Twelve-Step Facilitation (TSF)

Twelve-Step Facilitation (TSF) treatments are a set of semi-structured therapies designed to help people abstain from alcohol and other drugs by systematically linking them to, and encouraging their active participation in, community-based 12-step mutual-help organizations.

To this point, Twelve-Step Facilitation (TSFs) have primarily focused on linking individuals to Alcoholics Anonymous (AA), as it was the first and is currently the largest of the 12-step mutual-help organizations.

WHAT IS THE THEORY BEHIND TWELVE-STEP FACILITATION?

Central Assumptions of Twelve-Step Facilitation:

  1. Addiction is a multi-faceted illness influenced by medical, social, emotional, and spiritual factors.
  2. Consistent with 12-step mutual-help organization philosophy, abstinence is the most pivotal, though not the only facet of recovery from substance use disorder. Emotional (and in some case spiritual) growth is also a critical recovery process.
  3. AA participation will help people achieve and sustain recovery over the long-term.
  4. Will be effective only insomuch as the provider helps engage the person with AA and other 12-step mutual-help organizations.
  5. A skilful provider can help the person address practical and attitudinal obstacles to AA attendance.

EVIDENCE FOR TWELVE-STEP FACILITATION?

The evidence for Twelve-Step Facilitation interventions in the treatment of alcohol use disorder is strong.

TSFs produce outcome benefits as good or possibly better than other active treatments. It is particularly helpful and has clearer advantages when it comes to increasing rates of continuous abstinence and full sustained substance use disorder remission (i.e., absence of symptoms for 12 months). Whether one type of TSF is advantageous over another is uncertain.

Background Information:

The History Of The 12 Steps Of A.A.

The 12 steps are one of the most popular and successful rehabilitation programmes that exist. Twelve Steps is often practised within A.A. groups. It’s also used within various alcohol rehabilitation services.

What do the 12 steps mean?

Twelve Steps is a recovery programme (or model) that came out of the Alcoholics Anonymous group. It was designed to provide members of A.A. with a method to follow to empower them to become sober. You’ll enjoy reading about the history of the Twelve Steps and learning about Bill Wilson, the person who founded it as described below.

The concern, compassion and honesty of this approach are what many people require when starting the first step towards recovery. 

You’ll instantly recognise why the Twelve Step programme moved throughout the world. From its humble openings in the early twentieth century to now, Twelve Steps has been a massively significant and positive impact on millions of lives.

The Founder of Twelve Steps and Alcoholics Anonymous

The founder of Twelve Steps and A.A. was a chap named Bill Wilson (or Bill W). 

Bill W faced various troubles in his younger life and suffered bouts of depression and anxiety.

Obviously, like most people who face addiction, Bill Wilson experienced harrowing events and mental health issues. People start drinking or taking drugs for all kinds of reasons. It can be associated with both traumatic events or repeating a behaviour that has been witnessed in other family members.

What Inspired the Twelve Steps?

In November 1934, an old friend of Bill W’s, Ebby Thacher, reached him. Previously, they had drunk together, but Thacher was sober due to support from the Oxford Group, a Christian group he was a part of.

Thacher’s sobriety had a hugely significant impact on Bill W.

It’s no secret, however, that Bill W wasn’t keen on religion. Interestingly, it was reported that Bill W experienced what he considered an epiphany where he realised recovery could be a spiritual experience without being a religious one.

Bill W once stated, “It was only a matter of being willing to believe in a Power greater than myself. Nothing more was required of me to make my beginning.” 

Another source of inspiration for Bill W was gained from his doctor, Dr WIlliam Silkworth, who introduced the theory of alcoholism as a disease.

When Bill W was doing his best to remain abstinent, he became very friendly with a gentleman known as Dr Robert Smith (or Dr Bob). Bill W, in fact, moved in with Dr Bob and shared his ideas about the Twelve Steps. These two supported each other to remain sober.

The two came up with the idea for a group that they would call Alcoholics Anonymous.

Where Twelve Steps started

Alcoholics Anonymous founding date was 10th June 1935.

The 10th June 1935 is considered the founding date of A.A. This was when Dr Bob had his last drink.

Over the next few years, Bill W and Dr Bob would continue to attend Oxford Group meetings but was also building a new type of group. One that would focus on supporting people addicted to alcohol.

During this time, they came up with a list of six principles that governed their lives of sobriety.

In 1937 the two founders of A.A. started raising funds to begin the A.A. fellowship, which would be separate from the Oxford group. Its aim is to support people with drinking problems.

So what happened next?

Alcoholics Anonymous Big Book was published in April 1939.

In 1938, Bill W and Dr Bob started writing the Big Book. Initially, the purpose of the book was to support those who couldn’t attend A.A. groups. It was for those who might feel alone and as though there was no one else they could connect to who understood addiction to alcohol.

In the book, there was something that would come to change the world of addiction. It would change how practitioners and people with drinking problems would approach treatment and recovery.

