., 1985; Carroll, Nich & Rounsaville, 1997; Connors, et al., 1997; Barber, et
al., 2001). A positive working relationship is an essential component of virtually
all therapies, yet, by itself, is not necessarily sufficient to produce change.
Unique factors refer to a treatment’s active ingredients, or those techniques and
interventions that distinguish or characterize particular psychotherapies. While
common factors are shared, unique factors might include transference
interpretations in psychodynamic psychotherapies or invoking the “Twelve
Steps,” as in STAGE-12
STAGE-12, like most therapies, consists of a complex combination of common
and unique factors. For example, in STAGE-12 mere delivery of factual
information about 12-Step program tools without grounding in a positive
therapeutic relationship may lead to a dry, overly didactic psycho-educational
approach that alienates or bores patients and ultimately has the opposite effect
of what was originally intended. It is important to recognize that STAGE-12 is
thought to exert its effects through this intricate interplay of common and unique
factors and a major task of the counselor is to achieve appropriate levels of
balance between delivering the information about 12-Step recovery tools and
attending to the relationship. For example, without a solid therapeutic alliance, it

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is unlikely that a patient will either stay in treatment, be sufficiently involved to


learn the use of 12-Step recovery tools, or to share successes and failures in
trying to apply these tools to living. Rather, empathic delivery of knowledge
about recovery tools to help the patient manage his/her life more effectively, with
the counselor giving the message of, “I see you really struggling with craving.
These are some suggestions of effective ways that others have used to deal with
it,” may form the basis of a strong working alliance. To specify STAGE-12 in
terms of its active ingredients and to clarify the range of counselor interventions
that are consistent and inconsistent with this approach, STAGE-12 interventions
will be described in terms of the system recommended by Waltz and colleagues
(1993): First, STAGE-12’s essential and unique interventions, that is, the active
ingredients that are specific and unique to STAGE-12; second, STAGE-12’s
recommended interventions, those that are thought to be active and important,
but which are not necessarily unique to STAGE-12; third, interventions,
behaviors, or processes that are acceptable within the therapy but are not
essential or unique; and finally, interventions, behaviors, or processes that are
proscribed, or not consistent with this approach.
15.2 Essential and Unique Interventions
In STAGE-12, the active ingredients which distinguish it from other substance
abuse treatments and that must be delivered in order to adequately expose the
patient to STAGE-12 include:
1. Taking a drug history (or reviewing the history collected as part of the
standard clinic intake process), identifying positive and negative
consequences of drug use, and giving feedback as ground work to
Step 1.
2. Providing education about: Steps 1, 2, and 3 of the 12-Step programs;
the Process of Denial as it relates to the Grief Process; the 12-Step
program view of addiction as a disease; the principles of recovery in 12-
Step programs.
3. Examination of the patient’s “stinking thinking” about substance use and
suggesting the use of slogans and the Serenity Prayer as tools to change
this.
4. Exploring discrepancies between the patients’s stated goals and actions
in terms of denial.
5. Identification of “People, Places, and Things” that could trigger drug use
and identification of “People, Places, and Things” that support recovery.
6. Encouraging patients to actively work the “Twelve Steps” as the primary
goal of treatment.
7. Supporting the point of view that the best chance of staying clean over
the long run is if you accept the loss of control over drugs, and reach out
to fellow recovering drug abusers through the 12-Step programs.

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15.3 Recommended but Not Unique Interventions


Interventions or strategies that should be delivered during the course of each
patient’s treatment, but are not necessarily unique to STAGE-12 include:
1. Discussing, reviewing, reformulating the patient’s goals for group or
individual treatment
2. Monitoring drug use and craving
3. Monitoring general functioning
4. Exploring positive and negative consequences of drug use
5. Exploring the relationship of affect and drug abuse
6. Providing feedback on urinalysis results
7. Setting an agenda for the individual session
8. Covering content of group sessions based on session topic
9. Identifying alternative activities to replace drug use
10. Making group process comments as indicated
11. Discussing the advantages of abstinence as the goal of treatment
12. Exploration of patients’ commitment to abstinence
13. Supporting patient efforts to recover
14. Explaining the difference between a lapse and a relapse
15.4 Acceptable Interventions
Interventions that are not required or strongly recommended in the delivery of
STAGE-12 but are compatible with this approach include:
1. Eliciting concerns about substance use and consequences
2. Self-disclosure by the counselor regarding their recovery status
15.5 Proscribed Interventions
Interventions that are not consistent with STAGE-12:
1. Functional analysis of substance use
2. Coping skills training
3. Practice of skills during sessions
4. Exploration of interpersonal aspects of substance use
5. Exploration of patient‘s underlying conflicts or motives
6. Provision of reinforcement for abstinence (e.g., vouchers, tokens)
15.6 Compatibility with Adjunctive Treatments
This manual describes STAGE-12 for stimulant abuse or dependence as a short-
term, combined individual plus group, stand alone intervention that can be
integrated into ambulatory treatment programs. However, STAGE-12 is
compatible with various other approaches and treatments that address a wide
range of co-morbid problems and severity of the disorder. These include
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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.

16.0 STAGE-12 IN CONTRAST TO OTHER TREATMENTS


It is often easier to understand what a treatment is in terms of what it is not. This
section discusses STAGE-12 for drug abuse and dependence in terms of its
similarities and differences with other psychosocial treatments for substance
abuse.
16.1 Approaches Most Similar to STAGE-12
STAGE-12 for drug abuse and dependence is similar to TSF for Alcohol Abuse
and Dependence that was developed for Project MATCH (Nowinski, Baker &
Carroll, 1992) and TSF for Drug Abuse and Dependence developed for the Yale
University Psychotherapy Development Center (Baker, 1998). These treatments
share the same goal: the active use of 12-Step programs as a means for the
patient to remain drug free and using the 12-Step program to facilitate long-term
recovery. While the techniques employed by both approaches are very similar,
changes in TSF for Drug Abuse and Dependence reflect differences in the
resources that are drawn upon for help (e.g., a greater focus on Narcotics
Anonymous readings and material rather than Alcoholics Anonymous ratings and
material). Also, while these previous versions of TSF have been developed and
delivered as individual counseling, STAGE-12 is primarily a group-based
intervention that is augmented by brief individual sessions.
Sometimes counselors and patients mistakenly confuse 12-step facilitative
interventions such as TSF and STAGE-12 with 12-step support groups. They
are not the same. TSF and STAGE-12 are formal, systematic, manualized
counseling approaches, the goal of which is to facilitate patients’ involvement in
community-based 12-step meetings and activities.

17.0 APPROACHES MOST DISSIMILAR TO STAGE-12


While it is important to recognize that all psychosocial treatments for drug abuse
share a number of features and may overlap and closely resemble one another
in several ways, there are some approaches that are more dissimilar to STAGE-
12.
17.1 STAGE-12 vs. Cognitive-Behavioral Therapy (CBT)
STAGE-12 and other disease model approaches are dissimilar from CBT, or
learning model approaches, in a number of ways. STAGE-12 is grounded in the
concept of drug addiction as a spiritual and medical disease. The content of this
treatment is consistent with the Twelve Steps of NA, CA, CMA or AA, with the
primary emphasis given to Steps 1 through 3. In addition to abstinence from all
psychoactive substances, patients are actively encouraged to attend self-help

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meetings and to maintain journals of their 12-Step group attendance and


participation. While STAGE-12 and CBT share some concepts, for example the
similarity between STAGE-12’s people, places, and things, and CBT’s high risk
situations, there are a number of important differences. STAGE-12 is grounded
in a conception of addiction as a disease that can be controlled but never cured.
CBT views addiction as a learned behavior that can be modified.
While learning model approaches emphasize self-control strategies, STAGE-12
emphasizes the patient’s acceptance of loss of control over substance use and
other aspects of life due to the disease of addiction, and a willingness to follow
suggestions from 12-Step programs to recover from addiction. With CBT-like
models, the focus is on what the patient can do to recognize the processes and
habits that underlie and maintain substance use, and what can be done to
change them. The major change agent in STAGE-12 is involvement in the
fellowship of 12-Step programs such as NA, CA, CMA or AA and working the 12
Steps. STAGE-12 assists the patient in overcoming his/her resistance to
accepting help and suggestions. Behavioral learning approaches teach coping
skills to replace old, unsuccessful coping strategies the patient may have used in
the past (i.e., using drugs to deal with negative affect.) Contrasts between
STAGE-12 and CBT are also found in the table below.
17.2 STAGE-12 vs. Interpersonal Therapy (IPT) and Supportive-
Expressive Therapy (SET)
STAGE-12 is also different from Interpersonal Psychotherapy (IPT) (Rounsaville
& Carroll, 1993) and Supportive-Expressive (SET) Therapy (Luborsky, 1984), a
brief, dynamic form of therapy. IPT is based on the concept that substance
abuse and dependence are intimately related to disorders in interpersonal
functioning that may be associated with the onset or perpetuation of the disorder.
IPT for substance dependence has four definitive characteristics: (1) adherence
to a medical model of treatment, (2) focus on the patient’s difficulties in current
interpersonal functioning, (3) brevity and consistency of focus, and (4) use of an
exploratory stance by the counselor that is similar to that of supportive and
expressive therapies.
IPT and SE differ from STAGE-12 in several ways: STAGE-12 is a structured
approach, whereas IPT and SET are more exploratory. Extensive efforts are
made in STAGE-12 to teach and encourage the patient to use the tools of 12-
Step programs to address substance use as the primary problem, while the more
exploratory approaches view substance use as a symptom of other difficulties
and conflicts. As a result, substance abuse may not receive direct attention.
Contrasts between IPT and STAGE-12 are summarized found in the table below.

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Contrasts Between STAGE-12 and Other Psychosocial


Treatment
TSF and STAGE-12 Cognitive-Behavioral
(CBT)
Goals of Encourage patient to accept Help patient master coping
Treatment the diagnosis of addiction behavior as effective
and understand addiction as alternative to drug use.
a progressive, fatal disease. Increase patient's self-
Facilitate patient's integration efficacy.
into NA, CA, CMA or AA.

Approach Agent Medical/disease oriented Behavioral treatment.


of Change treatment. Mastery of skills
Fellowship/Higher Power
Labeling Labeling patient as addict is Labeling discouraged;
encouraged, as this label drug abuse/dependence is
provides the framework for conceived as over learned
the treatment. Acceptance behavior that can be
of the diagnosis is broken down into a finite
necessary; it determines a set of discrete problem
set of symptoms (e.g., loss of situations and behaviors.
control, denial) and the steps
required for recovery.
Control Emphasis on loss of control. Emphasis on self-control.
Patient cannot control drug Patient makes decisions
use; as s/he has the disease, regarding drug use over
addiction, which s/he is which s/he has control.
powerless to control. Patient Patient can learn to
can control whether s/he has understand and better
the next run, whether or not control the decision-
s/he uses NA/AA, whether or making process. Patient
not patient harbors the idea can exert self-control by
that s/he can control drug choosing to engage in
use. alternative behaviors.

Responsibility Patient responsible for own Patient responsible for


sobriety, by working the 12- own behavior. Emphasis
Step program. on enhancing self-efficacy
through skills training.

Conception of Because of disease Craving as conditioned


Craving processes, patient's body will response. Craving can be
crave drugs periodically. coped with and reduced
First use will trigger craving. through stimulus control,
urge control, etc.

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Motivational Interpersonal Therapy


Enhancement (MET) (IPT)

Goals of Maximize patient's Help patient develop more


Treatment motivation and productive commitment to
interpersonal problems change his/her strategies
associated with drug use. for dealing with social and
drug use.
Approach Motivational Brief dynamic
Agent of Patient Treatment
Change Readiness for change Acquisition of alternate
strategies for meeting
interpersonal needs
Labeling Labeling is strongly Labeling strongly
discouraged; alternative discouraged; drug use seen
conceptions of drug use are as highly individualized and
accepted/encouraged. related to interpersonal
context.
Control Emphasis on choice. Emphasis on self –control
Patient has full control over and the function that drug
decision to alter drug use. use serves for the patient.
Symptom of drug use seen
as a method of controlling
environment and others to
get needs met.
Responsibility Patient responsible for own Patient responsible for own
choices. Emphasis on behavior. Exploration of
autonomy, self-efficacy. own role in interpersonal
relationships.
Conception of Patient free to develop and Signal of unresolved
Craving capable of developing interpersonal problem.
strategies for dealing with Patient should begin to
craving on his/her own. translate what triggered
craving into underlying
interpersonal problem.

