How Twelve Step Facilitation (TSF) works

TSF is as effective as more research-based therapies and may be superior when total abstinence and delaying of the first drinking episode are desired outcomes.

A central objective of TSF is facilitating client engagement in Alcoholics Anonymous (AA), and accumulating evidence suggests that achieving this aim often explains later abstinence.

Less understood, however, are the therapeutic mechanisms of change within TSF itself that may be beneficial for mobilizing drinking reductions.

This summary examines three therapeutic elements in TSF that are hypothesized to be such active ingredients, with the ultimate intent of providing evidenced-based feedback to clinicians about the relative importance of current therapeutic TSF practices.

TSF adheres to the concepts and beliefs in the approved AA literature. These core assumptions include the beliefs that

  1. alcoholism is a progressive illness that affects the body, mind, and spirit;
  2. alcoholism is characterized by a loss of control over drinking that, if unarrested, will result in death or insanity; and
  3. the only effective remedy is total abstinence from alcohol.

From these core beliefs, TSF attempts to affect (at least) these three aspects of client functioning during the treatment phase of recovery.

  • First, TSF therapy strives for clients to internalize and endorse the goal of total abstinence from alcohol.
  • Second, TSF seeks to engage clients in AA, with engagement defined in multidimensional terms: attendance, step work, and participating in the AA fellowship.
  • Third, TSF therapy encourages the spiritual development of clients because, consistent with the core AA literature, a personal God relationship is considered essential for sustained abstinence from alcohol, one day at a time.

To conduct these analyses, we used the Project MATCH research database. The design of PM was straightforward: clients were recruited from five outpatient settings and six inpatient treatment centers. After baseline assessment, clients were randomly assigned to one of three 12-week treatments: TSF, cognitive behavioral therapy, or motivational enhancement therapy.

All clients then were interviewed in 3-month intervals for 1 year after treatment, and an additional 3-year follow-up was conducted with clients who were recruited in outpatient settings.

The present analyses are limited to clients who were treated in the outpatient sample, thereby removing the confounding of previous inpatient treatment.

Findings indicated that each of the intended TSF therapeutic change mechanisms was present and distinctive to the TSF therapy.

In addition, each of the therapeutic mechanisms produced the intended change (or response) in client functioning by the end of treatment.

Specifically, during the 12 weeks of therapy, TSF clients reported large gains in spiritual consciousness, endorsement of total abstinence, and engagement in AA practices.

Two of these active ingredients— emphasis on abstinence and commitment to AA practices—were predictive of greater abstinence, and commitment to AA practices mediated or explained why TSF clients reported significantly higher abstinence rates 6 months after treatment relative to cognitive behavioral therapy and motivational enhancement therapy.

J. Scott Tonigan. Examination of The Active Ingredients Of TSF In Project Match Outpatient Treatment, in Richard Longabaugh, Dennis M. Donovan, Mitchell P. Karno, Barbara S. McCrady, Jon Morgenstern, and J. Scott Tonigan. Active Ingredients: How and Why Evidence-Based Alcohol Behavioral Treatment Interventions Work. Alcoholism: Clinical and Experimental Research, Vol. 29, No. 2, February 2005

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