Kathleen M. Carroll, PhD
CHAPTER OUTLINE
■ HISTORICAL PERSPECTIVE
■ TREATMENT MODEL
■ THEORY OF CHANGE
■ TREATMENT PLANNING AND EVALUATION
■ INDICATIONS FOR TREATMENT
■ PRETREATMENT ISSUES
■ RELEVANT RESEARCH
■ SUMMARY AND CONCLUSIONS
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.
The TSF therapist also explores positive and negative consequences of substance use. Typically, the relationship with alcohol and drugs starts out very positively with tremendous enjoyment by the patient. However, as use increases in amount and frequency, there is invariably an increase in negative consequences (e.g., spending too much money, problems at work, problems at home, legal problems). These negative consequences are evidence of the “unmanageability” referred to in the first step. Examining major life events at different ages helps to place the patient’s relationship with alcohol and drugs in perspective. TSF rec-ognizes that substance use takes place in a social and environmental context and is not an isolated behavior.
After the alcohol and drug use history is completed, the TSF therapist asks the patient to react to what they have observed. For some, this is the first time they have looked at the big picture of how addiction has affected their life. The therapist then underlines evidence of unmanageability by pointing out negative consequences from their addiction in the following areas:
Physical: Health problems, accidents, or injuries the patient may have experienced
Legal: Arrests, difficulties with child protection agencies, civil problems, law suits, etc.
Social: Loss of friends, family relationship problems, lack of supportive relationships, lack of social skills
Sexual: Changes in sexual functioning, positive and negative, trading sex for drugs
Psychologic: Depression, anxiety, shame, and guilt about using despite the intention to remain abstinent
Financial: Loss of job, effects on job performance, income used to buy drugs or alcohol, indebtedness
Finally, the TSF therapist asks about loss of control over alcohol or drug use. This includes behaviors such as repeated failed attempts to stop or control use, using alone, preoccupation with drugs or alcohol, and substance substation. Using the evidence offered by the patient, usually the only logical conclusion is that the patient is an alcoholic or drug addict.
The TSF therapist then describes addiction as follows: Alcoholism or addiction is a disease that is chronic (the patient will remain an addict for the remainder of his or her life), is progressive, and, if left untreated, can be fatal. Because of the nature of the disease, once a person becomes an addict, he or she can never return to safe use of mood-altering substances. The progressive nature of the disease is noted in the patient’s history of increasing losses and problems and increasing amounts and frequency of use over time. The good news is that alcoholism and drug dependence are treatable. The therapist emphasizes that what has worked best for most is to abstain from all mood-altering substances, one day at a time. To learn how to do this and to gain support to do this task, the TSF therapist then recommends that the patient make use of Twelve-Step recovery programs such as AA. This leads naturally and easily into contracting with the patient about participating in TSF therapy and beginning to attend self-help meetings.
INDICATIONS FOR TREATMENT
In general, TSF therapy is intended for alcohol and drug users at the higher end of severity—that is, those who meet criteria for alcohol or drug dependence. As described previously, the assumption is that the patient is coming to treatment after incurring significant consequences of substance use and being unable to control or stop use on their own and thus would meet formal Diagnostic and Statistical Manual of Mental Disorders criteria for dependence. Thus, TSF is not intended for those who are at the earlier stage of addiction or are “at risk” users. It is of note, however, that contrary to expectations (and a Project MATCH a priori hypothesis), level of alcohol involvement did not predict differential response to TSF in Project MATCH (12).
Similarly, although it was predicted that several patient characteristics (gender, psychiatric severity, conceptual level, motivation) would be associated with poorer response to TSF compared with cognitive–behavioral therapy (CBT) and motivational interviewing, the primary matching hypotheses in Project MATCH did not receive strong empirical support. Thus, the data from Project MATCH suggested that TSF was generally appropriate for a wide range of alcohol-dependent individuals, that is, there were few strong contraindications for TSF found in that dataset.
PRETREATMENT ISSUES
Motivation
In TSF, motivation, especially lack thereof, is generally interpreted in terms of denial. The goal of treatment is to engage the patient’s interest in voluntarily committing to this TSF program. Hence, approaches that use excessive pressure, threat, or coercion toward this are likely to elicit a false commitment from the patient at best. In TSF, the therapist is advised to take a direct, nonjudgmental, and educative approach to confrontation of denial. The history of substance use, along with symptomatology (e.g., tolerance) and an understanding of the process of addiction, is relied on consistently as the basis for directly confronting patients with their current situation. The therapist attempts to highlight denial in a direct yet supportive and empathetic way.
Therapist Characteristics
In Project MATCH and the other research studies that have evaluated this approach, TSF has been implemented primarily by master’s-level therapists with substantial experience in and commitment to Twelve-Step programs as a therapeutic intervention, who also had extensive experience treating a broad range of substance abusers. Because the therapist training period for these clinical trials was brief, it was important to select therapists who already had a high level of expertise and experience in this approach and thus could achieve optimal levels of adherence and competence rapidly. However, a much broader range of therapists can, with appropriate training and supervision, implement this treatment effectively.