The Origin of the Twelve Steps

This Big Book was redrafted many times. Members of the early A.A. group that Bill W and Dr Bob had formed all wanted to give input and, indeed, helped create the book. There were some clashes of opinion, mainly around how religious the book and Twelve Steps should seem. This is why God is also referred to as “God as you know Him” and a “Higher Power”. It’s to be inclusive to those who are agnostic.

Eventually, there came the point where the book was finished, and it was published in 1939. The book would go on to become the guideline by which A.A. groups all over the world would be governed by.

The Big Book included the world-renowned Twelve Steps.

Interesting fact: Bill W reported that it took him approximately thirty minutes to write out the Twelve Steps. Before this moment, the A.A. groups that he and Dr Bob ran focused on six principles. Bill W based the Twelve Steps on these six. He wanted to ensure there was no wriggle room for people with alcohol addictions to make excuses to drink. 

Step One: We admitted we were powerless over our addiction – that our lives had become unmanageable

In this step, we gain a clearer picture of our drinking so that we can admit the problem. By accepting the problem we can start to look forward to finding a solution and putting in the action to make that solution real. We look at what we have lost as a result of our addiction, how it has affected our day to day lives, our relationships with friends and family, and the impact on our health (mental and physical). We look at how we have tried to control our drinking / using, failed previous attempts to stop and the psychological obsession with drinking / using. We consider how our addiction has led us to keep secrets and tell lies in order to protect our habit. We reflect on how our addiction has affected our moral code.

We also look at the psychological obsession which leads us to pick up and relapse if we have managed to stop for a period. We admit how we have physically craved alcohol and how, once we give in to this craving and start, we cannot stop. We have no ‘off switch.  It is like having an allergy – we cannot safely drink (or use other mood-altering substances) at all. We cannot control our drinking / using once we start, even if the people we love are affected and beg us to stop. We feel stressed and anxious, irritable and discontented – until we have that drink or drug to ‘fix’ us. Alcohol becomes a necessity, not a luxury – a ‘must have’ rather than a ‘nice to have’.

Step one also includes an examination of the ‘spiritual malady’ – how we are affected emotionally – having trouble loving ourselves and in our relationships with others, feeling depressed, fearful and unhappy.

Once we have worked through Step One, we should have no doubt that we have a BIG problem.

Step Two: Came to believe that a power greater than ourselves could restore us to sanity

If we accept that we are powerless over alcohol and drugs (step one), then we need to get power. However, if we had sufficient power within ourselves to control our drinking or using, then we would have used it. So the inevitable conclusion is that we need more power than we can find within ourselves – a power greater than ourselves – to stop our insane pattern of behaviour and get well. This is our only option – to find that power greater than ourselves – or to carry on with our old pattern of addiction.

The first part of step 2 is to acknowledge this fact and to be open-minded to the possibility of a power greater than ourselves. Most alcoholics and addicts have no religious beliefs at this point. No one is asked to believe in a religious God – but only in one of their own understanding. The sole requirement is to be willing and open-minded to this prospect – that there is a power out there that is greater than us individual humans and that we need this power, as if we try and run our lives on self-will as we have in the past, we will not be successful.

Step Three: Made a decision to turn our will and our lives over to the care of God as we understood Him

This step involves making a decision – not necessarily actually handing our will and our lives over. It involves surrendering our self will and acknowledging that we can no longer be the main directors in the show. We are going to be directed by someone else in the future – whatever or whoever our higher power might be. Once we have decided that we are ready to do this, we need to move straight in into the action steps – Steps Four to Nine.  These five action steps are followed by the maintenance steps – Steps Ten to Twelve- which are how we keep it up.

Step Four: Made a searching and fearless moral inventory of ourselves

Step Four involves taking a good honest look at ourselves. We identify the flaws in our personality and face up to the truth. We look at our resentments, fears and harms done to others. We are often angry about something, afraid of something or someone, or feel guilty about wrongdoing in the past.

In Step Four, we write a list of all of these things, how they have affected us, and where our responsibility is for all these things (‘our part’).  We can usually identify where we have been selfish, self-seeking, dishonest, frightened, over-sensitive and judgemental. Step Four also involves looking at our sex conduct – meaning how we have been in relationships.

Everyone has done things they feel ashamed or embarrassed about and behaved in ways they regret. The difference is that not everyone is prepared to do something about it. Step Four demonstrates a willingness to change and put the past behind us.

Step Four also enables us to begin to understand ourselves.

Step Five: Admitted to God, ourselves and to another human being the exact nature of our wrongs

Simply writing down our Step Four is not enough. We have to share it with another human being and our Higher Power to free ourselves of all the bad feelings that have been hiding within us. By doing this we are admitting our wrongs more forcefully and demonstrating a willingness to address them in the future.

Step Six: Were entirely ready to have God remove all these defects of character

Now we have seen the truth in ourselves and identified the parts of ourselves that we need to work on, we need to be willing to change. This step is not about changing but being willing to change.

