Atlas›Domain V · Systemic, relational, group & community›Guide 114
Guide V-114

Twelve-step facilitation

Nowinski, Baker, Carroll1992USA
A 29 · L 60 · M 1124 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Project MATCH Twelve Step Facilitation Therapy Manual (Nowinski, Baker & Carroll; NIAAA Project MATCH Monograph Vol. 1, NIH Pub. No. 94-3722), 12-session individual format. Where it helps, I note the later Hazelden revised TSF programme (Nowinski & Baker, Twelve Step Facilitation Handbook, 2nd ed., with facilitator guides, workbooks and a TSF-COD version) and two related group or referral formats: MAAEZ (Kaskutas & Oberste 2002) and Timko's intensive referral, as used in NIDA CTN STAGE-12.

Twelve-step facilitation (TSF) is a brief, structured, manualised individual therapy, also adapted for groups. A clinician uses it to help a client with alcohol (and, in adaptations, other drug) use disorder accept the need for abstinence and get actively involved in Alcoholics Anonymous (AA) or another twelve-step fellowship, such as NA or CA. It rests on AA's view of addiction as a chronic, progressive illness with medical and spiritual dimensions, marked by loss of control. In this view willpower alone is not enough. Change is expected to come mainly from the fellowship, not from the therapist. The therapist is a "facilitator": an advocate, guide and educator who moves the client through two goals. The first is acceptance (Step 1: loss of control, abstinence as the only viable option). The second is surrender (Steps 2–3: hope through trusting something beyond the self, and seeing the fellowship as the best route), together with getting active in the fellowship (meetings, phone list, sponsor, service). TSF is grounded in AA principles, but AA has no official relationship with it and does not endorse it. [source: TSF manual; Nowinski TSF chapter; Hazelden TSF scope and sequence]

Scope note (Domain V): the fellowships themselves are peer-run mutual aid, not something the therapist runs. TSF is the clinician's work of preparing, linking and supporting the client's participation. The therapist does not run meetings, does not take clients to meetings and does not sponsor. [source: TSF manual; Nowinski chapter]

Licensing and qualifications. The Project MATCH manual is a US government publication. No licence or certification requirement for delivering "TSF" by name is stated in the sources. [uncertain: no certifying body found] Qualifications in the source protocols:

  • Project MATCH / Nowinski: at least a master's in a counselling field plus 1,000 supervised hours. Two complete supervised cases (8 or more sessions each) before working unsupervised. Ongoing audio or video supervision to limit drift. Supervisors need at least 2 years' supervisory experience plus personal TSF experience.
  • Recovery status: the facilitator need not be in recovery. They must know the AA literature they will give clients and attend open AA and Al-Anon meetings: at least 10 of each per the manual, at least 6 of each per the Nowinski chapter. Clinicians opposed to abstinence or fellowship involvement are advised not to use TSF.
  • Hazelden revised programme: facilitators read the handbook first. Fidelity is checked by supervisors or observers with per-session checklists. Co-facilitation with peer counselors is recommended. No formal certification is described.
  • MAAEZ: the leader should be a counselor who is currently active in AA, NA or CA and skilled at running groups.

The NIAAA manual is free from NIAAA. The Hazelden materials are commercial products. [source: TSF manual; Nowinski chapter; Hazelden scope and sequence; MAAEZ manual]

2. Framework

Project MATCH TSF: format. Individual outpatient therapy, 12 sessions over 12 consecutive weeks, with abstinence as the stated goal.

  • Clients in a stable relationship get 10 individual plus 2 conjoint sessions.
  • Up to 2 emergency sessions are allowed for genuine crises.
  • Session 1 lasts up to 1.5 hours; later sessions about 1 hour.
  • For drug (e.g. cocaine) clients, the Nowinski chapter describes twice-weekly sessions for the first 3 weeks, and 12–15 sessions in all.
  • Any session may be repeated to fill the schedule.

In MATCH, a breath test before each session meant rescheduling if positive, and sessions were videotaped for supervision. [source: TSF manual; Nowinski chapter]

Programme components (MATCH).

  • Core programme (all clients):
    1. Introduction and assessment
    2. Acceptance (Step 1)
    3. Surrender (Steps 2–3)
    4. Getting active
  • Elective topics: chosen per client, in MATCH with a supervisor: Genogram; Enabling; People, Places, and Things; HALT; Steps 4 and 5 (moral inventories); Sober Living.
  • Conjoint programme: Enabling, then Detaching.
  • Termination: a final session, required for all clients.

[source: TSF manual] Hazelden revised TSF keeps 4 core topics, 1 termination session and 2 conjoint sessions, but its 5 electives are: Genograms; Enabling; People, Places, and Routines; Emotions (incl. HALT); Spirituality. Moral inventories and Sober Living drop out as separate electives. TSF-COD adds a fifth core topic, "Getting Active in Mental Health Treatment", and its own electives. [source: Hazelden scope and sequence]

Session format, sessions 2–11 (MATCH).

  1. Review (10–15 min): journal; meetings attended and reactions; reading; urges; slips (what, where, with whom, what to do differently); sober days recognised.
  2. New material (~30 min): the week's core or elective topic, taught through questions and discussion, not lecture.
  3. Recovery tasks (~10 min): specific suggestions for meetings, reading and other actions.
  4. Summary (~5 min): check the client's understanding and willingness to follow through.

From session 2, clients arrive 5–10 minutes early so the therapist can read the journal. [source: TSF manual] The CT DMHAS training slides give a similar 50-minute version: greeting and journal (10 min), core work (30 min), closing and directives (10 min). [source: Anez CT DMHAS slides]

Phase goals and moving between phases. TSF is topic-sequenced, not phase-gated. The four core topics come in order, then electives, then termination.