In TSF, the therapist uses his/her therapeutic skills to help the patient overcome barriers to becoming actively involved in Twelve-Step recovery programs. Skills such as active listening, accurate empathy, problem solving, feedback, and confrontation all have a place in this therapy. A critically important role is to be an educator about Twelve-Step programs and knowledgeable about local meetings, types of meetings, and guidance and advice about how best to access the resources of Twelve-Step programs. This may be based on the wisdom found in recovering literature, slogans, or the stories of other recovering addicts. Last, the therapist provides empathy and a sense of hope for the patient through communicating an understanding of the struggles of early recovery.
TSF requires an active, supportive, and involved presence by the therapist in sessions. Good TSF appears almost conversational in tone. A good session involves give and take between the therapist and the patient. The session, however, is quite focused. The therapist takes an active part in keeping the focus of the session on recovery. Some therapists begin their sessions by asking the patient, “How has your recovery week been?” When faced with the day-to-day struggles of the patient, the therapist refers the patient back to the use of Twelve-Step program tools. For example, the therapist frequently suggests also talking a problem over with a sponsor or peer as well as talk about the issue at a meeting.
Last, an effective TSF therapist uses confrontation constructively. The TSF therapist is careful to confront the patient’s behavior as it relates to his or her addiction (i.e., denial, avoidance) rather than the person. This means separating the person from the disease and communicating that the patient is a good person who has a disease (addiction) that leads him or her to act in ways that are hurtful toward himself or herself and others.
RELEVANT RESEARCH
For many years, treatments based on the Twelve Steps of AA and Cocaine Anonymous were widely used and had a great deal of popular support in the treatment community, but until recently have had very little empirical support from controlled clinical trials (13–15). Recently, however, several rigorous randomized clinical trials have been done that have found strong support for the efficacy of well-defined, manualized, Twelve Step–oriented treatments.
For example, in Project MATCH (16,17), the largest randomized trial of treatments for alcoholism conducted to date, TSF was not significantly different in effectiveness from cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET), two forms of treatment with strong records of empirical support. Moreover, where there were differences in outcome on some variables (e.g., rates of complete abstinence and negative consequences of drinking), these tended to favor the TSF approach over CBT and MET (16–19). TSF has also been associated with higher rates of self-help involvement (20–23), which in turn has been associated with better drinking and drug use outcomes (5,21,24,25).
TSF has also been found to be effective with drug abusers. In a clinical trial of disulfiram and psychotherapy with cocaine- and alcohol-dependent subjects, TSF was found to be comparable in effectiveness to CBT in reducing cocaine and alcohol use; moreover, both TSF and CBT were found to be significantly more effective than a psychotherapy control condition clinical management (26). The effects of TSF in this study were also durable and associated with good outcome up to 1 year after patients completed the 12-week treatment program (27). These findings were similar to those of Wells et al. (28), who demonstrated that TSF was comparable in effectiveness to CBT in a randomized controlled trial with cocaine abusers in a group setting. Finally, Ouimette et al. (29), in a nonrandomized trial, evaluated the effectiveness of Twelve-Step and CBT approaches in 15 Veterans Affairs programs in a sample of 3,017 subjects. Participants in both types of treatment programs had good outcomes at 1 year; moreover, patients in the Twelve Step– oriented programs had somewhat higher rates of abstinence.
Despite emerging support for the efficacy of TSF, it has proven challenging to disseminate TSF and other empirically validated treatments to the clinical community. Many clinicians have limited access to comprehensive training in TSF or other empirically validated therapies (30). Although workshops in some empirically supported therapies are more available recently, training sessions are usually quite brief (e.g., workshops of several hours duration) and hence unlikely to produce lasting change in the clinician’s ability to implement new therapies (31). Moreover, it should not be assumed that counselors, even those espousing a Twelve-Step model, can implement TSF without training. Although based on standard counseling models, TSF differs from it in several ways. These include its high emphasis on therapist support, discouragement of aggressive “confrontation of denial” and therapist self-disclosure, and highly focused and structured format.
In this context, Sholomskas and Carroll recently completed a randomized training trial in which predominantly bachelor’s- and master’s-level counselors were randomly assigned to one of two training conditions: either the TSF manual (1) or a computer-assisted training method (32). Pre- to posttraining data indicated that the clinicians’ ability to implement TSF, as assessed by independent ratings of adherence and skill for five key TSF interventions, was significantly higher after training for those assigned to the computer-assisted training method than for those who were assigned to the manual-only training condition. Those who were assigned to the CD-ROM condition also evidenced greater gains in a knowledge test assessing familiarity with concepts presented in the TSF manual. Moreover, no significant effects of the clinicians’ self-reported recovery status were seen on adherence, competence, or knowledge scores (32).
SUMMARY AND CONCLUSIONS
TSF is a professionally delivered, individual, manual-guided therapy that is grounded in the principles and Twelve Steps of AA. It is important to note, however, that TSF has no official relationship with, or sanction from, any Twelve-Step program. AA does not sponsor or conduct research on alcohol or drug treatment and does not endorse any treatment program. While intended to be consistent with Twelve-Step principles, it is important to note that TSF was designed for delivery in research protocols and in clinical settings and thus is a fairly recent addition to the repertoire of behavioral therapies for alcohol and drug use disorders. With that as its basis, TSF received comparatively strong empirical support in Project MATCH, one of the largest alcohol treatment trials ever conducted in the United States, and support is emerging for its use with other patient groups as well.
ACKNOWLEDGMENT
Sections of this chapter were adapted from Nowinski J, Baker S, Carroll KM. Twelve-step facilitation therapy manual: a clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: NIAAA, 1992.
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