National Institute on Alcohol Abuse and Alcoholism

Project MATCH Monograph Series

Volume 1

TWELVE 

STEP

FACILITATION

THERAPY

MANUAL

A Clinical Research Guide for

Therapists Treating Individuals

With Alcohol Abuse and Dependence

By:

Joseph Nowinski, Ph.D.

Stuart Baker, M.A., C.A.C.

Kathleen Carroll, Ph.D.

Project MATCH Monograph Series Editor: 

Margaret E. Mattson, Ph.D.

U.S. Department of Health and Human Services

Public Health Service

National Institutes of Health

National Institute on Alcohol Abuse and Alcoholism 

6000 Executive Boulevard

Rockville, Maryland 20892-7003
Project MATCH is supported by grants under a cooperative agreement 

funded by the National Institute on Alcohol Abuse and Alcoholism 

(NIAAA) and implemented by nine clinical research units and a data 

coordinating center. The project was initiated and is administered by 

the Treatment Research Branch of NIAAA. Questions or comments 

regarding this manual should be directed to Joseph Nowinski, Ph.D., 

196 Conantville Road, Box 435, Mansfield Center, CT 06250.

The views and opinions expressed on the following pages are solely 

those of the authors and do not necessarily constitute an endorsement, 

real or implied, of the Institute or the U.S. Department of Health and 

Human Services.

The tables appearing in appendix A are copyrighted and are reproduced herein with permission of the copyright holder. Further 

reproduction of these copyrighted materials is prohibited without 

specific permission of the copyright holder. All other material contained in this volume is in the public domain and may be used or 

reproduced without permission from the Institute or the authors. 

Citation of the source is appreciated.

NIH Publication No. 94-3722

Reprinted 1999
iii

Acknowledgments

As a treatment based on a 12-Step philosophy had never been standardized in manual form expressly for a clinical trial, the Project 

MATCH research group turned to the experts. Several personnel at 

the Hazelden Foundation in Center City, Minnesota—Patricia Owen, 

Ph.D., Vice-President; Dan Anderson, Ph.D., President Emeritus; and 

Fred Holmquist, Program Manager—were kind enough to lend us their 

substantial expertise in this effort. Hazelden staff reviewed two drafts 

of the Twelve-Step Facilitation Therapy Manual and provided thoughtful comments and extensive suggestions, which were incorporated into 

the manual. We wish to offer them special thanks, and we gratefully 

acknowledge their important contribution to the development of this 

manual. We are indebted to the Project MATCH therapists for their 

many constructive suggestions during the development of the 12-Step 

manual. The overall effort to design all three Project MATCH manuals 

and to implement the therapies in the Clinical Research Units was 

coordinated by the investigators at Yale University under the leadership of Drs. Kathleen Carroll and Bruce Rounsaville.

Project MATCH Research Group and

Other Contributors

William Miller, Ph.D.

Reid Hester, Ph.D.

Center on Alcoholism, Substance Abuse and Addictions

University of New Mexico

Albuquerque, NM

Gerard Connors, Ph.D.

Robert Rychtarik, Ph.D.

Research Institute on Alcoholism 

Buffalo, NY

Carrie Randall, Ph.D.

Raymond Anton, M.D.

Medical University of South Carolina and

Veterans Administration Medical Center

Charleston, SC

Principal and 

Coinvestigators 

ath the Sites
iv

Twelve-Step Facilitation Therapy Manual

Ronald Kadden, Ph.D.

Ned Cooney, Ph.D.

University of Connecticut School of Medicine 

Farmington, CT

Carlo DiClemente, Ph.D. 

Joseph Carbonari, Ed.D. 

University of Houston 

Houston, TX

Allen Zweben, D.S.W.

University of Wisconsin-Milwaukee 

Milwaukee, WI

Richard Longabaugh, Ed.D. 

Robert Stout, Ph.D.

Brown University

Providence, RI

Dale Walker, M.D.

Dennis Donovan, Ph.D.

University of Washington and Seattle VA Medical Center 

Seattle, WA

Thomas Babor, Ph.D.

Frances Del Boca, Ph.D. 

University of Connecticut

Farmington, CT

Kathleen Carroll, Ph.D.

Bruce Rounsaville, M.D.

Yale University 

New Haven, CT

John Allen, Ph.D.

Project Officer for Project MATCH

Chief, Treatment Research Branch

Margaret Mattson, Ph.D.

Staff Collaborator for Project MATCH

Coordinating 

Center

Principal and 

Coinvestigators

NIAAA Staff
v

NIAAA

Cooperative 

Education 

Program

Participant

Consultants

Contractor

Lisa Marshall

Gallaudet University

Washington, DC

Larry Muenz, Ph.D.

Gaithersburg, MD

Philip Wirtz, Ph.D.

George Washington University

Washington, DC 

Jane K. Myers

President

Janus Associates 

Bethesda, MD

vii

Foreword

A major focus of the efforts of the National Institute on Alcohol Abuse 

and Alcoholism (NIAAA) in treatment research is to rigorously test the 

patient-treatment matching approach to the clinical management of 

alcoholism. This commitment is particularly reflected in its multi-site 

clinical trial, Project MATCH. This study is the first national, multisite 

trial of patient-treatment matching and one of the two largest current 

initiatives of NIAAA. Established under a cooperative agreement that 

allows direct collaboration between the Institute and the researcher, 

the project involves nine geographically representative clinical sites 

and a data coordinating center. Researchers in Project MATCH are 

among the most senior and experienced treatment scientists in the 

field. Both public and private treatment facilities, as well as hospital 

and university outpatient facilities, are represented.

The manuals in this series are the result of the collaborative efforts of 

the Project MATCH investigators and are used as guides by therapists 

in the trial. They are presented to the alcohol research community as 

standardized, well-documented intervention tools for alcoholism treatment research. The final reports of Project MATCH will inform us on 

the relative efficacy of the interventions being evaluated in the trial and 

on the types of clients who benefit the most from each of the therapies.

Until the final results from Project MATCH are presented to the community, these interim manuals will summarize the consensus of the 

investigators on reasonable intervention approaches based on present 

knowledge. We look forward to offering further refinements of these 

approaches as Project MATCH data are analyzed and published and as 

the alcohol treatment field advances through the efforts of other ongoing research.

Enoch Gordis, M.D.

Director

National Institute on Alcohol Abuse 

and Alcoholism

ix

Preface

This manual for therapists is provided to the public to permit replication of the treatment procedures employed in Project MATCH, a 

multisite clinical trial of patient-treatment matching sponsored by 

the National Institute on Alcohol Abuse and Alcoholism (NIAAA). It 

describes Twelve-Step Facilitation Therapy (TSF), one of three treatment approaches studied in Project MATCH. Therapist manuals for 

the other treatments—Motivational Enhancement Therapy (MET) and 

Cognitive-Behavioral Coping Skills Therapy (CBT)—are available in 

volumes 2 and 3 of this series, respectively.

Although a number of therapies have had varying degrees of success, 

no single treatment has been shown to be effective for all individuals 

diagnosed with alcohol abuse or dependence. In recent years, interest 

in the field has increasingly focused on patient-treatment matching to 

improve outcome. The hypothesis is that more beneficial results can 

be obtained if treatment is prescribed on the basis of individual patient 

needs and characteristics as opposed to treating all patients with the 

same diagnosis in the same manner.

Many investigators have turned their attention from main effects evaluations (i.e., studies that ask whether one intervention is more effective 

than another) to studies specifically designed to identify interactions 

between particular treatments and patient variables. While treatments 

may not appear to differ in effectiveness when applied to a heterogeneous client population, specific treatments may indeed be more or 

less effective for specific, clinically meaningful subgroups.

This reasoning has led to a new generation of alcoholism treatment 

research studies whose design is driven by the objective of finding 

effective “matches.” Ultimately, the goal of this line of research is to 

provide the clinician with valid and practical rules applicable across 

a variety of treatment settings to assign patients to those treatment 

regimens particularly suited to them.

Rationale for

PatientTreatment

Matching
x

Twelve-Step Facilitation Therapy Manual

Project MATCH, a 5-year study, was initiated by the Treatment Research 

Branch of NIAAA in 1989. The details of the design and implementation 

of Project MATCH will be described in full in forthcoming publications. 

This section outlines the major features of the study.

The objective of Project MATCH is to determine if varying subgroups 

of alcohol abusing or dependent patients respond differentially to 

three treatments: (1) Twelve-Step Facilitation Therapy, (2) CognitiveBehavioral Coping Skills Therapy, and (3) Motivational Enhancement 

Therapy. Each treatment is delivered during a 12-week period by 

trained therapists following a standardized protocol.

The project consists of two independent treatment-matching studies, 

one with clients recruited at five outpatient settings, the second with 

patients receiving aftercare treatment at four sites following an episode 

of standard inpatient treatment. Patients are randomly assigned to one 

of the three treatment approaches. Each study evaluates the interaction effects between selected patient characteristics and the three 

treatments.

Each of the nine study sites is recruiting approximately 150-200 clients. 

Clients are evaluated at intake and again at 3, 6, 9, 12, and 15 months. 

Outcome measures for the trial include drinking behavior, psychological and social function, and consequences of drinking. Analyses of a 

priori hypotheses, as well as exploratory analyses, will show whether 

different patient characteristics are associated with differential treatment outcomes in each of the three therapeutic interventions.

Twelve-Step Facilitation Approach. This therapy is grounded in the 

concept of alcoholism as a spiritual and medical disease. The content of this intervention is consistent with the 12 Steps of Alcoholics 

Anonymous (AA), with primary emphasis given to Steps 1 though 5. In 

addition to abstinence from alcohol, a major goal of the treatment is 

to foster the patient’s commitment to participation in AA. During the 

course of the program’s 12 sessions, patients are actively encouraged 

to attend AA meetings and to maintain journals of their AA attendance 

and participation. Therapy sessions are highly structured, following 

a similar format each week that includes symptoms inquiry, review 

and reinforcement for AA participation, introduction and explication 

of the week’s theme, and setting goals for AA participation for the next 

week. Material introduced during treatment sessions is complemented 

by reading assignments from AA literature.