  • Electives: the manual chooses them by client need and supervisor consultation, not by mastery criteria.
  • Repeating a topic: a topic may be repeated, and Surrender "may span multiple sessions" in the Hazelden version.
  • Signs a client is ready to move on [synthesis, derived from the stated objectives]:
    • Acceptance: the client can name concrete examples of loss of control and unmanageability, and states abstinence as their goal.
    • Surrender: the client is open to help beyond willpower, in whatever form of higher power or fellowship they accept, and is attending meetings.
    • Getting active: the client has a phone list, has made calls, attends regularly (ideally step and discussion meetings), and is identifying or approaching a sponsor.

The objectives are grouped as cognitive, emotional, behavioural, social and spiritual, and may change at different rates. [source: TSF manual; Hazelden scope and sequence]

Target "dose" of fellowship involvement.

  • Starting suggestion: one meeting a day ("90 meetings in 90 days"), negotiated down if needed.
  • Ries's slides give a floor of at least 3 meetings a week, the same meetings each week, plus knowing members, getting a sponsor and working the steps.
  • Hazelden's Getting Active topic asks for at least weekly meetings.

[source: TSF manual; Ries UW slides; Hazelden scope and sequence]

Group variants (for clinicians delivering them).

  • Hazelden group TSF: 6–8 participants, about 90-minute sessions, usually open groups, weekly or more often. [source: Hazelden scope and sequence]
  • MAAEZ: six weekly 90-minute groups with a mid-session break. Each session: check-in 15 min, topic about 55 min, summary 5 min, homework 5 min.
    • Week 1: the Introductory session ("What to expect out of AA").
    • Weeks 2–5: four rotating core sessions (Spirituality; Principles, Not Personalities; Sponsorship; Living Sober).
    • Week 6: the client returns to the Introductory session as a graduate "helper". [source: MAAEZ manual]
  • STAGE-12 (NIDA CTN-0031): 5 group sessions of about 90 minutes using the TSF core topics, plus 3 individual sessions of 45–75 minutes. The individual sessions use the TSF introductory and termination sessions combined with intensive referral. Delivered over up to 8 weeks inside treatment as usual. [source: STAGE-12 protocol]

3. Guiding principles

[source for all items: TSF manual; Nowinski chapter; Ries UW slides, as marked]

  • The fellowship is the agent of change. Your job is to get the client into AA/NA and make it usable. You are not the main source of support.
  • Illness, not character flaw ("no-fault"). The client is not to blame for having the illness but is responsible for recovery. Keep the problem located in the disease, not the person.
  • Abstinence is the goal. Never suggest controlled use or the safe use of other substances. Treat substitution as a symptom.
  • Suggestions, not assignments. Frame recovery tasks as AA does, as suggestions, while making them specific (which meeting, which pages, by when).
  • Interactionally active, not lecturing. Be conversational, forthcoming and supportive. Give feedback and your views. Talk time should be roughly equal; never do most of the talking.
  • Confrontation as honest mirroring. Reflect the client's own facts back frankly and respectfully, especially around denial. Never be harsh, patronising or punitive.
  • Ally with the "recovering" side. Treat denial as a normal grief response to accepting a limitation. Side with the part of the client that wants recovery, and gently confront the part that bargains.
  • Resistance is expected and not punished. A complete lack of resistance is a warning sign of mere compliance. Pressure and threats produce compliance, not commitment. [source: Nowinski chapter; TSF manual]
  • Don't debate or defend AA, and don't argue about God. Explore the client's beliefs and frame a higher power broadly (the group, recovery itself, the wisdom of long-sober members). Ask what it means to them. [source: TSF manual; Ries UW slides]
  • Stay on focus. Keep sessions on sobriety and fellowship involvement. Defer marital, job, parenting or psychodynamic work, with a referral later if needed. MATCH capped other mental-health contact at 6 hours over the 12 weeks. Nowinski generally defers other therapies until about 6 months of sobriety, except for severe depression, major affective disorder or psychosis.
  • Do not become the support system. Don't take clients to meetings, don't sponsor, and don't take calls outside sessions for urges or slips. Teach the client to use AA resources (meetings, phone list, hotline, sponsor) in crises.
  • Never terminate a client for refusing meetings. Explore the refusal instead; the manual's wording is "Never terminate a patient for refusing to go to meetings."
  • Use slogans judiciously. Use them only when tied to the client's own experience: "One Day at a Time", "First Things First", "Easy Does It", "Turn It Over", "People, Places, and Things".
  • Know the territory. Read the Big Book, Twelve Steps and Twelve Traditions and Living Sober. Attend open meetings yourself. Build a network of active members you can link clients to.
  • Match meetings to the person. Take account of gender, age, sexual orientation, social background, location and time, smoking, and focus (AA, NA, dual-diagnosis, Double Trouble). [source: Ries UW slides]
  • Don't mix TSF with other approaches inside the protocol. In MATCH this was a fidelity requirement. In routine practice, Ries describes using motivational, CBT and disease-model framings to address meeting avoidance. [source: TSF manual; Ries UW slides] [uncertain: how strictly to keep "purity" outside research is a clinical judgement]

4. Intervention inventory

The order follows the MATCH manual: core topics, then the recurring in-session tools, then electives, termination, the conjoint programme and emergency sessions. Related formats (intensive referral, MAAEZ, TSF-COD) come last. All example language is my own illustrative wording unless it is quoted and cited.

