Twelve Step Facilitation (TSF) – An Evidence-based Intervention

TSF is an evidence based approach for educating, motivating, and referring people to A.A. and other 12- Step Programs.The information in the book is a complete compilation of all the information used in the TSF programs that I helped many treatment programs to develop. The book is based upon my personal interpretation of 12-Step Programs and information that proved effective in getting people to attend with and open mind.Many like it. Some hate it. Most say that it is worth the read. The book makes it easy to easy to pick and choose the information that you think is important and quickly build your own Twelve Step Facilitation Program.The book presents practical information about how to understand and get involved in 12-Step Programs. The book is written in a way that helps people to bridge the gap between Cognitive Restructuring for Addiction and the principles and practices that underlie 12-Step Programs.Studies of patterns of A.A. attendance over a seven you period of time show that people tend to follow one of four distinct patterns:A.A. ATTENDANCE IN LONG-TERM RECOVERYMany people assume that people who find sobriety in A.A. or other 12-Step Programs must regularly attend 12-Step meetings for the rest of their lives or they will relapse.

I have not believed that since the 1970’s. The A.A. Membership Survey shows that people often attend 12-Steps meetings heavily in the first two years of recovery, and then reduce attendance during the 3rd. thru 7th. years of recovery.

A recent study followed the A.A. attendance of 586 dependent alcoholics interviewed by telephone 1, 3, 5 and 7 years after initial referral and a starting base-line of meeting attendance was determined right after treatment. All patients were referred to A.A. as a result of addiction treatment. This referral process today is called Twelve-Step Facilitation (TSF).

This following classification of recovering people based upon their patterns of A.A. attendance was developed. These were:

Group 1: Low Attendance Group: Averaging fewer than 5 meetings at most follow-ups;
Group 2: Medium Attendance Group: Averaging about 50 meetings a year at each follow-up;
Group 3: Descending Attendance Group: About 150 meetings in year 1, then decreasing steeply);
Group 4: High Attendance Group: (about 200 meetings at 1 year, then decreasing gradually by year 7).


After accounting for the effect of time on AA attendance, treatment exposure was minimally related to AA attendance in all but the descending AA group, where it was negatively associated (p < 0.001).

Considering AA patterns over time highlights a different role for treatment in AA attendance than what is gleaned from analyses at single time points.

Research; Lee Ann Kaskutas, Jason Bond and Lyndsay Ammon Avalos. Addictive Behaviors, Volume 34, Issue 12, December 2009, Pages 1029-1035

Gorski Book:
Understanding The Twelve Steps

– Personality Change and The Twelve Step Plus Approach
– Is A.A. Legally A Religion?
– Twelve-Step Facilitation (TSF): An Evidence-based Approach

7 Responses to Twelve Step Facilitation (TSF) – An Evidence-based Intervention

  1. Linda R says:

    Terry, thank you for another thoughtful, informative and insightful blog. I read through the TSF Therapy Manual after reading your reference to it in your “Is AA Legally a Religion” blog. I do have a few comments on it, especially related to your comment: “The book is written in a way that helps people to bridge the gap between Cognitive Restructuring for Addiction and the principles and practices that underlie 12-Step Programs.”

    There is a need for addiction professionals to create a bridge. Professional treatment of a patient / client may vary in its timeframe, but there is always an end to the professional treatment. It seems like studies have indicated that once the patient / client has left treatment, peer-to-peer support from other recovering people in the community goes hand in hand with long term successful recovery, There are 64,414 groups that hold AA meetings in the US / Canada. These groups and their AA meeting provide a way for the patient / client to link into this peer-to-peer support.

    Terry, you commented that “This referral process today is called Twelve-Step Facilitation (TSF).” It’s not clear to me whether this is its only purpose. Clearly the primary purpose of TSF is to facilitate patients / clients into the recovery community to enable long term peer-to-peer support. But you had mentioned also a bridge between “cognitive restructuring for addiction and principles and practices that underlie 12-Step Programs.” Is the cognitive restructuring something that is provided through insight therapy during the sessions, or is it provided separately, perhaps in a more CBT focused program?

    One thing that I did not see in the TSF Therapy Manual is addressing the issue of AA groups that discourage secular interpretations of the 12 Steps. You referred to this issue in the “Is AA Legally a Religion?” blog:
    (1) raising the awareness that there are secular ways to interpret the steps and run meetings. This should be the preferred focus of TSF programs offered by providers.
    (2) encouraging the use of alternative secular support groups to give greater choice.

    AA groups do not uniformly provide an open environment during their meetings. People in these groups are not always receptive to the individual who wants to approach recovery from a non-dogmatic viewpoint. In particular, when an AA group becomes focused on the 12 Steps, the Big Book and the 12 & 12, the aim becomes one of fitting an individual into the pre-packaged solution. Rather than searching for spiritual truth with an open mind and an attitude of curiosity, the individual must fit everything into the pre-established framework of the 12 Steps, the Big Book and the 12 & 12. The US high courts put it this way:

    “Even though the primary objective of A.A. is to enable its adherents to achieve sobriety, its doctrine unmistakably urges that the path to staying sober and to becoming “happily and usefully whole,” is by wholeheartedly embracing traditional theistic belief.”

