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Stages of Affiliation with Alcoholics Anonymous

How do alcoholics get to AA?¹

AA has grown to over 100,000 groups with more than two million members simply on word-of-mouth recommendation. Often the recommendation has come from friends, family, employers, healthcare workers or law courts.

People progress through stages of affiliation with others and with Alcoholics Anonymous in pursuit of solutions to their problems. Two paths are identified; Direct Affiliation and Facilitated Affiliation².

The stages are not necessarily discrete where a person moves in clear progression from one stage to the next. A person is more likely to move up and down, sometimes jumping a stage in regression or progression. However, AA reports that 51% of current members stayed sober from their first meeting.

Facilitation plays a significant part in the process of AA affiliation as approximately 60%³ of AA members seek help from the helping professions prior to attending AA.

These stages of affiliation generally follow Prochaska and DiClemente Stages of Change model and are;

• Pre-contemplation,
• Contemplation,
• Preparation,
• Non-affiliation,
• Affiliation,
• Misaffiliation,
• Affiliation-mandated,
• Supra-affiliation,
• Altruistic affiliation,
• Ambivalent affiliation,
• Disaffiliation,
• Re-affiliation.

For full chart of Stages of Affiliation download PDF file below.

Attached Files:

• microsoft-word-stages-of-affiliation-with-alcoholics-anonymous.pdf (72 KB)

Alcohol use disorders represent a substantial public health problem all over the world affecting approximately 2 billion alcohol users worldwide as estimated by the WHO in 2000.

Given the harmful effects of alcohol on the distressed individuals and society as a whole, there is an increasing urge for the development of new, more efficient medications.

Although, investigation of the mechanisms underlying the actions of ethanol in the central nervous system has been ongoing for more than a century, the exact mechanism by which ethanol exerts its effect is still a matter of debate.

In recent years, scientists discovered evidence that alcohol acts on several neurotransmitter systems in the brain to create its alluring effects.

Besides altering the release of neurotransmitters like dopamine, ethanol alters the function of a number of neurotransmitter receptors as well as transporters.

When ethanol is used for longer period of time, changes in these specific neurotransmitter functions occur possibly underlying the development of alcohol dependence.

Therefore, modulators of these targets of ethanol can be useful pharmacotherapeutic agents in the treatment for alcohol dependence.

The aim of this review is to summarize the patent background of these potential candidates clustering them according to their mechanism of effects.

Research; Nagy J. Recent patents on pharmacotherapy for alcoholism. Recent Patents CNS Drug Discov. 2006 Jun;1(2):175-206.

See also;

• Twelve Step facilitation
• Brief-TSF professional training is complimentary to pharmacotherapy.

Recovering from alcohol and other drug dependency.

AA describes itself as a program of spiritual recovery from alcoholism. Its philosophy and methods have strongly influenced formal treatment programs.

AA’s 12 steps, beginning with an admission of powerlessness over alcohol, provide a structured series of self-examination and improvement tasks to help overcome alcoholism.

Although AA is difficult to evaluate because of its informality, subjectivity, and lack of control groups, formal treatment programs often involve AA participation as an adjunct.

AA’s reputation has led to the development of similar organizations for other types of psychological problems.

Al-Anon is modeled after AA and offers a similar 12-step program for codependents to help them realize their powerlessness over the drinking of their alcoholic family members.

This is seen as necessary before codependents can recover from their own addiction of trying to control their alcoholic family members’ drinking.

They are led to focus primarily on their own recovery, not that of the alcoholic.

Spontaneous recovery from alcohol and other drug dependency apparently occurs, and though most of the evidence is anecdotal, it does suggest that formal treatment is not always necessary.

It is possible that some types of personalities or environmental circumstances are more likely to be associated with such successes.

Research; Jung, J. Recovering from alcohol and other drug dependency. In: J. Jung, Psychology of Alcohol and other Drugs: Research Perspective, Thousand Oaks, CA: Sage Publications, 2000. 634 p. (pp. 398-421)

How Al-Anon Works for Families & Friends of Alcoholics

What does the Brief-TSF model look like?