4.1 Core Topic 1: Programme introduction and assessment (session 1)

  • Purpose: build rapport, take a broad-strokes use history, reach a shared diagnosis from the client's own report, explain TSF, and secure a commitment to try TSF and AA/NA with an open mind. [source: TSF manual; Nowinski chapter]
  • Steps:
    1. Welcome the client. Review prior treatment and any AA/NA experience. Using Ries's checklist, ask:
      • When and how often they attended, recently and in the past.
      • Whether they tried 90 in 90, or had one regular meeting.
      • Whether they got a sponsor, and if not, what stopped them.
      • Which steps they worked, whether they did service, and how "plugged in" they felt.
      • If they were highly involved before, what broke the link. [source: Ries UW slides]
    2. Take the drinking history in roughly 5-year blocks. Screen other drug use. [source: TSF manual]
    3. Inventory negative consequences across these domains: physical, legal, social, sexual, psychological and financial. Ask about tolerance and loss of control (drinking more or longer than intended, failed attempts to stop or cut down). [source: TSF manual]
    4. Share a diagnosis based on what the client has told you. The manual's appendix offers progression charts (Jellinek) as an optional visual aid. [source: TSF manual] Describe these charts; don't reproduce them.
    5. Explore compulsion through the Big Book's jay-walker story (p. 37), a man who keeps running into traffic despite injuries. Ask whether the client sees parallels. [source: TSF manual]
    6. Present the no-fault illness model: not to blame for having it, responsible for recovery.
    7. Explain the programme and both parties' responsibilities. Introduce the journal (4.6) and the first readings. Give the first meeting suggestions. [source: TSF manual]
  • Example language (illustrative): "Looking at what you've told me (the blackouts, the promise to stop at two that didn't hold, the licence), what do you make of it?" "Nobody chooses this illness. What you can choose is what you do about it from here."
  • Watch for: argument about labels. Base the diagnosis on the client's own data, not your assertion. Also watch for minimising answers in the history; mirror them back in Topic 2 rather than fighting them now. It is working when the client links consequences to drinking in their own words and agrees to a first meeting and reading. [synthesis]

4.2 Core Topic 2: Acceptance (Step 1)

  • Purpose: help the client accept loss of control (powerlessness) over alcohol or drugs, see that life has become unmanageable, and conclude that abstinence is the only viable option. [source: TSF manual]
  • Steps:
    1. Run the usual review (journal, meetings, slips, urges).
    2. Read Step 1 together. Introduce powerlessness and unmanageability.
    3. Present acceptance as three stages, and ask the client where they are:
      • (a) recognising there is a problem;
      • (b) seeing that drinking makes life harder;
      • (c) concluding that abstinence is the only option.
    4. Frame acceptance as grieving a limitation, like accepting any personal limit. "Bargaining" here is the belief that one can still drink safely.
    5. Teach the forms of denial and ask the client to find examples from their own life: refusing to face facts, minimising, avoiding, exaggerating others' use, blaming others, bargaining and rationalising.
    6. Introduce "stinking thinking" and AA's sense of "insanity": drinking again despite experience.
    7. Recovery tasks:
      • Meetings.
      • A journal entry on how drinking made life unmanageable.
      • Reading: 12 & 12 pp. 21–24; Big Book "The Doctor's Opinion", "Bill's Story" and "More About Alcoholism"; Living Sober pp. 7–10. [source: TSF manual]
  • Clarify limits of powerlessness: the client is powerless over alcohol, not over recovery actions such as going to meetings, avoiding bars, taking medication or keeping appointments. [source: Ries UW slides]
  • Example language (illustrative): "Which of these sounds most like you: 'I can handle it if I stick to beer,' or 'Everyone at work drinks more than me'?" "You've tried this your way several times. What does that tell you?"
  • Watch for: shame ("I'm weak"). Return to the illness frame. Watch also for intellectual agreement without emotion; ask how it feels to accept the limit. It is working when the client gives their own examples of denial and states abstinence as their goal, rather than "cutting down". [synthesis]

4.3 Working with denial: honest mirroring and the two "personalities"

  • Purpose: respond to minimising, slips and meeting resistance without a power struggle. [source: TSF manual]
  • Steps:
    1. Name the behaviour neutrally and set it beside the client's own facts (honest mirroring). The manual describes confrontation as helping clients see their behaviour "in perspective".
    2. Interpret it nonjudgmentally, using one of the manual's three frames:
      • a normal grief response;
      • the "insanity" of Step 2;
      • the voice of the "alcoholic personality" competing with the "recovering personality".
    3. Explicitly ally with the recovering side.
    4. Do not try to "break" denial. Nowinski says the facilitator should not try to, since responsibility stays with the client. [source: Nowinski chapter]
  • Example language (illustrative): "Part of you came here today wanting this to be different. Another part is saying Friday was no big deal. I'm on the side of the first part. What would it say about Friday?"
  • Watch for: sarcasm or a parental tone in yourself, and any implication of a character flaw (both proscribed). It is working when the client starts catching their own rationalisations ("I know, that's the bargaining"). [source: TSF manual; synthesis]

4.4 Core Topic 3: Surrender (Steps 2 and 3)

  • Purpose: move from accepting loss of control to hope. The client becomes open to help from a power greater than themselves (however they define it) and comes to see the fellowship as their best route. [source: TSF manual]
  • Steps:
    1. Review, including recognition of sober days. Don't overemphasise day-counting.
    2. Step 2. Explore the client's beliefs, values, religious history and openness to help. Define AA's "insanity" as repeating harmful behaviour despite clear evidence. Examine defiance and arrogance as forms of denial.
    3. Step 3. Present turning one's will over as opening a locked door out of denial. Explore trust, the "cult of self-reliance", and the AA alternative of interdependence.
    4. Don't argue about God. Offer broad higher-power options and ask what fits:
      • the group;
      • recovery itself;
      • the wisdom of long-sober members. [source: Ries UW slides]
    5. Recovery tasks:
      • Try varied meetings, including step and discussion meetings.
      • Reading: Big Book "Bill's Story", "There Is a Solution" and "We Agnostics"; 12 & 12 pp. 25–41; Living Sober pp. 77–87. [source: TSF manual]
    6. In Hazelden's version: define surrender, name a higher power, and begin believing it can help restore them. The topic may span several sessions. [source: Hazelden scope and sequence]
  • Example language (illustrative): "When you've been at your worst, who or what got you through, even for a day?" "Some people start with 'the group is wiser than me alone.' Could that be a starting point for you?"
  • Watch for: atheist or agnostic clients feeling coerced. Point them to "We Agnostics" and the group-as-higher-power option; MAAEZ also reframes this (see 4.20). Watch for religious trauma: explore it, don't push. It is working when the client can say what they are willing to rely on besides willpower, and keeps attending. [source: TSF manual; MAAEZ manual; synthesis]

