College research paper by Henry Tarkington, MSW, LCSW, LCAS, CCS

Introduction

This writer has been working in and around the addictions treatment field for almost 14 years. During the first 10 years of that time, 12-Step Facilitation and the Minnesota Model were the therapy models of choice. Things began to change during the early 1990's. The agency where this writer was employed began to admit patients with co-occurring substance dependence and mental disorders. This was a radical change from 1987 when very few patients were admitted to Wake County Alcoholism Treatment Center (ATC) if they even had a drug problem besides alcohol. Any type of diagnosis for a mental disorder disqualified them from the program.

The ATC used the Minnesota Model of substance abuse treatment, which is based on the program of Alcoholics Anonymous (AA). The goal of the Minnesota model is lifetime abstinence from alcohol and other mood altering drugs by applying the 12-steps of AA (NIDA, 2000). This was the only model used by recovering counselors at the ATC. There seemed to be an attitude that “if it worked for me, it will work for them.” Some recovering counselors maintain this attitude even today. However, there were no outcome studies to determine the effectiveness of models used there. Treatment did not allow for patients with dual-diagnosis and different needs (such as mothers with young children) who did not respond well to the model. It was a one-size-fits all program. The only problem was it did not fit all and those it did not fit were screened out or provided treatment that did not work for them.

During the 1990's patients with dual-diagnosis and issues such as being court mandated, Social Service referrals, and (later) Work First had become a regular part of the milieu. New models of treatment were necessary to reach the new population served. The model most often taught to staff at the ATC was Cognitive-Behavioral Therapy (CBT). Though the 12-step Facilitation and the Minnesota Models are still used extensively, they are used in conjunction with CBT and other models.

Included in this paper will be a review of the Minnesota Model, Twelve-Step Facilitation, theories of cognitive therapy, behavioral therapy, and cognitive-behavioral therapy. The 12-step Facilitation and Minnesota Models will be reviewed. A comparison of cognitive-behavioral therapy to other therapies will be discussed along with the practice of CBT in substance abuse treatment. Strengths and limitations, implications for practice and recommendations will conclude this discussion.

Twelve-Step Facilitation and Minnesota Model

Ninety-five percent of inpatient addictions programs in the U.S. incorporate Alcoholics Anonymous and Narcotics Anonymous into their treatment programs at some level (Bristow-Braitman, 1995). In her research, Bristow-Braitman found that of AA participants, 77% received psychotherapy before abstinence and 45% received psychotherapy after abstinence. The research indicated that because of relapse rates as high as 75%, clients are utilizing as many resources as possible to overcome addiction and its presenting problems.

Therapists best serve their clients by having a thorough understanding of the spiritual principles of 12-step programs in addition to the necessary cognitive-behavioral changes to maintain recovery (Bristow-Braitman, 1995). To effectively treat clients using a combination of CBT and referral to 12-Step programs, therapists must be able to reconcile some of the striking differences. For example, the 12-step program necessitates “admitting powerlessness over one's addiction [which] flies in the face of psychologically constructed self-efficacy as posited by social-learning theorists” (p. 416). To conform to CBT principles, “the admission of powerlessness could be viewed as the first step in improving self-efficacy by preparing a person to use the 12-steps as an alternative coping strategy” (p. 417). Though they do not necessarily need to be in recovery themselves, therapists must have a thorough understanding of the 12 Steps and 12 Traditions and should have attended a number of meetings to use this model effectively (NIDA, 2000).

Twelve-step Facilitation (TSF) is a brief, structured approach designed to help clients in treatment and early recovery maintain complete abstinence from alcohol and drug use. NIDA (The National Institute on Drug Abuse) states that TSF is designed to incorporate the “behavioral, spiritual, and cognitive principles that form the core of 12-step fellowships such as Alcoholics Anonymous and Narcotics Anonymous” (2000, p.95). A basic premise of the 12-steps is acceptance that willpower is not enough to achieve long-term sobriety. “Self-centeredness must be replaced by surrender to the group conscience, and long-term recovery consists of a process of spiritual renewal” (p. 95).

TSF may be used in conjunction with pharmacotherapy. Antebuse and naltrexone are often used to support abstinence. It is not compatible with severely depressed patients or those with major affective disorders or psychotic disorders. It was designed to support individual therapy and active participation of the client in 12-step programs. Though designed for individual therapy, it has been adapted for use in groups.