How does the Brief-TSF model work?

Defining the Brief-TSF processes

This model brings together three people to achieve sobriety in one of them. These are the;

• experiential contributor (AA Peer Sponsor) and
• professional care (Twelve Step Facilitator) to collaborate in facilitating self help recovery for the
• alcoholic (normally known as the patient or client).

Each of the three people brings to the intervention knowledge’s and functions known as ‘domains of praxes’. Within each domain are the constituents of experience, training, perceptions, goals and capabilities.

Functional Domain

The Brief Twelve Step Facilitator facilitates self-assessment by the patient, introduces them to a ‘Peer Sponsor’ and facilitates understanding of the ‘Program of Recovery’. In addition the healthcare worker assesses and addresses or refers the patient for any co-morbidities.

The Peer Sponsor shares their ‘experience, strength and hope’ with the patient, provides initial resources to attend meetings, introduces the ‘Newcomer’ to Alcoholics Anonymous members and explains the program of recovery from drinking.

The patient chooses what, when, and how they can use information, from each of the providers. This is true Self help within a paradigm of mutual help.

Additionally, the patient is supported in seeking professional treatment/therapy for other issues.

Recovery Domain

Each participant maintains their integrity and independence within their domain.

The primary goal of Brief-TSF is affiliation with Alcoholics Anonymous as described in the Stages of AA Affiliation.

Recovery includes attending AA meetings and other activities, stopping drinking, ‘working’ the program of recovery and consulting with a peer sponsor within an affiliation scheme.

The whole facilitated process producing a ‘Domain of Recovery’.

Disease Domain

Alcoholism is a primary, chronic, progressive three fold disease - mental, physical and spiritual. Alcohol dependence is fatal if not arrested by abstaining from alcohol.

Each participant has a hand in recovery

Brain research shows why long-term drug users just can’t say no

Groundbreaking research from the University of Melbourne has shed new light on why long term drug users find it hard to say no, despite dire consequences to their health.

A study into the frontal cortex, the key region of the brain involved in decision making, has shown that drug users have to place much greater demand on the brain to control impulses.

The two year study was conducted by researchers Dr Murat Yücel and Dr Dan Lubman of the ORYGEN Research Centre and the Melbourne Neuropsychiatry Centre, based at the University of Melbourne and was recently published in the July edition of the prestigious international journal Molecular Psychiatry.

“Drugs can capture and hijack some parts of the brain,” said Dr Murat Yücel a lead researcher in the study.

“In this study we found the frontal cortex, an area that is essential for exercising control over thoughts and behaviours, was working inefficiently.”

“These findings may help explain why it takes addicted individuals enormous effort to exercise control over their drug-taking behaviour in the face of adverse consequences, and why they are vulnerable to relapse back into uncontrolled, compulsive patterns of use.”

The studies involved brain-imaging technology to probe the physiological and biochemical properties of a key region of the brain, the frontal cortex.

Participants were asked to complete a test of self-control in which they had to overcome an automatic response in favour of a more controlled alternative response, thus requiring them to control their impulsive tendencies.

They researchers discovered two important differences between the opiate-using group and a group who have never used heroin.

Firstly, the opiate-using group needed to activate more of their brain by placing greater physiological demand on it to avoid making an error on a test of self control.

At the same time, brain cells in the frontal region were revealed to be less healthy than the non opiate-using group.

“What people don’t tend to understand about long term drug users is that this is not a matter of choice. They have a reduced level of biological resources and find it hard to stop.”

Dr Dan Lubman, an addiction psychiatrist and a senior investigator on the project, says this new evidence is likely to lead to the development of innovative strategies for the treatment of addiction

“These findings tell us that we need to provide a combination of pharmaceutical and psychological treatments that will help bolster the efficiency of the frontal cortex and hence the individual’s ability to stop their urge to use drugs.” Dr Lubman said.