4.5 Core Topic 4: Getting active

  • Purpose: turn attendance into involvement: phone contacts, sponsorship, service and the slogans as practical tools. [source: TSF manual]
  • Steps:
    1. Review sober days ("One Day At A Time"), urges and slips.
    2. Teach three slogans as practical guides:
      • "People, Places, and Things": avoid slippery situations.
      • "Easy Does It": don't take on too much.
      • "First Things First": sobriety comes first.
    3. Explain why effort matters. Active involvement (helping at meetings, connecting with members) supports recovery, especially at times of anger, loneliness or fatigue.
    4. Telephone therapy. The client calls members when facing urges, slips, loneliness, anger, tiredness, overwhelm or complacency. Explore hesitations ("I'd be bothering them"). Role-play a first call in session.
    5. Sponsorship. Explain the sponsor's role: a source of practical advice, not a therapist or parent. Manual ground rules: same sex, same age or older, at least a year sober, actively working the programme. Teach how to ask at meetings.
    6. Recovery tasks:
      • Collect three names and numbers, at least two from same-sex members.
      • Call one person this week.
      • Name three qualities they want in a sponsor.
      • Reading: Living Sober pp. 13–18 and 24–30; continue the Big Book. [source: TSF manual]
    7. Hazelden version: the client names abstinence as the goal, learns slip-avoidance and slip evaluation, commits to at least weekly meetings, lists three people for immediate help, and begins working with a sponsor. [source: Hazelden scope and sequence]
  • Example language (illustrative), role-play: "I'll be the AA member. You call me after Thursday's meeting. Just say who you are and that you're new. Go." Afterwards: "What was hardest about that?"
  • Watch for: names collected but never called. Ask what stopped the call and rehearse it again. It is working when calls happen before or after a craving, not only as homework. [synthesis]

4.6 Recovery journal

  • Purpose: gives each session's review its raw material and builds self-monitoring. [source: TSF manual]
  • Steps:
    1. In session 1, ask the client to keep a notebook.
    2. Each entry records:
      • meetings (date, time, place);
      • unedited reactions to meetings and readings;
      • slips and how the client responded;
      • reactions to recovery tasks;
      • urges and how they were handled.
    3. From session 2, the client arrives 5–10 minutes early so you can read it.
    4. Open each review from the entries. [source: TSF manual]
  • Example language (illustrative): "Write what you really thought of the meeting, including 'boring' or 'they're all hypocrites'. That's useful to us."
  • Watch for: blank or sanitised journals. Explore fear of judgement or literacy barriers, and allow a voice memo or checklist instead [synthesis]. Nowinski notes calendars often show patterns, such as sobriety holding for a day or two after each meeting. [source: Nowinski chapter]

4.7 Meeting suggestions, coaching and matching

  • Purpose: get the client to meetings that suit them, and move them from attending to belonging. [source: TSF manual; Ries UW slides]
  • Steps:
    1. Give a written local meeting schedule.
    2. Suggest specific meetings (name, day, time).
    3. Open with the 90-in-90 suggestion, then negotiate a realistic number.
    4. Coach the client on what to expect:
      • format, readings and first-name introductions;
      • no obligation to speak;
      • open vs closed meetings.
    5. Over time, steer the client toward step and discussion meetings.
    6. Match meetings to the client: gender, women's meetings, LGBTQ meetings, age, social background, smoking, location and time, NA vs AA, dual-diagnosis or Double Trouble meetings.
    7. Don't drive or accompany the client. [source: TSF manual; Ries UW slides]
  • Example language (illustrative): "Of these three, which could you actually get to on Tuesday? Good, write it down. What might stop you?"
  • Watch for: one bad meeting generalised to "AA doesn't work". Explain that a few scattered meetings are an inadequate trial, like an unfinished antibiotic course, and find a better-matched meeting. [source: Ries UW slides]

4.8 Bibliotherapy (reading suggestions)

  • Purpose: introduce the fellowship's ideas between sessions in its own literature. [source: TSF manual]
  • Steps:
    1. Suggest specific short passages from:
      • the Big Book (Alcoholics Anonymous);
      • Twelve Steps and Twelve Traditions;
      • Living Sober;
      • for NA clients, the NA equivalents (in MAAEZ, e.g. "Who Is an Addict").
    2. Fit the passage to the client's reading level and available time.
    3. Ask for written reactions in the journal and discuss them in review. [source: TSF manual; MAAEZ manual]
  • Example language (illustrative): "Just the five pages of 'More About Alcoholism' this week. Mark one line that annoyed you and one that rang true."
  • Watch for: reading as a chore. Shorten the passage rather than drop it. [synthesis]

4.9 Slip review

  • Purpose: turn lapses into learning without shaming, and keep the client engaged. [source: TSF manual; Nowinski chapter]
  • Steps:
    1. Ask nonjudgmentally what happened, where, and with whom.
    2. Frame the slip as the illness overpowering willpower.
    3. Identify fellowship-consistent responses for next time: call the hotline or a sponsor, go to a meeting, use the phone list.
    4. Never scold.
    5. If slips are frequent despite attendance, consider recommending more intensive or inpatient care. [source: TSF manual; Nowinski chapter]
  • Example language (illustrative): "Let's walk through Saturday like a replay. Where was the first moment you could have picked up the phone?"
  • Watch for: concealment of slips, the "abstinence violation" spiral, and substitution of another drug. Treat substitution as a symptom. [source: TSF manual; synthesis for the spiral point]

4.10 Slogans as cognitive tools

  • Purpose: give compact, portable coping rules drawn from fellowship culture.
  • Steps:
    1. Introduce one slogan at a time, linked to the client's own situation. Examples: "First Things First", "One Day at a Time", "Easy Does It", "Fake It Till You Make It", "Turn It Over".
    2. Ask how it would apply to this week's high-risk moment. [source: TSF manual]
  • Example language (illustrative): "You've got the debt, the court date and your sister angry at you. If 'First Things First' applied, what's first today?"
  • Watch for: slogans used as platitudes. Use them sparingly. [source: TSF manual]

