Monday, November 25, 2013

12-Step Familiarity vs 12-Step Facilitation

A pair of studies were published last month to little fanfare and which seem to be contradictory in nature. Both papers involve 12-step programs and focus on the role of the counselor in delivering Twelve-Step Facilitation (TSF), a SAMHSA-recognized evidence-based practice. Published in the American Journal of Drug and Alcohol Abuse, the studies come to the following conclusions: Therapist familiarity and personal experience with twelve-step programs (TSPs) improves their credibility among clients and, in turn, therapeutic alliance; yet therapists who viewed TSPs favorably and who described themselves as being in recovery tended to do a poorer job at maintaining fidelity and adherence to TSF in a large, multi-site trial.

In the first paper, researchers at the State University of New York administered surveys to clients and counselors at a host of treatment programs in and around Albany. Clients (n=180) rated counselors on their perceived familiarity with  TSPs, the amount of time in-session devoted to discussion of TSPs, and the credibility of each counselor, as rated in a 12-point questionnaire. In addition, counselors (n=30) answered a demographic questionnaire, reporting such information as education level, recovery status, and months of experience in the field. As hypothesized, counselors who were perceived to be in recovery and more personally-familiar with TSPs received higher ratings of credibility from their clients, presumably resulting in better therapeutic alliances and, therefore, better outcomes.

In the second paper, researchers in Oregon and California sought to determine the characteristics associated with fidelity and TSF adherence among therapists participating in a large trial of the EBP. Notably, the authors found that 1) "Therapists reporting more positive attitudes toward 12-step groups had lower adherence ratings;" 2) "Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis;" and 3), "Fidelity was higher for therapists reporting self-efficacy in basic counseling skills" (as well as for therapists with a graduate degree) "and lower for self-efficacy in addiction-specific counseling skills." 

The "juxtaposition" of the two outcomes, as Yale's Steve Martino puts it, leads the reader to believe that the ideal therapist in this setting can't possibly exist, or ar the very least is exceedingly rare. Someone who is very familiar with 12-step principles is likely to report a positive attitude toward them, and counselors in recovery are likely to rate themselves as possessing strong addiction-specific counseling skills. So, what is the moral to the story, if one exists? Where do we focus workforce development energy with mixed messages like these? It would be interesting to hear from readers who fall on either side (or both sides) of this issue...


  1. Christopher Cook, B.A., CADCNovember 29, 2013 at 10:37 PM

    Just a thought: there are significant differences in 12-Step Community culture across the Country. These papers might actually point to this rather than any specific set of skills by the therapists. The more familiar one becomes with the organizational structure of NA/AA/CA and others, you can see drastic differences in norms, values, and group-behavior in different regions. To me, this is a reason to ALWAYS individualize treatment. The success of 12 Step Programs, not necessarily the therapy, lies with the social nature of the program. Said simply: people in the programs who make friends stay clean. Since the differences in culture can be drastic, one should familiarize themselves with it before referring clients there, and certainly before hiring therapists that readily self-identify as recovering. I will catch hell for this possibly, but many times the culture of the programs in an area/region does not translate therapeutically at all. Meaning, the bias and belief systems fostered in the programs marginalize clients and therapists will bring these belief sets with them in session. The conflicting outcomes in these papers may just illustrate my point perfectly. Remember , cultures the opioid epidemic surges and more and more young adults flood the church basements we will continue to see significant shifts in the priorities of the members. As a MPH student the changing landscape of 12-step programs is interesting to me; will they stand the test of time?

  2. Proselytizing is a form of directive therapy and consequently disrespectful of the client's ability to uncover what will work for themselves. Most of us have met 12-step zealots who preach more than teach. Self-disclosure in therapy must be used judiciously. If it builds identification, fine, but if it is laden with "you should" or "we must," it can easily set up an argument or outright defiance.

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  4. Results from these two studies are logical because while TSF counselors who are themselves recovering may be more able to convey enthusiasm and 'street cred' to their clientele, they may also be more likely to chafe when tasked with delivery of the more structured, formulaic cook-book approach to counseling that is characteristic of TSF, and to deviate from protocol when the opportunity arises to share their or others' (e.g., out of the AA Big Book) recovery experience. So it comes down to which has greater influence on positive treatment outcome, client-counselor connection, or TSF protocol delivery.

    Mark Edmund Rose, MA
    Licensed Psychologist

  5. Am not sure SAMHSA and the staff in facilities understand what evidence based mean. For too long I think that clinician have been saying things for which they have not evidence. Then claim that they are doing evidence based only by name, because I can not recognize the procedures. The Behavioral Contract they develop are punitive directive than any contract and positive reinforcement based I know. Before they can say they are doing evidence based I think they need to learn the science concepts that makes it evident that the approach is effective and why? I have a lot of question and doubt about clinicians. I think most states most do a moratorium on treatment until clinicians can prove through independent panels. Patients have been harmed by the mentality that most clinicians in mental health seem to operate.

  6. I have a TBI and it involves my spelling and ability to write. So i'm learning to spell and write again. so please forgive my writing. When it comes to self rating anything I have trouble accepting it as reliable research. I will tell you my incounters with AA and therapy. I tried AA maybe 10 times and have been in therapy for more than 10 or 12 years Most of my sponsors discounted what my therapist said. You need to know first that I wouldn't talk to a therapist unless they were in recovery. How could somebody understand what an addict goes through unless they are one. So I was forced to pick who to work with and thats my sponsor because i was with him all the time. I was forced to go to therapy and to groups at the behavioral health department i was going to in order to get my medication. My sponsors weren't very interested in my 12 step program. They would just ask if I had a sponsor and how many times a week I went. I never found therapy to be of any help in my life. But AA promised if I did what they said I would be sober. It never work They wanted me to write out my steps and I couldn't write They couldn't understand that and I didn't know I was injured till much later. I was in an accident while I worked for the fire department . I walked into a toxic gas and when I was removed I had complete expressive aphasia. I don't think the counclers were the right people to rate their credibility with their client. They should have questioned the clients. because like pyschiatrist they seem to be a little to self absorbed. But then so were my sponsors. However so am I. What people think other people see in them usually isn't what they see at all. So I don't think you can trust the data. so I don't believe the study. Who is on the proof page . Anybody note worthy ? Is it well backed up with documentation? I know it's not well said but the point is valid. I been sober since 2009 and I do have a degree in chemistry. .