“To improve treatments for long term drug users we need to understand at what stage these brain deficits occur. The next question we need to ask is are these latest research findings a consequence of addiction or do they explain people’s vulnerability to problematic drug use?” he said.

In future, the researchers would like to examine whether these processes recover with abstinence.

From a press release of the University of Melbourne, Australia.

Brain Damage, Brain Repair by James W. Fawcett, Anne E. Rosser, Stephen B. Dunnett Read more about this title…

Designed By Professionals for Professionals

Brief-TSF is a professionally written continuing professional education program for healthcare workers.

All disciplines of the helping profession who come in contact with patients may benefit from Brief-TSF training for alcoholism.

The professions included are nurses, doctors, psychiatrists, psychologists, social workers, faith based workers (pastors, priests, ministers, Rabbis, and other clergy) and counselors.

Brief-TSF may also be used by trained and supervised volunteers.

The Federation of Drug & Alcohol Professionals (FDAP) is the professional body for the substance use field and works to help improve standards of practice across the sector. It is part of NAADAC, a registered charity.

FDAP offers a range of training courses - online, distance learning and face-to-face - aimed at developing the competence of workers and managers in line with the DANOS-based competence framework and relevant workforce development targets.

Introductory Certificate for Counsellors

We have launched a new introductory certificate for drug and alcohol counsellors, in partnership with Alcohol Concern. The new award is aimed at counsellors in training and volunteer counsellors. See training for more details.

FDAP Qualifications

FDAP provide a range of qualifications & certifications designed to recognise and demonstrate the competences of managers and practitioners in the drugs and alcohol field - in line with the DANOS-based competence framework and relevant workforce development targets.

Practitioners (general)

FDAP Drug & Alcohol Professional Certification [DANOS-based]

A competence-based certification for practitioners, covering 10 units from DANOS and related national occupational standards, and providing externally-validated evidence of workplace competence. Cost: £75 (reductions available for FDAP affiliate agencies, no charge for FDAP NCAC Accredited Counsellors). [Open to FDAP members/associates only.] more…

OU/FDAP Professional Awards for Drug & Alcohol Practitioners

Open University qualifications providing evidence of competence against units from DANOS - including a 10 unit Professional Award for Drug & Alcohol Practitioners and smaller Professional Development Awards. Cost: from £245 (10% off for FDAP members/affiliates). [Open to all.] more…

Counsellors

FDAP National Counsellor Accreditation Certificate (NCAC)

Specialist certification for drug & alcohol counsellors, conferring eligibility to the United Kingdom Register of Counsellors and complementing FDAP’s Drug & Alcohol Professional Certification. Cost: £150 (reductions available to FDAP affiliates). [Open to FDAP members/associates only.] more…

FDAP/AC Introductory Certificate for Drug & Alcohol Counsellors

A certification from FDAP and Alcohol Concern, aimed at counsellors in training and volunteer counsellors working in alcohol and drugs services. Cost: £75 (£50 for FDAP members/affiliates and AC members). [Open to all.] more…

Managers

OU/FDAP Awards for Managers of Drug & Alcohol Practitioners

Open University qualifications based on an assessment of competence against national occupational standards units relevant to line managers. Cost: £440 (10% off for FDAP members/affiliates). [Open to all.] more…

Brief-TSF professional training is adjunctive to all these courses.

See also;

• Twelve Step Facilitation
• NACoA’s Clergy Training and Certification

Alcoholic jealousy: an old and current dilemma.

The relation between alcohol and jealousy is a deeply rooted belief within the general population as well as in the medical, and particularly psychiatric, environment.

Furthermore, in recent years there has been a growing interest on the forensic aspects of pathological jealousy, since they are a frequent cause of severe violence, homicide and suicide.

Some authors have described a high prevalence of pathological jealousy in alcoholic patients, even awarding it a specific value in alcoholism.

Nevertheless, recent studies do not completely support this relation, and draw attention to other factors.