4.11 Elective: Genogram

  • Purpose: reinforce acceptance and reduce shame by showing addiction as a family illness across generations, and help the client see they can break the pattern. [source: Nowinski chapter; Hazelden scope and sequence]
  • Steps:
    1. Draw a family tree of at least three generations, marking alcohol and drug problems and related consequences.
    2. Discuss the patterns, framing addiction as an illness that runs in families.
    3. Ask what the client wants to be different in their own branch. [source: Nowinski chapter; Hazelden scope and sequence; drawing conventions are synthesis]
  • Example language (illustrative): "Your grandfather, your uncle, your father. None of them chose it either. What would it mean for your kids if it stopped with you?"
  • Watch for: grief or anger about family members, and blame shifting ("it's genetic, so it's not up to me"). Return to the no-fault-but-responsible frame. [synthesis] [uncertain: content from Nowinski chapter and Hazelden]

4.12 Elective: Enabling

  • Purpose: identify the people and behaviours that have protected the client from consequences, and the client's part in recruiting them. [source: Hazelden scope and sequence]
  • Steps:
    1. Define enabling: others covering for, rescuing, excusing or supplying.
    2. The client completes a personal Enabling Inventory, listing who enabled and how. Hazelden links this to Steps 4, 8 and 10.
    3. Explore how the client encouraged enabling, for example through promises, guilt or anger.
    4. Discuss what changes when enablers stop. [source: Hazelden scope and sequence] Describe the Hazelden inventory; don't reproduce it.
  • Example language (illustrative): "Who has called in sick for you, lent you money, or told you it wasn't that bad? What did you do that made it easy for them?"
  • Watch for: the client feeling attacked, or using the list to blame others. Keep the focus on the client's own part. [synthesis] [uncertain: MATCH text for this elective]

4.13 Elective: People, places, and things (Hazelden: people, places, and routines)

  • Purpose: restructure daily life away from the people, settings and routines tied to use and toward fellowship-based alternatives. [source: Hazelden scope and sequence; TSF manual (slogan)]
  • Steps:
    1. The client inventories:
      • people they drank or used with;
      • places where they drank or used;
      • routines such as payday, after work or weekends;
      • healthier alternatives for each.
    2. Write a Recovery Lifestyle Contract listing specific changes: avoid X, replace the after-work bar with the 6 pm meeting, and so on.
    3. Review the contract in later sessions. [source: Hazelden scope and sequence; Anez CT DMHAS slides] MAAEZ adds two points:
    • Reduce time with slippery people rather than necessarily cutting them off.
    • Remove alcohol and paraphernalia from the home now. [source: MAAEZ manual]
  • Example language (illustrative): "Walk me through a typical Friday from 5 pm. Where's the first risk point? What will you do instead, and who will you be with?"
  • Watch for: contracts that are vague or impossible, such as a client who lives with a drinking partner. Prioritise and problem-solve. [synthesis]

4.14 Elective: HALT / Emotions

  • Purpose: recognise the emotional and physical states that trigger cravings, and manage them without substances, using the fellowship. [source: Hazelden scope and sequence; MAAEZ manual]
  • Steps:
    1. Teach HALT (Hungry, Angry, Lonely, Tired). Hazelden adds boredom and shame.
    2. The client identifies their most frequent HALT state in recent slips or urges.
    3. For each state, plan a fellowship-based response. MAAEZ's urge-coping list includes:
      • calling a member or going to a meeting;
      • time with sober people or sharing a meal;
      • reading literature;
      • a walk, a quiet task or a nap. [source: Hazelden scope and sequence; MAAEZ manual]
  • Example language (illustrative): "Looking at your last three urges, two were late at night after a long shift. Tired and lonely. What's your plan for 11 pm Thursday?"
  • Watch for: intense anger, shame or depression beyond what HALT handles. Assess, and refer if severe (see section 5). [source: TSF manual on depression; synthesis] [uncertain: MATCH HALT elective text]

4.15 Elective: Steps 4 and 5, moral inventories (MATCH only)

  • Purpose: the MATCH manual lists an elective on Steps 4 and 5. Nowinski calls moral inventories an advanced concept, introduced only if time permits. [source: TSF manual (title only); Nowinski chapter]
  • Steps: [uncertain: the MATCH session content for this elective]. What can be said from the sources:
    • Step 4 is a personal moral inventory and Step 5 is admitting it to oneself, a higher power and another person. [source: Anez CT DMHAS slides]
    • In fellowship practice these steps are worked with a sponsor. [synthesis] Safe clinician role [synthesis]:
    1. Explain what the steps involve.
    2. Explore the client's fears, such as shame or legal disclosures.
    3. Encourage the client to do the inventory with their sponsor, not as therapy homework.
    4. Discuss limits of confidentiality before any disclosure of crimes in session.
  • Watch for: premature inventory in very early sobriety, or with high shame or trauma, can increase relapse risk. Pace it. [synthesis]

4.16 Elective: Sober living (MATCH) / Spirituality (Hazelden)

  • Purpose:
    • MATCH "Sober Living": building a life in sobriety. [uncertain: MATCH content; only the title known]
    • Hazelden "Spirituality": spiritual values in recovery (honesty, community, altruism, prayer and meditation), the difference between spirituality and religion, and daily spiritual practices. [source: Hazelden scope and sequence]
    • MAAEZ "Living Sober" covers sober networks, service and sober fun (see 4.20).
  • Steps (Hazelden):
    1. Distinguish spirituality from religion.
    2. Ask the client which values matter to them now.
    3. Choose one small daily practice, such as a morning moment of reflection, reading or a gratitude note.
    4. Review it next session. [source: Hazelden scope and sequence; specific practice examples are synthesis]
  • Example language (illustrative): "Spirituality here doesn't have to mean church. What's one thing bigger than you that you could connect to each day?"
  • Watch for: boredom and loneliness in early sobriety. Help plan sober social activities. [source: MAAEZ manual]