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TSF and STAGE-12 Cognitive-Behavioral (CBT)

Strategies Remember last run. Addiction is Positive/negative consequences


Addressing a disease that motivates denial, of decisions to use or stay
Ambivalence educate patient re sinister abstinent. Instill belief that
and Motivation aspects of disease. Current effective coping will provide
problems attributed to disease. alternatives to drug use.
Patient's External, uniform approach. Individual approach.
Response to Use NA/AA social network (call Develop and use individualized
Substance Use sponsor, go to a meeting). set of coping strategies
Remember slogans (eschews (challenge cognitions, problem-
alternative strategies, because of solve, etc.).
denial). Examine antecedents,
“Do not think you can control the behaviors, and consequences.
consequences of use.” “You can learn skills to avoid
lapses and prevent lapses from
becoming relapse.”
Coping NA/AA fellowship/network Individualized set of strategies,
Behaviors constitutes a ready-made set of generalizable problem-solving
strategies and the one preferred approach. Specific training in
solution. drug refusal skills, urge control,
altering cognitions, emergency
planning, etc.
Cognitions Generally interpreted as Identified, examined, and
evidence of denial, e.g., "stinking challenged; encourage
thinking". alternative
perceptions/cognitions.
Handling Confrontation of denial, Application of problem-solving.
Resistance exhortation of acceptance of Reinforcement of even minimal
addiction. positive steps.
Reduce enabling, facilitate Reinforce positive behavior
Role of
detaching, and seek support change.
Spouse/S.O. in through Nar-Anon mutual
Treatment support program.
Phone Refer patient to NA sponsor. Encourage patient to implement
Calls/Crises "Use the fellowship". coping and problem-solving
strategies.
Level of Highly directive and structured Moderately directive and
Structure structured

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Motivational Enhancement Interpersonal Therapy (IPT)


(MET)

Strategies Acknowledge validity of patient Challenge positive view of drug


Addressing feelings, elicit self-motivational effects and emphasize
Ambivalence statements. deleterious effects by
and Motivation Empathic listening, primacy of enumerating cost repeatedly.
patient's choice. FRAME. Emphasize authentic
gratification patient will
experience from improved
interpersonal functioning.
Patient's Internal, individualized Explore interpersonal
Response to approach. consequences of drug use and
Substance Use Reviews progress, what needs were being met by
reviews/evaluates initial plan, using. Call attention to
and renews motivation and discrepancy between patient's
commitment. goals and drug use.
"It's up to you whether you use "You feel more sociable when
or not." you're high, yet your cocaine use
has alienated your family. What
about that?"
Coping Patient free to develop own Patient free to develop own
Behaviors coping strategies. Development coping strategies. Development
of strategies encouraged, but of strategies is encouraged, but
not provided by counselor. not provided by counselor.
Encouragements to use social
supports instead of drugs.
Cognitions Accepted as valid, met with Exploration of effects of thinking
distorted exploration and on interpersonal relationships is
reflection. critical.
Handling Reflection, empathy, reframing. Explored and interpreted in
Resistance Patient actively avoids evoking interpersonal context. Limited
resistance. exploration of transference.
Role of Facilitate patient's motivation to Explore ways of providing
Spouse/S.O. in change drug use behavior. support to patient. Exploration of
Treatment relationship vis-à-vis drug use.
Phone Meets patient's concerns with Reinforce use of interpersonal
Calls/Crises reflection. contact instead of drugs in times
of crisis. Encourage use of social
supports.
Level of Patient structured Moderately directive and loosely
Structure structured
Adapted from: Carroll, K.M. (1997). Cognitive-Behavioral Coping Skills
Treatment for Cocaine Dependence. Yale University Psychotherapy
Development Center, NIDA P50 DA 09241.

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18.0 STAGE-12 INDIVIDUAL SESSIONS


18.1 Introduction
Patients who participate in the STAGE-12 protocol will be those who are
attending a Partial Hospital, Intensive Outpatient, Day or Evening ambulatory
treatment program consisting of group and individual sessions for a minimum of
five treatment hours per week. Therefore, they will already have been assessed
and will meet specific criteria for this protocol.
The original Twelve-Step Facilitation Therapy (TSF) protocol from which STAGE-
12 was developed included an introductory session involving an in depth
assessment of the substance use disorder. However, the assessment of patients
participating in this protocol will have been completed prior to participation in
STAGE-12 by a member of the community treatment agency’s clinical staff. A
thorough assessment usually involves gathering information on the following
areas to determine the level of care needed for treatment of the substance use
disorder.
1. Current and past substance use history: types, amounts and patterns of
current and past substance use, frequency of use, age at first use for
each substance, consequences of substance use (positive and negative),
significant events associated with substance use disorders onset or
relapse following periods of recovery.
2. DSM-IV symptoms: for diagnoses of intoxication, withdrawal, abuse
and/or dependence. This includes information about withdrawal
symptoms, physical or psychological dependence, tolerance changes,
loss of control, and impact of substance use on psychosocial functioning.
3. Motivation to change: current level of acceptance of addiction and the
need for treatment, and level of internal and external motivation to
change.
4. Past treatment experiences: in addiction, mental health, or co-occurring
treatment programs. In addition, it is helpful to gather information on
treatment completion, AMA experiences, adherence to ambulatory
treatment, medications for addiction, and outcomes of treatment.
5. Experiences in mutual support groups: experiences attending NA, CA,
CMA, AA ,other 12-Step or other mutual support groups for addiction or
co-occurring disorders, use of a sponsor, “working” the 12-Steps, or
service work within the program.
6. Medical history: current symptoms, disorders diagnosed or treated in the
past, current medications, and any history of adverse reactions to
medications. The medical history also includes a review of infectious
diseases since these are common among individuals with substance use
disorders.

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7. Psychiatric history: current symptoms, disorders diagnosed in the past,


current and past treatments of psychiatric illness, suicidality and
homicidality.
8. Family history: impact of disorder(s) on family and children, family
involvement in past treatment, current family relationships, and significant
family history of medical, substance use or psychiatric disorders.
9. Support system: current family and social supports, access to a
confidante, and involvement in community or recovery organizations.
10. Other history: work, school, legal, financial and spiritual issues.
In addition to a history obtained from clinical interviews and completion of
questionnaires by the patient, laboratory tests and urinalysis are also used in the
assessment process. Details of the results of these procedures and the history
are used to determine current and past substance use disorder diagnoses,
current severity of substance problems, other problems (medical, psychiatry,
family, legal, occupational), current level of social support, relapse potential, and
type of treatment needed (e.g., detoxification, residential, ambulatory, specialty
program, etc). This information is also used to develop the initial treatment plan
for a given patient with specific problems, goals and steps that will be used to
reach these goals. This approach is compatible with the American Society on
Addiction Medicine’s patient placement criteria, which evaluate all major
dimensions of functioning to determine the type of treatment setting most
appropriate for a specific patient.
Because the standard clinic intake assessment has already been completed, it is
not necessary to do another history as part of the initial STAGE-12 individual
session. However, it is important to review the intake assessment in order to get
an overview of the individual’s substance abuse and treatment history, which will
be reviewed with the individual during the initial session
18.2 Individual Treatment Sessions
Three individual sessions are held to augment the group sessions, one each
during week one, week three and at termination from the protocol (week 5-8). In
order to facilitate the rolling admission to groups, two of the core sessions from
the TSF for Drug Abuse and Dependence manual will be delivered as individual
sessions. These include the introductory session and the termination session.
These individual sessions will complement the STAGE-12 group sessions and
will incorporate clinical strategies from the Intensive Referral Program (formerly
called SECA), a model developed by Timko and colleagues (2006, 2007). All
three sessions focus on the patient’s use of 12-step recovery programs in the
community, emphasizing active participation in 12-step activities as a primary
means to recovery from addiction. The program participant is encouraged to
attend 12-step meetings, to secure a “sponsor” as a mentor in recovery, to turn to
the fellowship of the 12-step program to gain support from other recovering
addicted individuals to change thinking and behaviors that maintain substance
use, to “work” the 12 steps, and to increase social involvement with other 12-step

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members. A particularly salient aspect of the intervention noted by participants in


Timko’s study was the positive experience of personal contact with a 12-step
program volunteer who served as both a role model and an additional source of
support.
The first individual session, incorporating the STAGE-12 introductory component
and the phone call to a 12-step program member to arrange contact with the
participant, is likely to require more time than the other two sessions, which have
considerably less content to cover. A description of each individual session
follows:
18.3 First Individual Session
In the first individual session, the counselor introduces and provides an overview
of the STAGE-12 intervention, what is involved in the 5 group and 3 individual
sessions, and where the person will be starting in the sequence of group
sessions. The counselor discusses how these sessions will be integrated into
the patient’s Partial Hospital, Intensive Outpatient, and Day or Evening
ambulatory treatment program.
The objectives of the initial sessions are to:
1. Establish rapport with the patient.
2. Review the NA philosophy of addiction and recovery.
3. Briefly review the patient’s history of addiction and give feedback
regarding the addiction. Ask the patient what they see regarding the
addition and then build a case that abstaining from drugs “one day at a
time” is the best action to take with the help of NA, CA or CMA 12-Step
programs.
4. Explain the STAGE-12 program and orient the patient to individual and
group sessions.
5. Initiate the process of engaging the participant in active participation in
12-Step programs.
6. Facilitate the patient’s acceptance to meet with an NA, CA, CMA or AA
“buddy” to serve as a bridge to participation in 12-Step programs.
This first session includes discussion of the patient’s history and future goals for
sobriety and 12-Step program participation. The counselor provides information
about specific 12-Step meetings and orients the patient to participation to NA,
CA, CMA and AA. This includes the counselor giving the patient a schedule of
AA, NA, CA, CMA and other self-help group meetings in the local area and
encourages him/her to attend 12-Step self-help group meetings. The counselor
also gives the patient a list of local meetings favored by other patients in the
CTPs outpatient program, with the times and locations of, and directions to (by
foot, car and public transportation) these meetings. In addition, the counselor
gives the participant a handout on 12-Step self-help groups for alcohol and drug
misuse (Using 12-Step Programs in Recovery: For Individuals with Alcohol or
Drug Addiction) that provides an introduction to 12-Step philosophy and the

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structure and terminology of 12-Step groups, addresses common concerns about


participation and encourages participants to set goals for attending self-help,
working the first Steps, joining a home group and obtaining a sponsor. The
counselor reviews the handout with the patient.
This session also incorporates contact with an outside 12-Step member who
agrees to serve as a “buddy” or a temporary sponsor to accompany the
participant to an NA, CA, CMA or AA meeting following the procedures of the
Intensive Referral Program. The counselor and patient may call a self-help
group volunteer and make arrangements for this person to meet with participant
so they can attend a 12-Step meeting together. If the patient is already active in
NA, CA, CMA or AA and has a sponsor, this intervention may not be needed.
The patient and counselor agree on the 12-Step meetings to be attended before
the next session, and this agreement is written into the patient’s journal. Patients
in the STAGE-12 condition are asked to keep this journal to record the meetings
attended (dates, times, places) and, briefly, their personal reactions to and
thoughts about the meetings (or their reasons for not attending). At the end of
the session, the recovery task assignments to be reviewed at the next session
are discussed.
Here is an outline of the basic elements involved in Session 1, with some
additional information about the types of issues that might be covered in each
element:
STAGE-12 Session 1: Basic Elements
1. Build Rapport
• Why is the client coming for help at this time?
• Were there any outside pressures from job, family, or the law?
• How does then patient feel about coming for treatment?
• If the patient was mandated to come, what possible benefits could
the patient derive from treatment?
• Give the patient an opportunity to tell his/her story briefly.
2. Briefly Review the Client’s History of Addiction
• Drugs of use
• Use of alcohol
• Nature of use
• Length of use
• Positive and negative consequences of use
• Ask client what he/she sees regarding the addiction
3. Give Feedback Regarding the Addiction
• What you see regarding the addiction
4. Briefly Review Treatment History and Experiences
1. Prior Involvement in Treatment

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When? What type?


