Facilitating 12-Step Approaches to Change for Service Members with Problematic Drinking

Shots lined up on a bar with a service member turning an empty shot glass upside down
U.S. Air Force photo illustration/Samuel King Jr.
By Philip R. Magaletta, Ph.D.
April 16, 2019

The interrelated sets of practices, beliefs, and experiences of the 12-step approach to change have helped many service members to initiate and/or sustain recovery from alcohol use disorders. As April is Alcohol Awareness Month, we have an opportunity to review and consider the distinctions between group mutual help programs, such as Alcoholics Anonymous (AA), and 12-step facilitation (TSF), an evidence-based treatment that can be delivered to service members with problematic alcohol use.    

The VA/DoD Clinical Practice Guideline (CPG) for the Management of Substance Use Disorders supports involvement in group mutual help programs for service members in early recovery, and summarizes strong evidence for TSF as an effective intervention for service members presenting with alcohol use disorders. 

Distinct from psychosocial substance-abuse treatment services, AA and other 12-step group mutual help programs rely upon experiential knowledge, not professional expertise, and mutual support between peers. They are free and not time limited – and the anonymous nature of a 12-step group approach may be particularly appealing for service members who are concerned about career implications of help-seeking.

I’ll illustrate the interrelated sets of practices, beliefs, and experiences conveyed through 12-step approaches and mutual support among peers with some examples.

  • Practices are behavioral aspects of an individual’s participation in 12-step approaches to change and might include attending meetings, speaking at meetings, reading 12-step literature, conducting the action and/or reflection suggested in a step, meditating, or helping a new 12-step member.
  • Beliefs are cognitions and cognitive changes related to substance use, recovery, and lifestyle. For example, challenging or eliminating a belief that one’s drinking is not problematic.
  • The experiences element is the center of gravity in 12-step approaches and refers to the realization that one is able to do something that he or she had previously been unable to do. In the case of those with substance use disorders, this typically means to cease using. 

TSF is a manualized treatment that is delivered by a behavioral health provider over 12 individual therapy sessions – or over 10 individual sessions and two conjoint sessions with a patient’s spouse or partner. During this process, a provider introduces the first five of the 12 steps, facilitates the patient’s progress toward or through those steps, and encourages engagement in AA. In addition to attending weekly sessions, patients are asked to journal, are assigned recovery tasks, and are encouraged to attend several AA sessions each week. The National Institute on Alcohol Abuse and Alcoholism Twelve Step Facilitation Therapy Manual is a great resource to learn more about the approach and read a summary of the literature in this area.

As is the case with any treatment approach for any mental health concern, it is important to consider patient preferences and characteristics when recommending a specific treatment or group mutual help program. It is important for providers to weigh the pros and cons of approaches to change to move toward resolving ambivalence in the change process. As they do so, providers may want to discuss the following elements of 12-step approaches with patients so they can determine together whether TSF and/or a community mutual help program would be a good fit for them:

  • TSF, AA, and other 12-step programs emphasize the benefit of abstinence for supporting recovery from substance use disorders. Other treatment approaches might emphasize a harm reduction approach.
  • Surrender to and reliance on a “higher power” is central to a 12-step approach to change and is outlined by TSF and AA. While the identity and nature of this higher power is decided by the individual, some service members will resonate with this approach and others will not.
  • Providers should recall that group mutual help programs are not frontline or standalone options for clinically significant substance misuse. Service members meeting criteria for alcohol use disorders should be encouraged to pursue formal mental health treatment with a licensed provider. AA is supported as an option for service members in early recovery, or those who have recently relapsed following treatment. It may also be an appropriate recommendation for service members who are concerned about their alcohol use, but have not experienced occupational or interpersonal consequences rising to the level of an alcohol use disorder diagnosis.

Given the prevalence of alcohol problems among service members, and the cost-effectiveness and availability of 12-step approaches to change, it is worthwhile for providers and line staff to familiarize themselves with this approach and facilitate service members’ involvement as appropriate. Providers can do this by:

  • Expanding their knowledge and understanding of the 12-step approach through reading 12-step literature and the TSF manual.
  • Developing an understanding of the 12-step approach through attending an open meeting or two.
  • Procuring information on the locations and schedules of local meetings on base, or off base in civilian settings near where they practice.   

Dr. Magaletta is a contracted psychologist subject matter expert on the Clinical Care Risk Reduction team at the Psychological Health Center of Excellence. He has a doctorate in clinical psychology and has administrative, research, and practice experience in public health, safety, and educational systems.  


The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


Comments

  • Prevention is very Important , and is no problem only for us army- Thank You-

  • I appreciate the balanced approach with this topic and the inclusion of clinician delivered treatments. Well written.
    I’ve struggled with the military’s seemingly over reliance on the use of AA in treatment and after care. Anonymous programs come across more theistic/dogmatic than scientific, they don’t lend well to scientific evaluation, and the one Cochrane meta analysis on these programs was not at all positive, even suggested harm.
    Treatment “failure” for substance abuse can result in discharge for AD members, suggesting we should be doing our absolute best to try and get it right the first time in delivery of care. This article steps in that direction.

  • I know that there are many labels (technically referred to as a diagnosis) in the AODA treatment world but they are so revealing that I am compelled to respond. The recovery world does not for example recognize terms such as opiate use disorder in remission. We believe that addiction is a disease comprised of obsession and compulsion. There is another school of thought called "harm reduction" that passes toxic shame onto the addict who is finding out the hard way that knowledge doesn't equal recovery. This is also true about the belief within the recovery community that abstinence does not equal recovery. Abstinence is very important as is harm reduction. I am communicating that it is appropriate for many but not for an addict. The disease of addiction has many manifestations including, alcohol, gambling, eating, sex, drugs etc.
    First of all 12 step recovery is not based in knowledge. It is based on wisdom. Recovery is about the heart and soul. This comes from literally millions of days of abstinence transformed into recovery. Addicts are shown how to live not taught what to do. The 12 step process is not something that is appropriate to be facilitated. People are shown how to live by becoming a part of the community of recovery. It's about community inclusion. Treatment is treatment and the medical model of care is beyond excellent in helping our Veterans gain abstinence. It's the part referred to as helping someone get away from where they don't want to be. I personally did not attend treatment because of the reason that was so stated in this article. For those of us in mental health recovery as well as addictions recovery it is the stigma attached by the world we live in. Sad but true. Well said by the author of this blog.
    It's ironic that I am again trying to share the wisdom of the recovery community with the knowledge and expertise of the treatment system. God willing tomorrow I will celebrate 27 years in addictions recovery and close to 40 years in mental health recovery.
    Treatment people should continue to do what they do very well. I must say that recovery is about the journey towards humility. I have hope that some day the medical model system will give way (where appropriate) to the recovery model that the VA is moving towards. As a system we must find some humility. If we continue to define recovery as a way to help people not die then we are missing the point. Recovery is about showing people how to live and that joy is a possibility. It's about hope! The recovery community that I am a part of believes that lost dreams awaken and new possibilities arise. Respectfully submitted.

    • As one of my mentors has wisely said, it's a problem of lifestyle. Substance abuse often functions as the veil obscuring a fundamental deficit in the ability to live a meaningful, fulfilled life, and manage the inevitable challenges that come with it. Treating the substance abuse is therefore the "necessary but not sufficient" step on a much longer recovery process.

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