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Twelve Step Facilitation Therapy
Date of Review: January 2008

Twelve Step Facilitation Therapy (TSF) is a brief, structured, and manual-driven approach to facilitating early recovery from alcohol abuse, alcoholism, and other drug abuse and addiction problems. TSF is implemented with individual clients over 12 to 15 sessions. The intervention is based on the behavioral, spiritual, and cognitive principles of 12-step fellowships such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). These principles include acknowledging that willpower alone cannot achieve sustained sobriety, that surrender to the group conscience must replace self-centeredness, and that long-term recovery consists of a process of spiritual renewal. Therapy focuses on two general goals: (1) acceptance of the need for abstinence from alcohol and other drug use and (2) surrender, or the willingness to participate actively in 12-step fellowships as a means of sustaining sobriety. The TSF counselor assesses the client's alcohol or drug use, advocates abstinence, explains the basic 12-step concepts, and actively supports and facilitates initial involvement and ongoing participation in AA. The counselor also discusses specific readings from the AA/NA literature with the client, aids the client in using AA/NA resources in crisis times, and presents more advanced concepts such as moral inventories.

The Twelve Step Facilitation manual reviewed for this summary incorporates material originally developed for Project MATCH, an 8-year, national clinical trial of alcoholism treatment matching funded by the National Institute on Alcohol Abuse and Alcoholism. Project MATCH included two independent but parallel matching study arms, one with clients recruited from outpatient settings, the other with patients receiving aftercare treatment following inpatient care. Patients were randomly assigned to Twelve Step Facilitation, Cognitive-Behavioral Therapy, or Motivational Enhancement Therapy. Findings from Project MATCH are included in this summary.

Descriptive Info Outcomes Ratings Study Populations Studies/Materials Replications Contacts

Descriptive Information

Topics	Substance abuse treatment
Areas of Interest	Alcohol (e.g., underage, binge drinking)
Outcomes	Outcome 1: Percentage of days abstinent from alcohol Outcome 2: Adverse consequences of drinking Outcome 3: Combined assessment of drinking and drinking problems Outcome 4: Number of days before first drink/heavy drinking ("time to event") Outcome 5: Drinks per drinking day Outcome 6: Alcoholics Anonymous involvement
Study Populations	Age: 18-25 (Young adult), 26-55 (Adult) Gender: Female, Male Race: Black or African American, Hispanic or Latino, White, Race/ethnicity unspecified (See Study Populations section below for percentages by study)
Settings	Inpatient, Outpatient, Suburban, Urban
Implementation History	The TSF approach has been widely used in treatment programs in the United States. It also has been implemented in Canada in an aftercare setting using a group format.
Replications	This intervention has been replicated. (See Replications section below)
Adaptations	Client handouts are available in Spanish.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the applicant.
Public or Proprietary Domain	Mix of public and proprietary
Costs	Materials for the TSF outpatient program are available for $295 from Hazelden Publishing and Educational Services. This cost includes the therapist manual, reproducible client handouts, a DVD for use in therapy, and session guidelines. In-service training for therapists and supervisors, which is highly recommended but not required, is available at a cost of $1,500 per day plus expenses. The original TSF manual used in the Project MATCH trial is available free from the National Institute on Alcohol Abuse and Alcoholism.

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Outcomes

Outcome 1: Percentage of days abstinent from alcohol

Description of Measures	Percentage of days abstinent from alcohol, a measure of drinking frequency over the past 90 days, was obtained using Form 90, an interview procedure using the Timeline Followback methodology.
Key Findings	Toward the end of the 15-month follow-up period, TSF clients reported a significantly higher percentage of days abstinent from alcohol (i.e., fewer drinking days) than clients receiving Cognitive Behavioral Therapy (CBT) or Motivational Enhancement Therapy (MET) (p < .001). At 3-year follow-up, TSF clients also attained higher rates of abstinence than clients receiving CBT or MET (p = .007). Specifically, 36 percent of the TSF clients were abstinent during months 37 to 39, compared with 24% of the CBT and 26% of the MET clients. TSF and CBT clients with social networks supportive of drinking reported a higher percentage of days abstinent than clients receiving MET. Effect size for alcohol use during this period was large (eta-squared = 0.74, p = .0058).
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.7 (0.0-4.0 scale)

Outcome 2: Adverse consequences of drinking

Description of Measures	Adverse consequences of drinking were assessed using the Drinker Inventory of Consequences (DrInC), a 50-item self-administered questionnaire designed to measure alcohol-related problems in five areas: Interpersonal, Physical, Social, Impulsive, and Intrapersonal.
Key Findings	Toward the end of the 15-month follow-up period, TSF clients reported a significantly higher percentage of days abstinent from alcohol than clients receiving Cognitive Behavioral Therapy (CBT) or Motivational Enhancement Therapy (MET; p < .001). At 3-year follow-up, TSF clients also attained higher rates of abstinence than clients receiving CBT or MET (p = .007). Specifically, 36% of the TSF clients were abstinent during months 37 to 39, compared with 24% of the CBT and 26% of the MET clients. TSF and CBT clients with social networks supportive of drinking reported a higher percentage of days abstinent than clients receiving MET (p = .0058). Effect size for alcohol use during this period was large (eta-squared = 0.74).
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Outcome 3: Combined assessment of drinking and drinking problems