How often? Completed?
Outcome? Longest period substance –free?
2. Prior Involvement in 12-Step Groups
What groups? How frequently attended?
Duration of attendance? Other activities?
Had a sponsor? Outcome?
General experience? See it as resource?
Potential barriers, concerns, objections, negative expectancies?
5. Review the 12-Step Philosophy of Addiction and Recovery
• Addiction is a progressive disease
• One is powerless and unable to control the use of alcohol or drugs -
they control your life
• This results in unmanageability, which means that problems result
• Abstaining from drugs “one day at a time” is the best action to take
• One effective way to do this is with the help of AA, NA, CA or CMA
12-Step programs
• Attending meetings and getting actively involved in 12-Step
programs has been shown to help people stop using alcohol and
drugs
• The 12-Steps provide a guide for recovery and the fellowship
provides the support
6. Provide Information on Addiction and 12-Step Approach
• Counselor gives the participant a copy of Using 12-Step Programs
in Recovery: For Individuals with Alcohol or Drug Addiction, which:
- provides an introduction to 12-Step philosophy and the structure
and terminology of 12-Step groups
- addresses common concerns about participation
- encourages participants to set goals for attending self-help,
working the first Steps, joining a home group and obtaining a
sponsor
• Counselor reviews this handout with the patient
7. Explain the STAGE-12 Program
• Orient the participant to individual and group sessions, including
where he/she will begin in the sequence of groups
- Combines two approaches, TSF and Intensive Referral, that
have been shown to contribute to increased 12-Step
engagement and improved outcomes
- Combined individual and group counseling based on CTP input

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- Individual sessions focus primarily on GETTING ACTIVE in 12-


Step
- Group sessions focus primarily on UNDERSTANDING 12-Step
principles (e.g., acceptance, surrender)
- Understanding + Action leads to better outcomes than either
Understanding or Action alone
8. Provide Client with Information about Local Meetings
• Give client a schedule of AA, NA, CA and other self-help group
meetings in the local area and meetings favored by other
participants who have been in the out-patient program
• Include the times and locations of, and directions to (by foot, car
and public transportation) these meetings
• Encourage the participant to attend 12-Step meetings
9. Arrange for 12-Ste Counselor arranges a meeting between the client
and a participating member of an AA, NA, CA or other self-help
group
• Counselor arranges a meeting between the client and a
participating member of an AA, NA, CA or other self-help group
• The counselor and client call a 12-Step volunteer during the
session
• The volunteer arranges to meet the participant before a self-help
meeting so that they can attend the meeting together
10. Introduce the Participant Recovery Journal
• The client and counselor agree on the 12-Step meetings to be
attended before the next session
• Clients are asked to keep this journal to record the 12-Step
meetings attended (dates, times, places) and, briefly, their personal
reactions to and thoughts about the meetings (or their reasons for
not attending).
18.4 Second Individual Session
The primary objective of the second individual session is to determine whether
the individual has hooked up with a 12-Step “buddy” based on the arrangements
made in Session 1 and whether he/she has attended a 12-Step meeting. The
focus and content of the remaining portion of this session will vary, depending on
whether the patient attended 12-Step meetings since the initial individual
session. If the individual has attended a 12-Step meeting since the last session,
explore the client’s reactions to the meeting and review his/her recovery tasks.
Provide a list of currently available sponsors who are active in that group and
recommend that the individual obtain a temporary sponsor from this list (by
calling or by approaching the individual at a meeting), explaining that this
sponsor could be replaced by a more permanent one when the participant is
more familiar with other 12-Step members. Also, address any concerns the

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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

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recovering peers or going to 12-Step related social activities. Specific recovery


tasks include:
• A mutually agreed upon list of 12-Step meetings to be attended.
• Suggested readings from NA, CA, CMA or AA texts:
o Narcotics Anonymous (“Basic Text of NA”).
o Living Sober
o It Works: How and Why
Other suggested readings or materials the counselor is familiar with and thinks
the patient would benefit from reading may also be used. Mutual support
programs such as NA and AA have an extensive recovery literature. In addition,
major publishers of recovery literature also provide informational booklets,
pamphlets, books and interactive workbooks that are used in the treatment of
addiction.
18.9 Third Individual Session/Termination from STAGE-12 Program
The third and final individual session should take place during weeks 5-8 after
the fifth group session. This session focuses on helping the participant evaluate
the treatment experience in the STAGE-12 protocol, and establish goals for the
future regarding the use of 12-Step programs for use in ongoing recovery. This
session will also review recovery assignments and experiences in NA, CA, CMA
or AA. It will focus on discussing the participant’s views of 12-Step programs
now compared to prior to treatment. It will focus on finding an NA, CA, CMA or
AA sponsor if the participant has been attending meetings. Or, if will focus on
setting up a meeting with a 12-Step program volunteer if NA, CA, CMA or AA
meetings have not been attended. Barriers to participation will also be
discussed. Goals and plans for future 12-Step meeting attendance and
involvement in the program will be discussed. Finally, the participant’s
willingness to continue keeping a written journal will be reviewed.
In this final session, the counselor reviews the following issues:
1. Meetings: NA, CA, CMA, AA, and other 12-Step meeting attendance
during the time in the protocol, plans for future meetings, resistance to
ongoing meeting attendance and patient’s level of participation at
meetings.
2. Drug free days: how is the patient doing living “one day at a time” as
espoused by NA? How is the patient doing in regards to Step 1? What
can the patient do differently next time? What people, places and/or
things does he or she agree to change?
3. Drug cravings: how often did the patient crave drugs and to what
degree? What did the patient do to manage drug cravings (give in and
use; use other positive coping strategies)? How can the patient use NA,
CA, CMA or AA to help with drug cravings in the future?
4. Lapses or relapses: if the patient used drugs or alcohol, where did this
occur, when and with whom? What can the patient do differently next

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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.

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19.0 STAGE-12 GROUP TREATMENT SESSIONS


19.1 Structure of Group Sessions
Weekly group sessions of 90-minutes each are held for five weeks. The first 15-
20 minutes of each group session is the “check-in” period during which time
group participants share briefly their experiences or concerns regarding
participating in 12-step programs since the previous sessions. During this check-
in period, each participant shares his or her addiction, date of last drug use, and
whether or not strong cravings for drugs or any episodes of drug use occurred
since the previous session. However, if the group is particularly large, it is
important and necessary to stick to the time frame even if this means that not all
group members are able to share.
The next 45-60 minutes focus on a recovery oriented discussion of the group
topic for the day. New material is discussed and the patients relate to this in a
personalized manner to express their questions and concerns and to share their
experiences. For example, in the session on “Acceptance,” patients may vary in
what they share about accepting their addiction and the need for involvement in
professional treatment and mutual support programs like NA, CA or AA. Or, the
session on “Emotions” may review strategies to manage boredom or depression
without relapsing to drug use.
The final 15-20 minutes of each group session reviews participants’ reactions to
the material presented and discussed during the session, as well as their plans
for the upcoming week regarding 12-step program participation (meetings,
sponsor, calling NA members on the telephone, service at meetings, and reading
NA or recovery literature).
19.2 Topics of Group Sessions
The five topics covered in the STAGE-12 group component include those listed
below. Topics one through four were adapted from the TSF manual’s “core”
topics and topic five was adapted from its “elective” topics.
1. Acceptance
2. People, Places and Things (Habits and Routines)
3. Surrender
4. Getting Active in 12-Step Programs
5. Managing Emotions
Each group session is structured and has a specific agenda with a topic,
objectives and specific points for discussion. The group leader conducts the
session in an interactive manner that engages patients in the discussion of the
topic areas covered by sharing personal experiences, opinions and questions.
Given that a rolling admission procedure will be used, participants can enter the
groups at any point in the sequence of topics/sessions. They will be informed
about where they will be joining the group in the first STAGE-12 individual
counseling session to help orient them to sequence. Group counselors will need

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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

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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

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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
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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?”

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19.12 A member does not disclose any personal information or open


up much in the group session
The Group Counselor can share his/her observations about the member’s
behavior, generalizing the issues that group members have talking about any
difficulties that contribute to problems in self-disclosing (e.g., shame, shyness,
social anxiety). Discussion can then focus on ways this member (or other group
members who have trouble self-disclosing) can gradually learn to trust the group
and self-disclose personal thoughts, feelings, problems or concerns. The Group
Counselor can also mention that learning to share in the STAGE-12 group may
help members feel more comfortable sharing at NA, CA, CMA or AA meetings.
For example, if Robert shies away from sharing personal information when the
group is discussing spirituality, the Group Leader might say “Robert, you appear
to be a bit uncomfortable with our discussion about a Higher Power. We would
be interested in hearing your opinions and any concerns you have about using a
Higher Power in Recovery.”
19.13 A member rejects the input, advice or feedback of other group
members regarding 12-Step involvement or recovery from
addiction
The Group Counselor can point out this pattern and engage the group in a
discussion of why this pattern is occurring. Members’ who offer help and support
only to have their attempts rejected can be asked to talk about what this feels like
so that the member rejecting their help is aware of the impact of this behavioral
pattern on others. For example, if Lisa rejects ideas shared by the group on
asking a member of NA to be her sponsor, the Group Counselor could say “Lisa,
other group members strongly recommended that you not get a male NA
sponsor, but you seem to disagree with this. Why do you think they are
suggesting you stick with a female when you get a sponsor?”
19.14 A member can only pay attention when the discussion focuses
on his problems or who interrupts others when they talk
The Group Counselor can point out his/her observations of the group member
and discuss the reasons for this behavior. The group can then engage in a
discussion of the effects of this behavior (e.g., upsets other members, turns them
off, makes them feel like their problems aren’t important) and the importance of
“giving and receiving” mutual support by listening to each other’s concerns and
problems. For example, if John keeps jumping into the group discussion about
the Steps and cutting other members off, the Group Leader may say “John, I’m
glad you are freely expressing your opinions, but you’re cutting other people off.
I’d like you to sit back and listen for awhile.”

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19.15 A member wants easy answers to problems or is quick to


provide easy solutions to others when they discuss personal
problems
The Group Counselor can share his/her observations of these behavioral
patterns and ask the group to discuss the importance of taking responsibility to
find solutions to their problems, and to identify more than one strategy to address
a particular problem. The leader can emphasize that while there are many
different alternative ways to resolve specific problems, seldom are there easy or
simple solutions, and that time, patience and persistence are needed for group
members to adequately resolve problems. When a group member provides an
easy solution, the Group Counselor can acknowledge that this is one strategy
that may help some people, but it is also helpful to have other strategies. The
Counselor can then engage the group in a discussion of other strategies to
resolve the problem under discussion. Finally, the Group Counselor can
emphasize to the group that learning how to think about problem solving is just
as important as dealing with specific problems since everyone in the group will
continue to face multiple problems in their ongoing recovery. For example, if
Trina repeatedly asks group members what she should do when she has strong
cravings for meth, the Group Counselor could ask her “Trina, what do you think is
one or two things you can do to not give in to your cravings for meth? There
have been times when you did manage your cravings. What helped you?”

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20.0 STAGE-12 GROUP TOPIC #1: ACCEPTANCE (STEP 1)


20.1 Objectives of Group Session #1
1. Review format of STAGE-12 group sessions and recovery journal
assignments.
2. Provide a brief overview of the 12-Step program of NA, CA, CMA and
AA.
3. Review and the key concepts of Step 1: Powerlessness,
unmanageability, and denial.
20.2 Methods and Points for Group Discussion
1. Use a brief presentation and an interactive discussion format to review
the content of this group session. Elicit experiences and examples from
group members related to the content as it is reviewed in group.
2. Review format of group sessions.
a. Each session will start with a check-in of 15-20 minutes.
b. During this time, group members will briefly report on any
substance use, strong urges or desires to use drugs, involvement
in 12-step meetings and use of the “tools” of recovery, and
completed journal assignments.
c. This will be followed by a 45-60 minute discussion of group topic.
d. Each session will end with a check-out of 15-20 minutes.
3. Review the use of recovery journals while in STAGE-12.
a. Journals will be kept by group participants to summarize their
experiences in 12-Step programs.
b. Information in journals will include meetings attended as well as
patients’ responses and experiences to meetings: what they liked
or disliked, what they learned, how they felt attending meetings.
c. Some entries of group participants may be briefly shared during
the check-in phase of the group.
4. Discuss how 12-Step programs are a major source of support in recovery
from addiction. These include NA, CA, CMA, AA and many other 12-Step
programs. These programs involve many components such as:
a. Meetings
b. Sponsorship
c. 12-Steps
d. Recovery events
e. Readings on addiction and recovery
f. Service
g. Slogans

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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

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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.

