Intervention Summary

Twelve Step Facilitation Therapy

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 or groups over 12-15 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 reaching out to others 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 TSF 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 receive TSF, Cognitive Behavioral Therapy, or Motivational Enhancement Therapy. Findings from Project MATCH are included in this summary. In addition, participants received individual therapy in all research reviewed for this summary.

Descriptive Information

Areas of Interest	Substance use disorder treatment
Outcomes	1: Alcohol abstinence 2: Alcoholics Anonymous involvement 1: Percentage of days abstinent from alcohol 2: Adverse consequences of drinking 3: Combined assessment of drinking and drinking problems 4: Number of days before first drink/heavy drinking ("time to event") 5: Drinks per drinking day 6: Alcoholics Anonymous involvement
Outcome Categories	Alcohol Mental health Social functioning Treatment/recovery
Ages	18-25 (Young adult) 26-55 (Adult)
Genders	Male Female
Races/Ethnicities	Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Inpatient Outpatient
Geographic Locations	Urban Suburban Rural and/or frontier
Implementation History	The TSF approach has been widely used in treatment programs in all 50 States. It also has been implemented in Australia, Bermuda, Canada, Greece, Ireland, New Zealand, South Africa, Taiwan, and the United Kingdom.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Walitzer, K. S., Dermen, K. H., & Barrick, C. Facilitating involvement in Alcoholics Anonymous during out-patient treatment: A randomized clinical trial. Addiction, 104(3), 391-401.

Supplementary Materials

Sobell, L. C., & Sobell, M. B. Timeline Follow-Back: A technique for assessing self-reported alcohol consumption. In R. Z. Litten & J. Allen (Eds.), Measuring alcohol consumption: Psychosocial and biological methods (pp. 41-72). Totowa, NJ: Humana Press.

Tonigan, J. S., Connors, G. J., & Miller, W. R. Alcoholics Anonymous Involvement (AAI) scale: Reliability and norms. Psychology of Addictive Behavior, 10(2), 75-80.

Worley, M. J., Tate, S. R., & Brown, S. A. Mediational relations between 12-step attendance, depression and substance use in patients with comorbid substance dependence and major depression. Addiction, 107(11);

Outcomes

Outcome 1: Alcohol abstinence
Description of Measures	Alcohol abstinence was measured by the Timeline Followback (TLFB) interview, a calendar-based method for reconstructing days of drinking over a specified period of time. Participants used the TLFB interview to report the number of drinks for each day of the prior 6-month period at baseline and for each day of the prior 3-month period at 3 months after baseline (posttreatment) and at the 3-, 6-, 9-, and 12-month posttreatment follow-ups. Days were coded as abstinent, light drinking (one to three standard drinks), moderate drinking (four to six standard drinks), or heavy drinking (more than six standard drinks). The percentage of days abstinent was calculated for each time period. Research interviewers conducted in-person assessments with participants at baseline, at posttreatment, and at 6- and 12-month posttreatment follow-ups, and they conducted telephone assessments at 3- and 9-month posttreatment follow-ups. Research interviewers also conducted separate telephone assessments with collaterals (e.g., significant others) for the TLFB-derived alcohol abstinence at baseline, at posttreatment, and at 3-, 6-, 9-, and 12-month posttreatment follow-ups.
Key Findings	In a randomized clinical trial conducted over 3 years, adult drinkers were recruited from an urban outpatient center and assigned to one of three types of treatment for 3 months: (1) TSF, (2) a motivational enhancement approach, or (3) treatment as usual. All three treatments included 12 sessions that covered topics such as problem-solving skills, drink refusal, and relaxation skills, but they differed in the way the therapist discussed AA from the 2nd through 12th sessions. TSF and the motivational enhancement approach were intended to facilitate involvement in AA, whereas treatment as usual placed no special emphasis on AA; however, beginning with session 2, all participants received weekly instruction to "attend at least a couple of AA meetings each week." Compared with participants who received treatment as usual, TSF participants had a higher percentage of days abstinent in the prior 3 months at the 6-month (p < .05) and 12-month (p < .05) posttreatment follow-ups. Motivational enhancement participants and those who received treatment as usual did not differ significantly on the percentage of days abstinent in the prior 3 months at the 6- and 12-month posttreatment follow-ups.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.7 (0.0-4.0 scale)