    In the pamphlet “The AA Group….. Where it all Begins,” published by AA World Services (AAWS), guidance is provided to AA groups on the use of the 12 Steps. On page 29, it says: “Many groups periodically hold a “group inventory meeting” to evaluate how well they are fulfilling their primary purpose: to help alcoholics recover through A.A.’s suggested Twelve Steps of recovery.” Clearly, AA groups are being told that their primary purpose is the 12 Steps. However, AA groups may not modify, alter or extend the 12 Steps. This is part of the AA Board’s bylaws, quoted below:

    “The General Service Board of Alcoholics Anonymous (hereinafter referred to as either the “General Service Board” or the “Board”) claims no proprietary right in the recovery program, for these Twelve Steps, as all spiritual truths, may now be regarded as available to all mankind. However, because these Twelve Steps have proven to constitute an effective spiritual basis for life which, if followed, arrests the disease of alcoholism, the General Service Board asserts the negative right of preventing, so far as it may be within its power so to do, any modification, alteration, or extension of these Twelve Steps, except at the instance of the Fellowship of Alcoholics Anonymous in keeping with the Charter of the General Service Conference of Alcoholics Anonymous as the same may from time to time be amended (hereinafter referred to as the “Charter”).”

    The bylaws create issues for any AA group that changes the 12 Steps, or even wants to show an alternate version side-by-side with the original 12 Steps.. Furthermore, if the AA group decides to leave the Steps as written, but instead decides to focus on interpretations of the Steps, using literature not published by AAWS, then AAWS will strongly discourage this approach. Any AA group may email AAWS about this matter and AAWS will send an email with this:

    “Attached please find a service piece that describes A.A. literature and the Conference-approval process. Individual members, of course, have always had the personal choice of using whatever materials they feel best enhances their spiritual lives, including religious books and periodicals. The understanding of this office is that the Conference had the intention of keeping the focus of the A.A. meeting on the A.A. message as expressed in our literature rather than outside material. However, we know of A.A. groups that use literature such as Twenty-Four Hours a Day that has not been published by A.A.”

    It is difficult for AA groups to use any literature containing interpretations of the Steps that are different from the Big Book or the 12 & 12, without risking becoming de-listed and non-affiliated with AAWS. This puts a decided damper on the notion of “raising the awareness that there are secular ways to interpret the steps and run meetings.”

    On the other hand, professionals do not have these limitations. During TSF therapy sessions, professionals should be able to provide guidance to patients / clients on literature that is not published by AAWS. Furthermore, they may need to determine if their role is to teach the religious doctrine that is in the Big Book and 12 & 12 textbooks, or if this is more appropriately the role of the AA group or the AA sponsor. Professionals may want to look at whether they are receiving government funding or if their patients / clients are referred by the courts. The 2007 court case involved a probation officer being personally sued for requiring an offender to attend AA meetings. If the courts are requiring addiction treatment as part of their sentencing, then the addiction professional may be in the same position as the probation officer if they mandate that the patient / client use the 12 Steps, the Big Book or the 12 & 12 as part of their treatment.

    • Terry Gorski says:

      Dear Linda,
      I need to read and break apart your response above. It is very interesting.

      I was not aware the AAWS prohibited the use of any other versions of the steps.

      What I intend to do, in my spare time, is to take my book Understanding The Twelve Steps and convert the information into a structured TSF Modality.

      Do you have a link to a TSF Manual in the Internet.

      I am preparing for a week long intensive relapse prevention training next week. I will be pretty much if of the grid until a week from Monday.

      I am really enjoying our communication.

    • Linda R says:

      Hi Terry,

      Yes, I now have a link to the TSF manual on the internet. Thanks for the information about your training course, and having to be off the grid for a week. I’ll post a couple of thoughts here on this topic, but I won’t be surprised if you are not able to comment right away.

      First of all, people in the US are free to exercise their religious rights. They should be able to form AA groups in which the group teaches the religious expressions and practices found in the original 12 Steps, the Big Book, the 12 & 12, and ends the meeting in group prayer. But it is a different thing for government to encourage or even mandate that individual citizens join these religious groups. This is where government would stray too closely into establishing religion.

      AA adopted a slogan in its early years: “AA is spiritual, but not religious.” Without defining what “religious” means, this slogan is meaningless. The US court cases defined what religious means from a legal perspective. It designated the original 12 Steps, the Big Book, the 12 & 12 and prayer in meetings as religious.

      Thus, if you have a group of people whose purpose when they meet is to teach the original 12 Steps, and use the Big Book and 12 & 12 as their textbooks, and the group ends their meeting with a group prayer, then you have a religious group. If you have a world-wide network of 114,000+ of these groups, then you might likely have a religious organization.

      In the past, an AA group might have been able to say its purpose wasn’t religious. However, in more recent years, the purpose of the AA group has been defined as teaching the original 12 Steps, using the Big Book and 12 & 12 as textbooks. This is spelled out in the current publications and communications of AAWS.