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a. Stage 1: I have a problem with drugs.


b. Stage 2: Using is gradually making my life more difficult and is
causing problems for me.
c. Stage 3: Since I have lost my ability to limit my use of drugs, the
only alternative that makes sense is to stop using.
11. Summarize this portion of the session with a brief recap of how 12-Step
programs view the disease of addiction:
a. There is no cure, only recovery.
b. Abstinence--one day at a time--is the only option that works.
c. Self-reliance and willpower are not enough. The support of peers
is vital.
d. Remind the patient that the goal of 12-Step programs is to
maintain abstinence by avoiding the first use, one day at a time.
20.3 Recovery Tasks
1. The last 15-20 minutes of the group session focuses on what
recovery tasks the patients will do during the week related to 12-
Step programs. Ask patients about which specific 12-Step meetings
they will attend during the week.
Remind them to keep their journal and instruct them to complete the written
questions on the “First Step Worksheet.”
2. Suggested readings include:
a. The Narcotics Anonymous “Basic Text” (Narcotics Anonymous,
1988, pp. 17–22)
b. It works How and Why (Narcotics Ananymous) pp. 5-16
c. Living Sober (Alcoholics Anonymous, 1975, pp. 7–10)
20.4 Wrap-Up
Before ending the session, ask the group members what they understood to be
the gist of the session. Then ask them if they understand the recovery task
assignments and ask for their commitment to follow through on them.
20.5 Troubleshooting
Once the concept of denial is presented, slips and resistance to getting involved
in 12-Step programs can be interpreted in this light. These interpretations should
be made frankly and repeatedly, though non-judgmentally. One approach to
denial regards it as a normal part of the grief process. People seem to be
naturally predisposed to deny losses and limitations, and drug dependence
represents both. Here are some examples of interpretations that reflect this point
of view:
1. “I think that part of your unwillingness to go to meetings is denial. I think
there’s a part of you that does not want to accept this limitation — that
you are drug dependent and you have to give up using drugs. That part
of you wants you to avoid going to an NA, CA, CMA or AA meeting.”

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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.
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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.

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21.0 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?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

2. How have you lost self-respect due to your drug use?


__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

3. How have you tried to control your use of drugs?


__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

4. What types of physical abuse have happened to you, or others, as a result


of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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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?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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6. What work problems have you had as a result of your drug use?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Remember that “loss of control” (powerlessness) and problems


(unmanageability) are symptoms of the disease of drug dependence. In order to
recover, people have admitted their limitations and accepted that the solution is
to be open to support from others (NA, CA, CMA or AA) and to stay away from
the first use, one day at a time!

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22.0 STAGE-12 GROUP TOPIC #2: PEOPLE, PLACES, & THINGS


Objectives of Group Session #2
1. Review experiences in 12-step meetings, readings, urges or episodes of
use (lapse or relapse).
2. Discuss the concept of “People, Places, and Things” in recovery from
addiction.
3. Identify when to avoid certain people, places, events and things that pose
a relapse risk.
4. Review strategies to manage people, places and things without using
drugs.
22.1 Review and Check-in
1. Written Journal and Meetings: Ask if patients kept their written journal
and attended any NA, CA, CMA or AA meetings. Invite some members
to share parts of their journals.
a. Did the patients attend any 12-Step meetings? If they did attend,
discuss their reactions. This therapy is based on the belief that the
best way for the patient to remain clean and sober is through active
involvement in 12-Step recovery programs. Help the patients make
sense of their experiences at 12-Step group meetings.
b. If any patients failed to attend 12-Step meetings, explore their
resistances. What interfered with their ability to access this
resource for recovery?
c. Some patients may act out their denial by failing to attend agreed
upon meetings. When confronting denial remember to separate the
person from their disease. Constructively point out how their failure
to follow through with commitments is symptomatic of the disease
of addiction.
2. Readings: Next, review the patients’ reactions or thoughts about any
assigned readings or recovery activities.
a. How did they relate to the readings or other members of 12-Step
meetings? Some patients see themselves as different from others
in 12-Step programs because they have not experienced the losses
they hear or read about.
b. The slogan “Y.E.T.” is fitting in this instance.
c. This stands for “You’re Eligible Too!” meaning that anyone with an
addictive disease, who continues to use drugs, will continue to
experience progressively more severe symptoms and problems.
Encourage patients to keep an open mind about what they hear or
read.

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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,
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recovery, the patient can begin to develop a plan for


making concrete behavioral changes.
3. Lifestyle Agreement: The heart of this session is getting group members
to complete and discuss the “Lifestyle Contract,” a table with four
columns and three rows. Start with asking one or two patients to
volunteer to complete this in front of other group members, which can
help other group members understand how to personalize this recovery
assignment.
a. In the left column, the patients list the people, places and things
(rituals or routines) that they believe are “dangerous to recovery”
and what needs to be given up for recovery to progress.
b. In the next column, patients list their “feelings” about these
dangers to recovery. This helps patients become aware of how
people, places and things can impact on their feelings, which in
turn can impact on their behaviors.
c. In the next column, patients list people, places and things that
“support recovery” or that can be substituted to counteract the
“dangers” to recovery.
d. In the last column, patients list their feelings about these supports.
4. For those who are currently struggling with being clean and sober, ask
who, where, and what the current dangers are to recovery.
a. Be specific as possible. For example, list people by first name.
Name as many as necessary, prompting the patient to think of any
one else.
b. Be specific about places and habits, routines and rituals as well.
5. Once the group members have exhausted all possibilities on the
dangerous side, list those people, places, and things (habits, routines,
and rituals) that are supportive of recovery.
a. In early recovery from drug abuse or dependence, this list is
typically short. By posting these on a board or flip chart the weight
of the negative lifestyle can be dramatically seen by the patient.
b. What can group members do to shift this balance and fill the void
left by abandoning dangerous people, places, and things?
6. As part of this topic’s recovery tasks, contract with the group members to
identify one new positive person, place and activity to shift the balance
away from danger.
22.3 Recovery Tasks
The last part of the session focuses on the recovery tasks the patient will do
during the upcoming week. Remind the patient of the three things they agreed to
do to actively change their lifestyle during the exercise and get a commitment
from them about specific 12-Step meetings they will attend during the week.
Remind them to keep their journal. Suggested readings include:
Narcotics Anonymous (Narcotics Anonymous, 1998, pp. 84–96)

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Living Sober (Alcoholics Anonymous, 1975; chapters “Changing Old


Routines,” (pages 19 – 22), and “Being Wary of Drinking Occasions”
(pages 65 – 71)).
Wrap up the session by asking the patient what they understood to be the gist of
the session. Then ask them if they understood the recovery task assignments
and get their commitment to following through with them.

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?

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STAGE-12 GROUP SESSION #2: LIFESTYLE AGREEMENT

DANGEROUS TO PATIENT’S SUPPORTS PATIENT’S


RECOVERY FEELINGS ABOUT RECOVERY FEELINGS ABOUT
(what needs to be DANGERS SUPPORT
(what needs to be
given up) substituted)
People

Places

Things
(rituals/routines)

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STAGE-12 GROUP SESSION #2: LIFESTYLE AGREEMENT


Example of Levon

DANGEROUS TO PATIENT’S SUPPORTS PATIENT’S


RECOVERY FEELINGS ABOUT RECOVERY FEELINGS ABOUT
(what needs to DANGERS SUPPORT
(what needs to be
be given up) substituted)
People I feel he’s a threat to my NA sponsor and I feel they will
Dealer John recovery; he wants to friends support me, help
Girlfriend make money, that’s all. Hang with brother and me focus on my
JJ (get high She likes to get high a couple friends who program and
partner) more than me don’t get high. staying off drugs.
JJ and me are tight, but Attend NA meetings at These people care
he don’t care about least every day for about my well-
recovery. Be hard to cut awhile. being and will help
him loose, but I got to. Have to stick with me. Makes me feel
others who don’t get good.
high.
Places I feel these places could NA meetings. I feel safer at these
Bars be a negative influence Local recovery club; places.
JJ’s house on me and my recovery. they sponsor dances I feel part of family
Parties I’d be tempted if I went and social events in when I hang with
to JJ’s. He always gets addition to meetings. my brother.
high. My brother has an I know I can get
I might miss parties for open invitation to go to used to being bored
awhile, but I see the his home every without the action
danger, even if I drink weekend. of bars and parties.
I’m more likely to use
cocaine.

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.

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23.0 STAGE-12 GROUP TOPIC #3: SURRENDER


(STEPS 2 AND 3)
Objectives of Group Session #3
1. Review experiences in 12-step meetings, readings, urges or episodes of
use (lapse or relapse).
2. Discuss the concept of “Surrender”
3. Review Steps 2 and 3 of NA, CA, CMA or AA.
23.1 Review and Check-In
1. Written Journal and Meetings: Begin the session with a review of the
patients’ recovery efforts. Ask the patients if there is any part of their
written journal that they wish to share in group. If they have not kept a
journal, explore what obstacles prevented them from doing so.
a. Did the patients attend 12-Step meetings? What were their
reactions to meetings?
b. Explore any resistance to or avoidance of meetings. How might
this be a reflection of denial? Some patients present the situation of
putting others’ needs and wants ahead of their own needs and
wants. In this situation, the counselor may want to remind the
patient that recovery must come first.
c. The 12-Step adage to put “first things first” is appropriate here.
Another slogan is “whatever you put in front of your recovery is the
first thing you lose”.
2. Recovery Tasks: Review any reactions that the patient has from the
previous session recovery task assignments and to determine if the
patients follow through?
a. If not, what got in their way of trying to add new people, places
and things for recovery? What 12-Step tools might have helped
the patient?
b. Have group members made efforts to collect and use phone
numbers of recovering peers they have met at meetings?
c. Have they established a routine for attending 12Step meetings on
a regular basis?
3. Readings: Next, review the patients’ reactions or thoughts about any
assigned readings or recovery activities.
a. How did they relate to the readings or other members of 12-Step
meetings? Some patients see themselves as different from others
in 12-Step programs because they have not experienced the
losses they hear or read about.

