Twelve-Step Facilitation (TSF)
Twelve-Step Facilitation (TSF) treatments are a set of semi-structured therapies designed to help people abstain from alcohol and other drugs by systematically linking them to, and encouraging their active participation in, community-based 12-step mutual-help organizations.
To this point, Twelve-Step Facilitations (TSFs) have primarily focused on linking individuals to Alcoholics Anonymous (AA), as it was the first and is currently the largest of the 12-step mutual-help organizations. (Thus we refer only to AA below, though other mutual-help organizations, such as Narcotics Anonymous, may also be part of TSF for patients whose primary substance is not alcohol.)
WHAT HAPPENS IN TWELVE-STEP FACILITATION?
There are several different kinds of Twelve-Step Facilitation interventions:
- As was delivered in the large randomized controlled trial Project Match (the first TSF developed for clinical research)
- Making AA Easy (MAAEZ), Network Support
- Systematic Linkage
- Integrated within a cognitive-behavioral problem solving framework
Each of these interventions offers a slightly different way to facilitate 12-step mutual-help organization participation. The approaches range from leveraging AA and other mutual-help organizations as just one platform to help patients make recovery-supportive changes to their social networks (Network Support), to focusing almost entirely on AA and its core principles (Project MATCH TSF).
Regardless of how much they focus specifically on AA, the common thread of TSF interventions is the clinical emphasis that the patient engage and actively participate with 12-step mutual-help organizations, like AA, as the primary means of achieving and sustaining long-term remission from substance use disorder.
Over the course of 4 to 12 sessions, depending on the specific type of TSF, the provider first and foremost encourages and actively facilitates the patient’s attendance at AA meetings. Collaboratively, the provider and patient may track AA meeting attendance and active involvement (e.g., finding a sponsor) through logs or journals.
During sessions, the provider and patient may discuss common themes in AA meetings (e.g., spirituality and the purpose of a higher power), explore the patient’s attitudes about these themes, and problem solve how the patient can overcome any obstacles these themes pose to their engagement.
Consistent with the philosophy in AA that substance use is part of an overall syndrome or disease, and that abstinence is the best way to address the problem, Twelve-Step Facilitation providers also strongly emphasize abstinence as a treatment goal, and assign the patient work between sessions related to AA engagement, including AA readings (e.g., from AA’s main text “The Big Book”) and practical tasks related to attendance (e.g., talk with another member after the meeting).
WHAT IS THE THEORY BEHIND TWELVE-STEP FACILITATION?
Central Assumptions of Twelve-Step Facilitation:
- Addiction is a multi-faceted illness influenced by medical, social, emotional, and spiritual factors.
- Consistent with 12-step mutual-help organization philosophy, abstinence is the most pivotal, though not the only facet of recovery from substance use disorder. Emotional (and in some case spiritual) growth is also a critical recovery process.
- AA participation will help patients achieve and sustain recovery over the long-term.
- Will be effective only insomuch as the provider helps engage the patient with AA and other 12-step mutual-help organizations.
- A skillful clinical provider can help the patient address practical and attitudinal obstacles to AA attendance.
WHAT ARE THE ORIGINS OF TWELVE STEP FACILITATION?
Twelve-Step Facilitation originates from the Minnesota Model of addiction treatment (also known as the abstinence model), first created in a Minnesota hospital in the 1950s.
In this model, both clinical (doctors, psychiatrists, psychologists, etc.) and non-clinical staff (most of, if not all of whom are, themselves, in recovery) provide care as part of a multi-disciplinary and comprehensive treatment program. The primary goal of the Minnesota Model, sometimes referred to as 12-step-based treatment, is centered on engaging patients with AA and other 12-step mutual-help organizations in their community.
Rooted in this model, Kathleen Carroll, Joseph Nowinski, and Stuart Baker developed the first manualized TSF as part of the large randomized trial Project MATCH in the early 1990s. After several studies showed TSF was as or more effective at enhancing abstinence over time than Motivational Enhancement Therapy and a cognitive-behavioral approach, several clinical researchers developed other kinds of TSF interventions that could potentially engage a wider range of patients with substance use disorder (e.g., those with lower severity disorders).
EVIDENCE FOR TWELVE-STEP FACILITATION?
The evidence for Twelve-Step Facilitation interventions in the treatment of alcohol use disorder is strong.
TSFs produce outcome benefits as good or possibly better than other active treatments. It is particularly helpful and has clearer advantages when it comes to increasing rates of continuous abstinence and full sustained substance use disorder remission (i.e., absence of symptoms for 12 months). Whether one type of TSF is advantageous over another is uncertain.
While there is sound reason to assume Twelve-Step Facilitation approaches also work for individuals with other drug use disorders, evidence for drug use disorder populations (other than alcohol) is more limited.
TSF FOR ADOLESCENTS
An intervention has been developed for adolescents with alcohol and other drug use disorders that integrates Twelve-Step Facilitation with Motivational Enhancement Therapy and Cognitive Behavioral Therapy (MET/CBT). An initial trial of this integrated TSF, or iTSF, suggests that compared to standard MET/CBT, it may facilitate greater 12-step mutual-help organization involvement during treatment, resulting in fewer substance use consequences over time but similar levels of actual substance use. Overall, however, adolescents and other youth (e.g., 18-25 year old individuals, sometimes referred to as emerging adults) warrant greater attention in the study and implementation of TSFs.
- Kaskutas, L. A., Subbaraman, M. S., Withrodt, J., & Zemore, S. E. (2009). Effectiveness of making Alcoholics Anonymous easier: A group format 12-step facilitation approach. Journal of Substance Abuse Treatment, 37(3), 228-239. doi:10.1016/j.jsat.2009.01.004
- Kelly, J. F., Yeterian, J. D., Cristello, J. V., Kaminer, Y., Kahler, C. W., & Timko, C. (2016). Developing and testing Twelve-Step Facilitation for adolescents with substance use disorder: Manual development and preliminary outcomes. Substance Abuse, 10, 55-64. doi: 10.4137/sart.s39635
- Litt, M. D., Kadden, R. M., Tennen, H., & Kabela-Cormier, E. (2016). Network Support II: Randomized controlled trial of Network Support treatment and cognitive behavioral therapy for alcohol use disorder. Drug and Alcohol Dependence, 165, 203-212. doi: 10.1016/j.drugalcdep.2016.06.010
- Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58(1), 7-29. doi:10.1046/j.1360-0443.1997.9212167110.x
- Walitzer, K. S., Dermen, K. H., & Barrick, C. (2009). Facilitating involvement in Alcoholics Anonymous during out-patient treatment: A randomized clinical trial. Addiction, 104(3), 391-401. doi: 10.1111/j.1360-0443.2008.02467.x