Motivational Enhancement Therapy. MET is based on principles of 

motivational psychology and is designed to produce rapid, internally motivated change. This treatment strategy does not attempt to 

guide and train the client, step by step, through recovery, but instead 

Project

MATCH:

An Overview
xi

Preface

employs motivational strategies to mobilize the client’s own resources. 

MET consists of four carefully planned and individualized treatment 

sessions. The first two sessions focus on structured feedback from the 

initial assessment, future plans, and motivation for change. The final 

two sessions at the midpoint and end of treatment provide opportunities for the therapist to reinforce progress, encourage reassessment, 

and provide an objective perspective on the process of change.

Cognitive-Behavioral Therapy. This therapy is based on the principles 

of social learning theory and views drinking behavior as functionally 

related to major problems in the person’s life. It posits that addressing 

this broad spectrum of problems will prove more effective than focusing on drinking alone. Emphasis is placed on overcoming skill deficits 

and increasing the person’s ability to cope with high-risk situations 

that commonly precipitate relapse, including both interpersonal difficulties and intrapersonal discomfort, such as anger or depression. The 

program consists of 12 sessions with the goal of training the individual 

to use active behavioral or cognitive coping methods to deal with problems rather than relying on alcohol as a maladaptive coping strategy. 

The skills also provide a means of obtaining social support critical to 

the maintenance of sobriety.

Although all three manuals were developed for a randomized clinical trial focusing on patient-treatment matching hypotheses, the 

substance of the interventions is equally suitable for other research 

questions and designs. However, the reader needs to be aware of the 

parameters of Project MATCH.

Therapy is delivered in a structured research situation. All three treatments are manual guided and administered by experienced therapists 

who receive specialized training in one of the three project interventions. 

Therapists closely follow the procedures outlined in their manual, with 

regular supervision (by observation of videotapes) from both local and 

projectwide clinical supervisors.

This manual is written for therapists with similar intensive training 

and supervision. A summary of the procedures used to select, train, 

and supervise therapists in Project MATCH is provided in appendix B.

There is an important difference between a therapy textbook and a 

therapy manual. A therapy textbook is a comprehensive presentation 

of a particular therapeutic approach, usually describing a conceptual 

model, general principles, and a broad range of applications and examples. It is typically meant to facilitate broad utilization of a therapeutic 

approach by a wide range of practitioners in a variety of settings. A 

therapy manual, on the other hand, is intended to operationalize and 

standardize a treatment approach to be used in a particular context, 

usually a specific clinical trial. In writing a therapy manual, the authors 

Caveats and

Critical

Considerations
xii

Twelve-Step Facilitation Therapy Manual

must make a number of specific decisions (e.g., the number and timing 

of sessions, the content of each session) that are ordinarily left to clinical judgment in a therapy textbook.

This manual is designed to standardize TSF as a 12-session treatment modality within the particular context of Project MATCH. All 

treatments are preceded by the same extensive assessment battery, 

requiring approximately 7-8 hours. Abstinence is the expressed goal of 

all treatments and, except in unusual situations, all sessions are videotaped. Each treatment session is preceded by a breath test to ensure 

sobriety, and a positive breath alcohol reading results in rescheduling the session. Therapists are prohibited from mixing TSF with other 

treatment approaches, and the purity of approach is maintained by 

local and national supervisors who review videotapes. All therapy has 

to be completed within 90 days. A significant other can be invited to 

participate in up to two sessions.

Other design requirements of clinical trials are likewise standardized 

across all sites, including features such as defined patient eligibility 

criteria, randomized assignment of treatment, and guidelines for dealing with patients who are late or absent for treatment sessions or who 

show significant clinical deterioration during the course of the intervention. Guidelines regulate and document the amount and type of 

therapy over and above that provided by Project MATCH that a client 

receives during the study. Data collection and delivery of treatment 

are kept strictly separate, with the former being handled by research 

assistants under the supervision of the project coordinators. The three 

manuals refer to these Project MATCH-specific procedures with the 

knowledge that some readers may wish to follow similar guidelines 

while others may choose to devise new guidelines more appropriate to 

the requirements of their own project.

The therapeutic approach underlying this manual is grounded in the 

principles and 12 Steps of AA. It is important to note, however, that this 

manual has no official relationship with or sanction from Alcoholics 

Anonymous. The fellowship of AA is described in its official literature 

and is realized through its worldwide meetings. Alcoholics Anonymous 

does not sponsor or conduct research into alcoholism or its treatment 

or endorse any treatment program. While intended to be consistent 

with AA principles, this treatment program is designed for use in a 

research project. Its goals are to educate clients regarding the AA view 

of alcoholism and to facilitate their active participation in AA.

The general therapeutic principles underlying TSF can be applied in 

many other ways than those delineated here. Under ordinary circumstances, the number, duration, and distribution of sessions could be 

flexible. Significant others might be involved in all sessions or none at 

all. The goals of therapy might be more flexible, and the 12-Step facilitation procedures could be intermixed with other therapeutic strategies. 
xiii

Preface

The specific prescriptions outlined in this manual are imposed for 

purposes of standardization and separation of treatments in Project 

MATCH. An expanded text on 12-Step facilitation, for broad use in the 

treatment of alcohol and drug dependence, will be published by a private firm in the fall of 1992.

The staff of Project MATCH and NIAAA make no claims or guarantees 

regarding the effectiveness of the treatment procedures described in 

this manual. Although 12-Step programs are widely used both in this 

country and abroad, the specific efficacy of TSF as outlined in this 

manual remains to be tested. The final reports of Project MATCH will 

provide clearer information on the efficacy of this approach relative 

to others and on the types of clients for whom it may be optimal. In 

the interim, it is our hope that these manuals will serve as a useful 

tool for the alcohol clinical research community by offering a detailed 

description of TSF procedures as constructed by consensus among the 

investigators and implemented by the therapists of Project MATCH. All 

manuals of this kind should be regarded as under development and 

subject to ongoing improvement based on subsequent research and 

experience.

The planning and operation of Project MATCH and the products now 

resulting from it, including this series of manuals, reflect the efforts of 

many individuals over a period of several years. Their dedication and 

collegial collaboration have been remarkable and will enrich the field of 

alcoholism treatment research for years to come.

Margaret E. Mattson, Ph.D.

Project MATCH Staff Collaborator

Project MATCH Monograph Series Editor 

Division of Clinical and Prevention 

Research

National Institute on Alcohol Abuse and 

Alcoholism

xv

Contents

Page

Acknowledgments ............................................................... iii

Foreword ............................................................................ vii

Preface ................................................................................ ix

Introduction .........................................................................1

Therapist Guidelines .......................................................... 11

Part 1: Core Topics ................................................ 19

Topic 1: Program Introduction ............................................ 21

Format: Sessions 2-11 ........................................................ 35

Topic 2: Step 1—Acceptance ............................................... 37

Topic 3: Steps 2 and 3—Surrender ...................................... 45

Topic 4: Getting Active ........................................................ 51

Part 2: Elective Topics ........................................... 59

Topic 5: The Genogram ...................................................... 61

Topic 6: Enabling ............................................................... 67

Topic 7: People, Places, and Things .................................... 73

Topic 8: HALT (Hungry, Angry, Lonely, Tired) ..................... 79

Topic 9: Steps 4 and 5—Moral Inventories .......................... 87

Topic 10: Sober Living ........................................................ 93

Part 3: Termination ............................................... 97

Final Core Session: Termination.......................................... 99

Part 4: Conjoint Sessions ..................................... 103

Conjoint Session 1: Enabling ............................................ 105

Conjoint Session 2: Detaching .......................................... 111

Appendix A—Jellinek Charts for Men and Women ............. 115

Appendix B—Therapist Selection, Training, and Supervision

in Project MATCH ..................................................... 121

1

Introduction

The facilitation program described in this manual is intended for use 

in brief individual outpatient treatment for persons who satisfy the 

criteria for a diagnosis of alcohol dependence and abuse. It is intended 

to be flexible enough to allow for individual treatment planning and for 

use as a primary treatment for persons who have never been exposed 

to the 12 Steps of Alcoholics Anonymous (AA), as well as for individuals 

who have had such exposure, for example, through prior treatment.

The program described here is intended to be consistent with active 

involvement in Alcoholics Anonymous. It assumes that alcoholism is a 

progressive illness that affects the body, mind, and spirit for which the 

only effective remedy is abstinence from the use of alcohol. It adheres 

to the concepts set forth in the “Twelve Steps and Twelve Traditions” of 

Alcoholics Anonymous.

The overall goal of this program is to facilitate patients’ active participation in the fellowship of AA. It regards such active involvement as 

the primary factor responsible for sustained sobriety (“recovery”) and 

therefore as the desired outcome of participation in this program.

According to the AA viewpoint, alcoholism is a chronic progressive 

illness which, if not arrested, may lead to insanity or death. It is characterized by loss of the ability to control (limit) the use of alcohol:

We alcoholics are men and women who have lost the ability to 

control our drinking. We know that no real alcoholic ever recovers 

control. (“Alcoholics Anonymous,” p. 30)

As is true for all chronic illnesses, alcoholism has specific and predictable effects (symptoms) on the individual and a predictable course. In 

addition to its physical effects, alcoholism affects its victims on many 

levels, including the psychological, social, and spiritual.

Alcoholism is also characterized by “denial,” or resistance to accepting 

the reality of loss of control over drinking:

Most of us have been unwilling to admit we were real alcoholics. 

No person likes to think he is bodily and mentally different from 
2

Twelve-Step Facilitation Therapy Manual

his fellows. Therefore, it is not surprising that our drinking careers 

have been characterized by countless vain attempts to prove we 

could drink like other people. (“Alcoholics Anonymous,” p. 30)

Alcoholics Anonymous is not a treatment method but a fellowship of 

peers, connected by their common addiction, which is guided by its 12 

Steps and traditions. The only stated requirement for admission is a 

desire to stop drinking.

AA makes no commitment to a particular causal model of addiction; 

rather, it limits its schema to the concepts of loss of control and denial. 

Historically, AA has emphasized two themes in its program:

■ Spirituality: Belief in a “Higher Power,” which is defined by the individual and which represents faith and hope for recovery.

■ Pragmatism: Belief in doing “whatever works” for the individual, 

meaning doing whatever it takes in order to avoid taking the first 

drink.

Treatment Goals and Objectives

This treatment program has two major goals, which relate directly to 

the first three Steps of Alcoholics Anonymous.

