Chapter 26. Twelve-Step FacilitationAn Adaptation for Psychiatric Practitioners and Patients

Richard K. Ries, M.D.; Marc Galanter, M.D.; J. Scott Tonigan, Ph.D.
DOI: 10.1176/appi.books.9781585623440.353395



The goal of this chapter is to help clinicians better engage and support patients who have co-occurring or primary alcohol or drug problems through use of 12-step programs to enhance treatment outcomes and recovery. Twelve-step facilitation (TSF) is an evidence-based practice with a large research base, a therapy manual (Nowinski et al. 1995), and a Web-based training site (Sholomskas and Carroll 2006). It is a valuable technique easily available to the practicing psychiatrist and other mental health professionals. The research base of TSF is reviewed in other chapters of this book. This chapter is a condensed presentation of some of the key techniques and concepts of TSF, with some special adaptations for psychiatric practice. An important concept to recognize at the outset is that TSF is a therapist's technique to help patients engage in and maximize their response to 12-step meetings, such as Alcoholics Anonymous (AA). (TSF is not AA, nor is it, as far as we know, officially endorsed by AA or other 12-step programs.) TSF can also be applied to treat individuals who are dependent on substances other than alcohol, such as narcotics. Such individuals can be encouraged to go to Narcotics Anonymous (NA) meetings, where the 12 steps are applied as well.

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TABLE 26–1. The 12 Steps of Dual Recovery Anonymous
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TABLE 26–2. Engaging those with Alcoholics Anonymous (AA) resistance
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TABLE 26–3. Examples of working with patients
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Co-occurring and substance-induced disorders are common in psychiatric patients, and mental health practitioners can enhance outcomes from both disorders by applying 12-step facilitation (TSF).

TSF is not Alcoholics Anonymous (AA) nor is it endorsed by AA. It is an evidence-based therapy performed by the clinician to help a patient begin to attend and benefit from 12-step meetings, including AA.

Co-occurring disorders (COD) TSF is a practical enhancement of TSF that includes typical psychiatric issues and treatment but has not been separately tested.

Twelve-step approaches and meetings are ubiquitous, inexpensive, and evidence based and provide long-term, recovery-based help with patients with substance use disorders.

Twelve-step approaches to acceptance and denial for the chronic and often relapsing illness of addiction are appropriate for and benefit most psychiatric disorders.

The official policy of AA is supportive to seeing psychiatrists and taking psychiatric medications for mental disorders. However, a good deal of variability exists with many 12-step communities having COD 12-step meetings and others being neutral or even hostile toward the idea.

Developing COD TSF skills is an effective way for the mental health practitioner to stay productively involved with his or her COD patient, provides a good model of integrated care, and provides a great deal of low-cost but high-frequency psychosocial support to the patient.


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Sample questions:
Twelve-step facilitation (TSF), when integrated with usual therapy and medications for substance dependence, has several advantages. Which of the following is not one of these advantages?
The first of Dual Recovery Anonymous' (DRA) 12 steps is "we admitted we were powerless over our dual illness of chemical dependency and emotional or psychiatric illness—that our lives had become unmanageable." This means that persons with both psychiatric and addiction disorders are. . .
HALT is an Alcoholics Anonymous (AA) mnemonic and slogan that captures common emotional relapse states. Which of the following words is represented in the mnemonic?
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