Twelve Step Facilitation (TSF)

Individuals who qualify for a moderate to severe substance use disorder diagnosis according to criteria listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

Twelve Step Facilitation (TSF) utilizes education and coaching to help clients understand and make use of a recovery fellowship like AA. TSF is a treatment approach that is best thought of as “psychotherapy assisted recovery.” As such, it is based on key principles found in Twelve Step programs such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). Though it was only reviewed in the Substance Abuse Treatment (Adults) topic area, it can be used with adolescents as well.

Joseph Nowinski, PhD

• Website: https://josephnowinski.com
• Email: drjoe.nowinski@gmail.com
• Phone: 860-930-9988

The goals of Twelve Step Facilitation (TSF) are:

• Accept the reality of personal substance misuse
• Accept the need to reach out to others for support in overcoming substance misuse
• Understand the structure and goals of a recovery fellowship
• Introduce oneself to a fellowship
• Make use of fellowship resources
• Understand the importance of meetings, service activity, and sponsorship
• Understand addiction as an intergenerational illness
• Learn to identify and cope with emotions that threaten sobriety
• Integrate spirituality into recovery

The essential components of Twelve Step Facilitation (TSF) include:

• Education and skilled coaching
• The TSF core program contains four topics:
  • Assessment:
    • It is still essential for the facilitator to hear, at least briefly and at the outset, participants’ substance use histories as well as their reasons for seeking treatment now.
    • For participants who have undergone a thorough assessment prior to referral to the program, the assessment session may be abbreviated.
  • Acceptance:
    • Acceptance means the breakdown of the illusion that the individual who has a severe substance use disorder, through willpower alone, can effectively and reliably limit or control their use of alcohol or other drugs.
  • Surrender:
    • Surrender involves a willingness to reach out beyond personal willpower and accept the solution for addiction laid out in the Twelve Steps.
  • Getting Active in Twelve Step Fellowships:
    • The term getting active refers to the behavioral and social changes that participants need to make in order to support their recovery. Getting active is part of that process.
  • It is recommended that the core topics be covered for all participants, regardless of any prior addiction treatment, experience with Twelve Step fellowships.
• The TSF package includes:
  • TSF Handbook: Includes the rationale for TSF, its content and its structure; is a useful reference guide for those wishing to implement TSF
  • TSF Facilitator Guide: Includes guidelines for facilitators conducting TSF sessions. Suggests how to present new material, facilitate discussion, and useful “recovery tasks” to assign between sessions
  • Participant workbooks: To be used by the facilitator in collaboration with participants to further explore TSF topics. Includes many worksheets.
  • Fidelity Checklists: Can be used by supervisors to monitor fidelity of TSF group sessions
  • Videos: Includes segments describing the different TSF topics, combined with testimonials from actual clients

Adult Services

Twelve Step Facilitation (TSF) directly provides services to adults (regardless of whether they are parents or caregivers) and addresses the following:

• Substance misuse

Recommended Intensity

Once weekly, one hour 

Recommended Duration

12 weeks

Delivery Settings

This program is typically conducted in a(n):

• Adoptive Home
• Birth Family Home
• Community-based Agency / Organization / Provider
• Foster / Kinship Care
• Group or Residential Care
• Outpatient Clinic
• Virtual (Online, Smartphone, Zoom, Telephone, Video, etc.)

Homework

This program does include a homework component.

Recovery tasks are assigned to be done between sessions.

Resources Needed to Run Program

The typical resources for implementing the program are:

The program materials as described in the Essential Components above and equipment for showing video clips.

Prerequisite/Minimum Provider Qualifications

Some counseling experience (including peer counseling) is required.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Manual details:

• Nowinski, J. (2017). Twelve Step Facilitation Facilitator Guide (2nd Ed.). Hazelden. https://www.hazelden.org/store/item/514177 

Training Information

There is no training available for this program.

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Twelve Step Facilitation.

Formal Support for Implementation

There is no formal support available for implementation of Twelve Step Facilitation.

Fidelity Measures

There are fidelity measures for Twelve Step Facilitation as listed below:

Fidelity Checklists are available and can be used by supervisors to monitor fidelity of TSF group sessions.

Implementation Guides or Manuals

The program representative did not provide information about implementation guides or manuals for Twelve Step Facilitation.

Implementation Cost

The program representative did not provide information regarding studies of the costs of implementing Twelve Step Facilitation.

Research on How to Implement the Program

The program representative did not provide information about research conducted on how to implement Twelve Step Facilitation.

Child Welfare Outcome: Child/Family Well-Being

What is included in the Relevant Published, Peer-Reviewed Research section? 