Acceptance

■ Acceptance by patients that they suffer from the chronic and progressive illness of alcoholism.

■ Acceptance by patients that they have lost the ability to control 

their drinking.

■ Acceptance by patients that, since there is no effective cure for 

alcoholism, the only viable alternative is complete abstinence from 

the use of alcohol.

Surrender

■ Acknowledgment on the part of the patient that there is hope for 

recovery (sustained sobriety) but only through accepting the reality of loss of control and by having faith that some Higher Power 

can help the individual whose own willpower has been defeated by 

alcoholism.

Goals
3

Introduction

■ Acknowledgment by the patient that the fellowship of AA has helped 

millions of alcoholics to sustain their sobriety and that the patient’s 

best chances for success are to follow the AA path.

The two major treatment goals are reflected in a series of specific objectives that are congruent with the AA view of alcoholism.

Cognitive

■ Patients need to understand some of the ways in which their thinking has been affected by alcoholism.

■ Patients need to understand how their thinking may reflect denial 

(“stinking thinking”) and thereby contribute to continued drinking 

and resistance to acceptance (Step 1).

■ Patients need to see the connection between their alcohol abuse 

and negative consequences that result from it. These consequences 

may be physical, social, legal, psychological, financial, or spiritual.

Emotional

■ Patients need to understand the AA view of emotions and how certain emotional states (e.g., anger, loneliness) can lead to drinking.

■ Patients need to be informed regarding some of the practical ways 

AA suggests for dealing with emotions so as to minimize the risks 

of drinking.

Behavioral

■ Patients need to understand how the powerful and cunning illness 

of alcoholism has affected their whole lives and how many of their 

existing or old habits have supported their continued drinking.

■ Patients need to turn to the fellowship of AA and to make use of its 

resources and practical wisdom in order to change their alcoholic 

behavior.

■ Patients need to “get active” in AA as a means of sustaining their 

sobriety.

Social

■ Patients need to attend and participate regularly in AA meetings of 

various kinds, including AA-sponsored social activities.

Objectives
4

Twelve-Step Facilitation Therapy Manual

■ Patients need to obtain and develop a relationship with an AA 

sponsor.

■ Patients need to access AA whenever they experience the urge to 

drink or suffer a relapse.

■ Patients need to reevaluate their relationships with “enablers” and 

fellow alcoholics.

Spiritual

■ Patients need to experience hope that they can arrest their 

alcoholism.

■ Patients need to develop a belief and trust in a power greater than 

their own willpower.

■ Patients need to acknowledge character defects, including specific 

immoral or unethical acts, and harm done to others as a result of 

their alcoholism.

This facilitation program is very structured, with each session having a 

specific agenda and following a prescribed pattern. Patients are asked 

to keep a personal journal. Each session includes specific “recovery 

tasks”: suggestions made to patients for reading and action between 

sessions. Therapists will suggest reading material drawn from AA 

Conference-approved texts.

Central to this approach is strong encouragement of the patient to 

attend several AA meetings per week of different kinds and to read the 

“Big Book” (“Alcoholics Anonymous”) as well as other AA publications 

throughout the course of treatment.

The facilitation program consists of 12 sessions, divided as follows:

■ 12 individual sessions with alcoholic patients if they are single.

■ 10 individual sessions plus 2 conjoint sessions with patients and 

their partners if they are in a stable relationship.

■ A maximum of two individual emergency sessions as needed.

The above sessions are intended to be offered within a period of 12 

consecutive weeks.

Treatment

Overview

Sessions
5

Introduction

The goal of the conjoint sessions is to educate the partner regarding 

alcoholism and the AA model, to introduce the concept of enabling, and 

to encourage partners to make a commitment to attend six Al-Anon 

meetings of their choice.

The program is organized as follows:

■ Four core topics

■ Six elective topics

■ Termination

It is intended that the four core topics plus the termination session be 

provided to all patients. There is more flexibility in the therapist’s use 

of the six elective topics. Any core or elective session may be repeated 

if needed to complete the 12-session schedule. These can be tailored 

to the individual patient with supervisory consultation. The use of a 

combination of core and elective topics allows this program to develop 

individualized treatment plans within broad parameters. For example, 

it can be used with patients who have had no prior exposure to AA 

concepts, patients who have never undergone treatment of any kind 

for alcoholism, and patients who have had one or more inpatient treatment experiences plus extensive exposure to AA.

Patients are asked to maintain a personal journal, which is reviewed 

by the therapist prior to the start of each session, and which is used to 

record the following:

■ All AA meetings attended (dateWtimeWplaces).

■ Personal reactions to and thoughts about meetings.

■ Reactions to suggested readings.

■ “Slips” (occasions when the patient has taken one or more drinks) 

and what was done about them.

■ Reactions to recovery tasks.

■ Cravings or urges to drink, and what the patient did about them.

When working with patients who may be actively drinking or whose 

sobriety is compromised by slips, it is not uncommon for therapists 

to be confronted by various “emergencies.” Typical examples of such 

emergencies include patients—

Organization 

and Structure

Journals

Emergencies
6

Twelve-Step Facilitation Therapy Manual

■ Getting drunk.

■ Getting arrested for driving while intoxicated (DWI).

■ Having a family dispute as a result of drinking.

■ Experiencing intense urges to drink.

■ Feeling depressed about being an alcoholic (or about a slip).

■ Getting into trouble on the job as a consequence of drinking.

■ Needing medical detoxification as a consequence of a binge.

Emergencies of a psychiatric nature (e.g., suicidal thinking, psychosis, 

violence, self-injury) may require either an emergency session with the 

therapist or referral to an emergency mental health service for evaluation and possible intervention. In such instances, patients’ continued 

involvement in the facilitation program may require review. In general, 

uncomplicated medical detoxification (up to 72 hours) should not disqualify patients as long as they are willing to continue and as long as 

the 12 sessions can still be provided within 12 weeks.

In addition to having to deal with emergencies of a psychiatric nature, 

and possibly detoxification, contact with the therapist outside of scheduled treatment hours, for example, as a method of helping patients 

cope with urges to drink or dealing with slips, is discouraged in this 

program. Instead, patients should be consistently encouraged to turn 

to the resources of AA as the basis for their recovery. The therapist may 

offer specific advice and help in this regard, such as assisting a patient 

in contacting the AA Hotline or the patient’s sponsor.

Session Format

In the first session, the therapist covers topic 1. The therapist introduces this program and provides an overview of it (including its goal of 

active involvement in AA), helps patients evaluate their level of alcohol 

involvement, introduces the AA view of alcoholism, and attempts to 

motivate patients to stay sober.

All four core topics need to be covered in sessions 2 through 11, plus 

as many elective topics as are appropriate to the individual patient. 

This treatment planning should be done in collaboration with a supervisor. The format for these sessions is as follows.

Session 1—

Introduction

Sessions 2-ll
7

Introduction

Part 1: Review

Beginning with session 2, each session begins with a review of the 

patient’s experience since the last session, with special emphasis on 

drinking. It is important to avoid protracted discussions of collateral 

issues (work, relationships, children, etc.). The therapist should focus 

on drinking as much as possible. In addition to patients’ self-reports, 

journal entries can be very helpful in guiding treatment and establishing future recovery tasks.

Specific mention should be made of all sober days. These are legitimate cause for sincere congratulations. Strong urges to drink should 

be discussed openly and nonjudgmentally. Similarly, slips need to be 

approached nonjudgmentally as events that can be openly acknowledged and discussed by the patient without fear of recrimination. Slips 

should be thought of (and interpreted) as times when the powerful and 

cunning illness of alcoholism overcomes the patient’s willpower.

In addition to briefly reviewing sober days and slips, the review time 

(10-15 minutes) should be used to talk about the patient’s reactions to 

readings and to meetings that were attended since the last session. If 

no meetings were attended or if the patient seems to be resisting going 

to meetings, the reasons for this resistance should be explored.

Part 2: New Material

Following the review, each session should move on to cover its specific 

focus, either a core or an elective topic. These are described in detail 

in this manual. Even within a topic, the material can be adjusted to a 

particular patient’s situation, so long as the presentation remains consistent with the AA view of alcoholism.

Part 3: Recovery Tasks

Each session should end with specific suggestions—recovery tasks—for 

the patient to follow up on between sessions, including—

■ A mutually agreed-upon list of AA meetings to be attended.

■ Suggested readings from the three AA texts: “Alcoholics Anonymous,” 

“Twelve Steps and Twelve Traditions,” and “Living Sober.”

■ Other suggested readings, including pamphlets, meditation books, 

and other materials that the therapist is familiar with and would 

recommend as pertinent to the individual patient’s recovery.
8

Twelve-Step Facilitation Therapy Manual

NOTE: When offering patients advice or giving them recovery tasks 

from the point of view of an AA-oriented program like this one, it 

is important to remember that AA itself prefers the word “suggestion” to the word “rule.” Specific strategies for staying sober are 

as varied as the number of people who make up the AA membership. The bottom line is to do what works for individual alcoholics, 

meaning how they have succeeded in staying sober.

In keeping with the spirit of AA, therapists using this manual are 

advised to avoid making “assignments,” in the sense of telling 

patients what they should do. The AA tradition tells us that it is 

better to share with a particular patient “some things that other 

alcoholics have found helpful in your situation” without pressing 

for the kind of commitment that other therapies might. This boils 

down to making suggestions as opposed to prescribing behavior.

Suggestions made by the 12-Step therapist should be consistent 

with what is found in AA-approved publications such as those that 

are recommended to patients. Examples of strategies for dealing 

with urges and slips that are consistent with AA include—

■ Calling an AA friend.

■ Going to a meeting (or another meeting or a different meeting).

■ Going to an AA social.

■ Calling your sponsor.

■ Calling the AA Hotline.

■ Changing a habit pattern (doing something different).

■ Distracting yourself.

■ Praying.

Aside from being consistent with AA traditions, recovery tasks 

should be specific, and the therapist should make a point of following up on them at the beginning of each session.

Needless to say, the therapist should be thoroughly familiar with 

the three AA texts, as well as with the locations, times, and types 

of meetings that may be available in the area, when giving a patient 

recovery tasks that involve going to meetings or reading.
9

Introduction

The final session has its own goals and follows a process somewhat different from that described above. Refer to the specific material in this 

manual regarding termination.