Results from the various studies contain several definitions and classifications of pathological jealousy, and although most of them highlight the prevalence of jealousy in alcoholic patients, they question its specific quality.

Also, the presence of pathological jealousy in subjects with psychiatric disorders other than alcoholism is suggested, indicating the existence of predisposing and triggering factors which could explain the development of pathological jealousy.

Yet, the important methodological difficulties in the published articles and the shortage of studies do not allow the confirmation of the alcoholic etiology in pathological jealousy; this is the reason why considering alcoholic jealousy as a separate entity is debatable.

In this sense, the best diagnosis in these patients would be paranoid disorder combined with alcoholic dependence, hence, a dual diagnosis.

Research; Jiménez-Arriero MA, Hernández B, Mearin Manrique I, Rodríguez-Jiménez R, Jiménez Giménez M, Ponce Alfaro G. Alcoholic jealousy: an old and current dilemma. Adicciones 2007; 19(3): 267-72

Emotional Wellness: Transforming Fear, Anger, and Jealousy into Creative Energy

Craving Reduction Medications

What medications are used in the direct treatment of alcoholism?

Anti-craving drugs and Brief-TSF, a good combination.

The process of Brief-TSF supports the use of anti-craving medications to aid in alcoholic relapse prevention. Most prescribing authorities require that alcohol craving medications be accompanied with counseling. Evidence based best practice guidelines recommend the use of craving reduction drugs where appropriate

Alcoholics Anonymous has a clear policy on the use of medications to help restore health. As always AA makes suggestions to its members;

• During their drinking days, many alcoholics made their problems worse by mixing liquor with sedatives, tranquilizers, marijuana, or other drugs. They may cling to the pill or drug habit even after they stop drinking. It will probably also be wise if you encourage the alcoholic to seek medical advice from a physician knowledgeable about the special problems recovering alcoholics experience. Using medications or discontinuing their use without proper professional guidance may be dangerous, and either course may lead a sober alcoholic back to the first drink.

(The pamphlet "The A.A. Member - Medications and Other Drugs" discusses the problem in detail.) (AA, 1976).

’Alcoholics Anonymous and the Use of Medications to Prevent Relapse’.

This study did not find any strong or widespread negative attitudes toward medication for preventing relapse among AA members. Most of those who experienced unfavorable pressure continued taking their health medication (Rychtarik et al, 2000).

Two Craving Reduction Medications

There are two alcohol anti-craving drugs recommended for alcoholism or alcohol dependence. These are; acamprosate tablets (Campral™) and naltrexone tablets (Revia™).

A new formulation - long-acting Injectable naltrexone - is currently under development. May 2007 - Now available in the USA.

Naltrexone Tablets (ReVia™)

A Cochrane Review of 29 studies from around the world concluded that naltrexone provides real help to people trying to moderate their drinking and "should be accepted as a treatment for alcoholism.”

This study reported that in comparison to placebo, a short-term treatment of naltrexone (ReVia™) significantly decreased relapse by as much as 36% over and above normal rates, and significantly reduced withdrawal symptoms.

Naltrexone and intensive psychosocial treatment, such as counseling or attending AA meetings, was superior in the medium-term. (Srisurapanont et al, 2005).

Acamprosate (Campral™) Tablets

Seventeen randomized, placebo-controlled trials of acamprosate (Campral™) were reviewed covering 4087 alcoholics. Continuous abstinence rates at 6 months were significantly (54%) higher in the acamprosate-treated patients compared to placebo patients. Acamprosate also had a modest but significant beneficial effect on retention in treatment (Mann et al, 2004).

Overall, patients treated with acamprosate (Campral™) exhibited a significantly greater rate of treatment completion, time to first drink, abstinence rate, and/or cumulative abstinence duration than patients treated with placebo. The drug’s reliable effect on prolonging abstinence, in conjunction with an excellent safety profile, suggests that acamprosate may be useful for a broad range of patients with alcohol dependence (Mason, 2001).

