By Philip R. Magaletta, Ph.D.
April 16, 2019

U.S. Air Force photo illustration/Samuel King Jr.

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.