Since its inception, AA has emphasized reading, particularly the “Big 

Book” and the “12 x 12,” as a way of understanding the fellowship and 

its principles. This facilitation program incorporates reading materials 

to augment the material covered in sessions. It is suggested that all 

patients be strongly encouraged to obtain personal copies of the following books:

■ “Alcoholics Anonymous.” 3rd edition. New York: Alcoholics 

Anonymous World Services, 1976

■ “Twelve Steps and Twelve Traditions.” New York: Alcoholics 

Anonymous World Services, 1952.

■ “Living Sober.” New York: Alcoholics Anonymous World Services, 

1975.

In addition to the above, therapists using this manual should familiarize themselves with the contents of the following publications, which 

are relevant to one or more of the treatment topics described later:

■ “Things My Sponsors Taught Me,” by Paul H., Center City, MN: 

Hazelden, 1987.

■ “Denial,” by Melody Beattie, Center City, MN: Hazelden, 1986.

■ “Releasing Anger,” by Richard S., Center City, MN: Hazelden, 1985.

■ “Grieving: A Healing Process,” by Peter McDonald, Center City, MN: 

Hazelden, 1985.

■ “Detaching With Love,” by Carolyn W., Center City, MN: Hazelden, 

1984.

Final Core 

Session: 

Termination

Readings
10

Twelve-Step Facilitation Therapy Manual

This treatment program differs from a social learning model and a 

motivational model of alcoholism treatment in several ways. Specific 

assumptions associated with this treatment program include the 

following:

■ Alcoholism is a chronic progressive illness with predictable symptoms and a predictable course.

■ Alcoholics have permanently lost the capacity to control their 

drinking.

■ Alcoholism affects the alcoholic’s body, mind, and spirit, and true 

recovery requires healing in each of thesefellow.,

■ The only viable alternative for the alcoholic is total and lifelong 

abstinence from alcohol.

■ Even a single drink can trigger the alcoholic’s craving for alcohol 

and lead to a renewed cycle of compulsive drinking.

■ Individuals will have the best chance of staying sober over the long 

run if they—

— Accept their loss of control.

— Reach out to fellow, alcoholics through AA.

■ Spirituality—faith in a Higher Power—plays a more powerful role in 

recovery than individual willpower.

■ Encouraging patients to actively work the 12 Steps of Alcoholics 

Anonymous is the primary goal of treatment, as opposed to any 

skill that the therapist can teach.

■ Patients will be better served if they can be taught and encouraged 

to utilize the fellowship of AA and its resources (meetings, Hotline, 

sponsorship) as opposed to relying primarily on the therapist as a 

means of sustaining sobriety.

■ The ultimate goal for the alcoholic is to resist taking the first drink, 

one day (or hour) at a time.

Contrast

With Other

Treatment

Approaches
11

Therapist Guidelines

It is important that therapists make every effort to follow the format 

laid out in this manual. Therapists should decide before each session 

which topic will be covered (either core or elective). Therapists should 

be thoroughly familiar with the contents of a session prior to beginning 

it. Allowing for some degree of individual therapeutic style, therapists 

should nevertheless attempt to ask questions and cover issues in ways 

similar to how they are presented here. While it is recognized that the 

actual content of therapy will be affected by the individual patient, 

every effort should be made to cover as much material as possible, 

including all core topics and as many electives as is reasonable given 

the individual case.

The primary role of the therapist is as a facilitator of patients’ acceptance of their alcoholism and of a commitment to the fellowship of 

Alcoholics Anonymous as the preferred path to recovery. This is accomplished by the therapist serving the following functions.

The therapist acts as a resource and advocate of the 12-Step approach 

to recovery. The 12-Step therapist—

■ Explains the AA view of alcoholism and interprets slips and resistance to AA in terms of the power of alcoholism and the dynamics 

of denial.

■ Introduces several of the 12 Steps and their related concepts and 

helps the patient to understand key AA themes and concepts (e.g., 

denial, powerlessness) by identifying personal experiences that 

illustrate them.

■ Introduces, explains, and advocates reliance on the fellowship of 

AA as the foundation for recovery, which should be thought of as 

an ongoing process of “arrest” (as opposed to cure).

■ Explains the role of a sponsor and helps patients identify what they 

would most benefit from in a sponsor.

Using This 

Manual

Role of the 

Therapist

Education
12

Twelve-Step Facilitation Therapy Manual

■ Answers questions about material found in the “Big Book,” the “12 

x 12,” and other readings.

The therapist uses patients’ reports of their experience between sessions 

to actively facilitate their involvement in AA. The 12-Step therapist—

■ Encourages attendance at AA meetings, monitors patient involvement in AA, and actively promotes a progression toward greater 

involvement in AA, for example, by going to meetings that require 

more personal involvement, such as “Step” meetings and “discussion” meetings.

■ Clarifies the role of therapist versus sponsor and refuses to become 

a sponsor while helping the patient find one.

■ Remains vigilant for signs of denial, particularly in patient accounts 

of slips, and explains slips in terms of denial.

■ Suggests recovery tasks that will enhance patients’ understanding 

of alcoholism and AA as well as their successful integration into the 

fellowship of AA.

Desired Therapist Characteristics

Twelve-Step therapists, being professionals whose goal is to facilitate 

and encourage active participation in Alcoholics Anonymous, need not 

be personally in recovery. However, they must be knowledgeable of and 

comfortable with the foundation of 12-Step recovery as described in AA 

Conference-approved literature. Therapist self-disclosure of recovery 

status is to some extent a clinical issue (i.e., dependent on the particular case), but generally speaking, the authors encourage honesty in the 

therapeutic relationship.

If experienced therapists who are not in recovery contemplate using this 

manual, it is strongly recommended that they attend at least 10 open 

AA meetings and an equal number of Al-Anon or Families Anonymous 

meetings and be thoroughly familiar with all of the reading material 

that is recommended for patients. In addition, to be maximally effective 

as a facilitator, the therapist is advised to develop a network of AA contacts: men and women who are active in AA and who could be called 

on to assist in getting a shy or ambivalent patient to those first meetings, giving advice about particular meetings, providing directions, and 

so forth. Persons who have been sober and active in AA for a least a 

year are candidates for doing this type of 12-Step work as part of their 

own recovery. Therapists can develop working relationships with these 

Facilitation

Status With 

Respect to 

Recovery
13

Therapist Guidelines

people by going to AA meetings on some regular basis or by talking 

with recovering persons they know. Firsthand knowledge of such contact people is desirable.

In general, therapists using this approach are expected to be forthcoming and conversational, as well as appropriately self-disclosing. 

Twelve-Step therapists are expected to be interactionally active and 

nonjudgmentally confrontive during therapy sessions, as opposed to 

merely reflective. This does not mean that the therapist lectures the 

patient, does more talking than the patient, or chastises the patient 

for slips. Rather, the therapist utilizing this approach should be prepared to identify denial and confront the patient consistently in a frank 

but respectful manner regarding the patient’s attitudes or behaviors, 

to actively encourage the patient to get involved in the fellowship of 

AA, and to help the patient understand key AA concepts as they are 

reflected in the patient’s actual experience.

Therapists should recognize that while this facilitation program is 

structured, it is not inflexible. Patients can be expected to interpret 

the AA concepts presented here in light of their own experience. This 

is consistent with the AA approach, which allows for a great deal of 

individuality of interpretation within broad guidelines. For example, 

the 12 Steps specifically allow for individuality in conceptualizing a 

Higher Power (“God as we understand Him”). Similarly, what represents unmanageability (Step 1) for one patient may not be meaningful 

to another. What is most important is not whether patients interpret 

these concepts in the same way; rather, what counts is the end result: 

active involvement in the fellowship of Alcoholics Anonymous.

The 12-Step therapist is familiar with basic AA traditions and introduces them, along with various AA slogans, as they are appropriate in 

treatment. These slogans (Easy Does It, One Day at a Time, Fake It Till 

You Make It, Turn It Over, etc.) are most helpful when they are related 

to a patient’s life. The successful 12-Step therapist uses slogans judiciously and gives them meaning by connecting them to the individual 

patient’s experience.

Twelve weeks is a short time in which to facilitate lasting change. This 

is a structured program with much material to be covered; therefore, 

it becomes a therapeutic challenge to cover as many issues as possible 

for each patient in the time alloted. It is expected that all core topics 

will be covered, plus as many electives as possible.

At the beginning of each session, through the process of reviewing the 

previous week, issues relevant to the individual patient’s life can be 

expected to come up. Patients should be given time to articulate their 

problems and concerns and to feel heard by the therapist. At the same 

Active, 

Supportive, 

and Involved

Focused 

Treatment
14

Twelve-Step Facilitation Therapy Manual

time, it is important to keep in mind that the focused nature of this 

program does not allow therapists to “follow the patient” entirely—in 

other words, to create therapeutic agendas that ignore the facilitation 

program’s content or objectives.

In light of this, it is the therapist’s responsibility to keep therapy sessions focused on sobriety-related issues and to avoid getting off the 

track into lengthy discussions of other matters (marital, job, or parenting problems). In such cases, therapists should invoke the First Things 

First slogan: Emphasize the patient’s need to focus on sobriety as the 

foundation for all other changes and growth. Benefits gained from 

establishing sobriety may very well have beneficial spillover effects into 

many other areas of the patient’s life. One response to a patient’s persistent efforts to divert the discussion to relationships, work, or family 

problems could be assurance of referral to appropriate therapy following completion of the 12-Step facilitation program, should these issues 

continue to be of concern.

In this program, the fellowship of AA, and not the individual therapist, 

is seen as the major agent of change. Involvement in AA (including 

regular attendance at a variety of meetings and AA social activities 

plus the use of a sponsor) is therefore considered preferable to reliance 

on the therapist (who will be unavailable after the 12th session). In 

general, patients should be encouraged to rely on the resources of the 

fellowship, more than on the therapist, in times of crisis.

When bona fide crises arise that cannot be reasonably solved by going 

to an AA meeting or by calling an AA friend, the AA Hotline, or a sponsor, the therapist may elect to schedule an emergency session. The 

goals of such sessions should be-

■ To help the patient assess the nature of the crisis in terms of how 

it threatens sobriety.

■ To establish priorities (First Things First).