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4. Drug Cravings: Ask the group members if they experienced any


thoughts about using or cravings to use. In early recovery from drug
addiction strong cravings are common.
a. For group members who report strong urges, what strategies to
delay the first use of drugs did they apply when they had these
urges? What have they learned from this? How many clean and
sober days did the patients accomplish? Congratulate all efforts
made by the patient towards recovery.
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.
5. Slips (Lapses): If any patients lapsed or relapsed, review the factors,
events or situations that may have contributed to their drug use.
a. Explore their “stinking thinking” and the possible role of denial.
b. Identify dangerous people, places, and things.
c. What internal feelings may have contributed to lapse or relapse?
d. How did they (or could they) stop a lapse from becoming a full
blown relapse?
6. 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 patients for their
sober days and efforts at recovery.
23.2 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 the new material is about the process of surrender, Steps 2
and 3 of the 12 Steps.
a. Step 1, which deals with “powerlessness” and “unmanageability”
can be phrased as “I can’t handle it.”
b. Step 2 deals with belief that someone or something more powerful
than the individual can help.
c. Step 3 states that one is going to allow an outside force to help.
1. Acknowledge that some people are wary of the spiritual part of 12-Step
programs. By this point in treatment, they may have already
mentioned some of their concerns. This topic allows a structure for

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discussion of these concerns. Begin with Step 2: “Came to believe


that a power greater than ourselves could restore us to sanity.”
2. Ask the group members what the words of Step 2 mean to them.
Reassure them that 12-Step fellowships are open to people of all
beliefs and backgrounds, including atheists and agnostics.
3. As with the first Step, break Step 2 down into its key concepts. The
action of the Step is “Came to believe.” Explore with the patient their
beliefs. What are the nature and qualities of their “higher power”? How
did they come to this belief? In what religious background was the
patient raised? Has this been a positive or negative experience in their
life? The group leader can write the responses of group members on a
chalkboard or flip chart.
a. If group members do not believe in a Higher Power, what would
they be open to exploring or trying? How do group members define
spirituality? At this point the counselor may want to differentiate
between spirituality and religious belief.
b. One definition of spirituality is: What gives a person a sense of
purpose in their life. The process of becoming more spiritual is
discussed in the “Big Book of AA (Alcoholics Anonymous, 1976, pp.
569–570).
c. Some patients may feel ashamed and guilty about past behaviors
that they do not believe that anyone or anything would care about
their welfare. Others may be angry because of the traumatic
events in their life. The counselor needs to be prepared and open
to whatever issues patients present.
d. Remind group members that recovery is a process that takes place
over time. They may not believe today, but remain open to the
possibility that they may come to believe in the future. Have a
group member share a brief story of personal spiritual group or
provide an example to the group.
1. Power greater than ourselves: explore ideas about what a “power
greater than ourselves” means to group members.
a. What forces outside of themselves have been more powerful than
they? Did they ever have people that they looked up to or admired?
b. What did they admire or respect about those people?
c. What “Higher Powers” have been benign and loving?
d. Share with the patients that recovery from addiction works best
when it is with and through other people. The appropriate slogan
is, “We alone can do it, but we can’t do it alone.”
e. Explore with the patients what their relationship with their “higher
power” is like? When was the last time the patient used prayer or
meditation to help themselves? Does the patient want help? Does
the patient believe s/he can be helped? Does the patient believe

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that he is worth helping? What is the patient’s experience with


asking for help? The issue is “trust” in other people.

2. Restore us to sanity: what were some of the “insane” behaviors that


the group members engaged in while actively using drugs. These
are all examples of “unmanageability” from Step 1.
a. Some examples of the insanity of drug addiction are the poor
decisions people make regarding managing their lives, the stubborn
belief that they can stay in recovery without help (arrogance), and
the sense of false pride that they don’t need others advice or help
(defiance).
b. One definition for “insanity” that comes from 12-Step programs is
“continuing old behaviors and expecting new results.”
c. Tying this all together, who then is responsible for restoring the
addict to sanity? Clearly, the Step states that it is the job of one’s
higher power. What is required in Step 2 is the belief that this can
happen.
d. Step 3: This Step has to do with allowing someone or something to
help: “Made a decision to turn our will and our lives over to the
care of God--as we understood him.”
3. Write Step 3 on the board or flip chart.
a. The third Step is an action step. Like a key opening a locked door,
moving away from the destruction, hopelessness and despair of
addiction towards the hope and opportunity of recovery. The
patients’ willingness to work this Step is demonstrated by their
ability to accept and follow the suggestions of others about
recovery. This may mean going to meetings and changing old
habits and routines.
b. Turning one’s will over to the care of a higher power does not mean
that God will take care of everything in one’s life. It does mean that
one will be presented with opportunities to take care of oneself.
The individual is responsible for taking advantage of those
opportunities to help him/herself.
4. Made a decision: discuss the key phrases in the Step and discuss
the meaning of each. The action of the Step is that we “Made a
decision.”
a. While in Step 2 it was a process of coming to believe, here it is an
action of decision. The decision is to trust one’s life to someone or
something outside themselves.
b. This decision is made repeatedly throughout recovery.
c. This is a conscious and deliberate decision on the part of the
patient.

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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
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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.

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24.0 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.
• Spirituality does NOT mean mysticism or spiritualism, or an Eastern
religious practice.
• It is NOT a set of rules about what is good and bad, right and wrong.
• It is NOT a church doctrine or religious belief.
• Spirituality is a way of life, a way of thinking that helps sobriety.
• The following is a comparison of non-spiritual vs. a spiritual way of living
and thinking:
NON-SPIRITUAL SPIRITUAL
VALUE Things People

THE GOAL IS… Acquire Things Good Relationships

THE GOOD LIFE IS… Money Friends

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

Adapted from: Woodard, A. & Wuelfing, J. (1991)

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25.0 STAGE-12 GROUP TOPIC #4: GETTING ACTIVE


Objectives
1. Review patients’ experiences in recovery and participation in 12-Step
programs in the past week, which should be documented in their
journals.
2. Review differences between “abstinence” from substances and
“recovery.”
3. Review specific strategies to be “active” in using 12-Step Programs:
meetings, phone contact with other members, and getting and using an
NA, CA or CMA sponsor.
25.1 Review and Check-in
1. Written Journal and Meetings: Ask if patients kept their written
journal and attended any NA, CA, CMA or AA meetings. Invite some
members to share parts of their journals.
a. Did the patients attend any 12-Step meetings? If they did attend,
discuss their reactions. This therapy is based on the belief that the
best way for the patient to remain clean and sober is through active
involvement in 12-Step recovery programs. Help the patients make
sense of their experiences at 12-Step group meetings.
b. If any patients failed to attend 12-Step meetings, explore their
resistances. What interfered with their ability to access this
resource for recovery?
c. Some patients may act out their denial by failing to attend agreed
upon meetings. When confronting denial remember to separate the
person from their disease. Constructively point out how their failure
to follow through with commitments is symptomatic of the disease
of addiction.
2. Readings: Next, review the patients’ reactions or thoughts about any
assigned readings or recovery activities.
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
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? Be sure to congratulate the patients for
stopping, returning to treatment and being honest with the group.
b. Review what role the patient’s denial may have played in continued
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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.
25.2 Methods and Points for Group Discussion of New Material
1. Ask the group what they think is the difference between “abstinence
from drugs” and “sobriety” (or recovery from addiction).
2. Discuss how just stopping drug use is not enough for recovery to
progress as addiction affects all parts of a person’s life and often
leaves a void in a person’s life that needs to be filled.
a. Have a group member read the following passage, which is
adapted from the recovery guide entitled Living Sober:
“Just stopping drinking (using drugs) is not enough.
Just not drinking (using drugs) is a negative sterile
thing. That is clearly demonstrated by our
experience. To stay stopped, we’ve found we need to
put in place of our drinking (drug using) a positive
program of action.” (Living Sober, Alcoholics
Anonymous, 1975, p. 13).
25.3 Getting Involved in 12-Step Programs:
1. Ask the group members how they define “a program of action.”
Use their ideas to discuss the following points and to give
examples:
a. Recovery, then, needs to address each of these areas of life
b. This program of action involves “getting involved” in 12-Step
programs since addiction is a disease that erodes a person’s life
such as: mental abilities, emotional well-being, physical well-being,
social relationships, spiritual well-being, and willpower.
2. Simply stopping drug use without changing one’s lifestyle, beliefs or
attitudes leaves an addicted person vulnerable to relapse.
a. Discuss the difference between “white knuckle” abstinence
and sobriety with a program.
b. White knuckle abstinence refers to someone who has
stopped use, but is still unhappy because they are carrying
around resentments and self-pity from the past.

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c. Often addicted people can go for long stretches without


using drugs, but because they do not use the tools of 12-
Step recovery, they are more vulnerable to relapse when life
presents a stressful situation.
25.4 12-Step Program Participation:
1. Getting involved in 12-Step programs and following the suggestions
of what has been helpful to other addicts seems to be what has
worked the best for most.
2. Sobriety with a program of recovery offers an opportunity to learn
about living life on life’s terms with out unnecessary feelings of
resentment and self-pity.
a. Ask the group members if they have noticed people in
different stages of recovery at 12-Step meetings.
b. What is the difference between those who have surrendered
and are willing to follow suggestions and those who are still
struggling with acceptance?
c. Encourage the patients to stick with the winners in 12-Step
programs. Their job is to learn from those who have
recovered.
3. Another danger is growing complacent about recovery, a
phenomenon that is common in early recovery.
a. Some 12-Steppers refer to it as being on a “pink cloud.”
b. The danger is that after a period of abstinence the person
relaxes their participation in 12-Step recovery efforts (i.e.,
cutting back on the number of meetings they attend or
allowing other activities, like work, to take precedence over
recovery). This leaves a person vulnerable to relapse.
4. As mentioned in the material on Step 3, simply believing that a
“higher power” can help is not enough. Each person is responsible
for their own recovery.
a. Put another way, “faith without work is dead.”
b. Explain that getting active in 12-Step programs, in part,
involves going to meetings, making use of telephone
therapy, and making use of a sponsor.
5. Ask the group members what types of NA, CA, CMA or other 12-
Step meetings they are attending, and their experiences in these
recovery programs. If they only attend “speaker” meetings,
encourage them to give the reasons for them and to be open to
attend discussion meetings.
a. Open vs. closed meetings.
b. Speaker vs. discussion meetings (listening to a lead vs.
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speaking at a meeting, ask group members to share


strategies to increase verbal participation.
c. Home group where member attends the same meeting
regularly.
d. Meetings on the 12-Steps of NA, CA, CMA.
e. Meetings to discuss “topics” of relevance to recovery from
addiction.
f. Meetings to discuss specific readings from the NA “Basic
Text.”
g. Meetings for specialty groups (women, gay men, health care
professionals, etc.).
h. Where do patients “sit” during meetings? If they sit at the
back alone, encourage them to move up to the front of the
room. Some successful recovering addicts report that they
choose to sit as close to the front as possible so they won’t
be distracted during the meeting.
6. Encourage patients to attend different types and formats of
meetings and to get involved in “service.”
a. This may include helping to set up or clean up the meeting,
make coffee, set out literature, etc.
b. These jobs may be assigned during the business meeting
held monthly following the regular NA, CA or CMA group
meeting.
7. Encourage patients to meeting and interact with other people in
recovery, before and after the meetings.
8. Discuss events sponsored by NA, CA or CMA such as dances,
sporting events, holiday celebrations, dinners, and 24-hour meeting
marathons.
9. Discuss frequency of meeting attendance.
a. Depends on availability of meetings, motivation of each
patient, severity of addiction, and level of commitment to
recovery.
b. Discuss commonly accepted guideline of attending “90
meetings in 90 days” in early recovery. However, provide
support and encouragement for patients who attend
meetings regardless of the frequency of attendance.
25.5 Telephone Therapy as a Recovery Tool
1. This is a long tradition in 12-Step programs dating back to the day
when Bill Wilson, one of the co-founders of AA, used the telephone
to contact another alcoholic for help.

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a. This involves calling other 12-Step group members to gain


support from them.
b. Ask the patients if they have observed other group members
exchanging phone numbers. Advise them that someone
may ask for their number. Explore what the patient’s
experience has been with this and any resistance there may
be to using the phone. Does the patient have a phone?
c. Examples of when to use the phone to reach out to
recovering peers are:
• Daily, to stay in touch and keep reaching out
• Whenever there is an urge to use
• As soon as possible after a slip
• Whenever they feel hungry, angry, lonely, or tired
• Whenever they feel overwhelmed
• Whenever they feel good
d. Suggest to group members that they commit to obtaining
phone numbers from at least three 12-Step program
members during the coming week. For some patients, using
the telephone has been a turning point in their recovery.
• Advise them to get at least 2 numbers from same sex
friends.
• Suggest that each commit to calling at least one of
these people and have a five-minute conversation
with them.
• If necessary, role play with the patients around asking
for a phone number or talking to a recovering peer on
the phone.
25.6 Sponsorship in AA and NA
1. Another important part of “getting active” involves finding a 12-Step
sponsor.
a. The tradition of sponsorship started in the early days of AA.
b. Originally sponsors were people who were willing to take
responsibility for visiting alcoholics in the hospital and for
taking them to an AA meeting when they were discharged.
c. Also, sponsors were used as resources for questions about
material in the Alcoholics Anonymous literature.
d. Today, in 12-Step programs, sponsorship has evolved into a
way for newcomers to get practical advice and support from
more experienced peers.
e. Being a sponsor is both a privilege and a responsibility.

