Adoption of “Best Practices”

Dawn Farm is committed to integrating “best practices” into all areas of operations. All members of the Dawn Farm management team are responsible for staying informed of “best practices” in their areas of responsibility and, where deemed appropriate by them and the President or Clinical Director, integrate them into Dawn Farm policy, procedures and practice.

While Dawn Farm is committed to “best practices”, we also recognize that the concept of “best practices” is often driven by fads. Therefore, a “wait and see” approach may be appropriate with recently identified “best practices.”

Finally, Dawn Farm attributes its longevity to being a value-driven organization. Therefore, great care should be taken to assure that a “best practice” is aligned with Dawn Farm’s values before it is adopted.

Our Treatment Approach

The information in this document was part of a letter written in response to an organization that questioned the effectiveness of our treatment approach in favor of a Motivational Enhancement Therapy and Cognitive Behavioral Therapy.

Our treatment approach integrates a variety interventions based on the individual needs of the client. However, Twelve Step Facilitation is the foundation of our treatment programs. Twelve Step Facilitation is an approach that seeks to familiarize clients with the basic concepts and beliefs of twelve step programs and encourage the client’s participation in the appropriate twelve step program. We have three basic reasons for our use of Twelve Step Facilitation over other methods:

1. Treatment programs based on the 12 steps work and work well;
2. Dawn Farm is not averse to MET and CBT, in fact we frequently employ them in our other programs;
3. MET and CBT are not more effective than programs that focus on 12 step facilitation (TSF), and they may even be less effective with a population like the one that Community Corrections serves.
   1. Twelve step programs work and facilitating twelve-step involvement (TSF) is an effective treatment strategy. Dawn Farm’s years of experience demonstrate this truth. Our outcomes data and hundreds of anecdotal stories speak to the power of twelve step programs to help addicts and alcoholics abstain and improve functioning in many areas of their life. I understand that you met some at your last meeting.
      1. Research supports this assertion as well. Researchers consistently find that affiliation with Alcoholics Anonymous (AA) is one of the strongest predictors of abstinence.[1],[2],[3],[4],[5],[6] Affiliation with AA has been found to have other benefits as well. It has been associated with an improved sense of self-efficacy and coping skills.1 Even clients low levels of recovery motivation benefit from weekly or more twelve-step participation. This finding persisted even if the client dropped out of treatment and their outcomes were better than clients who remained in treatment but participated in a twelve-step group less than once per week.4 These types of findings have led to recommendations that twelve-step participation be an integral part of treatment programs for the purpose of stretching treatment dollars by facilitating ongoing therapeutic support that is free.[3], [4]
   2. While CBT and MET are not part of Dawn Farm’s core philosophy, they are frequently used in our programs.
      1. Dawn Farm believes that addiction is a disease rather than a product of cognitive distortions or lack of coping mechanisms as the CBT model of addiction asserts or the result of a person’s willingness to pay a high price for their use of a drug as the MET model suggests. Our experience, as the above research supports, is that the most effective intervention for this disease process is to facilitate enmeshment in twelve step programs like Alcoholics Anonymous or Narcotics Anonymous.
      2. While Dawn Farm’s primary goal is connecting clients with this recovering community, we do recognize that the barriers to this goal may require other interventions like CBT or MET. We use MET interventions to build motivation in clients who question the power of drugs and alcohol in their lives. MET interventions are also used with clients who find more directive approaches alienating. We also frequently use MET interventions for purposes of value clarification and goal development, which can be used to address substance, abuse as well as other self-destructive behavior. We use CBT interventions in conflict resolution and with clients struggling with anger management, depression, anxiety and histories of trauma.
      3. Not only do we use these modalities to address our client’s problems, but twelve step groups use them as well. The concepts of “stinking thinking” and “a new pair of glasses” have been used in AA for decades. It has been asserted that they 12 steps themselves are a framework for “exploring and reframing (cognitive restructuring) assumptions, beliefs, attitudes, perceptual filters, internal dialogue and unconscious patterns of processing information”[7], [8], [9], [10] Additionally, one of the developers of MET argued that the AA is consistent with the MET model.[10]
   3. Research does not support the assertion that these modalities are more effective than Twelve Step Facilitation (TSF).
      1. Project Match, the largest treatment outcome research project ever conducted, found that TSF was the most effective intervention in promoting abstinence. 24% of TSF outpatient clients were abstinent at follow-up while 14% and 15% of MET and CBT were abstinent at the same follow-up.[5] Additionally, Project MATCH found that whenever differences occurred, they favored TSF.[5],[11] It was found that TSF was more effective for clients whose social networks supported their drinking [5],[12],[13], clients high in alcohol dependence [5],[12] and clients low in psychiatric severity. [5],[12] Project MATCH data has also led to the suggestion that TSF might be the treatment of choice for clients with antisocial characteristics.[14] It is worth noting that Project MATCH clients in MET and CBT groups were permitted to attend 12 step groups as well.
      2. Other studies have found similar results. One study found that CBT clients required almost twice as many outpatient visits and significantly more inpatient care as TSF clients. The result was that CBT clients cost the system 64% more than TSF clients.[15] Another study compared a CBT program that encouraged 12-step participation and TSF, TSF was found to be more effective.[16] Some studies have even found that TSF is more effective than CBT in achieving CBT goals of enhancing self-efficacy, enhancing coping responses and developing an internal locus of control.[17],[18]