4.17 Termination session

  • Purpose: help the client critically assess progress, consolidate fellowship involvement and set ongoing recovery goals. [source: Nowinski chapter; Hazelden scope and sequence]
  • Steps:
    1. Review the course of treatment, including the disease model and understanding of denial.
    2. Review concrete progress: meetings attended, home group, phone list, sponsorship status and steps worked.
    3. Discuss openly what was helpful and what was difficult.
    4. Identify positive changes and set future recovery goals.
    5. Hazelden gives a medallion in the final session. [source: Anez CT DMHAS slides; Hazelden scope and sequence] The manual says termination follows a different process from other sessions. [uncertain: MATCH termination text]
  • Example language (illustrative): "Twelve weeks ago you weren't sure about one meeting. Where are you now, and what keeps you going after today?"
  • Watch for: a client who is relying on you rather than the fellowship. Ending is a test of that transfer. Make sure a named sponsor, a home group or a continuing-care plan is in place. [synthesis]

4.18 Conjoint programme: Enabling and Detaching (2 sessions with partner or significant other)

  • Purpose:
    • educate the partner about alcoholism and the fellowship model;
    • introduce enabling and caring detachment;
    • assess the partner's own use and refer if needed;
    • encourage the partner to use Al-Anon. MATCH aims for a commitment to six Al-Anon meetings of the partner's choice. [source: TSF manual; Nowinski chapter]
  • Steps, Session 1 (Enabling):
    1. Give an overview of TSF and its goals.
    2. Define enabling.
    3. Complete a joint Enabling Inventory (Hazelden).
    4. Explore motives for enabling (love, fear, avoiding conflict) and the client's role in inviting it. [source: Hazelden scope and sequence]
  • Steps, Session 2 (Detaching / "Caring Detachment"):
    1. Define caring detachment and distinguish it from enabling. It is not rejection; it lets the loved one carry responsibility.
    2. Practise with real situations from the couple's life.
    3. Introduce Al-Anon or Nar-Anon. For co-occurring cases, Hazelden adds Double Trouble in Recovery. [source: Hazelden scope and sequence]
  • Boundaries: validate the partner's concerns but defer intensive couples or family therapy. If the partner calls in crisis, support them and refer to Al-Anon. [source: Nowinski chapter]
  • Example language (illustrative): "Detaching doesn't mean you stop caring. It means you stop catching him every time he falls, so he can feel the floor."
  • Watch for: domestic violence or coercive control. Screen separately before any conjoint work, and don't run it if there is a safety risk. [synthesis] Also watch for a partner who uses the sessions to prosecute grievances; redirect to enabling and detaching and to Al-Anon. [synthesis]

4.19 Emergency sessions

  • Purpose: handle a genuine crisis (up to 2 in MATCH) without derailing the protocol. [source: TSF manual]
  • Steps:
    1. Assess the threat to sobriety.
    2. Set priorities ("First Things First").
    3. Solve the problem through fellowship resources (meetings, sponsor, hotline, phone list).
    4. For psychiatric emergencies (suicidality, psychosis, violence), suspend TSF and refer or manage per standard care. [source: TSF manual; Nowinski chapter]
  • Example language (illustrative): "Right now, what's the single thing that most threatens your sobriety tonight? Who in your phone list can you call before you leave here?"

4.20 MAAEZ group sessions (Making AA Easier)

  • Purpose: a six-week group to soften newcomers' resistance, correct myths about AA, and prepare clients for the group process of AA, NA or CA. It is not a Big Book curriculum; that is left to the fellowship. [source: MAAEZ manual]
  • Steps (90 min each; check-in, topic, summary, homework):
    1. Introductory, "What to expect out of AA":
      • Set group rules and do round-robin introductions.
      • Graduates share their experiences.
      • Discuss why to go, citing research quotes.
      • Note NA and CA terminology differences.
      • Teach how to choose a meeting from the directory codes (open or closed, women-only, beginners, Big Book or Step study).
      • Cover the "rules of the road": don't dominate, no crosstalk, listen at first, first names only, donations optional, avoid romance in the first year.
      • Homework: attend a meeting within 7 days (pairs allowed, same gender), write about it, read "The Doctor's Opinion" or NA's "Who Is an Addict".
    2. Spirituality:
      • Spiritual vs religious.
      • A self-defined higher power, including the fellowship as "Good Orderly Direction".
      • HOW (Honesty, Open-mindedness, Willingness).
      • Spirituality as behaviour: daily responsibility, the Serenity Prayer, "act as if" experiments, service.
      • Homework: talk to someone with more sobriety after a meeting.
    3. Principles, Not Personalities:
      • Elicit objections to AA.
      • Discuss cult vs culture: abstinence is the only rigid requirement, the rest is suggested; "take what you need and leave the rest".
      • Decode rituals and slogans. Address feeling like an outsider.
      • Disease vs moral failing (believing in the disease model is not required).
      • Diversity of meetings and members' views, including on psychiatric medication.
      • Reasons for 90 in 90.
      • Homework: get a member's number and actually speak to them.
    4. Sponsorship:
      • What a sponsor is; temporary sponsors.
      • How to choose one: has what you want, sober a while, has worked the steps, makes you comfortable, same gender.
      • Asking is not imposing, because sponsoring is the sponsor's Twelfth-Step service.
      • A 25-minute role-play of four scenarios: after coffee, after phone calls, asking a speaker, handling a "too busy" refusal.
      • Small steps; a personal plan.
      • Homework: ask for a temporary sponsor.
    5. Living Sober:
      • HALT; slippery people, places and things.
      • Building a sober network; small service commitments.
      • An urge-coping list; sober fun; doing things sober for the first time.
      • Homework: a social activity with a sober member, reading Living Sober.
    6. Week 6: the graduate returns to the Introductory session as a helper and passes on their books. [source: MAAEZ manual]
  • Facilitator rules:
    • Cover every outline point, in order, paraphrased rather than read aloud.
    • Self-disclose no more than once or twice a session.
    • Allow cross-talk, keep shares to 3–5 minutes, and involve everyone.
    • Be supportive, not confrontational. Speak privately with reluctant members after group. [source: MAAEZ manual]
  • Example language (illustrative), sponsorship role-play debrief: "When she said she was too busy, what did you tell yourself? Was that about you, or about her week?"
  • Watch for: a counselor who is not in recovery. The manual treats personal fellowship experience as essential, so adapt cautiously or co-lead with a peer. [source: MAAEZ manual; synthesis]

