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Continued: Written plan helps clients note relapse triggers

Traditional Twelve Step Groups: Alcoholics Anonymous

Client readiness and motivation to attend Twelve Step meetings are important considerations for the clinician. The first step is for clinicians to become familiar with Twelve Step programs. For example, AA is the most well-known of all the Twelve Step groups. It began in the 1930s in Akron, Ohio, when Bill Wilson and Dr. Bob met and held the first meeting. Since then, AA has grown to over two million members with meetings in more than 150 countries around the world. There are three components to AA: fellowship, meetings, and the Twelve Step program of AA.

Fellowship. The AA preamble states: "AA is a Fellowship of men and women whose primary purpose is to stay sober and to help other alcoholics achieve sobriety." AA members set up and run their own meetings and organize activities. It is all done voluntarily. Service work is a highly valued part of recovery. There are no officials or leaders in AA, just members who volunteer for service positions. Fellowship is the feeling that the individual is not alone but with others who share a common humanity.

Meetings. AA meetings are held in different locations in the community, often in a church basement or a local library. A list of meetings can be found on the Internet or in the Yellow Pages. Meetings are usually one hour in length and called to order by a chairperson who reads the AA preamble, asks for a moment of silence, and then leads the group in the Serenity Prayer. At some point during the meeting, a basket is passed for donations, but there is no pressure to contribute. The meeting typically ends with people joining hands in a circle and saying the Lord's Prayer. No one is required to speak at a meeting and people can simply pass when it is their turn to speak. When someone does speak, they generally start by saying, "Hi, I'm __________, and I'm an alcoholic." They typically go on to tell their story, usually guided by a framework of "experience, strength and hope" or "what it was like, how I got here [to AA] and what it's like now."

Different Types of AA Meetings. Meetings vary in composition by size, gender, and age. They also vary in stability and consistency of members' attendance. Different meetings have different levels of humor or solemnity and degree of welcoming for newcomers. The chairperson often invites newcomers to introduce themselves at the beginning of the meeting. (Many clients are fearful of doing this and typically remain silent at this invitation.) An alternative to this public welcoming is for AA members to introduce themselves to a newcomer one-to-one before or after the meeting.

The various types of AA meetings include the following:

  • speaker and discussion meetings where one person with ninety days or more of sobriety shares his or her experience and then opens the meeting up to discussion
  • speaker-only meetings where two or more speakers share their stories with no discussion
  • discussion meetings where the group reads a piece of AA literature and then discusses it
  • Step meetings where the group reads one of the Twelve Steps from the book Alcoholics Anonymous (also known as the "Big Book") and then discusses it
  • Big Book meetings where the group reads a chapter from the Big Book and discusses it

Regardless of the type of meeting, all meetings are designated as "open" or "closed":

  • An open meeting is for anyone who is interested in finding out what AA is all about.
  • Closed meetings are only for people who identify themselves as alcoholics.

Twelve Step AA Program. The program of recovery is outlined in Alcoholics Anonymous and Twelve Steps and Twelve Traditions (also known as "Twelve and Twelve"). Part of the program involves affirming or positive slogans. These slogans are intended to help people in recovery cope when they are having a bad day or struggling with a difficult situation. For example:

  • Let go and let God.
  • Turn it over.
  • Easy does it.
  • Work the Steps.
  • Take it one day at a time.
  • I can't, but God can.
  • H.A.L.T. (Don't get too hungry, angry, lonely, or tired.)
  • Keep it simple.

The best way for clinicians to familiarize themselves with Twelve Step programs is to attend a few open meetings. They might ask a substance abuse counselor to go with them. Clinicians will be much better prepared to help their clients if they have such firsthand knowledge.

Twelve Step Groups for Clients with Co-occurring Disorders

Clinicians can start introducing clients to Twelve Step programs in the late persuasion stage. Providing clients with a menu of options is a motivational strategy. Among the meetings that clinicians could suggest are Dual Recovery Anonymous (DRA), Dual Diagnosis Anonymous (DDA), and Double Trouble in Recovery (DTR). These are Twelve Step groups like AA but designed specifically for people with co-occurring disorders. In these meetings, people talk about recovering from both substance abuse and mental illness.

One strategy clinicians can use to connect clients with meetings is to try out several meetings with them. Not all meetings are the same, and it may take several times for clients to find one they like. Once clients have a meeting they like, clinicians should monitor their attendance. Clinicians might ask clients to keep a weekly record of the meetings they attend and whether or not they spoke at the meeting. As time goes on, clinicians should encourage clients to do some service work in the group (making coffee, setting up chairs, etc.). When clients are ready, clinicians can also support them in finding a sponsor. This process may happen over an extended period of time, which is fine, because recovery is a lifelong process.


Mental health clinicians are already likely to possess the basic skills to do substance use counseling, but they may need to work on becoming more comfortable with engaging clients in dialogues about substance use. Clinicians can use motivational interviewing techniques to process this information. Cognitive-behavioral techniques can help clients learn new ways of coping or interacting without using substances. These techniques also help clients develop different patterns of thought and behavior to minimize relapse. Connecting with others who are also developing new ways of living without substances can be enormously helpful to clients and increase their chances for long-term recovery.


This article is excerpted and adapted from Integrated Dual Disorders Treatment: Best Practices, Skills, and Resources for Successful Client Care, Hazelden, 2010.

Table of Contents


Integrated Dual Disorders Treatment (IDDT) is available from Hazelden Publishing.
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Preface by Lindy Fox


Chapter 1
Introduction to Integrated Dual Disorders Treatment

Chapter 2
Recovery-oriented Treatment

Chapter 3
Senior Organizational Leadership Tasks

Chapter 4
Clinical Leadership Tasks

Chapter 5
Screening and Assessment

Chapter 6
Stagewise Treatment and Routine Clinical Tasks

Chapter 7
Treatment Planning for Clients with Co-occurring Disorders

Chapter 8
Motivational Interviewing

Chapter 9
Stagewise Group Treatment

Chapter 10
Social Skills Training Group

Chapter 11
Substance Abuse Counseling Skills

Chapter 12
Housing Issues

Chapter 13
Supported Employment

Chapter 14
Family Psychoeducation

Chapter 15
Dual Disorders Treatment for Persons in the Criminal Justice System

Chapter 16
Physical Health Issues for People with Dual Disorders

Chapter 17
Co-occurring Mental Illness and Substance Use in Older Adults

Chapter 18
Trauma Treatment and Recovery

Chapter 19
Medications for the Treatment of Clients with Co-occurring Serious Mental Illness and Substance Use Disorder

Chapter 20
Client and Family Tasks

Chapter 21
Training, Consultation, and Supervision


Appendix A
Integrated Dual Disorders Treatment (IDDT) Fidelity Scale Materials

Appendix B
General Organizational Index (GOI)

Appendix C
Individualization and Quality Improvement Scales to Assess Client and Organizational Factors in Implementation

Appendix D
Screening for Co-occurring Disorders

Appendix E
Domains of Assessment for Co-occurring Disorders

Appendix F
Training and Consultation Resources

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