Yes, Twelve Step Facilitation is An Evidence Based Treatment.

The latest buzzword in the addiction treatment world over the past few years is “Evidence Based Treatment” (or EBT).  Generally, an EBT is a method of treatment for which there is evidence proving its effectiveness.  I think most people would be shocked to find out what’s really being passed off as “treatment” for addiction, and the fact that that most practitioners really don’t care whether there is evidence of its effectiveness or not.  Nevertheless, that is the state of things, as respected addiction researcher William Miller noted in 2005:

Although we do expect primary care and specialist physicians to keep current in their field and to provide us the most current and effective treatment that science has to offer, the same standard has not been applied in behavioral health care. In treating substance use disorders, practice has been largely guided by whatever approach a provider was trained in or preferred. Because providers are inclined to believe that their services are effective, and because payment for services has not been linked to the content of treatment, incentives to change and update one’s practice have been minimal. Third-party payers have reimbursed for generic contexts of mental health and substance abuse treatments, such as evaluation, group therapy, inpatient treatment, and case management. What goes on behind closed doors has been left to professional judgment, and practitioners have preferred it that way.

Standards of care are changing, however, with the recognition that not all treatment works (White, 2005). States and cities are beginning to mandate that behavioral health care providers observe the same evidence-based treatment (EBT) standards that are expected in health care more generally. Reimbursement is gradually being tied to the delivery of EBTs and even to the outcomes of treatment. The handwriting is on the wall: Those who are not providing empirically supported interventions are going to have a harder time getting paid for their services. Anything goes is gone. [1]

Doesn’t that sum it all up?  What a novel idea – if you want to get paid, then you should deliver an effective product.

As addiction has become medicalized over the last century, rates of addiction have only risen; more people have become “chronic relapsers” as they’ve been taught by the recovery culture that they’ve got an incurable disease; more people are stuck in the revolving door rehab system; and its become painfully obvious to too many people that treatment just doesn’t work.  So, the regulators have clamped down and said that if you wanna get reimbursed by the state for providing treatment, then you better be doing something that works.  This covers the ass of the regulators, and restores faith in treatment for the naive public – but it hasn’t really improved treatment.

But you ask, how could it not improve treatment?  If they have to use methods proven to work, then it must improve treatment.  Not really.

The recovery culture has simply kept business as usual, and responded to the call for EBTs by declaring their ineffective treatments to be effective, with the use of specious “evidence.”  Case in point: Twelve Step Facilitation (TSF).

TSF is a more formalized version of the teachings of Twelve Step programs (which have never really been shown to be effective themselves), delivered by therapists.  Here’s the official summary of TSF from SAMHSA’s National Registry of Evidence Based Programs and Practices (NREPP):

Twelve Step Facilitation Therapy (TSF) is a brief, structured, and manual-driven approach to facilitating early recovery from alcohol abuse, alcoholism, and other drug abuse and addiction problems. TSF is implemented with individual clients over 12 to 15 sessions. The intervention is based on the behavioral, spiritual, and cognitive principles of 12-step fellowships such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). These principles include acknowledging that willpower alone cannot achieve sustained sobriety, that surrender to the group conscience must replace self-centeredness, and that long-term recovery consists of a process of spiritual renewal. Therapy focuses on two general goals: (1) acceptance of the need for abstinence from alcohol and other drug use and (2) surrender, or the willingness to participate actively in 12-step fellowships as a means of sustaining sobriety. The TSF counselor assesses the client’s alcohol or drug use, advocates abstinence, explains the basic 12-step concepts, and actively supports and facilitates initial involvement and ongoing participation in AA. The counselor also discusses specific readings from the AA/NA literature with the client, aids the client in using AA/NA resources in crisis times, and presents more advanced concepts such as moral inventories.[2]

Indeed, Twelve Step Facilitation is listed as an evidence based treatment by SAMHSA, and they cite research from the infamous Project MATCH as the ‘evidence’ for the method’s effectiveness.  An honest review of this research would never lead a sane person to call TSF an ‘evidence based treatment.’

Project MATCH was the US government’s most expensive study of addiction to date, coming in at a cost of $35,000,000.  Yet with all those millions of dollars, the researchers still failed to include one extremely important feature of good studies – a control group!  The most reliable method science has for determining whether a treatment works is by comparing it to the absence of treatment.  This is the norm for drug testing – give half of your study subjects the real drug, and give the other half of them an inactive placebo or sugar pill.  Then, effectiveness is measured by counting just how many people in the treatment group did better than those in the placebo (or control) group.

The logic behind the use of control groups is simple, if significantly more people get well with the treatment than those without it, then the treatment is probably effective.  If an equal number of people get well both with and without the treatment, then it’s ineffective.  And finally, if more people get well without the treatment than with it – then the treatment is actually counterproductive.  None of this can be ascertained without a control group of untreated subjects, or at the very least, by comparing the treated group’s effectiveness to previously established rates of self-change in similar untreated individuals.