■ To identify courses of action that are consistent with the AA 

approach to recovery.

■ To solve the crisis by relying on AA.

In the context of this program, confrontation is something that therapists can think of as helpful and honest mirroring. The most appropriate 

form of confrontation is to share frankly but respectfully what you 

see the patient doing. Most often this involves confronting the patient 

about some form of denial.

Reliance on AA

Confrontation
15

Therapist Guidelines

Confrontation that is patronizing or harsh or implies that the patient 

has a character problem as opposed to a powerful and cunning illness 

is likely to be counterproductive in the long run. The therapist needs 

to keep the following goal of confrontation in mind:

Confrontation is a method for helping patients see their behavior in 

perspective: as reflecting resistance to accepting the reality of loss 

of control and unmanageability (Step 1).

The following is one example of the preferred mode of confrontation:

“What you’re saying is that you can’t find the time to go to a meeting. What I hear is that lots of other things are more important to 

you than going to a meeting. I see that as denial, meaning some 

resistance on your part to accepting the fact that you’ve lost control 

over alcohol. It seems that way to me because if you really accepted 

your limitation with alcohol and your need to abstain completely 

from using it, then hardly anything would be more important than 

getting active in a program that offers you hope. I think you’d find 

the time to go for treatments, even every day of the week, if you 

had a potentially terminal illness and if treatment could mean the 

difference between life and death. That’s the way it is with alcoholism. It’s an illness, it’s chronic and progressive, and it can lead to a 

premature death. How do you feel about that?”

Alcoholics Anonymous is both a spiritual and a practical program. 

Both its practical wisdom and its spirituality are reflected in many of 

its slogans.

The 12-Step therapist should not only be familiar with many AA slogans but should actively use them in therapy to promote involvement 

in AA and advise patients in how to handle difficult situations. The better patients understand the meaning behind each AA slogan, the better 

they will be at applying it on a day-to-day basis.

Some key AA slogans are described below.

■ One Day at a Time. Recovery is best thought of as a journey that is 

undertaken one step at a time. The goal is to avoid taking the first 

drink and to stay sober a day at a time. Anniversaries of sobriety 

are important, but ultimately what is most important is whether 

you drink today, not whether you drank yesterday or will drink 

tomorrow.

■ First Things First. If alcoholics do not stay sober, nothing else will 

matter, since they may end up in an institution, in jail, or prematurely dead; meanwhile, alcoholism will undermine their body, 

mind, spirit, and relationships, making the overall quality of life 

Slogans
16

Twelve-Step Facilitation Therapy Manual

progressively worse. Although all people, including alcoholics, have 

multiple commitments, obligations, and responsibilities, the first

commitment of alcoholics must be sobriety. In this area, sponsors 

are especially helpful, as is active participation in meetings.

■ Fake It Till You Make It. Not everything in the AA fellowship will 

appeal or make sense to the recovering person. The slogan asks the 

alcoholic to be humble: to follow advice on faith in the belief that it 

will prove beneficial in the long run. This includes going to meetings, working the Steps, and doing what one’s sponsor advises.

■ Easy Does It. The recovering person meeds to avoid excess stress, 

which will invite relapse. The serenity prayer is relevant here, as 

it urges the recovering person to accept what cannot be changed. 

This includes alcoholism, some family problems, past transgressions, and decisions that have already been made.

■ Turn It Over. A Statement of faith, this slogan encourages acceptance of what cannot be changed in the belief that all will work out 

for the best in the end.

When dealing with technical problems like those described below, the 

goal is to determine if the patient is still interested in and capable of 

participating in the facilitation program.

In general, the therapist should begin by exploring the reason why the 

patient was late, missed, or rescheduled a therapy session. Listen for 

evidence of denial: “I can do this on my own,” “I don’t think my problem 

is as bad as you seem to think it is,” “I don’t believe I’ve lost control of 

my drinking,” “I was busy and forgot about our session,” and so on.

When denial seems to be the issue, the therapist should identify and 

interpret it as part of the illness of alcoholism. Remember that denial 

is necessarily verbalized, but may be “acted out” through behavior or 

through various excuses for not going to the meetings, not doing suggested readings, and so forth. One form that denials often takes is 

chronic lateness and cancellations. If this pattern emerges, but patients 

refuse to “own up to it” as resistance, try to engage them in a frank 

and nonjudgemental discussion of their reservations about treatment. 

If the pattern continues, a more open discussion about motivation for 

treatment may be helpful.

Keep in mind that this form of resistance does not invariably reflect 

denial of alcoholism. In some cases, it may be due to fear of failure, or 

social shyness. Help resistant patients clarify their reasons for resisting active involvement in AA and work from there.

Technical 

Problems

Patient Is 

Consistantly 

Late for 

Appointments/

Cacels Sessions
17

Therapist Guidelines

Do not proceed with a session if a patient shows up under the influence. Ask the patient to call the AA Hotline, an AA friend, or his/her 

sponsor, if possible. If the person is not willing, have him/her call a 

significant other to arrange transportation home. As a last resort, rely 

on local resources or police for transportation. Reschedule the session.

This common resistance can take many forms, from making excuses to 

criticizing AA or its members. Interpret this respectfully as denial—as 

evidence of the patient’s refusal to accept loss of control and the fact 

that alcohol is making life progressively more unmanageable (Step 1.)

It is appropriate to coach patients regarding how to go to a meeting 

and what to expect. The therapist should not offer to take the patient 

to a meeting but may do anything reasonable short of that, such as 

role-playing or arranging for an escort through various AA contacts the 

therapist has developed.

Patiently persist in trying to get the person to make definite commitments to meetings, using the AA schedule to identify specific meetings 

that would be appropriate. Never terminate a patient for refusing to go 

to meetings, since to do so would be inconsistent with AA.

Substance substitution is one symptom of addiction and should be so 

interpreted if the patient appears to be using a substitute for alcohol. 

Addicts cannot be allowed to believe that they can safely use other substances, for two reasons. First, use of another substance will reduce 

resistance to use of the patient’s substance of choice. Second, there 

is a definite risk of cross-addiction (multiple addiction) if the patient 

turns to a substitute mood-altering chemical.

Mild depression may be regarded as either a symptom of withdrawal 

or an appropriate response to acceptance—to admitting to loss of control over alcohol use and the personal limitation that Step 1 implies. 

In contrast, severe depression or other psychopathology may require 

assessment for referral to alternative treatment.

Several additional procedures are consistently implemented in all 

Project MATCH clinical research units. Key MATCH-specific procedures are summarized in the following paragraphs for the information 

of those interested in the details of the trial.

According to MATCH protocol, if a patient misses an appointment 

and cannot be contacted within the following 2 days, the therapist is 

responsible for notifying the project coordinator who then sends a letter to the patient.

Patient Comes 

to Session Drunk

Patient Resists 

Going to 

Meetings

Patient Uses

Other 

Substances

Patient Appears 

Clinically 

Depressed or 

Psychotic

Project 

MATCH 

Guidelines
18

Twelve-Step Facilitation Therapy Manual

Some patients request extra sessions with the therapist, particularly 

in the early weeks of treatment. The need for extra sessions should 

be determined by the clinical judgment of the therapist based on the 

seriousness of the situation. The maximum number of permissible 

extra sessions under the MATCH protocol is 2 (making the maximum 

number of sessions 14). If a patient requires more than two additional 

sessions with the therapist, the possibility of clinical deterioration or 

withdrawal from the study should be considered.

All instances of clinical deterioration must be reviewed with the project 

coordinator. These include development of acute psychosis, suicidal 

or homicidal ideation, onset of cognitive impairment, deterioration of 

physical health, and extensive drinking or drug use. Project MATCH 

has procedures for responding to these developments, and they should 

be reviewed with the project coordinator at the first indication of a 

problem.

Since the goal of Project MATCH is to determine optimal patienttreatment matches in the three therapies, the protocol seeks to avoid 

dilution or duplication of the dose of the intervention received by an 

individual during the treatment period. Project MATCH clients may 

not be seen by other mental health professionals for more than 6 contact hours during their 12 weeks of treatment in the study. If clients 

express interest in other forms of treatment, they should be urged to 

postpone them, if possible, until after the 12-Step treatment is completed. As a routine part of each followup, data are collected on any 

nonstudy therapy a patient may have received.

The final MATCH-specific procedure involves referring patients who 

are dissatisfied with their treatment. If all attempts to keep a patient 

in treatment fail, the study must provide a specific referral and help 

the patient make contact. Additional treatment may not be provided 

by the 12-Step therapist or any other therapist in the study. Referral 

is to be made to an outside agency or to a therapist within the same 

agency who has no involvement in the study. Referral must first be discussed with the project coordinator or project director, because it has 

implications for the patient’s continuation in the study. In any event, 

the patient is urged to participate in followup interviews as originally 

planned.
19

Part 1: Core Topics

In order to expose patients to key AA concepts of alcoholism, therapists 

need to be sure to cover all of the four core topics described in part 1 

and to do so thoroughly. These topics should be discussed in the order 

in which they are presented here:

Topic 1: Program Introduction

Topic 2: Step 1—Acceptance

Topic 3: Steps 2 and 3—Surrender

Topic 4: Getting Active

It may be necessary to refer back to one or more core topics from time 

to time, even when the topic for a given session is an elective (see part 

2).

Topic 1: Program Introduction should be covered in the first session. It 

follows a unique format and may take up to 11/2 hours to complete.

Topic 2: Step 1—Acceptance should be presented in the second session. 

Sessions 2 through 11 follow a consistant format, which is described 

later.

After all four core topics have been covered, sessions may move on to 

one or more elective topics.

21

Topic 1: Program Introduction

Session 1, which may run as long as 11/2 hours, has several objectives:

■ Introduce patients to the AA view of alcoholism.

■ Help patients assess their level of alcohol involvement (including 

symptoms of dependency).

■ Explain the 12-Step facilitation program.

■ Attempt to engage patients in active participation in this program; 

in other words, to “give AA a chance.”

The therapist can begin by establishing rapport and getting basic background information:

■ Therapist’s name. NOTE: First names are appropriate.

■ “Where do you live?”

■ “Do you live alone or with someone? Who?”

■ “Are you working? Where? What do you do?”

■ “Were you able to find the clinic okay?”