• 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. https://doi.org/10.15288/jsa.1997.58.7

  Type of Study: Randomized controlled trial

  Sample:

  Age — Average=38.6 years

  Participants: 52

  Race/Ethnicity — 80% White

  Gender — 72% Male and 28% Female

  Status — Participants were outpatient subjects recruited directly from the community or from outpatient treatment centers, aftercare subjects were individuals following completion of inpatient or intensive day hospital treatment.   

  Location/Institution: Nine clinical research units (CRUs) - five outpatient CRUs were located in Albuquerque, NM, Buffalo, NY, Farmington, CT, Milwaukee, WI, and West Haven, CT. The aftercare CRUs were located in Charleston, SC, Houston, TX, Milwaukee, WI, Providence, RI, and Seattle, WA.

  Summary:

  The purpose of the study was to assess the benefits of matching alcohol dependent clients to three different treatments with reference to a variety of client attributes. Participants were randomly assigned to one of three 12-week, manually-guided, individual treatments: Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy, and Twelve-Step Facilitation Therapy (TSF) [now called Twelve Step Facilitation (TSF)]. Measures utilized include the Structured Clinical Interview for DSM-III-R, the Addiction Severity Index, the Form 90, the Computerized Diagnostic Interview Schedule (C-DIS), and the Drinker Inventory of Consequences. Results indicate that clients attended, on average, two-thirds of treatment sessions offered, indicating that substantial amounts of treatment were delivered, and research follow-up rates exceeded 90% of living subjects interviewed at the 1-year posttreatment assessment. Significant and sustained improvements in drinking outcomes were achieved from baseline to 1-year posttreatment by the clients assigned to each of these individually delivered psychosocial treatments. There was little difference in outcomes by type of treatment. Only one attribute, psychiatric severity, demonstrated a significant attribute by treatment interaction: In the outpatient study, clients low in psychiatric severity had more abstinent days after TSF than after cognitive behavioral therapy. Neither treatment was clearly superior for clients with higher levels of psychiatric severity. Two other attributes showed time-dependent matching effects: motivation among outpatients and meaning-seeking among aftercare clients. Client attributes of motivational readiness, network support for drinking, alcohol involvement, gender, psychiatric severity, and sociopathy were prognostic of drinking outcomes over time. Limitations include that Project MATCH results may not be applicable to a portion of the population presenting for substance abuse treatment with comorbid drug dependence.

  Length of controlled postintervention follow-up: 3, 6, 9, and 12 months.

• Brown, S. A., Glasner-Edwards, S. V., Tate, S. R., McQuaid, J. R., Chalekian, J., & Granholm, E. (2006). Integrated cognitive behavioral therapy versus Twelve-Step Facilitation Therapy for substance-dependent adults with depressive disorders. Journal of Psychoactive Drugs, 38(4), 449–460. https://doi.org/10.1080/02791072.2006.10400584 

  Type of Study: Randomized controlled trial

  Sample:

  Age — 31–68 years (Mean=48 years)

  Participants: 66

  Race/Ethnicity — 75% Caucasian, 13% Hispanic, 11% African American, and 2% American Indian

  Gender — 61 Male and 5 Female

  Status — Participants were veterans with substance use disorder and major depressive disorder.

  Location/Institution: Veterans Administration San Diego Healthcare System (VASDHS)

  Summary:

  The purpose of the study was to compare the longitudinal outcome patterns of veterans with substance use disorders and major depressive disorder receiving standard pharmacotherapy and either 12-Step Facilitation Therapy (TSF) [now called Twelve Step Facilitation (TSF)] or disorder-specific Integrated Cognitive Behavioral Treatment (ICBT). Participants were randomly assigned to either TSF or ICBT. Measures utilized include the Composite International Diagnostic Interview, the Hamilton Depression Rating Scale (HDRS), and the Time Line Follow Back (TLFB). Results indicate that reductions in depression during treatment were comparable between the two treatment groups; however, their posttreatment patterns were distinct. While ICBT participants evidenced a steady linear decline in depression through six months posttreatment, a quadratic trend characterized TSF participants, for whom depression declined during treatment, but increased throughout posttreatment follow-up. During treatment, TSF participants used substances less frequently relative to those in ICBT; however, reductions in substance use were more stable through six months posttreatment among those in ICBT relative to TSF. Limitations include the small sample size, limited generalizability of the findings to those with minimally adequate exposure to the intervention, and high rates of attrition.

  Length of controlled postintervention follow-up: 3 and 6 months.

• Project MATCH Research Group. (1998).  Matching alcoholism treatments to client heterogeneity: Treatment main effects and matching effects on drinking during treatment. Journal of Studies on Alcohol, 59(6), 631–639. https://doi.org/10.15288/jsa.1998.59.631

  Type of Study: Randomized controlled trial

  Sample:

  Age — Average=38.6 years

  Participants: 952

  Race/Ethnicity — 80% White

  Gender — 72% Male and 28% Female

  Status — Participants were outpatient subjects recruited directly from the community or from outpatient treatment centers, aftercare subjects were individuals following completion of inpatient or intensive day hospital treatment. 