4.21 Intensive referral (Timko)

  • Purpose: a brief, active linkage procedure: connect the client in person with a fellowship member, rather than only handing over a meeting list. [source: STAGE-12 protocol; BU summary of Timko et al. 2006]
  • Steps (three sessions, as described in STAGE-12):
    1. Session 1:
      • Give local meeting information and a pamphlet on twelve-step philosophy.
      • The client sets goals: attending meetings, working the first steps, joining a home group, getting a sponsor.
      • During the session, phone a fellowship volunteer to arrange for them to meet the client and go to a meeting together.
      • The client keeps a journal of meetings and reactions.
    2. Session 2: if the client attended, review the journal and reactions and give a list of potential sponsors. If not, focus on barriers. Either way, arrange another volunteer contact.
    3. Session 3: check attendance and whether a temporary sponsor has been arranged. If not, phone a volunteer again. [source: STAGE-12 protocol] Standard referral, for comparison, was a meeting schedule plus encouragement only. [source: BU summary]
  • Prerequisite: a local pool of fellowship volunteers willing to take calls. Local AA intergroup or hospital and institution committees are a likely route. [synthesis]
  • Example language (illustrative): "I know someone from the Tuesday group who meets newcomers. Shall we call her now, together, and set a time?"
  • Watch for: consent to share the client's name and number. Get it explicitly before the call. [synthesis]

4.22 STAGE-12 combined format

  • Purpose: a group plus individual TSF for stimulant and other drug users, delivered inside routine community treatment. [source: STAGE-12 protocol]
  • Steps:
    1. Run 5 group sessions (~90 min) on the TSF core themes: acceptance, surrender (Steps 1–3), lifestyle change, and getting active. These are based on Baker's drug-abuse adaptation of the MATCH manual, adapted for groups by Brown et al.
    2. Interleave 3 individual sessions (45–75 min): the TSF introduction and termination contents plus intensive referral (4.21). The volunteer takes the client to a meeting and can act as a temporary sponsor.
    3. Complete within 8 weeks. [source: STAGE-12 protocol] [uncertain: per-session group topic order]

4.23 Rehearsed self-introduction for socially anxious clients

  • Purpose: remove a common barrier to attendance and sharing. [source: Ries UW slides]
  • Steps:
    1. Help the client script a one-line introduction in their own words.
    2. Write it on a card.
    3. Have the client visualise walking in and saying it.
    4. Rehearse it aloud in session and between sessions.
    5. Where needed, build a symptom-management plan. Remind the client that meetings are relatively safe places to have symptoms. [source: Ries UW slides] Medication for social anxiety is a prescriber's decision. Ries's slides mention options and caution against benzodiazepines; no dosing is given here.
  • Example language (illustrative): "You don't have to share. Just your first name and 'I'm new.' Let's say it three times right now."

4.24 TSF-COD: Getting active in mental health treatment

  • Purpose: for clients with co-occurring mental disorders, extend acceptance and getting active to psychiatric treatment as well as to the fellowship. [source: Hazelden scope and sequence]
  • Steps:
    1. In assessment, cover mental health diagnoses.
    2. In acceptance, address powerlessness over the mental disorder too. Ries frames this as powerless over the illness but not over taking part in treatment.
    3. In Core Topic 5, review:
      • treatment options;
      • taking medication as prescribed;
      • keeping appointments with prescribers and case managers;
      • attending specialised peer meetings (e.g. Double Trouble).
    4. Electives address barriers to fellowship and to mental-health treatment, the dangers of self-medicating, and "Living for Recovery" (diet, activity, hobbies, spirituality). [source: Hazelden scope and sequence; Ries UW slides]
  • Example language (illustrative): "You didn't choose bipolar disorder any more than the drinking. What's in your power is the meds, the appointments and the meetings."
  • Watch for: members advising the client to stop psychiatric medication. MAAEZ notes that members' views on medication vary and no one speaks for AA, so prepare the client for this. [source: MAAEZ manual]

5. Handling problems

Tags show what comes from the sources and what is my own synthesis.