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f. The job of a sponsor is to:


• Provide basic information about 12 Step programs
and their traditions.
• Answer questions about working the Steps.
• Suggest 12-Step meetings that may be helpful.
• Introduce the newcomer to other recovering addicts.
• In short, the sponsor facilitates the newcomer’s
participation in 12-Step recovery. A sponsor is not a
counselor, a judge, or a parent. A good sponsor can
only share by example and make suggestions to the
newcomer.
25.7 Difference Between Sponsor and Counselor
1. Both a counselor and sponsor offer support and advice, however,
there are important differences.
a. A counselor knows the patient for a prescribed period of
time, with specific appointment times for counseling sessions
that focus on agreed upon goals.
b. Once treatment is over, the counselor is no longer part of the
patient’s life. A sponsor however, is available throughout the
patient’s life, for as long as that relationship exists.
c. A sponsor does not use therapeutic techniques to treat the
patient, rather shares experience through self-disclosure and
offers support. Whereas the roles of the counselor and the
sponsor differ, it is not uncommon for each to give the
patient similar advice.

25.8 Guidelines for Choosing a Sponsor:


a. Sponsors should be of the same sex as the patient. (With
Gay or Lesbian patients, care should be taken to avoid
situations with the potential for sexual attraction, as
involvement in an intimate relationship too early in recovery
may trigger a relapse).
b. Sponsors should be of the same age or a little older than the
patient. Having shared experiences makes it easier to bond.
c. Sponsors should have at least one full year of recovery from
drugs and be actively working a 12-Step program, including
going to meetings, using the telephone, and having their own
sponsor.
25.9 How to Find a Sponsor
a. The simplest way to find a sponsor is to ask for a “temporary
sponsor” at an NA, CA, AA or CMA meeting.

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b. As most patients are just getting involved in 12-Step


recovery, they do not know many people well. A “temporary
sponsor” can be available to a patient until they find
someone else who can be their regular sponsor.
c. Let the patients know that there is nothing binding about
sponsorship. If the relationship is not working out, it can be
ended and another sponsor can be found.
d. Another way to find a sponsor is to observe and listen at
meetings and look for someone they can relate to and whom
they respect. Advise them to seek out someone who is
happy in recovery and working a solid 12-Step program.
Encourage the patient to then seek this person out, before
and after meetings. Some patients are more shy than
others. It may be necessary to role play asking someone to
be a sponsor. Ask the patient to commit to looking for a
sponsor over the next week, before the next session.
25.10 Recovery Tasks
Recovery tasks for this topic include the following readings:
Living Sober (Alcoholics Anonymous, 1975) pp. 13–18, 24–30
Narcotics Anonymous (Narcotics Anonymous, 1988) chapters 5, 8, 9; and
“I Kept Coming Back”, pp. 238–242
Contract with the patient about which 12-Step meetings they will attend during
the upcoming week. Ask the patient to continue to work towards the goal of “90
meetings in 90 days”. Ask what specific commitments they are willing to make to
becoming more active in their recovery program (e.g., obtaining three phone
numbers, calling at least one recovering peer, finding a sponsor).
25.11 Wrap-Up
In closing, ask the patient the gist of today’s session. Do they understand the
recovery tasks and are they willing to follow through with them?
25.12 Troubleshooting
The counselor should be thoroughly familiar with the material in all readings:
Narcotics Anonymous “Basic Text” (Narcotics Anonymous, 1988), It Works: How
and Why (Narcotics Anonymous, 1993), and Living Sober (Alcoholics
Anonymous, 1975), and should make efforts to integrate readings from all into
each session. These books are filled with practical advice and wisdom and
should be resources to counselor and patient alike. Do not hesitate to read a
relevant passage together and discuss its relevance to any issue at hand.
A guide for the counselor with “Getting Active” is to meet the patients where they
are in regards to accepting the need for involvement with 12-Step programs in an
aware and sensitive manner. Getting Active is a process that takes place on a
continuum of activity level. At one end of the continuum is the patient who flatly
refuses to go to meetings, yet who appears for scheduled therapy sessions.

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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.

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26.0 STAGE-12 GROUP TOPIC 5: MANAGING EMOTIONS OBJECTIVES


1. Review experiences in recovery and 12-Step programs during the
past week, which should be documented in patients’ journals.
2. Help patients identify emotions which are most often associated
with lapses and relapses to drug use after a period of recovery.
3. Review strategies that patients can use to manage their emotions
to reduce their risk of relapse.
26.1 Review and Check-in
1. Written Journal, Meetings and Drug-Free Days: Ask if patients
kept their written journal and invite some members to share parts of
their journals.
Discuss groups that members attended and their reactions.
a. Review their plans for future meetings.
b. Discuss any resistance at this point to going to meetings.
c. Review their level of participation in meetings.
d. If they did attend, discuss their reactions.
e. How many drug free days do group members have?
f. How have patient done with living “one day at a time?”
2. Readings: Review the patients’ reactions or thoughts about any
assigned readings or recovery activities.
a. What is being read?
b. What are group members’ reactions to readings?
c. What questions do they have from these readings?
3. Drug Cravings and Urges to Use: Ask group members if they
experienced any thoughts about using or cravings to use.
a. Where and when did drug cravings occur?
b. What did they do to manage cravings?
c. How could group members use AA, NA, CA and other 12-
Step programs to help with cravings in the future?
2. Slips (Lapses): If any patients relapsed, or continued their active use,
review the events that occurred prior to use.
a. Review where, when and with whom drugs or alcohol were
used.
b. How are group members who lapsed or relapsed coming to
terms with Step 1?
c. What can group members do differently in the future
regarding people, places and things to change to reduce
relapse risk?
3. Getting a Sponsor: Ask what efforts group members made in obtaining
and using a sponsor in NA, CA, CMA or AA.

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a. What progress has been made in getting and using a


sponsor?
b. If they have not made any attempt, what is the basis of their
resistance?
c. What suggestions can the group counselor make, and what
commitments will the patients make to get a sponsor
immediately?
4. Using the Telephone: Ask group members about their use of the
telephone to stay connected to other members of support groups.
a. How are they doing with this (who have they called? what
have they discussed? how helpful has this been? if they
have not called anyone, what are the reasons?).
b. What suggestions can the group counselor make, and what
commitments will the patients’ make to use the telephone to
talk with others about recovery?
26.2 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. The purpose of this group session is to help group members use of
12-Step tools for dealing with the stresses of everyday life, and
manage their feelings without abusing drugs or alcohol.
a. Inability to manage negative emotional states is one of the
most common relapse risk factors in drug abuse and
addiction.
b. Awareness of feelings and skills in managing them reduce
the risk of relapse, and enhance the quality of recovery.
c. HALT: the advice given in 12-Step programs is “don’t let
yourself get too hungry, too angry, too lonely, or too tired or
you may have a slip (lapse).”
d. Ask group members to identify feelings or emotions that they
believe can increase their risk of relapse following a period
of recovery.
e. Review the following common feelings or emotional states
that can precede relapse if the recovery individual does not
recognize or use coping skills include:
• Anger and resentment
• Anxiety
• Boredom or emptiness
• Depression and grief
• Loneliness

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• Shame and guilty


1. The belief in 12-Step programs is that drug dependent persons are most
vulnerable to the above emotions and most likely to use when they are
either hungry or tired. Therefore, the program puts a strong emphasis on
getting rest and eating well.
2. Many 12-Step slogans and sayings — Easy Does It, Let Go and Let God,
One Day at a Time, First Things First, Turn it Over — relate to one or
more of the above feelings.
a. They reflect common wisdom for handling difficult emotions.
Their value lies in their simplicity. Through these sayings
and slogans, the fellowship teaches drug dependent persons
how they can live without drugs. The counselor should
therefore be familiar with these slogans and use them in
treatment.
b. In addition, teaching patients to connect particular slogans to
situations in their lives that trigger risky emotions can be
extremely helpful.
3. Fatigue: group members need to develop a lifestyle that allows them to
get adequate rest and nutrition. A state of exhaustion is an invitation to
use drugs for some.
4. Related to this topic is physical conditioning — a body in poor physical
condition will get tired more quickly than one that is being taken care of.
c. How much sleep does the patient get on average? Is this
adequate? What changes, if any, could be made so the
person could get more rest?
d. Have you experienced using, or had a strong desire to use
when you were especially tired?
e. What is the overall state of the person’s health? Are they
capable of doing some routine exercise to gain stamina?
5. Hunger: along with the need to avoid exhaustion, 12-Step programs
emphasize the need for the recovering person to avoid excessive hunger.
Regular meals are encouraged and, beyond that, the addicted individual is
encouraged to snack so as to avoid getting too hungry. Some issues to
discuss with group members include:
a. What is your diet like now? What did it used to be like?
b. Do you sometimes experience cravings for sweets?
c. How can you satisfy this need? (fresh fruit can be helpful).
6. Emotions: anxiety
a. Sometimes a source of anxiety can be from a sense of
isolation, not having any one to trust or rely on when faced
with a difficult life decision.
b. What makes group members feel anxious or uneasy?

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c. Review the Serenity Prayer and how group members can


use this in their recovery.
“God grant me the serenity to accept the things
I cannot change, courage to change the things I can,
and the wisdom to know the difference.”
d. Discuss “existential anxiety,” the feeling of being isolated, of
facing difficult decisions and choices but feeling totally alone
in making them.
e. Do group members pray, meditate, or turn to a Higher Power
in times of stress, despair, confusion, or anxiety?
f. Do group members relate to having difficulty deciding at
times what they cannot change versus what they can (and
should) change?
g. What do group members think about feel saying the Serenity
Prayer at these times, or talking to other 12-Step friends
about the dilemmas they face that cause anxiety?
h. Other methods of dealing with anxiety are found in the
following 12-Step slogans such as “first things first” and
“easy does it.”
i. First Things First: the first priority is to not to take that first hit
of a drug.
• At times, individuals in recovery will be in conflict and
will have to choose between taking care of
themselves versus taking care of someone else.
• The choice may be to please oneself or to please
someone else; make oneself happy or make
someone else happy.
• Group members need to be encouraged to make their
ongoing recovery their first priority, even if that means
frustrating or disappointing someone else.
• The group counselor can elicit examples of situations
in which group members felt conflicted about taking
care of themselves versus taking care of others:
o What could be the price of pleasing or
satisfying others at one’s own expense?
o What can be done in that situation? It this
consistent with putting abstinence first?
j. Easy Does It: the pressures of deadlines and over
commitment create stresses that invite using drugs as a
means of coping. This slogan speaks to this particular issue.
• Does the patient identify with the stresses created by
having to meet deadlines or competing commitments?

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• What in the patient’s life contributes to stress, to time


pressure, or to over commitment?
k. Strategies for dealing with this form of stress are built around
developing a system of realistic priorities.
• Make a list of things to do today, then discard half of it
• Schedule things twice as far in advance as you
usually would.
• Sit quietly for 15 minutes a day.
• Talk to someone else (preferably a recovering
person) about your feelings or being overextended.
7. Emotions: anger and resentment
a. Anger and resentment are pivotal emotions for most recovering
individuals.
b. Anger that evokes anxiety drives some addicted individuals to use
drugs to anesthetize this feeling. Resentment, which comes from
unexpressed (denied) anger, represents a threat to abstinence for
the same reason.
c. Resentments, reflecting as they do unexpressed anger, represent
past issues. The recovering person cannot afford to live in the past
but must live in the present (one day at a time).
d. Therefore, resentments must be confronted and let go in favor of
more effective ways of dealing with anger in the present.”
e. Use the following guidelines and the Resentment Worksheet when
working on these issues:
• What situations are patients resentful over?
• How did they handle these at the time they happened?
• Can they see how these issues cannot be resolved now
but that, on the other hand, they can learn how to express
anger better, so as to avoid building up stores of
resentments in the future?
• Can the patient make the connection between
unexpressed anger (at the moment) and resentment
(holding on to the anger)?
• What can the patient learn from those experiences so as to
not avoid being honestly angry in the future?
• What would stop the patient from experiencing anger in the
future?
• What makes patients angry in the here and now? Are they
willing to make a commitment to expressing their anger
honestly and to having faith that it will be better if they do
that?