Keywords:

Evidence Based Practices

[1] Morgenstern J, Labouvie E, McCrady BS, Kahler CW & Frey RM (1997) Affiliation with alcoholics anonymous after treatment: a study of its therapeutic effects and mechanisms of action, Journal of Consulting & Clinical Psychology, 65 (5) 768-777.

[2] Noda T, Imamichi H, Kawata A, Hirano K, Ando T, Iwata Y & Yonenda H (2001) Long term outcomes in 306 males with alcoholism, Psychiatry and Clinical Neurosciences, 55 (6) 579-586.

[3] Oimette PC, Moos RH & Finney JW (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.

[4] Fiorentine R (1999) After drug treatment: are 12 step programs effective in maintaining abstinence?, American Journal of Drug and Alcohol Abuse, 25 (1) 93.

[5] Project MATCH Research Group (1999) Summary of Project Match, Addiction, 94 (1) 31-34.

[6] Fiorentine R & Hillhouse MP (2000) Drug treatment and 12-step program participation: the addictive effects of integrated recovery activities, Journal of Substance Abuse Treatment, 18 (1) 65-74.

[7] Henman JO & Henman S (1990) Cognitive-perceptual reconstruction in the treatment of alcoholism. In Sterman CM (Ed.), Neurolinguistic programming in alcoholism treatment (pp 105-124). New York: Haworth Press.

[8] Steigerwald F & Stone D (1999) Cognitive restructuring and the 12-step program of alcoholics anonymous, Journal of Substance Abuse Treatment, 16 (4) 321-327.

[9] Bean-Bayog M (1993) AA processes and change: how does it work? In McCrady BS & Miller WR (Eds.), Research on alcoholics anonymous: opportunities and alternatives (pp. 99-112). New Brunswick, NY: Rutgers Center of Alcohol Studies.

[10] DiClemente CC (1993) Alcoholics anonymous and the structure of change. In McCrady BS & Miller WR (Eds.), Research on alcoholics anonymous: opportunities and alternatives (pp. 79-98). New Brunswick, NY: Rutgers Center of Alcohol Studies.

[11] Project MATCH Research Group (1999) A study to remember: response of the Project MATCH Research Group. Addiction, 94 (1) 66-69.

[12] Gordis E & Fuller R (1999) Project Match. Addiction, 94 (1) 57-59.

[13] Longabaugh R, Wirtz PW, Zweben A & Stout RL (1998) Network support for drinking, alcoholics anonymous and long term matching effects. Addiction, 93 (9) 1313-1333.

[14] Project MATCH Research Group (1997) Project MATCH secondary a priori hypothesis. Addiction, 92 (12) 1671-1698.

[15] Humphreys K & Moos R (2001) Can encouraging substance abuse patients to participate in self-help groups reduce the demand for health care: a quasi-experimental study. Alcoholism: Clinical and Experimental Research, 25 (5) 711-716.

[16] Humphreys K (1999) Professional interventions that facilitate 12-step self-help group involvement. Alcohol Research and Health, 23 (2) 93-98.

[17] Finney JW, Noyes CA, Coutts AI & Moos RH (1998) Evaluating substance abuse treatment process models. Journal of Studies on Alcohol, 59 (4) 371.

[18] Elkus LA (2000) Locus of control as affected by alcoholics anonymous and moderation management. Dissertation Abstracts International, 60 (11).