Outcome 2: Alcoholics Anonymous involvement
Description of Measures	Alcoholics Anonymous involvement was assessed using two measures: The Timeline Followback (TLFB) interview, a calendar-based method for reconstructing days of a target behavior over a specified period of time. Participants used the TLFB interview to report the presence or absence of attendance at AA meetings for each day of the prior 6-month period at baseline and for each day of the prior 3-month period at 3 months after baseline (posttreatment) and at the 3-, 6-, 9-, and 12-month posttreatment follow-ups. The average number of days of AA meeting attendance per month was calculated for each time period. The AA Involvement (AAI) questionnaire, a 13-item self-report inventory that measures lifetime and recent attendance and involvement in AA. An AA behaviors scale score was calculated from the sum of the presence (coded as 1) or absence (coded as 0) of six behaviors: (1) attendance at a meeting, (2) considering self to be a member of AA, (3) going to "90 sobriety meetings in 90 days," (4) celebrating an AA sobriety birthday, (5) having an AA sponsor, and (6) being an AA sponsor. Another score was calculated from the count of the number of AA steps "worked." The AAI questionnaire was administered at baseline, at posttreatment, and at 6- and 12-month posttreatment follow-ups. At baseline, the AAI questions were asked from a lifetime perspective; at the posttreatment assessment, the questions were asked from the perspective of the prior 3 months; and at the 6- and 12-month posttreatment follow-ups, the questions were asked from the perspective of the prior 6 months. Research interviewers conducted in-person assessments with participants at baseline, at posttreatment, and at 6- and 12-month posttreatment follow-ups, and they conducted telephone assessments at 3- and 9-month posttreatment follow-ups. Research interviewers also conducted separate telephone assessments with collaterals (e.g., significant others) for the TLFB-derived attendance at AA meetings at baseline, at posttreatment, and at 3-, 6-, 9-, and 12-month posttreatment follow-ups.
Key Findings	In a randomized clinical trial conducted over 3 years, adult drinkers were recruited from an urban outpatient center and assigned to one of three types of treatment for 3 months: (1) TSF, (2) a motivational enhancement approach, or (3) treatment as usual. All three treatments included 12 sessions that covered topics such as problem-solving skills, drink refusal, and relaxation skills, but they differed in the way the therapist discussed AA from the 2nd through 12th sessions. TSF and the motivational enhancement approach were intended to facilitate involvement in AA, whereas treatment as usual placed no special emphasis on AA; however, beginning with session 2, all participants received weekly instruction to "attend at least a couple of AA meetings each week." Findings included the following: Compared with participants who received treatment as usual, TSF participants had a higher average number of days of AA meeting attendance per month in the prior 3 months at the 3-month (p < .05), 9-month (p < .01), and 12-month (p < .05) posttreatment follow-ups. Motivational enhancement participants and those who received treatment as usual did not differ significantly on the average number of days of AA meeting attendance in the prior 3 months at the 3-, 9-, and 12-month posttreatment follow-ups. Compared with participants who received treatment as usual, TSF participants had a higher AA behaviors scale score in the prior 6 months at the 12-month posttreatment follow-up (p < .01). Motivational enhancement participants and those who received treatment as usual did not differ significantly on the AA behaviors scale score in the prior 6 months at the 12-month posttreatment follow-up. Compared with participants who received treatment as usual, TSF participants had more AA steps worked in the prior 6 months at the 12-month posttreatment follow-up (p < .05). Motivational enhancement participants and those who received treatment as usual did not differ significantly on the number of AA steps worked in the prior 6 months at the 12-month posttreatment follow-up.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.6 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	26-55 (Adult)	66.3% Male 33.7% Female	88.2% White 9.5% Black or African American 2.4% Race/ethnicity unspecified

