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CHAPTER OUTLINE
Of the behavioral therapies described in this volume, Twelve-Step facilitation (TSF) is perhaps unique in that it is an approach that had its roots in traditional clinical practice and was then codified and moved into clinical research, as opposed to a scientifically developed treatment then transferred to clinical practice. TSF therapy (1) is a manual-guided treatment that was developed for use in Project MATCH, a major multisite trial of behavioral treatments for alcohol abuse and dependence. TSF was developed specifically to approximate the style of counseling commonly used in treatment programs throughout the United States. Thus, its content was intended to be consistent with active involvement in Twelve-Step recovery programs such as Alcoholics Anonymous (AA) and with a treatment goal of abstinence from all psychoactive substances. Since its introduction in 1992, utilization and empirical support for this approach have grown steadily. This chapter describes its historical roots, summarizes its use in clinical practice, and briefly reviews the empirical data regarding its use with substance-abusing populations.
HISTORICAL PERSPECTIVE
For many years, treatment based on or related to the Twelve Steps of AA was widely practiced in the clinical community, particularly residential and 90-day programs. In many ways, self-help and Twelve Step–oriented groups formed the foundation of substance abuse treatment in the United States and played major formative roles in the philosophies of some of the most influential treatment centers and programs, including the Hazelden Foundation, the Betty Ford Center, and many more programs using the Minnesota Model and similar approaches. Although there were differences across programs, programs in general had two related foci: emphasis on abstinence from all psychoactive substances and encouraging self-help attendance. Although AA has been challenging to study systematically (2) and the quality of research on the effectiveness of self-help has been variable (3), the bulk of the evidence suggests that attendance at self-help groups is associated with better outcomes (see previous work (4,5)).
Recognizing that self-help programs represent an important, broadly available, and inexpensive resource, the defining feature of TSF is to encourage meaningful, long-term involvement with AA and other self-help groups. Because of the importance of including an approach that was representative of the dominant model of clinical practice in Project MATCH (6), and the need for a clear, structured description of these approaches that could be used in a large research protocol, the Project MATCH Steering Committee asked Joe Nowinski, PhD, and Stu Baker, two clinical experts, to collaborate with our group at Yale (7) to develop the TSF manual, which was done in close collaboration with experts from the Hazelden Foundation (6,8). After its initial evaluation in Project MATCH, TSF and closely related approaches have been evaluated in several subsequent trials and have extended to populations other than those with alcohol use disorders.
TREATMENT MODEL
TSF is a highly structured, individual, manual-guided approach delivered over the course of 12 to 24 weeks. As described in the manual (1), it consists of a set of core topics (assessment and overview, acceptance, surrender, and getting active), which are to be covered with all patients; a set of elective topics, which can be selected to tailor the treatment to different individuals (people places and things; review of a genogram; enabling, HALT); as well as guidelines for conjoint sessions with family members.
TSF sessions follow a common format in that each session begins with a careful review of the previous week and self-help attendance, as well as review of the patient’s recovery journal and reactions to any AA-related readings that may have been assigned. Next, the TSF therapist introduces the “recovery topic” for the week from the set of core and elective sessions, to which the bulk of the session is devoted. Finally, sessions end with assignment of the patient’s recovery tasks for the weeks (specific self-help meetings and activities to attend, readings, and other tasks).
TSF assumes that alcoholism and addiction are progressive diseases of mind, body, and spirit, for which the only effective remedy is abstinence from mood-altering substances, one day at a time. TSF adheres to the concepts set forth in the Twelve Steps and Twelve Traditions (9). Core, essential features of TSF include the following:
■ Taking a thorough alcohol and substance use history, identifying positive and negative consequences of substance use, and giving feedback as ground work to Step 1
■ Providing education about Steps 1, 2, and 3 of AA as well as explanation of the disease concept of alcoholism and addiction
■ Exploring discrepancies between the patient’s stated goals and actions in terms of denial
■ Identifying “people, places, and things” that could trigger substance use and identification of “people, places, and things” that support recovery
■ Encouraging patients to actively work the “Twelve Steps” as the primary goal of treatment
■ Supporting the point of view that the best chance of abstinence and health is to accept loss of control and the need to reach out to the fellowship of AA (or NA or CA)
THEORY OF CHANGE
As with AA, which grew out of the experiences of a group of men as they struggled with severe alcohol dependence, TSF has historic, rather than theoretic, foundations. In TSF, change is thought to occur through building a meaningful relationship with the fellowship of AA and in following the Twelve Steps of AA. Several authors have pointed out similarities between the processes of change in AA and those of other effective behavioral therapies (10,11). McCrady (11) noted that the key change principles of AA include changing reference groups through group affiliation, articulating a clear treatment goal through commitment to abstinence, and emphasis on spirituality and intra- and interpersonal change parallel those of some aspects of cognitive and behavioral therapies. The theory of change in TSF is, essentially, the process of the Twelve Steps, as the individual moves from acceptance of alcoholism or addiction and the need for complete abstinence, through the need for affiliation with others and a Higher Power, to recognizing and making amends to others. Hence, TSF makes no commitment to a particular causal model of addiction; emphasis is placed on the core concepts of loss of control and denial and two themes are emphasized.
■ Spirituality: Belief in a “power greater than ourselves,” which is defined individually, by each person, and represents faith and hope for recovery
■ Pragmatism: Belief in doing “what works” for the individual, meaning doing whatever it takes in order to avoid taking the first drink
TREATMENT PLANNING AND EVALUATION
A thorough evaluation of the individual’s alcohol and drug use history is an essential feature of TSF, and in fact dominates much of the first session and may extend into several sessions. The goal is to begin the breakdown of the patient’s denial system. The comprehensive alcohol and drug history is taken in a particular format to do this, highlighting progressive loss of control over alcohol and drugs and covering age, substance used (amount and frequency), positive and negative consequences of use, and major life events.
Therapists introduce this section by advising the patient that completing this history will help them begin to make sense of what has happened in their life in relation to their use of alcohol or drugs and is used as a means for preparing for Step 1 (admitting powerlessness and acknowledging unmanageability). The TSF therapist begins with the age of earliest use, outside the home, and then progresses by looking at different time periods. Typically, the TSF therapist would ask about a period 3 years after the initial use and then ask about subsequent periods of time in 5-year intervals. For example, if a patient were a 28-year-old, who started using marijuana at age 12, the TSF therapist would start at 12, then go to age 15, then to age 20 (or late teens), and then to age 25 (or early 20s). Finally, the TSF therapist would ask about the past year to get a sense of current use patterns and issues. At each age, the TSF therapist would work across the table, asking about each of the categories. As this is done, patterns usually emerge. The TSF therapist pays particular attention to any increase in the amount and frequency of use and periods of time that the patient abstained from use or attempted to control their use. This information is used to highlight loss of control over alcohol or drugs, which is the hallmark of addiction in TSF.
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