Professional Interventions That Facilitate 12-Step Self-Help Group Involvement

Alcohol Research & Health, Spring, 1999 by Keith Humphreys

Facilitating patients' involvement with 12-step self-help organizations, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), is often a goal of substance abuse treatment. Twelve-step-facilitation (TSF) interventions have been found to be more effective than comparison treatments in increasing patients' 12-step group involvement and in promoting abstinence. Future TSF evaluation research should address the effectiveness of incorporating TSF interventions with cognitive-behavioral treatment methods, the relative impact of brief versus extended TSF interventions, and the cost-effectiveness and health care cost-offset of TSF interventions within managed health care systems. KEY WORDS: twelve step program; intervention; treatment outcome; cognitive therapy; behavior therapy; cost effectiveness; managed care; AODD (alcohol and other drug dependence) recovery; treatment program; evaluation; motivational interviewing; AOD (alcohol and other drug) abstinence; comparative study; literature review

Although the United States has developed an extensive array of professional alcohol treatment services over the past 30 years, the peer-led, voluntary fellowship known as Alcoholics Anonymous (AA) continues to be the most widely accessed resource for people with alcohol problems (McCrady and Miller 1993). This article discusses the rationale for interventions that facilitate alcohol-dependent patients' affiliations with AA and related mutual-help organizations (e.g., Narcotics Anonymous [NA]). The article also reviews recent research comparing those interventions with other treatment methods.

IMPORTANCE OF 12-STEP GROUP AFFILIATION IN ALCOHOL TREATMENT

The rationale for facilitating patients' involvement in 12-step self-help groups stems primarily from recent AA outcome research and from developments in the management and organization of health care in the United States. From the 1940s through the 1980s, most studies on AA did not directly evaluate AA's effectiveness. Rather, researchers examined AA's organizational structure and functioning; its history; and the ways in which AA participation changed members' values, sense of identity, and spiritual outlook (see Kurtz 1993 for a review). The few AA outcome studies that were conducted typically did not study AA members over time or include non-PA members for comparison purposes, making conclusions about AA's effectiveness tenuous. Given this limited empirical base, many clinicians and researchers doubted whether AA truly helped its members recover from alcohol dependence.

In the 1990s, the breadth and depth of AA research increased significantly, as evidenced by a National Institute on Alcohol Abuse and Alcoholism (NIAAA)-sponsored conference on PA (McCrady and Miller 1993), the International Collaborative Study of AA (Makela et al. 1996), and other projects. Recent AA outcome research, which has demonstrated the benefits of treatments intended to facilitate AA involvement, as well as of AA involvement per se, has typically employed longitudinal designs (i.e., studied AA members over time), reliable measures, comparison groups and, in some cases, random assignment to conditions. The improved methodological quality of AA research has reduced skepticism in the treatment community about AA's effectiveness and has increased clinicians' interest in facilitating connections between substance abuse treatment and 12-step self-help groups.

The other major factor that has enhanced interest in 12-step facilitation (TSF) interventions is the growth of managed health care. In both the public and private sectors, managed care has reduced the length and intensity of professional addiction treatment services (Humphreys et al. 1997) and increased the pressure for cost-effective care. Because managed care has reduced the amount of time available for practitioners to work with patients, clinicians are increasingly interested in facilitating patient involvement in self-help groups as an inexpensive way to achieve and maintain treatment gains. Three recent studies (Tonigan et al. in press; Humphreys et al. 1999; McCrady et al. in press) have evaluated the effectiveness of such efforts.

RECENT EVALUATIONS OF TSF INTERVENTIONS

One large study, known as Project MATCH, compared a TSF intervention with cognitive-behavioral (CB) therapy and motivational enhancement therapy (MET) among 1,726 patients (76 percent male) diagnosed with either alcohol abuse or dependence, including 774 inpatients who were beginning outpatient aftercare and 952 patients receiving outpatient care as their primary treatment (Project MATCH Research Group 1997, 1998). GB therapy focuses on teaching coping skills to reduce alcohol use (i.e., patients who use alcohol to cope with stress learn and practice alternative coping methods). In contrast, MET employs motivational strategies to mobilize patients' internal resources for change.

The TSF intervention in the Project MATCH study was a form of one-on-one professional counseling explicitly designed to work synergistically with AA and other 12-step groups (Nowinski et al. 1992). Consistent with AA's philosophy, TSF therapists presented alcohol dependence as a disease with spiritual, emotional, and physical components and emphasized that the disease could be arrested but not cured through permanent abstinence from alcohol. Also consistent with AA's approach, patients were strongly urged, but neither ordered nor forced, to attend AA meetings and to maintain a journal describing their reactions to the meetings. The textbox above lists the major goals of the 12-session TSF intervention employed in Project MATCH.