Drinking and craving alcohol must be addressed first

Management of Adults Recovering From Alcohol or Other Drug Problems

Patients recovering from substance use disorders are commonly seen in the primary care setting, and relapse is a serious long-term problem for these patients.

Extrapolating from therapeutic strategies effective in specialty addiction treatment settings, this article outlines a practical approach to relapse prevention in the primary care setting.

Working within a supportive patient-physician relationship, the primary care physician can help recovering patients decrease their susceptibility to relapse, recognize and manage high-risk situations, and use available self-help, pharmacological, and specialty resources.

Drawing on the therapeutic relationship and skills they already possess, primary care physicians can have an important, productive, and satisfying role in the long-term management of patients in recovery from alcohol or other drug problems.

RELAPSE, a return to the use of alcohol or other drugs, is a serious problem for patients recovering from substance use disorders. Despite the effectiveness of addiction treatment for initiating recovery, only 20% to 50% of patients remain abstinent during the first year.

Specialty aftercare may lessen relapse, but addiction treatment duration and access to aftercare have decreased in recent years, resulting in earlier return of recovering patients to the care of their primary care practitioners. Primary care physicians are poorly prepared for the long-term management of patients with substance use problems. To help these patients avoid relapse, generalist physicians need skills in the support and maintenance of recovery.

Consensus statements recommend that primary care physicians routinely screen all patients for substance use disorders. Recent publications provide the primary care physician with brief, effective approaches to motivate patients to recognize and address their substance use problems.

Based on the theoretical model of the stages of behavioral change, these approaches are designed for the management of patients with current, active substance use problems who either do not recognize the problem (ie, the precontemplation stage) or are considering change (ie, the contemplation stage), but provide little guidance about how to work with patients who have stopped using alcohol or other drugs (ie, the maintenance stage).

This article focuses on the care of patients in recovery from substance use disorders.

For primary care physicians aware of their recovering patients’ struggles, we outline a practical approach to the support of a substance-free lifestyle. Our discussion centers on patients who are early in recovery and at highest risk for relapse, although many of these principles also apply to longer-term recovery.

The full article includes sections on the following topics;

• IDENTIFY PATIENTS IN RECOVERY
• ESTABLISH A SUPPORTIVE PATIENT-PHYSICIAN RELATIONSHIP
• SCHEDULE REGULAR FOLLOW-UP
• MOBILIZE FAMILY SUPPORT
• FACILITATE INVOLVEMENT IN 12-STEP RECOVERY GROUPS
• HELP RECOVERING PATIENTS RECOGNIZE AND COPE WITH RELAPSE PRECIPITANTS AND CRAVING
• ADVISE RECOVERING PATIENTS TO DEVELOP A PLAN TO MANAGE EARLY RELAPSE
• FACILITATE POSITIVE LIFESTYLE CHANGES
• MANAGE DEPRESSION, ANXIETY, AND OTHER COMORBID CONDITIONS
• CONSIDER ADJUNCTIVE PHARMACOTHERAPY
• COLLABORATE WITH ADDICTION SPECIALTY PROFESSIONALS

CONCLUSIONS

The primary care physician can have a central, productive, and satisfying role in the long-term management of patients in recovery from substance use problems. Generalist physicians already possess many of the skills necessary for relapse prevention. Specific recommendations and counseling strategies, extrapolated from therapeutic modalities effective in other settings, are feasible in the primary care physician’s office. Future research should examine the effectiveness and cost of relapse prevention in the primary care setting. Given current knowledge about relapse prevention and the effectiveness of physician involvement with their patients’ substance use problems, primary care physicians should begin the important work of supporting, monitoring, and maintaining patients in recovery from alcohol or other drug problems.

Research report; Peter D. Friedmann, Richard Saitz, Jeffrey H. Samet. Management of Adults Recovering From Alcohol or Other Drug Problems; Relapse Prevention in Primary Care; JAMA. 1998;279:1227-1231.

Brief-TSF supports and addresses all these suggestions.