  Location/Institution: Nine clinical research units (CRUs) - five outpatient CRUs were located in Albuquerque, NM, Buffalo, NY, Farmington, CT, Milwaukee, WI, and West Haven, CT. The aftercare CRUs were located in Charleston, SC, Houston, TX, Milwaukee, WI, Providence, RI, and Seattle, WA.

  Summary:

  The study used the same sample as Project MATCH Research Group (1997). The purpose of the study was to examine client drinking and related psychosocial functioning during the course of alcoholism treatment. Participants were randomly assigned to one of three 12-week, manually-guided, individual treatments: Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy, and Twelve-Step Facilitation (TSF). Measures utilized include the modified Form 90 (Form 90F), the Addiction Severity Index, the Drinker Inventory of Consequences, the Alcoholics Anonymous (AA) Involvement Scale, the Alcohol Abstinence Self-Efficacy Scale, the Psychosocial Functioning Inventory, the Social Support Questionnaire, and the University of Rhode Island Change Assessment. Results indicate that during the treatment phase, small but statistically significant differences among treatments were found only in the outpatient arm on measures of alcohol consumption and alcohol-related negative consequences. Forty-one percent of CBT and TSF clients were abstinent or drank moderately without alcohol-related consequences, compared with 28% of MET clients. Tests of 10 a priori primary client-treatment matching hypotheses failed to find any interaction effects that had an impact on drinking throughout the treatment phase. Limitations include that pretreatment attention from professional staff may have attenuated treatment main effects or matching effects during the treatment phase, and Project MATCH results may not be applicable to a portion of the population presenting for substance abuse treatment with comorbid drug dependence.

  Length of controlled postintervention follow-up: None

• Project MATCH Research Group. (1998). Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism: Clinical and Experimental Research, 22(6), 1300–1311. https://doi.org/10.1111/j.1530-0277.1998.tb03912.x

  Type of Study: Randomized controlled trial

  Sample:

  Age — Average=38.6 years

  Participants: 952

  Race/Ethnicity — 80% White

  Gender — 72% Male and 28% Female

  Status — Participants were outpatient subjects recruited directly from the community or from outpatient treatment centers, aftercare subjects were individuals following completion of inpatient or intensive day hospital treatment.

  Location/Institution: Nine clinical research units (CRUs) - five outpatient CRUs were located in Albuquerque, NM, Buffalo, NY, Farmington, CT, Milwaukee, WI, and West Haven, CT. The aftercare CRUs were located in Charleston, SC, Houston, TX, Milwaukee, WI, Providence, RI, and Seattle, WA.

  Summary:

  The study used the same sample as Project MATCH Research Group (1997). The purpose of the study was to report 3-year outcomes for clients who had been treated in the five outpatient sites of Project MATCH, a multisite clinical trial designed to test a priori client treatment matching hypotheses. Participants were randomly assigned to one of three 12-week, manually guided, individual treatments: Twelve-Step Facilitation (TSF), Motivational Enhancement Therapy (MET), or Cognitive Behavioral Coping Skills Therapy (CBT). Measures utilized include the modified Form 90 (Form 90F), the Addiction Severity Index, the Drinker Inventory of Consequences, the Alcoholics Anonymous (AA) Involvement Scale, the Alcohol Abstinence Self-Efficacy Scale, the Psychosocial Functioning Inventory, the Social Support Questionnaire, and the University of Rhode Island Change Assessment. Results indicate that clients high in anger fared better in MET than in the other two MATCH treatments: CBT and TSF. Among subjects in the highest third of the anger variable, clients treated in MET had, on average, 76.4% abstinent days, whereas their counterparts in the other two treatments (CBT and TSF) had, on average, 66% abstinent days. Conversely, clients low in anger performed better after treatment in CBT and TSF than in MET. Significant matching effects for the support for drinking variable emerged in the 3-year outcome analysis, such that clients whose social networks were more supportive of drinking derived greater benefit from TSF treatment than from MET. Among subjects in the highest third of the support for drinking variable, TSF participants were abstinent 16% more days than MET participants. At the lower end of this variable, the difference in percent days abstinent between MET and TSF was 3%, with MET clients having more abstinent days. A significant matching effect for psychiatric severity that appeared in the first year posttreatment was not observed after 3 years. Of the 21 client attributes used in testing the matching hypotheses, 11 had prognostic value at 3 years. Among these, readiness-to-change and self-efficacy emerged as the strongest predictors of long-term drinking outcome. With regard to the overall outcomes, the reductions in drinking that were observed in the first year after treatment were sustained over the 3-year follow-up period; almost 30% of the subjects were totally abstinent in months 37 to 39, whereas those who did report drinking nevertheless remained abstinent an average of two-thirds of the time. As in the 1-year follow-up, there were few differences among the three treatments, although TSF continued to show a possible slight advantage. Limitations include the possibility that the above research-related activities might have inflated treatment outcomes, and the relatively weak matching findings.