Step Seven: Humbly asked Him to remove our shortcomings

In Step Seven we actually hand ourselves over to our Higher Power and ask for our character defects to be removed. In reality, this often means us constantly working to make sure they do not surface – it is very much a work in progress. For example, if a character defect is that we are controlling, we need to recognise when we are tempted to be controlling and stop the defect in its tracks. With continued practise and experience, this becomes more and more our new ‘second’ nature.

Step Eight: Made a list of all persons we had harmed and became willing to make amends to them all

Step Eight can usually be derived from step 4. If we look at all the people, groups and institutions (for example) that we identified in our step 4 inventory – people we had harmed, cheated, been angry with, lied to etc – then these are what we need to list in our Step Eight in order to be ready and willing to make amends. If there is anyone we are reluctant to put on the list, then they most certainly need to be there. Do not leave off the most difficult ones – it is important that they are there and that they are dealt with if our recovery is to be on firm foundations.

Step Nine: Made direct amends to such people wherever possible, except when to do so would injure them or others

This is a true action step. We need to say sorry to the people we have harmed – even if they have done us harm. We can only ‘clean up our side of the street’. We are not responsible for theirs and must not be disappointed if we do not get the response we expected. We are putting things right to make us feel better about ourselves, knowing we have done the right thing.

Sometimes it is not possible to make amends as the individual may no longer be with us. So we make amends in some other way – a visit to the grave, a donation to a charity that is connected to them, for example.

Think about your motivation for making amends and what might be the reaction of the other person. That is not a reason or excuse to avoid the amends but if, for example, your amends will reveal something that will hurt them – an affair is a good example – then leave well alone. In these instances, you can do something else. For example, you might make indirect amends – do something that will benefit them from behind the scenes but without them necessarily knowing that it is you that has made the gesture.

Step Ten: Continued to take personal inventory and when we were wrong promptly admitted it.

Having cleaned up the debris from our past, we now clean up on a daily basis. Each day we consider what we have done that is good and what we have done that we wish we had not / should not. If we have said or done anything for which we need to say ‘sorry’ we do it promptly and immediately. It is like a mini step 4, 5 and 8 and 9 each day.

Step Eleven: Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

In order to maintain a strong, healthy and happy recovery, we need to keep our spiritual health in prime condition. We, therefore, need to consciously avoid self-pity, dishonesty and selfishness. We need to ask for our Higher Power’s support and guidance in facing the day’s challenges and making the right decisions. At the end of each day, we look back in gratitude for what has been good and right about our day and learn from the day’s experiences in order that we can continue to grow.

Step Twelve: Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

The twelfth step is about helping other alcoholics and addicts. No one else can understand how they feel more than someone who has been there. By meeting with other alcoholics and addicts in all stages of their recovery and including those still in active addiction, we remind ourselves how bad the illness is and how we do not want to return to the drinking / using days. By helping them to get well, it gives purpose to our own experience and makes us feel good that we can help other people.

Power of the Group

Individual therapy is effective, but according to psychologists, one of the best ways to change human behavior is to treat individuals with similar problems in groups.  In 1905 Joseph Pratt, a physician in Boston, was one of the first to note this occurrence. He began organizing tuberculosis patients into weekly groups meetings. Even though he initially thought the groups would teach members better hygiene, Pratt quickly realized group therapy provided members a beneficial emotional lift. He noted that by giving patients the chance to share their hardships with one another, “in a common disease, they have a bond”. More recently a pair of Stanford University researchers identified why this group approach is so effective. After reviewing approximately 200 articles on group therapy their conclusion was that: “members find the group to be a compelling emotional experience, they develop close bonds with the other members and are deeply influenced by their acceptance and feedback.”

12-Step Effectiveness

According to Project Match, a multisite clinical trial of alcohol treatment at the University of Connecticut Health Center, “no single treatment is effective for all persons with alcohol (drug) problems. A more promising strategy involves assigning patients to alternative treatments based on specific needs and characteristics of patients”.

Project Match was conducted between 1989 and 1997 wherein more than 1,700 individuals suffering from alcohol dependence were assigned to one of the three successful drug treatment therapies used by professional drug rehab programs. The therapy used was called 12-step facilitation, wherein a licensed therapist assists clients through Bill Wilson’s 12-step method. The second was cognitive behavioral therapy (CBT) which teaches individuals with a substance use issue to recognize the triggers and situations that have lead to relapse. By specifically identifying people, places and situations that have lead to relapse, individuals can learn to avoid these compromising situations in the future. Finally, motivational enhancement therapy (MET) was incorporated. MET is an individual-therapy-interview process that strengthens a person’s reasons for maintaining recovery.

The final conclusion of Project Match was that all three of these therapies were about equally successful at reducing alcohol (drug) intake among participants.   12 step facilitation was substantially more effective at achieving total abstinence as compared to just limiting alcohol (drug) consumption.