■ “How does this time work out for you?”

■ Why is the patient in the program?

— “How do you feel about being here today?”

— “What circumstances led to your being here?”

— “How did you find out about this program?”

Opening
22

Twelve-Step Facilitation Therapy Manual

Having briefly established the reasons for being in treatment, move 

on to an assessment of the patient’s previous experiences, if any, with 

alcohol treatment programs.

■ Has the patient been in an alcohol rehabilitation program or any 

other treatment program for drinking?

— “Have you ever gone for help about your drinking before today?”

— “If you have been in treatment before, give me a quick run-down 

of those experiences:

• Where and when did they occur?

• What was the orientation (philosophy) of the program(s)?

• What did you learn about yourself and your drinking from 

those treatment experiences?

• How long did you stay sober after each of those treatments?”

■ What, if any, experience has the patient had with Alcoholics 

Anonymous?

— “Have you ever gone to AA? How many times?”

— “Approximately how many AA meetings have you attended in 

the last year?”

— “When did you stop going to AA and why?”

— “If you had a period of sobriety, what were the circumstances of 

your relapse? How did you react to your relapse? How did you 

feel? What did you do?”

■ How has the patient attempted to stop or control alcohol use aside 

from formal treatment or AA?

— “How have you tried to either control or stop your drinking on 

your own? What were these experiences like?”

— “What has been the longest period of time, over the past year or 

so, that you’ve gone without having even a single drink?”

■ What is the patient’s interest in this program?

— “Do you honestly believe you have a drinking problem?”

— “Are you interested in doing something about your drinking?”

— “Do you think you need help? If so, why?”

Previous

Treatment

Experience
23

Topic 1: Program Introduction

C

A

H

o

o

c

E

a

p

T

e

a

t

R

t

r

R

a

— “Do you believe you need to stop drinking altogether?”

— “How do you feel about being in this treatment program at this 

time? What are your hopes? What are your fears or concerns?”

Following the introduction, proceed to the alcohol history. This is 

a chronological account of alcohol use, including patterns of use 

(increases, changes in preference) as well as life events and transitions that were associated with either the onset of drinking or some 

significant change in drinking habits. The therapeutic goal of an alcohol history is to facilitate acceptance (Step 1) by identifying patterns 

of problems associated with drinking, based on information collected 

through self-report. In particular, an alcohol history can help draw 

a connection between alcohol abuse and negative consequences (life 

becoming unmanageable).

The alcohol history can be introduced as follows:

“I’d like to spend some time with you doing an alcohol history 

together. The purpose of an alcohol history, by the way, is to help 

us both identify the patterns of your alcohol use over time, as well 

as to see how the use of alcohol as a mood-altering substance may 

have had an impact on your life.

“It is important that you be honest with me about this information, 

which will be held in confidence. Also, it will be helpful if you can 

identify what was going on in your life at times when your drinking 

increased. I’ll also be asking you about how drinking affected you, 

positively and negatively, at different times. Let’s start your alcohol 

history at the age when you first used alcohol.”

Here is an example:

Age Amount used/

how often

Positive/negative 

effects

Significant events at 

this time of life

11 Sips from my 

father’s beer once 

or twice.

Felt grown up and 

high. Felt sick 

sometimes.

My family moved. I 

had to leave all my old 

friends.

13 Drank beer after 

school with friends 

two or three times 

a week.

It was exciting, 

kind of cool and 

rebellious.

My father was changing 

jobs a lot at the time.

NOTE: In addition to the above basic information, some therapists 

may want to get more detailed information on the following:

Alcohol 

History
24

Twelve-Step Facilitation Therapy Manual

■ What type of alcohol was consumed at different ages, including 

preferred forms of alcohol.

■ Amount used, including least, most, and average amounts consumed at different points in time.

■ Changes (increases) in use, by age.

■ What feelings were associated with significant increases in 

alcohol use.

Take the history in broad strokes. Starting with the age of first use, 

ask what drinking was like 3 years later; then proceed in 5-year 

increments. Note significant life changes (marriages, divorces, job 

changes, births) that correlate with changes in drinking patterns.

The therapist should also inquire at some point during the alcohol history about the patient’s use of other mood-altering chemicals. Inquire 

specifically about the patient’s history of use, and current use, of each 

of the following:

■ Marijuana

■ Cocaine

■ Amphetamines (“speed”, “uppers”)

■ Barbiturates (“downers”)

■ Prescription drugs

■ LSD (acid, mushrooms)

■ Heroin

Note any current use of any of the above substances, since the treatment goal will change from abstinence from alcohol use to abstinence 

from use of all mood-altering chemicals.

Having established a history of alcohol use, the therapist now works 

with the patient to determine the nature and chronology of negative 

consequences that have been associated with alcohol abuse, using an 

introduction such as the following:

“Now let’s take a look at some of the issues, problems, and conflicts 

that you’ve experienced these past several years, starting with your 

physical health.”

Consequences can be divided into several categories.

Negative

Consequences
25

Topic 1: Program Introduction

Included here are all medical problems, as well as accidents or injuries, 

that have occurred while under the influence of alcohol, such as—

■ Hypertension (high blood pressure).

■ Gastrointestinal (digestive) problems.

■ Insomnia.

■ Weight loss.

■ Auto, home, or job accidents / injuries.

■ Blackouts.

■ Passing out.

■ Heart disease.

■ Diabetes.

Includes DWI arrests and other legal consequences associated with 

alcohol use. For veterans, inquire about military history for any drinking-related incidents.

The therapist should inventory all social consequences of alcohol use, 

including—

■ Job problems.

■ Marital problems.

■ Loss of old friends subsequent to alcohol abuse.

Sexual dysfunctions associated with habitual alcohol use include—

■ Problems of arousal in both men and women (e.g., impotence).

■ Orgasmic dysfunction (anorgasmia in women, delayed ejaculation 

in men).

The therapist should ask whether the patient is experiencing any 

symptoms of depression: 

■ Insomnia or disturbed sleep (e.g., waking up consistently in the 

middle of the night).

■ Appetite disorders, especially loss of appetite.

Physical

Consequences

Legal 

Consequences

Social 

Consequences

Sexual 

Consequences

Psychological

Consequences
26

Twelve-Step Facilitation Therapy Manual

■ Irritability or moodiness.

■ Loss of motivation/drive/interest.

■ Memory problems (especially “forgetfulness”).

Ask patients specifically about their current financial status and 

problems they may have had over the past few years, including-

■ Creditor problems (revoked credit cards, etc.).

■ Mortgage/rent problems.

■ Delinquent loans.

■ Problems “making ends meet.”

■ Fines.

■ Legal fees associated with alcohol-related arrests.

Summarize the completed inventory of problems or consequences. Do 

this partly to get concurrence and partly to elicit yet further consequences that may not have been mentioned so far.

The final step in the alcohol history is to test the patient’s willingness 

to draw a connection between negative consequences and drinking:

“I’m interested in knowing if you see any connection between any 

of these problems you’ve had and drinking. What do you think? Do 

you believe that any of these could have been avoided if you weren’t 

drinking at the time? Which ones? What consequences of alcohol 

use have you suffered recently?”

Another symptom of alcohol dependency to be assessed is tolerance—

the tendency to require progressively larger amounts of a mood-altering 

chemical like alcohol to produce a similar physical/emotional effect. 

The therapist should ask questions like the following to determine if a 

tolerance to alcohol has been developed:

■ “Does it take more alcohol now than it used to for you to get really 

drunk?”

■ “Have you noticed that your ability to drink has gotten stronger 

over time; in other words, that you can hold your liquor better now 

than before?”

Financial 

Consequences

Summary

Tolerance
27

Topic 1: Program Introduction

■ “Have you noticed any tendency in yourself to develop a ‘reverse tolerance,’ meaning the tendency to feel drunk on just a single drink 

or two?”

Symptoms of loss of control over alcohol use include—

■ Repeated failures in efforts to stop use.

■ Failed efforts to control or restrict use, such as:

— Drinking only on weekends.

— Drinking only wine (beer, etc.).

— Limiting amount consumed (“no more than ”).

NOTE: The following passage from the “Big Book” may also be useful with patients:

Here are some of the methods we have tried: Drinking beer only, 

limiting the number of drinks, never drinking alone, never drinking 

in the morning, drinking only at home, never having it in the house, 

never drinking during business hours, drinking only at parties, 

switching from scotch to brandy, drinking only natural wines, 

agreeing to resign if ever drunk on the job, taking a trip, not taking 

a trip, swearing off forever (with and without a solemn oath), taking 

more physical exercise, reading inspirational books, going to health 

farms, accepting voluntary commitment to [hospitals]—we could 

increase the list ad infinitum. (p. 31)

■ Substance substitution: substituting a second- or third-favorite 

form of alcohol (or another mood-altering chemical) if the preferred 

form is not available.

■ Hiding a supply of alcohol.

■ Preoccupation:

— Thinking about having a drink while at work or anticipating the 

first drink on the way home from work.

— Avoiding responsibilities and obligations in order to drink.

— Buying extra alcohol in case your supply runs low.

■ Drinking alone.

■ Drinking within an hour or two of waking up.

■ Guzzling drinks in order to get high faster (“chasing a high”).

Loss of Control
28

Twelve-Step Facilitation Therapy Manual

■ Drinking before social occasions in order to get a head start.

■ Feeling upset if one’s supply is low, or having a tantrum if deprived 

of alcohol.

■ Drinking more than you intended to on a number of occasions.

Using information obtained from the alcohol history as well as other 

information (such as negative consequences associated with use, tolerance, and loss of control), the therapist now needs to share a diagnosis 

with the patient. In doing so, it is vitally important to emphasize that 

it is based on information provided directly by the patient. One way to 

do this is as follows:

“It seems to me, based on the information you’ve given me so far, 

that you have the following symptoms:

■ Tolerance (explain, using specific examples from self-report).

■ Loss of control (give supportive evidence).

■ Continued drinking even though you’ve experienced the following negative consequences as a result of it: (summarize 

consequences).

“Taken together, this information you’ve given me suggests that 

you cannot effectively control your use of alcohol. Basically, that 

inability to control your use is what it means to be an alcoholic.”