  Length of controlled postintervention follow-up: 3 years.

• Longabaugh, R., Wirtz, P. W., Zweben, A., & Stout, R. L. (1998). Network support for drinking, Alcoholics Anonymous and long-term matching effects. Addiction, 93(9), 1313–1333. https://doi.org/10.1046/j.1360-0443.1998.93913133.x

  Type of Study: Randomized controlled trial

  Sample:

  Age — Average=38.6 years

  Participants: 806

  Race/Ethnicity — 80% White

  Gender — 72% Male and 28% Female

  Status — Participants were alcohol-dependent clients from 5 clinical research units distributed across the United States.

  Location/Institution: United States

  Summary:

  The study used the same sample as Project MATCH Research Group (1997). The purpose of the study was to (1) examine the matching hypothesis that Twelve Step Facilitation Therapy (TSF) [now called Twelve Step Facilitation (TSF)] is more effective than Motivational Enhancement Therapy (MET) for alcohol-dependent clients with networkls highly supportive of drinking 3 years folowing treatment; and (2) to test a causal chain providing the rationale for this effect. Participants were randomly assigned to one of three 12-week, manually-guided, individual treatments: TSF, MET, or Cognitive Behavioral Coping Skills Therapy (CBT). Measures utilized include the modified Structured Clinical Interview for DSM-III-R, the AA Involvement Scale (AAI), the Important People and Activities Instrument (IPA), and self-reported percentage of days drinking abstinence and drinks per day. Results indicate that the hypothesis that TSF is more effective than MET for clients with networks supportive of drinking was supported at the 3-year follow-up; Alcoholics Anonymous (AA) involvement was a partial mediator of this effect; clients with networks supportive of drinking assigned to TSF were more likely to be involved in AA, and AA involvement was associated with better 3-year drinking outcomes for such clients. Limitations include that the outpatient setting was chosen over after care for the extended follow-up.

  Length of controlled postintervention follow-up: 3 years.

• Lydecker, K. P., Tate, S. R., Cummins, K. M., McQuaid, J., Granholm, E., & Brown, S. A. (2010). Clinical outcomes of an integrated treatment for depression and substance use disorders. Psychology of Addictive Behaviors, 24(3), 453–465. https://doi.org/10.1037/a0019943

  Type of Study: Randomized controlled trial

  Sample:

  Age — Mean=48 years

  Participants: 206

  Race/Ethnicity — 71% White

  Gender — 92% Male

  Status — Participants were veterans recruited from referrals to the Veterans Administration Substance Abuse Mental Illness (SAMI) program.

  Location/Institution: Not specified

  Summary:

  The study used the same sample as Brown et al. (2006). The purpose of the study was to compare longitudinal treatment outcomes for depressed substance-dependent veterans assigned to Integrated Cognitive Behavioral Therapy plus standard pharmacotherapy (ICBT+P) or Twelve Step Facilitation Therapy [now called Twelve Step Facilitation (TSF)] plus standard pharmacotherapy (TSF+P). Participants were randomly assigned to either TSF+P or ICBT+P. Measures utilized include the Hamilton Depression Rating Scale (HDRS), the Composite International Diagnostic Interview (CIDI), the Time Line Follow Back (TLFB), the Addiction Severity Index (ASI), and the AA Affiliation Scale. Results indicate that participants in both treatment conditions showed decreased depression and substance use from intake. ICBT+P participants maintained improvements in substance involvement over time, whereas TSF+P participants had more rapid increases in use in the months following treatment. Decreases in depressive symptoms were more pronounced for TSF+P than ICBT+P in the six months posttreatment. Within both treatment groups, higher attendance was associated with improved substance use and depression outcomes over time. Initial levels of depressive symptomology had a complex predictive relationship with long-term depression outcomes. Early treatment response predicted long-term substance use outcomes for a portion of the sample. Although both treatments were associated with improvements in substance use and depression, ICBT+P may lead to more stable substance use reductions compared to TSF+P. Limitations include that the sample was primarily male, comprised exclusively of veterans, and requires replication with women and non-veteran populations; a slightly larger proportion of ICBT+P participants had completed an inpatient substance use program prior to treatment entry; medication compliance or other factors related to psychopharmacology efficacy were not monitored; and the study’s notable attrition rates.

  Length of controlled postintervention follow-up: 3, 6, 9, and 12 months.

There are currently no references available for Twelve Step Facilitation.