      People will say an AA group isn’t religious because it allows agnostics to join an AA group. But that’s like saying a catholic mass isn’t religious because agnostics are allowed to attend. When an agnostic attends the mass, that action doesn’t make the mass itself any less religious. And if an agnostic believes there might be an impersonal force, instead of a personal, intervening God, that also doesn’t make the mass itself any less religious. And the agnostic’s belief that an impersonal force might exist, rather than a personal, intervening God, doesn’t change what’s written in the bible or the written doctrines of Catholicism.

      Similarly, the presence of agnostics in an AA group’s meeting does not change the legal fact that the original 12 Steps, as well as the doctrines of the Big Book and the 12 & 12 are religious. Nor does it change the AA group’s purpose, which is to teach the original 12 Steps, using the Big Book and 12 & 12 as textbooks.

      It is very important for TSF to prepare the patient / client to attend AA meetings. It can be somewhat of a shock for an agnostic to walk into this religious environment without preparation. Although the agnostic may believe in a Universal Spirit, rather than a personal intervening God, or have any number of other religious beliefs, they need to be prepared to cope with the teaching of a specific set of religious beliefs, as defined in the original 12 Steps, the Big Book and the 12 &12.

      In particular, the TSF should address the “We Agnostics” chapter (chapter 4) in the Big Book, which pertains to agnostics. In this chapter and in other AA literature, agnostics are depicted in an extremely negative manner. Agnostics are labeled “vain” “contentious” “obstinate” “unreasoning” “belligerent” “savage” and “perverse.” Agnostics “worship” science, they are “too smart for their own good” “read wordy books and indulge in windy arguments” and their doubt that a personal, intervening deity exists is merely an “ego-feeding” proposition.

      An AA group is not professionally facilitated. A divisive topic, such as the existence of a personal, intervening deity is highly likely to be discussed during an AA meeting, especially since an entire chapter of AA’s basic textbook is devoted to the subject. And not only are agnostics discussed in the “We Agnostics” chapter, but AA group members are encouraged by the chapter’s content to denigrate, censure and belittle agnostics. TSF needs to prepare patients / clients to face this environment.

      • Terry Gorski says:

        This is an excellent summary o the Issue of A.A. Being legally viewed as a Religion. In prisons and other large organizations it is best to off secular alternatives, such as SMART RECOVERY. I believe that people recovery best when we challenged to try different tools that match the current plot that we are working on.

        Terence T. Gorski Author, President and Founder of The CENAPS Corporation Cell: 352-279-3068 Office: 352-596-8000 Personal Assistant: Tresa Watson 352-596-8000

  2. Linda R says:

    The 2007 Pew Report data below shows the breakdown of “Conception of God” for the total U.S. population, regardless of religious affiliation.

    Conception of God – Total U.S. Population
    60% Personal God
    25% Impersonal Force
    7% Other conception of God
    8% No conception of God
    100% Total

    It should be assumed that the addicted population in the U.S. do not have different beliefs than the general population: In which case, 40% of the addicted population, like the general population, does not have a conception of a personal God.

    The “We Agnostics” chapter (chapter 4) in the Big Book was written to convince alcoholics who might already believe in something else, perhaps an Impersonal Force, to believe in an intervening, personal God. People who read this textbook will notice how words used in 1939, such as agnostic, are used somewhat differently than how the same words are used today. In modern Big Book Study meetings, teachers of the Big Book often have to provide definitions from 1939 dictionaries, in order to explain the meaning of words and demonstrate how the words were used in 1939. The word agnostic, used in the “We Agnostics” chapter, refers to 40% of today’s addicted population, because this demographic does not have a conception of a personal God.

    In addition, it’s not certain that even the 60% of today’s addicted population who do believe in a personal God also believe that a personal God will intervene on their behalf as a result of prayer. Unlike the theology taught in the Big Book and 12 & 12, many modern churches teach their members to take responsibility for their actions and not to expect a personal God to intercede on their behalf or send them special communications and instructions.

    Clearly, it is problematic for TSF or professionals to use a textbook with a chapter such as “We Agnostics” for a large segment of the addicted population, without becoming entangled in religious conversion.

    • Terry Gorski says:


      92% of people in America believe in the concept of God, some supernatural deity which interacts with individual human beings as we journey through life. ~ PEW INSTITUTE

      GIven the diverse way people conceptualizer God and the sometimes radically diffident thing that God requires human beings to do to save their divine souls, it is a miracle that we survived the dark shes.

      We are all free to believe in the God of our choice and even try to peacefully convince others to believe in and obey the God of our understanding. We our not allowed by the USA constitution to use the force or resources of government to force our view of God onto others.

      TOLERANCE of beliefs other than our own is, of and by itself, a discipline for spiritual growth.

    • Terry Gorski says:

      I believe that we all need to work toward restoring a balance between quantitative and qualitative research. Both are directed toward the study if different scientific questions. The use of both is necessary to get a clear multidimensional picture of that which is being studied.

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