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Resentment Worksheet
WHAT HOW I FELT WHAT I DID WHAT I SHOULD DO
HAPPENED DIFFERENTLY USING
PROGRAM TOOLS

© Baker, S. & Nowinski, J. (1991)

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Resentment Worksheet
Example of Melissa

WHAT HOW I FELT WHAT I DID WHAT I SHOULD DO


HAPPENED DIFFERENTLY USING
PROGRAM TOOLS
My husband Angry and I used to use The program says to drop
blamed me for bitter at first. this in the past off your resentments at a
messing up our Once I thought as another meeting. My sponsor
budget cause I about this, I excuse to get says I need to evaluate
spent money on realized he high. how my family was
drugs. was right. I also used this affected by my addiction.
My mom I felt judged as a reason to I need to accept that my
criticizes me for and berated. get high. I also addiction hurt him and our
the way I deal I felt like a argued with her kids, talk with him, and
with my teen- victim at first, and said some when I’m ready, make
age kids. which pissed rotten things. amends.
Got written up me off. I I made Listen to her concerns
by my boss for realized she promises to be and accept that she is
being late and was right and on time and not concerned about my
missing too felt guilty for miss work, but welfare. I know that I
much work. letting her the more drugs I need to make amends to
down and not used, the less her and my at some time,
doing my job. dependable I too.
became. Accept responsibility for
my behaviors and make a
commitment to do my job,
and don’t blame others. I
will talk with my sponsor
each day to report on my
work attendance and
being on time.

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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.

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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?

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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.

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27.0 STAGE-12 COUNSELOR SELECTION, TRAINING AND SUPERVISION


27.1 Counselor Characteristics and Training Requirements
In the prior research studies that have evaluated therapy approaches, TSF has
been implemented by mostly Masters level counselors with substantial
experience in and commitment to 12-Step programs as a therapeutic
intervention, who also had extensive experience treating a broad range of
substance abusers. These counselors were selected to reduce the likelihood of
counselor effects on treatment outcomes by utilizing a comparatively
homogeneous group of highly skilled counselors. Furthermore, because the
counselor training/piloting period for these clinical trials is comparatively brief, it
was important to select counselors who already had a high level of expertise and
experience in this approach, and thus could achieve optimal levels of adherence
and competence rapidly.
The recommended educational and experience characteristics for counselors
involved in the STAGE-12 protocol are:
• A bachelor’s or master’s degree or equivalent in psychology, counseling,
social work.
• Or, a certification in addiction counseling (e.g., CADC, CAC or equivalent
certification).
• At least 3 years experience working with a substance abuse population.
• Familiarity with and commitment to a 12-Step approach.
Personal characteristics of counselors that are associated with improved
outcome using TSF or STAGE-12 have not been an explicit focus of research to
date. However, we assume the attributes identified by Luborsky and colleagues
(1985) as associated with better patient outcomes in psychotherapy would apply
to this treatment as well, including personal adjustment, interest in helping the
patient, ability to foster a positive working alliance, and high empathy and
warmth.
27.2 Role of STAGE-12 Counselor
The counselor in this protocol uses skills to help the group members and
individual patients overcome barriers to becoming actively involved in 12-Step
recovery programs such as NA, CA, CMA or AA. Skills such as active listening,
accurate empathy, problem solving, feedback, and confrontation all have a place
in this therapy.
One role is to act as an educator about 12-Step programs. This psycho-
education must be tailored to the specific needs of the group members.
Recovery tasks and topic material are presented in such a way that the patients
can relate in personal ways to the information, and incorporate this in their
ongoing recovery. The counselor, as a believer in the efficacy of 12-Step
programs, acts as an advocate. Beyond this, the counselor supports the group

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members’ ability to successfully work this program of recovery. In layman’s


terms, the counselor is both “coach” and “cheering squad” for the patients. The
counselor provides guidance and advice about how best to access the resources
of 12-Step programs. This may be based on the wisdom found in recovering
literature, or slogans, or the stories of other recovering addicted persons.
Lastly, the counselor provides empathy and a sense of hope for the group
members that recovery is possible. The counselor communicates clearly an
understanding of the struggles of early recovery. In doing so, the process of
acceptance and surrender are “humanized” so that the patients are given support
that they are not alone. By encouraging the patients to reach out to other
recovering addicts, the counselor helps them learn that it is possible to go
through this process and to recover successfully from addiction with the support
of others.
27.3 Familiarity with 12-Step Programs
To be able to deliver this treatment well the counselor needs to do certain things.
First, counselors must be familiar with 12-Step programs. This means feeling
comfortable with the language of NA, CA, CMA or AA, understanding types of
meetings and how the group meetings are conducted, where various 12-Step
programs meet, and being familiar with 12-Step recovery literature such as the
“Big Book” of AA and/or “Basic Text” of NA. In order to become familiar with 12-
Step programs, the counselor may attend several “open” meetings of 12-Step
programs in their area and read through recovery literature.

27.4 Group Facilitation


A major portion of the STAGE-12 intervention is delivered in the context of group
counseling sessions. Counselors need to be familiar with the general principles
of group therapy and its “curative factors,” be comfortable with presenting
psycho-educational materials in a group format, and be able to facilitate, direct,
and redirect group discussions and interactions as appropriate to the group topic,
group membership, and flow of the group.

27.5 Active and Facilitative


STAGE-12 requires an active, supportive and involved presence by the
counselor in sessions. A good session involves interaction between the
counselor and group members. The group sessions, however, are focused so
the counselor must insure that the content of the session is adequately covered
during the sessions. The counselor takes an active part in keeping the focus of
the session on recovery using the format present in this manual.
When faced with the day to day struggles of the patients, the counselor
encourages them to use 12-Step program tools. So, for example, after listening
with empathy to a patient during a group session, a counselor may suggest that
he or she talk about this problem with a sponsor or peer in the 12-Step program
as well as talk about the issue at a 12-Step discussion meeting.

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27.6 Confrontation and Feedback


Lastly, the counselor conducting STAGE-12 sessions uses confrontation and
feedback constructively. A term for the style of confrontation used by counselors
is “care-frontation.” This means that the counselor is careful to confront the
patient’s behavior as it relates to the addiction i.e., denial, avoidance, or
minimization rather than their person. This means separating the person from
their disease and communicating that the patient is a good person who has a
disease (addiction) that leads to acting in ways that are hurtful towards oneself
and others. By doing so, the counselor can endorse whatever efforts the patients
are making on behalf of recovery.
The use of “feedback” is another strategy to confront denial or behaviors that
interfere with recovery. Feedback is most effective when it comes from peers so
engaging group members in giving feedback to a patient during the group
session can be very powerful. Following are some examples of how a counselor
can elicit feedback from the group for a specific member.
1. “Devon made it very clear he doesn’t think he needs to stop using
marijuana, that giving up cocaine is enough. What do other group
members think about Devon’s position on this issue of continued drug use,
but not using cocaine?”
2. “Marcella said she ‘forgot’ to keep her recovery journal this past week. Do
other group members accept this excuse? What do you think about her
‘forgetting’ to complete her recovery assignment and keep her journal?”
3. “You just heard from Matt that when he wants to use meth real bad, he
keeps this to himself. Do you think this is good for his recovery? What do
you think about what he said about not sharing his drug cravings with
anyone?”
4. “Megan said she’s thinking about dropping her sponsor and getting a new
one because her sponsor said some things she didn’t like. What I heard
from her is that her sponsor called her on some behaviors she thought
were detrimental to Megan’s recovery. I would like other group members
to tell Megan their opinions about dropping her NA sponsor.”
5. “So Chris, you think 12-Step meetings are a waste of time, that you get
tired of hearing the same stories over and over. What are some opinions
of other group members about what Chris thinks about meetings being a
waste?”
27.7 Counselor Training
Just as reading a textbook on surgery could not be expected to produce a
qualified surgeon, mere review of this manual would be inadequate for a
counselor to apply this manual in clinical practice or research. Appropriate
counselor training for the STAGE-12 protocol requires completion of a didactic
seminar and at least two closely supervised training cases.

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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

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interventions s/he has trouble implementing with a given patient or group.


Fourth, the completion of the Checklist fosters process research by generating a
useful record of which interventions were or were not delivered to each patient in
a given session. Thus, for example we can construct a session-by-session map
of the order and intensity of interventions introduced to a range of patients
(Carroll, K.M., Nich, C., & Rounsaville, B.J., 1998).
The supervisor version of the form, called the STAGE-12 Rating Scale (adapted
from Carroll et al., 1998) differs from the counselor version by adding a
skillfulness rating. Thus for each intervention, both quantity and quality are rated.
The Rating Scale is an essential part of training, as it provides structured
feedback to the counselor and forms the basis of supervision. It also provides a
method of determining whether a counselor in training is ready to be certified to
deliver the treatment. When used with ongoing supervision, it enables the
supervisor to monitor and correct counselor drift in implementation of the
treatment. Finally, for counselors who have difficulty adhering to manual
guidelines but who maintain that they are, pointing out discrepancies between
the supervisor-generated Rating Form and the counselor-generated Counselor
Checklist is often a useful strategy for enhancing adherence.
For both versions of the scale, it is important to note that not all items on the
rating forms are expected to be covered, or covered at a high level, during all
sessions. However, items 7–16 reflect the essential STAGE-12 items that should
be present at least at a moderate level in the majority of sessions.
27.10 Certification of Counselors
Counselors are provisionally certified, or approved to implement the treatment
under supervision, following the completion of the didactic training and the
successful passing of a post-training knowledge examination. Counselors are
fully certified, being able to provide the intervention at reduced levels of
supervision when the supervisor determines that the counselor has completed an
adequate number of group sessions and individual training cases successfully.
After certification, levels of counselor adherence are monitored closely using the
STAGE-12 Rating Form. When counselor drift occurs, and the counselor strays
from adequate adherence to the manual, supervisors increase the frequency of
supervision until the counselor’s performance returns to acceptable levels.

27.11 Ongoing Supervision


We require ongoing supervision for all counselors delivering STAGE-12.
However, the level and intensity of ongoing supervision reflects the experience
and skill of the counselors, as well as the time available for supervision. The
minimum acceptable level of ongoing supervision for an experienced counselor is
monthly; weekly supervision is recommended for less experienced counselors.
In addition, supervisors should review and evaluate using the STAGE-12 Rating
Scale, 1–2 randomly selected group and individual sessions per patient.
Supervision sessions themselves should include a general review of the
counselors current groups and individual cases, discussion of any problems in

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implementing STAGE-12, review of recent ratings from the supervisor, and at


least one of every two supervision sessions should include review of a session
audiotape, with the counselor and supervisor both present.
27.12 Guidelines for Ongoing Supervision
In general, supervision is most effective when conducted at a consistent place,
date, and time; the goals of supervision are clear and both participant’s roles are
defined; the procedures that will be used for evaluation of the counselors are
clarified; and feedback to the counselor is based on session tapes and is focused
and concrete (“When you explored X’s last slip, I thought you could have gotten
more information about the events that led up to X’s use and connected those to
the 12-Step program idea of avoiding slippery people places and things. I think
that you need to be more explicit about how X can make use of specific 12-Step
program tools” (Witte & Wilber, 1997).
27.13 Common Problems Encountered in Supervision Failure to
Balance Manual-Specified Interventions and Patient Needs or
Concerns
STAGE-12 sessions integrate 12-Step program tools with effective supportive
counseling and education. Novice counselors, particularly those with less
experience in treating substance abusers and those who need to maintain a
higher level of structure than that to which they may be accustomed, often tend
to let group or individual sessions become unfocused, without clear goals, and do
not make the transitions needed to deliver 12-Step program tools effectively.
Such counselors often do not begin to introduce 12-Step recovery material early
enough in the group sessions, which results in rushing through important points,
failing to use patient examples or get patient feedback, and neglecting review of
the recovery tasks, all of which gives the impression that 12-Step program tools
are not very important. Similarly, other counselors allow themselves to become
overwhelmed by the constant substance-use related crises presented by patients
in groups and fail to focus on the content of the group sessions and the 12-Step
recovery tools in that they encourage patients to use as an effective way to help
avoid or manage crises. Falling into a crisis-driven approach tends to increase,
rather than decrease, patient anxiety and undermine self-efficacy. On the other
hand, maintaining a relatively consistent session routine and balancing the
patient-driven discussion of current concerns with focus on 12-Step recovery
tools is also a means by which the counselor can model the 12-Step principle of
putting “first things first”, i.e., putting the focus on recovery, without which nothing
else is possible.
Conversely, some counselors become overly fixed and inflexible in their
application of teaching 12-Step tools and adherence to the manual. Some
counselors, anxious to get it right, present the material in the manual more or
less verbatim to patients. This overly wooden approach necessarily fails to adapt
the teaching of 12-Step program tools to the particular needs, coping style, and
readiness of particular patients. For example, some counselors launch into

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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

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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.