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

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Alcohol abstinence	3.8	3.8	3.0	3.8	3.8	3.9	3.7
2: Alcoholics Anonymous involvement	3.5	3.5	3.0	3.8	3.8	3.9	3.6

Study Strengths

The TLFB interview is a psychometrically sound instrument with high reliability and validity for obtaining retrospective daily estimates of alcohol consumption. The AAI questionnaire has been demonstrated to have good internal consistency for the total score and test-retest reliability and construct validity for two factors, on the basis of factor analysis. The validity of the TLFB interview was enhanced by high correlation with reports from collaterals. The intervention is manual driven, and therapists received standardized training together in pairs with ongoing supervision that included a review of session audiotapes, with corrective action when necessary. Random assignment controlled for many confounds. Additionally, treatment dose and therapist face-to-face time with a participant were balanced across conditions, and research interviewers were blind to treatment condition. An intent-to-treat approach was used, which included all randomized participants with at least one completed posttreatment assessment, and sophisticated statistical modeling incorporated missing data at the follow-up assessments.

Study Weaknesses

Self-reported alcohol abstinence was not corroborated by any biomarkers of alcohol use at follow-up assessments. No tested fidelity instrument was used to formally evaluate treatment fidelity to the intervention manual, and no fidelity rating protocol was described for the review of the audiotapes. There was no baseline comparison of completers and noncompleters for differences, despite the moderate participant attrition across study conditions and the lower percentage of participants who completed at least 6 (of 12) sessions in each condition at the 12-month posttreatment assessment. Randomness of the missing data was not demonstrated.

Documents Reviewed

Study 1

Longabaugh, R., Wirtz, P. W., Zweben, A., & Stout, R. L. Network support for drinking, Alcoholics Anonymous and long-term matching effects. Addiction, 93(9), 1313-1333.

Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58, 7-29.

Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism: Clinical and Experimental Research, 22, 1300-1311.

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 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 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 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 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 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 Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	18-25 (Young adult) 26-55 (Adult)	75.7% Male 24.3% Female	80% White 10% Black or African American 7.9% Hispanic or Latino 2% Race/ethnicity unspecified

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

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Percentage of days abstinent from alcohol	3.8	3.8	3.5	4.0	3.0	4.0	3.7
2: Adverse consequences of drinking	3.3	3.3	3.5	4.0	3.0	4.0	3.5
3: Combined assessment of drinking and drinking problems	3.0	3.0	3.5	4.0	3.0	4.0	3.4
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
5: Drinks per drinking day	3.5	3.5	3.5	4.0	3.3	4.0	3.6
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

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Hazelden Foundation. Introduction to twelve step groups [DVD]. Center City, MN: Hazelden Foundation.

Hazelden Foundation. Introduction to twelve step groups: Facilitator's guide. Center City, MN: Hazelden Foundation.

Nowinski, J. The Twelve Step Facilitation Outpatient Program: The Project MATCH Twelve Step Treatment Protocol. Facilitator guide. Center City, MN: Hazelden Foundation.

Nowinski, J. Twelve-step facilitation training slides.

Nowinski, J. Twelve-step facilitation overview.

Nowinski, J. Twelve-step facilitation professional training seminar.

Nowinski, J., & Baker, S. The Twelve Step Facilitation handbook: A systematic approach to recovery from substance dependence. The Project MATCH Twelve Step Treatment Protocol. Center City, MN: Hazelden Foundation.

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

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	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.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Twelve Step Facilitation Outpatient Program curricula	$349	Yes
Twelve Step Facilitation for the Dually Diagnosed Client curricula	$75	No
2 day onsite implementation training	$6,500 per site, plus travel	No
Clinical Supervision	Varies depending on scope of project	No
On-site or phone consultation	Varies depending on scope of project	No
Scope and sequence document, research information, and fidelity checklist	Included with curricula	No

Additional Information

The cost of implementation training does not include the curriculum. Discounts are available depending on the volume of orders.