Alternatively, a diagnosis based on the very same self-report data 

can be correlated to a Jellinek chart. Two such charts, one for men 

and one for women, are included in appendix A. Based on analyses of 

case histories, the Jellinek charts present a visual image of the course 

of alcoholism in terms of symptoms. They also lay out a pathway to 

recovery.

If you choose to use the Jellinek charts to share a diagnosis, once 

again be certain that you can document your case by referencing the 

patient’s self-reported experiences. It can be approached in this way:

“Let me give you this chart to look at. I have a copy too. It’s based 

on research, and it shows the course of alcoholism. It shows how 

symptoms progress and how alcoholism eventually ends in obsessive 

drinking. I believe that your use of alcohol at this time places you at 

the __________ stage of use. Let me give you my reasons for believing 

that, based on what you’ve told me today.”

Diagnosis
29

Topic 1: Program Introduction

The therapist should now review this 12-Step facilitation program, 

being sure to cover each of the following points.

There will be 12 sessions in all, 2 of which may be conjoint sessions 

with the patient and hiWher spouse or partner (to be determined jointly 

by the therapist and the patient). In addition, there can be up to two 

emergency sessions if needed. The therapist will decide if an emergency session is appropriate.

The therapist will help the patient achieve the following objectives:

■ Understand the AA view of alcoholism: That alcoholism is a chronic, 

progressive, and fatal illness that cannot be cured but which can be 

arrested so long as a person who has the illness is willing to follow 

some suggestions based on the experience of other alcoholics.

■ Understand how AA works: How to find meetings, different types of 

meetings, sponsorship, and so on.

■ Understand some of the key AA concepts, such as “surrender,” as 

well as the meaning behind many of its slogans.

■ Learn how to use AA as a resource for staying sober One Day At A 

Time.

Make it clear that you are there to—

■ Educate, support, and advise the patient.

■ Act as a resource person and coach to facilitate the patient’s understanding of alcoholism, the fellowship of AA, and its 12 Steps.

■ Help the patient focus on staying sober One Day At A Time with the 

help of AA.

Explain that you expect the patient to—

■ Attend all sessions.

■ Come to sessions sober.

■ Keep a journal.

Program 

Overview

Sessions

Objectives of 

Treatment

Responsibilities

of the Therapist

Responsibilities

of the Patient
30

Twelve-Step Facilitation Therapy Manual

■ Make an honest effort to follow through on recovery tasks suggested by the therapist.

■ Be honest, even about slips.

■ Focus on staying sober One Day At A Time.

NOTE: Ask patients to call 24 hours in advance if a session needs 

to be rescheduled and to call if they are going to be late or will 

miss a session. Also ask patients to try to arrive 5-10 minutes 

early for each session, beginning with session 2, so that you will 

have a few minutes to review the patient’s journal in advance. 

The purpose of this request is to emphasize the importance of 

the journal and to allow you to plan specific recovery tasks with 

respect to AA meetings and suggested readings.

Recovery tasks are specific suggestions made by the therapist at the 

end of each session. They should be followed up on at the beginning 

of the next session. Suggestions should always be made in two areas:

■ How many AA meetings the patient will attend between sessions, 

with the goal for initial recovery being the equivalent of one meeting 

a day.

■ What materials the therapist suggests that the patient read before 

the next session.

In addition to the above, the therapist may wish to make suggestions 

about specific AA meetings (or types of meetings) the patient should 

attend and about how the patient can get active in AA meetings.

Give patients a current schedule of AA meetings that are held in their 

geographic area. If patients live and work in two different areas, give 

them a schedule for each area. Help patients select which meetings 

they will attend between now and the next session. Note this in writing 

for followup purposes, and make sure that the patients write it down 

in their journal as well.

NOTE: The objective is to attend the equivalent of one AA meeting 

a day (i.e., 90 meetings in 90 days). The therapist should start out 

with this suggestion and then negotiate with patients to attend as 

many meetings as they are willing to. In later sessions, the therapist should continue to advocate going to meetings on a daily 

basis as well as whenever the patient has an urge to drink.

Recovery 

Tasks

Meetings
31

Topic 1: Program Introduction

Give the patients journals (a composition book is fine for this purpose). Ask them to make a note of all AA meetings they attend (dates 

and times) as well as their unedited thoughts and reactions to them. 

Encourage patients to be completely honest about both positive and 

negative feelings about meetings. Also, ask them to note any reactions 

to readings in the AA literature.

Provide the patient with a packet containing the following AA 

publications:

■ “Alcoholics Anonymous” (the “Big Book”)

■ “Twelve Steps and Twelve Traditions” (the “12 x 12”)

■ “Living Sober”

Ask the patient to begin reading these books, and make any specific 

suggestions you like with respect to them, keeping in mind the patient’s 

reading level and the amount of time (per day) that can reasonably be 

devoted to reading. Chapters 1, 2, and 5 of the “Big Book” are useful 

for those who are completely unfamiliar with AA, as are pages 1-7 of 

“Living Sober.”

The therapist should end this session by checking the patients’ willingness to follow through on recovery tasks. Help patients articulate any 

resistance you detect, and establish empathy with them. Encourage 

patients to do as much as they can, with primary emphasis on attending AA meetings. Clinical judgment and therapeutic skill should be 

utilized to modify recovery tasks if necessary (for example, if written 

material clearly appears to be above the patients’ reading level, or if 

they have already done extensive reading).

The purpose of the first session is to engage the patient’s interest in 

voluntarily committing to this 12-Step facilitation program. Approaches 

that utilize excessive pressure, threat, or coercion toward this end are 

likely to elicit a false commitment at best. This false commitment is 

called “compliance.” The compliant patient in treatment is “talking the 

talk” of recovery (most likely to either please or placate the therapist) 

but is not “walking the walk” of recovery, in the sense of being truly 

motivated to give the fellowship of AA an honest try. In this program, 

the therapist is advised to take a direct, nonjudgmental, and educative 

approach to confrontation. Stick to the facts as you see them, and do 

not allow yourself to be talked out of your interpretation of those facts. 

At the same time, respect the patient’s resistance to the idea of being 

powerless over alcohol.

The chemical history, along with symptomatology (tolerance, etc.) and 

an understanding of the process of alcoholism (Jellinek charts), should 

Journal

Reading

Troubleshooting
32

Twelve-Step Facilitation Therapy Manual

be relied on consistently as the basis for confronting patients firmly and 

frankly with their current situation. The therapist who is convinced 

that alcoholism is a disease process should have confidence that alcoholic patients have struggled to control their use and should attempt 

to elicit evidence of this in a direct but supportive and sympathetic 

way. Similarly, slips can be discussed frankly yet sympathetically as 

the result of a disease that is more powerful than individual willpower.

Faced with resistant patients, the therapist should attempt to 

consistently provide feedback to them regarding—

■ How the patient’s life is becoming increasingly unmanageable due 

to alcohol abuse.

■ How individual efforts have not proven effective in stopping or controlling use over the long run.

Resist temptations to be distracted from the main subject of this program, which is the patient’s alcohol use and AA. Remember that the 

goal here is facilitation of the patient into AA. Concurrent issues 

(marital problems, job problems, posttraumatic stress, depression) 

can be handled initially by encouraging the patient to make use of AA 

resources such as meetings and social events, peers, and sponsors.

For patients who have a difficult time understanding the concept of 

“powerlessness” as it applies to drinking, reading the following story, 

excerpted from the “Big Book” may be helpful:

Our behavior is as absurd and incomprehensible with respect to the 

first drink as that of an individual with a passion, say, for jay-walking. He gets a thrill out of skipping in front of fast-moving vehicles. 

He enjoys himself for a few years in spite of friendly warnings. Up 

to this point, you would label him as a foolish chap having queer 

ideas of fun. Luck then deserts him and he is slightly injured several times in succession. You would expect him, if he were normal, 

to cut it out. Presently he is hit again and this time has a fractured 

skull. Within a week after leaving the hospital a passing car breaks 

his arm. He tells you he has decided to stop jay-walking for good; 

but within a few weeks he breaks both legs.

On through the years his conduct continues, accompanied by his 

continual promises to be careful or to keep off the streets altogether. Finally, he can no longer work, his wife gets a divorce, and 

his friends laugh at him. He tries his best to get the jay-walking 

idea out of his head. But the day comes when he races in front of a 

fire engine, which breaks his back.

The fact is that alcoholics, for unknown reasons, have lost the power 

of choice in drinking. Their so-called willpower becomes practically
33

Topic 1: Program Introduction

nonexistent. They are without defense against taking the first drink. 

(p. 37)

Follow this up by engaging the patient in a discussion of this story, 

asking questions like-

■ “Can you relate to the idea of ‘compulsion’ that’s presented in this 

story?”

■ “Would you say that jay-walking was ‘out of control’ in this case?”

■ “Have you known anyone who had a compulsion or an obsession 

that they couldn’t control?”

■ “Can you see how some people are as out of control of their drinking as this man was out of control of his jay-walking?”

NOTE: In approaching alcoholic patients using this program, it is 

important that the therapist accept alcoholism as a no-fault illness. In other words, consider alcoholism to be a disease to which 

individuals are genetically predisposed. It is not their fault that 

they have either the predisposition or the illness itself; therefore, 

guilt over being an alcoholic is as inappropriate as is guilt over 

having renal disease or diabetes. There is also no cure for alcoholism; rather, there is only a method for arresting the process, 

which is active participation in the 12-Step program of Alcoholics 

Anonymous.

While alcoholics are not responsible for their illness, they are 

responsible for their recovery. Alcoholics cannot blame anyone 

else for their illness or assign responsibility to anyone else for 

their recovery.

35

Format: Sessions 2–11

Sessions 2 through 11 follow a common format. 

■ Review of journal

— All meetings attended since the last session.

— Reactions to meetings.

NOTE: Patients should be encouraged to attend meetings on a 

daily basis, and the therapist should negotiate down from that 

expectation with reluctance. Get specific commitments in this 

regard, and follow up by checking journal entries. Consult with 

your supervisor if there is strong resistance here and also regarding what types of meetings are appropriate for a particular patient.

■ Review of slips

— What, where, and with whom?

NOTE: The goal is to find out how patients handled a slip and what 

they could do next time that would be consistent with AA, such as-

■ Calling the AA Hotline.

■ Going to a meeting.

■ Calling someone the patient met at a prior meeting (an AA 

peer).