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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

Dependence 1991: Proceedings of the 53rd Annual Scientific Meeting.


Research Monograph, 119, 297-298.
Miller, W.R., Brown, J.M., Simpson, T.L., Handmaker, N.S., Bein, T.H., et al.
(1995). What Works? A methodological analysis of the alcohol treatment
outcome literature. In: Hester, R.K. & Miller, W.R. (eds.) Handbook of
alcoholism treatment approaches: Effective alternatives, 12-44. Boston, MA:
Allyn & Bacon.
Montgomery, H. A., Miller, W.R., Tonigan, J.S. (1995). Does Alcoholics
Anonymous involvement predict treatment outcome? Journal of Substance
Abuse Treatment, 12, 241-246.
Moos, R. H., & Moos, B. S. (2004). Long-term influence of duration and
frequency of participation in alcoholics anonymous on individuals with alcohol
use disorders. Journal of Consulting and Clinical Psychology, 72(1), 81-90.
Moos, R. H., & Moos, B. S. (2005). Paths of entry into alcoholics anonymous:
consequences for participation and remission. Alcoholism: Clinical and
Experimental Research, 29(10), 1858-1868.
Moos, R. H., & Moos, B. S. (2006). Participation in treatment and alcoholics
anonymous: A 16-year follow-up of initially untreated individuals. Journal of
Clinical Psychology, 62(6), 735-750.
Morgenstern, J., Blanchard, K. A., Morgan, T. J., Labouvie, E., & Hayaki, J.
(2001). Testing the effectiveness of cognitive-behavioral treatment for
substance abuse in a community setting: within treatment and post treatment
findings. Journal of Consulting and Clinical Psychology, 69(6), 1007-1017.
Morgenstern, J., Bux, D. A., Labouvie, E., Morgan, T., Blanchard, K. A., &
Muench, F. (2003). Examining mechanisms of action in 12-Step community
outpatient treatment. Drug & Alcohol Dependence, 72(3), 237-247.
Morgenstern, J., Frey, R. M., McCrady, B. S., Labouvie, E., & Neighbors, C. J.
(1996). Examining mediators of change in traditional chemical dependency
treatment. Journal of Studies on Alcohol, 57, 53-64.
Morgenstern, J., Kahler, C. W., Frey, R. M., & Labouvie, E. (1996). Modeling
therapeutic response to 12-step treatment: Optimal responders,
nonresponders, and partial responders. Journal of Substance Abuse, 8, 45-
60.
Morgenstern, J., Labouvie, E., McCrady, B. S., Kahler, C. W., & Frey, R. M.
(1997). Affiliation with Alcoholics Anonymous after treatment: a study of its
therapeutic effects and mechanisms of action. Journal of Consulting and
Clinical Psychology, 65(5), 768-777.
Narcotics Anonymous (1988). Narcotics Anonymous. Van Nuys, CA: World
Service Office, Inc.
National Institute on Drug Abuse. (2003, April 29-30, 2003). State of the science
of group therapy research for drug abuse and dependence: Workshop
summary. http://www.drugabuse.gov/whatsnew/meetings/grouptherapy.html
Niebuhr, R. (1950). The Serenity Prayer. The Alcoholics Anonymous
Grapevine, Jan: 6-7, 1950.

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

Sisson, R. W., & Mallams, J. H. (1981). The use of systematic encouragement


and community access procedures to increase attendance at Alcoholic
Anonymous and Al-Anon meetings. American Journal of Drug and Alcohol
Abuse, 8(3), 371-376.
Stinchfield, R., Owen, P. L., & Winters, K. C. (1994). Group therapy for
substance abuse: A review of the empirical evidence. In A. Fuhriman & G. M.
Burlinggame (Eds.), Handbook of group psychotherapy: An empirical and
clinical synthesis (pp. 458-488). New York: John Wiley & Sons.
Strupp, H.H. & Hadley, S.W. (1979). Specific vs. nonspecific factors in
psychotherapy: A controlled study of outcome. Archives of General
Psychiatry, 36, 1125-1136.
Timko, C., DeBenedetti, A., & Billow, R. (2006). Intensive referral to 12-Step self-
help groups and 6-month substance use disorder outcomes. Addiction,
101(5), 678-688.
Timko, C. & Debenedetti, A. (2007). A randomized controlled trial of intensive
referral to 12-step self-help groups: One-year outcomes. Drug and Alcohol
Dependence, 90(2-3), 270-279.
Timko, C., Finney, J. W., Moos, R. H., & Moos, B. S. (1995). Short-term
treatment careers and outcomes of previously untreated alcoholics. Journal of
Studies on Alcohol, 56:597-610.
Tonigan, J. S. (2001). Benefits of alcoholics anonymous attendance: Replication
of findings between clinical research sites in Project MATCH. Alcoholism
Treatment Quarterly, 19(1), 67-78.
Triffleman, E., Kellogg, S., & Syracuse-Siewert, G. (1997). Pilot Study Findings:
A Controlled Trial of Psychosocial Treatments in Substance Dependent
Patients with PTSD. Presented at the 13th Annual Meeting of the
International Society for Traumatic Stress Studies, Montreal, Quebec,
Canada.
Waltz, J., Addis, M.E., Koerner, K., & Jacobson, N.S. (1993). Testing the
integrity of a psychotherapy protocol: Assessment of adherence and
competence. Journal of Consulting and Clinical Psychology, 61, 620-630.
Watson, C. G., Hancock, M., Gearhart, L.P., Mendez, C.M., Malovrh, P., Raden,
M. (1997). A comparative outcome study of frequent, moderate, occasional,
and non-attenders of Alcoholics Anonymous. Journal of Clinical Psychology,
53, 209-214.
Weiss, R. D., Griffin, M. L., Gallop, R., Luborsky, L., Siqueland, L., Frank, A., et
al. (2000). Predictors of self-help group attendance in cocaine dependent
patients. Journal of Studies on Alcohol, 61(5), 714-719.
Weiss, R. D., Griffin, M. L., Gallop, R., Onken, L. S., Gastfriend, D. R., Daley, D.,
et al. (2000). Self-help group attendance and participation among cocaine
dependent patients. Drug and Alcohol Dependence, 60(2), 169-177.
Weiss, R. D., Griffin, M. L., Gallop, R. J., Najavits, L. M., Frank, A., Crits-
Christoph, P., et al. (2005). The effect of 12-step self-help group attendance

118
NIDA-CTN-0031 Version 3.0
Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) April 2009

and participation on drug use outcomes among cocaine-dependent patients.


Drug Alcohol Depend, 77(2), 177-184.
Weiss, R. D., Jaffee, W. B., de Menil, V. P., & Cogley, C. B. (2004). Group
therapy for substance use disorders: what do we know? Harvard Review of
Psychiatry, 12(6), 339-350.
Weissman, M.M., Rounsaville, B.J., & Chevron, E. (1982). Training psycho
counselors to participate in psychotherapy outcome studies. American
Journal of Psychiatry, 139, 1442-1446.
Wells, E. A., Peterson, P. L., Gainey, R. R., Hawkins, J. D., & Catalano, R. F.
(1994). Outpatient treatment for cocaine abuse: A controlled comparison of
relapse prevention and Twelve-Step approaches. American Journal of Drug
and Alcohol Abuse, 20(1), 1-17.
Witte, G. & Wilber, C. (1997). Therapy compliance and clinical supervision. In
Carroll, K.M. (ed.) (1997). Improving compliance with alcoholism treatment.
NIAAA Project MATCH Monograph Series.

119
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Appendix

CTN-0031 Lifestyle Contract


Date: ___________________

DANGEROUS TO PATIENT'S SUPPORTS


PATIENT'S
RECOVERY FEELINGS RECOVERY
FEELINGS ABOUT
(What needs to be ABOUT (What needs to be
SUPPORTS
given up) DANGERS substituted)

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.

A. Suggested Recovery Tasks

1. Mutually agreed upon list of CA, CMA, AA, and NA group meetings to
be attended this week:

DAY MEETINGS TIME PLACE

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

2. Suggested readings and recovery task activities to be completed this


week:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

121
Date: __________

B. Twelve Step Recovery (CA, CMA, AA, and NA) meetings attended:

1. Date attended: ___________ Time: ___________ Place: _____________________

Type of meeting/Topic:____________________________________________

What I heard/saw: ________________________________________________

_______________________________________________________________

_______________________________________________________________

What I think about what I heard/saw: _________________________________


_______________________________________________________________

_______________________________________________________________

Questions/Feelings about what I heard/saw:____________________________

_______________________________________________________________

_______________________________________________________________

2. Date attended:___________ Time:_____________ Place_____________________

Type of meeting/Topic:____________________________________________

What I heard/saw:________________________________________________

_______________________________________________________________

_______________________________________________________________

What I think about what I heard/saw:_________________________________

_______________________________________________________________

_______________________________________________________________

Questions/Feelings about what I heard/saw:____________________________

_______________________________________________________________

_______________________________________________________________

122
Date:__________

B. Twelve Step Recovery (CA, CMA, AA, and NA) meetings


attended (continued):
3. Date attended: ___________ Time: ___________ Place: _____________________

Type of meeting/Topic: _____________________________________________

What I heard/saw: ________________________________________________


________________________________________________________________
________________________________________________________________
What I think about what I heard/saw: _________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Questions/Feelings about what I heard/saw: ___________________________
_______________________________________________________________
_______________________________________________________________
4. Date attended: ___________ Time: ___________ Place: _____________________

Type of meeting/Topic: ___________________________________________

What I heard/saw: ________________________________________________

_______________________________________________________________

_______________________________________________________________

What I think about what I heard/saw: _________________________________

_______________________________________________________________

_______________________________________________________________

Questions/Feelings about what I heard/saw: ___________________________


_______________________________________________________________
_______________________________________________________________

123
Date: __________

C. Reactions to suggested readings/tapes:

What I read: __________________________________________________

What I think/feel about what I read: _______________________________

____________________________________________________________

What I listened to: _____________________________________________

What I think/feel about what I listened to: __________________________

____________________________________________________________

D. “Slips” (Dates that I used drugs or drank alcohol; how much; what I
did about it):
___________________________________________________________

___________________________________________________________

____________________________________________________________

______________________________________________________

E. Cravings or urges to use or drink; when these occurred; what I did:


____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

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.

Spirituality does NOT mean mysticism or spiritualism, or an Eastern religious


practice.

It is NOT a set of rules about what is good and bad, right and wrong.

It is NOT a church doctrine or religious belief.

Spirituality is a way of life, a way of thinking that helps sobriety.

The following is a comparison of non-spiritual vs. a spiritual way of living and


thinking:

NON-
SPIRITUAL
SPIRITUAL

VALUE………………………………... Things People

THE GOAL IS…………………… Acquire Things Good Relationships

THE GOOD LIFE IS…………….… Money Friends

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

Adapted from: Woodard, A. & Wuelfing, J. (1991)

125
STAGE-12 Resentment Worksheet
WHAT I SHOULD DO
WHAT
HOW I FELT WHAT I DID DIFFERENTLY USING
HAPPENED
PROGRAM TOOLS

© Baker, S. & Nowinski, J. (1991)

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?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

2. How have you lost self-respect due to your drug use?


__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

3. How have you tried to control your use of drugs?


__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Remember that “loss of control” (powerlessness) and problems (unmanageability) are


symptoms of the disease of drug dependence. In order to recover, people have admitted
their limitations and accepted that the solution is to be open to support from others (NA,
CA, CMA or AA) and to stay away from the first use, one day at a time!

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

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