Description of Measures	Data on respondents' percentage of days abstinent from alcohol and adverse drinking consequences were combined to yield a single, categorical outcome measure (category 1 = no drinking; category 2 = moderate drinking and nonrecurrent problems; category 3 = heavy drinking or recurrent problems; category 4 = heavy drinking and recurrent problems).
Key Findings	At 15-month follow-up, a higher percentage of TSF clients were shown to be in the no-drinking category (category 1) compared with clients receiving CBT or MET (p = .0024).
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Outcome 4: Number of days before first drink/heavy drinking ("time to event")

Description of Measures	Time to event was assessed using two measures on Form 90: time to first drink (number of days of abstinence preceding the occurrence of the first drink) and time to first episode of 3 consecutive days of heavy drinking (number of days of less than heavy drinking preceding 3 consecutive days of heavy drinking). Heavy drinking was defined as six or more drinks per day for men and four or more drinks per day for women.
Key Findings	For the time to first drink measure, a significantly larger proportion of clients in the TSF condition (24%) avoided drinking completely in months 4-15 than in the CBT (15%) and MET (14%) conditions (p = .0001). Similar results were found for time to first episode of 3 consecutive days of heavy drinking (p = .0016).
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.6 (0.0-4.0 scale)

Outcome 5: Drinks per drinking day

Description of Measures	Drinks per drinking day (number of standard units of alcohol consumed on days the respondent drank alcohol) in the past 90 days was obtained using Form 90.
Key Findings	At 3-year follow-up, TSF and CBT clients who reported having social networks supportive of drinking reported fewer drinks per drinking day compared with clients receiving MET (p = .0035). The effect size for this finding was large (eta-squared = 0.94).
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.6 (0.0-4.0 scale)

Outcome 6: Alcoholics Anonymous involvement

Description of Measures	A 13-item Alcoholics Anonymous Involvement Scale (AAI) was used to measure attendance and involvement in AA. Items assessed program participation as well as commitment to the AA fellowship.
Key Findings	Among clients with social networks supportive of drinking, AA involvement was higher for TSF clients (62%) than for those receiving MET (38%) or CBT (25%).
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

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Ratings

Quality of Research Ratings by Criteria (0.0-4.0 scale)

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
Outcome 1: Percentage of days abstinent from alcohol	3.8	3.8	3.5	4.0	3.0	4.0	3.7
Outcome 2: Adverse consequences of drinking	3.3	3.3	3.5	4.0	3.0	4.0	3.5
Outcome 3: Combined assessment of drinking and drinking problems	3.0	3.0	3.5	4.0	3.0	4.0	3.4
Outcome 4: Number of days before first drink/heavy drinking ("time to event")	3.8	3.3	3.5	4.0	3.0	4.0	3.6
Outcome 5: Drinks per drinking day	3.5	3.5	3.5	4.0	3.3	4.0	3.6
Outcome 6: Alcoholics Anonymous involvement	3.3	3.0	3.8	3.5	3.0	3.8	3.4

Study Strengths: The multisite study was large and well designed. It employed random assignment, excellent intervention fidelity and training methods, clear and well-specified treatments, sophisticated measures, and a high-quality data analytic approach.

Study Weaknesses: The study did not use a control (minimal or no treatment) condition.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

Implementation Materials	Training and Support	Quality Assurance	Overall Rating
3.0	3.0	3.0	3.0

Dissemination Strengths: The program materials include session-by-session instructions and tips for a systematic approach to implementation. The detailed training addresses program background, structure, process, and content. A protocol for monitoring outcomes is provided to support quality assurance.

Dissemination Weaknesses: No materials are available to assist program implementers in recruiting clients or addressing organizational implementation. Ongoing coaching or consultation is not available to support implementers beyond initial training. No protocol is provided to support implementation fidelity.

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Contact Information

Web site(s):

http://www.hazelden.org/bookstore

For information about implementation:

Roxanne Schladweiler
Executive Director of Sales
Hazelden Publishing and Educational Services
15251 Pleasant Valley Road
Center City, MN 55012
Phone: (800) 328-9000
Fax: (651) 213-4577
E-mail: rschladweiler@hazelden.org

For information about studies:

Joseph Nowinski, Ph.D.
Supervising Psychologist
University of Connecticut Health Center, Correctional Health Care Division
177 Weston Street
Hartford, CT 06120
Phone: (860) 240-1964
E-mail: jnowinski@sbcglobal.net

Stuart Baker
5 Blue Spruce
Middletown, CT 06457
Phone: (860) 346-4198
E-mail: smbaker@snet.net

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The NREPP review of this intervention was funded by the Center for Substance Abuse Treatment (CSAT).