This is the study on which SAMHSA has declared TSF to be an ‘Evidence Based Treatment’?  The fact is, people change their substance use habits without treatment ALL THE TIME.  A vast majority of people do it without treatment – so some comparison to untreated individuals is absolutely warranted.  We have no way of knowing whether those who were successful in Project MATCH should attribute their success to the treatment or not – we don’t know that they wouldn’t have simply gotten better on their own without formal help.  Yet, because some people happened to get better while undergoing TSF, we assume that it’s effective?  This is not only intellectually dishonest (by omission for sure), but also lends much undeserved credibility to TSF and those programs who employ it (at least 78% of treatment programs).

Guess what – there was a hidden (or accidental) control group of sorts in Project MATCH.  The data was uncovered in 2005, a full 7 years after the publication of the MATCH research reports used to support TSF.  Two researchers with access to the MATCH data found that the other researchers had ignored a large group of study subjects who had signed up for the study and treatment, went through intake, and then failed to attend even a single counseling session.  These subjects were even followed up with, and interviewed to gauge levels of substance use.  As if the failure to include a control group, as well as other problems with the design of MATCH weren’t enough, the analysis of the accidental control group deals a death blow to the conclusion that ‘TSF works.’

The researchers analyzed the data comparing those who attended all 12 treatment sessions in MATCH to these who only attended 1 session, and those who attended 0 sessions.  Whether they looked at percentage of days abstinent or drinks per drinking day, they found over and over again at each data point, nearly identical rates of improvement in each group.  They also found that in every group, the majority of the decrease in drinking happened in the very first week of the study, before exposure to any treatment, and essentially flatlined after that.  Here are some of their comments:

The results suggest that treatment was not particularly effective. The following lines of evidence point to this conclusion. Correlations between treatment attendance and outcome were very small (as shown in Table 2). A median 3% of the variance in outcome might be attributed to treatment.

The correlations existed before most treatment occurred, at week 1 (Table 3). We would normally infer from the correlations in Table 2 that more treatment produces better drinking outcomes, but the Table 3 correlations suggests the reverse, that better drinking levels predict more treatment.

Over 60 publications have been generated by Project MATCH, but, to the best of our knowledge, all have overlooked the main finding of this study, i.e., the good outcomes of the zero treatment group when compared to the full treatment group and that the improvement in all groups occurred immediately after enrollment in the trial. Ineffective treatment would be the most parsimonious explanation for the rather surprising main findings of Project MATCH, that there was no match between patient characteristics and different types of treatment, and that all three treatments were equal.[3]

This chart of some of that data may make the point clearer:

Although the team who reviewed the ‘evidence’ for TSF’s effectiveness did mention that there was no control group, they still managed to give TSF an average score of 3.5 out of 4 in six different dimensions, and classified it as an EBT.  The analysis I quoted above was conspicuously absent from their review.[2]

Another thing – let’s not forget William Miller’s review of the most well known treatment methods. He analyzed the evidence available to support these methods, and ranked them accordingly. Out of 48 methods, Twelve Step Facilitation ranked at #38 – with a negative cumulative evidence score! You can see the results of that analysis at this link.

Let’s also not forgot the results of this study done in the 70’s: Alcoholics Anonymous may lead to increased binge drinking– where it was found in follow-up that alcoholic men assigned to a year of 12 step based treatment became 5 times more likely to binge drink than alcoholic men assigned to receive no treatment whatsoever.

Based on the evidence presented, we do not know that TSF works.  And based on some of the evidence known, 12-step based methods of treatment may actually have a negative effect, actually increasing the problems experienced. If TSF can pass as an EBT with such a dearth of evidence of positive outcomes – when it is known that untreated individuals fare just as well if not better – then the title of Evidence Based Treatment is a complete and total joke.  The popularity of EBT’s is nothing more than a marketing tool for rehabs to keep providing more of the same ineffective treatment and avoiding any progress – and a way for regulators to appear like they’re doing their jobs.

[1] Evidence Based Treatment: Why, What, Where, When, and How?  Miller et al, 2005, Journal of Substance Abuse Treatment.

[2] Twelve Step Facilitation Therapy.  SAMHSA’s National Registry of Evidence-Based Programs and Practices, accessed Feb 28 20012.

[NOTE: That link was broken. Here is the currently active link: http://nrepp.samhsa.gov/ViewIntervention.aspx?id=358 – Steven, 10/17/2015]

[3] Are Alcoholism Treatments Effective? The Project MATCH Data.  Robert B Cutler and David A Fishbain, BMC Public Health, 2005.