  • Client refuses or avoids meetings.
    • Never terminate for this. [source: TSF manual]
    • Explore the reason and listen for denial, fear of failure or shyness.
    • Use three lenses [source: Ries UW slides]:
      • Motivational: "What might you have gained by going? What was the downside?"
      • Cognitive: examine the self-talk that talked them out of it, then plan the route there.
      • Disease model: was the barrier you, or the illness? Who could you have called?
    • Negotiate a smaller first step, such as one specific meeting or arriving early to help set up.
    • Try intensive referral (4.21).
  • "I tried AA, it doesn't work."
    • Take a dose history: how many meetings, how regular, sponsor or not. Scattered attendance is an inadequate trial. [source: Ries UW slides]
    • Explore the bad experience and the client's part in it, then match meetings better. [source: Ries UW slides]
  • The God problem (atheist, agnostic or religiously hurt clients).
    • Don't argue or defend AA. Ask what "a power greater than yourself" could mean to them: the group, recovery, long-sober members. [source: TSF manual; Ries UW slides]
    • Point to "We Agnostics". Use MAAEZ's spiritual-not-religious framing. [source: TSF manual; MAAEZ manual]
    • If the client still rejects it, accept partial uptake. Nowinski allows clients to accept or reject parts of the philosophy. [source: Nowinski chapter]
    • Consider secular mutual-help groups as an addition. [synthesis]
  • "AA is a cult" / put off by rituals or a dogmatic member.
    • Use MAAEZ's principles-not-personalities content:
      • abstinence is the only rigid requirement, the rest is suggestion;
      • no one speaks for AA;
      • try other meetings. [source: MAAEZ manual]
  • Compliance without commitment (agreeable but nothing changes).
    • A lack of resistance is a warning sign. [source: Nowinski chapter]
    • Check the journal against claims.
    • Ask for unedited reactions.
    • Reduce pressure: pressure produces compliance. [source: TSF manual]
  • Stuck in bargaining (wants to cut down, not stop).
    • Review consequences and past control attempts again, using the grief and bargaining frame. [source: TSF manual]
    • If the client firmly wants a moderation goal, TSF's abstinence aim is a poor fit. Say so openly and consider a different evidence-based approach rather than pretending agreement. [synthesis]
  • Repeated slips.
    • Run a nonjudgmental slip review each time (4.9).
    • If slips are frequent despite attendance, recommend more intensive or inpatient care. [source: Nowinski chapter]
    • Check for substitution of another substance and treat it as a symptom. [source: TSF manual]
  • Client arrives intoxicated.
    • Do not hold the session.
    • Help the client contact the AA hotline, a sober friend or sponsor, or a significant other to get them home safely. Use local services or police only as a last resort.
    • Reschedule. [source: TSF manual; Nowinski chapter]
    • Assess withdrawal or overdose risk and arrange medical care if needed. [synthesis, standard care]
  • Missed or late sessions.
    • Explore the reason as possible denial, fear of failure or shyness.
    • If the pattern persists, discuss motivation directly. [source: TSF manual]
    • Agree a contact plan in session 1 for no-shows. [synthesis]
  • Requests for out-of-session support, or for you to sponsor them or take them to a meeting.
    • Decline warmly and redirect to the phone list, sponsor, hotline and meetings. This is the point of TSF. [source: TSF manual; Nowinski chapter]
    • Make clear in advance how emergencies (risk to life) are handled in your service. [synthesis]
  • Drift into other problems (marriage, job, past trauma).
    • Acknowledge the problem.
    • Tie it back to sobriety ("First Things First").
    • Offer a referral later. Nowinski generally defers other therapies until about 6 months sober, except severe depression, major affective disorder or psychosis. [source: TSF manual; Nowinski chapter]
  • Depression, suicidality, psychosis.
    • Mild low mood can reflect withdrawal or the grief of acceptance.
    • Severe depression or other psychopathology warrants referral.
    • Suicidality, psychosis or violence suspend TSF: hold an emergency session or refer. [source: TSF manual; Nowinski chapter]
    • Use your standard structured risk assessment and safety plan. Include lethal-means counselling (secure storage or removal) and note that intoxication raises risk. [synthesis, standard care]
  • Overwhelm (too many demands at once).
    • Apply "Easy Does It" and "First Things First". [source: TSF manual]
    • Cut recovery tasks to one meeting and one call, and build up from there. [synthesis]
  • Rupture (client feels judged, lectured or pushed).
    • Check whether you have been doing most of the talking or confronting harshly; both are proscribed. [source: TSF manual]
    • Name it, apologise for your part, ask for feedback on the tasks (as Nowinski advises), and return to collaborative suggestions. [synthesis; Nowinski chapter for soliciting feedback]
  • Bad or unsafe fellowship experiences. These include unwanted sexual advances, exploitative sponsors and relapse with a meeting contact.
    • Explore what happened and match meetings better. [source: Ries UW slides]
    • Prepare newcomers in advance: same-gender sponsors and no romance in the first year are fellowship norms; sponsors can be changed; women's and LGBTQ meetings exist. [source: MAAEZ manual; TSF manual]
    • Safety-plan, and support reporting if there is abuse. [synthesis]
  • Medication for opioid use disorder or psychiatric medication.
    • Warn the client that some members may disapprove. MAAEZ notes members differ on psychiatric medication and no one speaks for AA. [source: MAAEZ manual]
    • Hazelden publishes material on integrating the Steps with MAT. [source: Anez CT DMHAS slides, title only]
    • Help the client choose meetings that are welcoming to people on medication, and reinforce that prescribed treatment is not "using". [synthesis]
  • Mandated clients.
    • Coercion can yield attendance without engagement. Separate your role from any attendance-verification duty where possible, and explore the client's own reasons for change. [synthesis]
  • Conjoint work complications (partner hostile, using, or in an abusive relationship).
    • Assess the partner's own use and refer if needed. [source: Nowinski chapter]
    • Screen for intimate partner violence individually before conjoint sessions, and skip conjoint work if unsafe. [synthesis]
  • Severe cocaine or opioid addiction without social support.
    • Nowinski describes these clients as poorly suited to standard TSF. [source: Nowinski chapter]
    • Consider adding intensive referral, a higher level of care, MOUD and case management. [synthesis]
  • Dissatisfied client who wants to leave TSF.
    • In MATCH, such clients were referred to an outside agency or an uninvolved clinician. In practice, discuss alternatives and refer without penalty. [source: TSF manual; synthesis]

Sources

Sources

Further reading (not drawn on)

  • Nowinski J, Baker S, Carroll K. Twelve Step Facilitation Therapy Manual. NIAAA Project MATCH Monograph Series Vol. 1, NIH Pub. No. 94-3722 (listed as 1995 on the NIAAA series page; original first-printing date [uncertain]).
  • Nowinski J, Baker S. The Twelve Step Facilitation Handbook, 2nd ed. Hazelden.
  • Baker S. (1998) Twelve Step Facilitation for Drug Dependence (drug-abuse adaptation of the TSF manual; cited in the STAGE-12 protocol).
  • Timko C, DeBenedetti A, Billow R. (2006) Intensive referral to 12-Step self-help groups and 6-month substance use disorder outcomes. Addiction 101(5):678–688.
  • Kelly JF, Humphreys K, Ferri M. (2020) Alcoholics Anonymous and other 12-step programs for alcohol use disorder. Cochrane Database of Systematic Reviews CD012880.pub2. Its framing of manualised vs non-manualised AA/TSF informed scope only; evidence findings are not reviewed here.
  • Alcoholics Anonymous World Services: Alcoholics Anonymous (Big Book); Twelve Steps and Twelve Traditions; Living Sober. Cited by title and passage only; no text reproduced.
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