Some people prefer the word “relapse” to the word “slip.” Either 

may be used, though the former seems to have more severe connotations than the latter.

■ Review of urges

— When and where?

Review

(10-15 minutes)
36

Twelve-Step Facilitation Therapy Manual

— How did the patients handle them?

— What could they do in the future that would be consistent with 

AA?

■ Review of sober days

— Every day of sobriety deserves recognition and praise, without 

going so far as to promote false confidence or complacency.

■ The therapist introduces new concepts or material for discussion.

■ Questions/reactions are elicited and discussed.

■ Meetings

■ Readings

■ Other suggestions

■ What was the gist of today’s discussion in the patient’s own words?

■ Does the patient understand the recovery tasks that have been 

suggested? Is s/he willing to follow through on them?

New Material 

(30 minutes)

Recovery Tasks 

(10 minutes)

Summary

(5 minutes)
37

Topic 2: Step 1—Acceptance

■ Meetings attended.

■ Reactions to meetings.

■ Discussion of why meetings were not attended, if appropriate.

■ Reactions to readings.

■ Where, when, and with whom?

■ What did the patient do about them?

■ What could the patient do in the future that would be consistent 

with AA?

■ When and where?

■ How did the patient handle it?

■ What could the patient do in the future that would be consistent 

with AA?

■ How many?

■ How many successive?

■ Reinforce with recognition of a significant accomplishment.

Session 2 introduces the first Step of AA and the following key concepts:

■ Powerlessness (and limitation).

■ Unmanageability.

■ Denial (versus acceptance).

Review

Journal

Slips

Urges

Sober Days

New Material:

Step 1 and

Denial
38

Twelve-Step Facilitation Therapy Manual

Step 1 of Alcoholics Anonymous reads as follows:

WE ADMITTED WE WERE POWERLESS OVER ALCOHOL—

THAT OUR LIVES HAD BECOME UNMANAGEABLE

Step 1 is, in fact, a complex statement. Its essence is the acceptance of 

personal limitation, in this case, one involving the loss of control over 

drinking. Although some individuals apparently achieve this acceptance via a single leap of faith, it is also possible to think of acceptance 

as a process involving a series of stages:

■ Stage 1: “I have a problem with alcohol.”

■ Stage 2: “Alcohol (drinking) is gradually making my life more difficult and is causing problems for me.”

■ Stage 3: “I have lost my ability to effectively control (limit) my use of 

alcohol, and the only alternative that makes sense is to give it up.”

When discussing Step 1, it may be helpful to keep these stages of 

acceptance in mind and to work with patients toward the end of helping them achieve acceptance in stages.

To begin, facilitate a discussion of Step 1, reading it aloud and then 

talking about it, making sure to cover the following points:

■ “What does this statement mean to you? What is your initial reaction to it? Does it make you mad at all?”

■ “How do you relate to the concept of powerlessness? What kinds 

of things are you powerless over? Can you understand how some 

people can be powerless over alcohol?”

■ “At this point, do you believe that you can still control your use of 

alcohol? On what basis do you believe this?”

■ “In what ways has your life become unmanageable?” Using a chalkboard or flipchart, list ways in which the patient’s life has become 

increasingly unmanageable.

Say to the patient something like the following:

“Step 1 represents a statement of personal limitation. Accepting 

powerlessness over alcohol is much like having to accept any other 

personal limitation or handicap. Some people who have a hard time 

relating to Step 1 as it is written relate to it better if it is framed in 

terms of limitation. I would like you to think of times in your life 

when you were confronted by a limitation of some sort. It could be 

physical, intellectual, economic, or whatever. Whatever it was, it 

stood between you and something you wanted. What was it?”

Stages of 

Acceptance
39

Topic 2: Step 1—Acceptance

Continue as follows:

“Typically, people do not react to limitation calmly; instead, they 

resist or deny it.

■ Can you relate to feeling mad about having to face some personal limitation in the past?

■ Is limitation easy or difficult for you to accept?”

Explain to the patient that “denial” is a term used to refer to the difficulty people often have in accepting or coming to terms with a personal 

limitation. The roots of denial lie in how it feels to have to accept a 

limitation, which usually is very unpleasant.

Limitation causes pain, and it is normal for people to protect themselves from pain. Limitation arouses feelings of anxiety, anger, shame, 

sadness, inadequacy, or guilt. Any or all of these emotions can motivate the individual to avoid (deny) coming to terms with (accepting) a 

personal limitation.

■ Ask the patient how it feels to think about being powerless over 

alcohol.

■ List these feelings.

Anger, anxiety, and depression are typical reactions to limitation. 

Acceptance of alcoholism, like acceptance of any limitation, is a grief 

process. Denial has a place in this process, as do anger and sadness. 

One stage of grief is “bargaining.” As it applies to Step 1, bargaining 

is alcoholics’ secret belief that they can “safely” drink; in other words, 

that they can control their drinking.

Explore this idea of bargaining, which is part of our natural defense 

against accepting loss and limitation. In this case, the loss is the loss of 

control over alcohol use, and the limitation is the fact that the patient 

can no longer safely drink.

Describe and explain the following forms of denial:

■ Refusing to face facts: Refusing to do a serious alcohol history, 

refusing to acknowledge negative consequences of use, rejecting 

clear evidence of tolerance, refusing to go to AA meetings.

■ Minimizing the facts: Understating negative consequences, tolerance, and so forth.

Denial
40

Twelve-Step Facilitation Therapy Manual

■ Avoiding: Sleeping a lot, becoming socially isolated, or becoming 

compulsive (addictive) in some other way, such as work or eating.

■ Exaggerating others’ use in an effort to “normalize” one’s own use.

■ Blaming someone/something else for alcohol use (a bad marriage, 

family conflicts, feeling depressed, etc.), as opposed to accepting 

the fact that cravings for alcohol are responsible for use.

■ Bargaining: Trying to limit or control either the amount or type of 

alcohol used or when it is used.

■ Rationalizing: Making up “good” reasons (usually ones that will get 

sympathy) for drinking.

Work with patients to list some of the ways in which they are denying 

their powerlessness and the limitation of alcoholism.

The therapist should now provide a brief summary of AA: It is a peerhelp movement (a fellowship) that was started by a physician and a 

stockbroker who had tried their best to control their alcohol use over 

many years, only to conclude defeat. If it would be helpful, read the 

following excerpt:

Most of us have been unwilling to admit we were real alcoholics. No 

person likes to think he is bodily and mentally different from his fellows. Therefore, it is not surprising that our drinking careers have 

been characterized by countless vain attempts to prove we could drink 

like other people. The idea that somehow, someday he will control and 

enjoy his drinking is the great obsession of every abnormal drinker. 

The persistent illusion is astonishing. Many pursue it into the gates of 

insanity or death. (“Alcoholics Anonymous,” p. 30)

Explain that the fellowship of AA was founded on this simple idea: 

Some people, for some reason, simply could not stop their use of alcohol by relying on individual willpower alone; instead, they had to come 

to terms with the need to abstain from alcohol altogether and to seek 

support from others in making whatever changes were necessary to do 

so.

Explain that AA is based on the following key ideas:

■ There is no cure for alcoholism; no treatment will enable an alcoholic to drink safely.

■ Abstinence—staying sober One Day At A Time—is the only viable 

option for alcoholics.

Alcoholics 

Anonymous
41

Topic 2: Step 1—Acceptance

■ Self-reliance is not enough, and the support of peers with the same 

problem is vital to sustained recovery.

Finally, the therapist should review the main goals of AA to make sure 

that the patient clearly understands the following:

■ The goal of AA is to avoid that first drink.

■ AA asks its members not to think about forever, but rather to focus 

on each day of sobriety.

■ AA is not looking for perfection. Slips are less important than what 

one does about them. Progress is more important than perfection.

Recovery Tasks

Which meetings will be attended this week? Review the results of the 

previous week and make specific suggestions, keeping in mind the goal 

of 90 meetings in 90 days.

Suggested readings relative to Step 1:

■ “12 x 12”: pages 21-24.

■ “Big Book”: “The Doctors Opinion,” “Bill’s Story,” “More About 

Alcoholism.”

■ “Living Sober,” pages 7-10.

Make additional suggestions as seem appropriate to the individual 

patient.

The patient should continue to note meetings attended and write down 

frank reactions to meetings as well as to readings.

Ask patients to describe in their journal, in chronological order, experiences and events that illustrate how their life has become gradually 

and increasingly unmanageable as a consequence of drinking.

Once the concept of denial is presented, slips and resistance to getting 

involved in AA can be interpreted in this light. These interpretations 

should be made frankly and repeatedly, though nonjudgmentally. One 

approach to denial regards it as a normal part of the grief process. 

Meetings

Journal

Reading

Unmanageability

Troubleshooting
42

Twelve-Step Facilitation Therapy Manual

People seem to be naturally predisposed to deny losses and limitations, 

and alcoholism represents both. Here are some examples of interpretations that reflect this point of view:

■ “I think that part of your unwillingness to go to meetings is denial. I 

think there’s a part of you that does not want to accept this limitation—that you are an alcoholic and that you have to give up drinking. 

That part of you wants you to avoid going to an AA meeting.”

■ “You slipped because you fooled yourself into thinking you were 

safe. So you went to the bar to meet your old friends, thinking that 

you could do that and not drink.”

■ “The part of you that wants to deny your addiction tells you that 

you can control your use, that it was okay for you to have those 

cocktails at _________‘s party. You fooled yourself into believing that 

you could limit your use, because you wanted to believe that.”

■ “I know you don’t like to hear this, but I see your denial at work 

again. The part of you that still wants to drink—that doesn’t want 

to let go of alcohol—was telling you that you could have that beer, 

and that you’d be able to stop there, even though experience proves 

you can’t.”

A second way of conceptualizing denial is to think of it as “insanity” 

as that word is used in AA. Alcoholism as a form of insanity is implied 

in Step 2 (“Came to believe that a Power greater than ourselves could 

restore us to sanity”). The form of insanity involved in alcoholism is 

alcoholics’ delusional belief (delusional because it flies in the face of 

experience) that they can safely drink.

Alcoholism has been described as an illness of the mind as much as an 

illness of the body. The alcoholic rationalizes drinking and creates an 

illusion of choice when in fact drinking is an obsession that leaves no 

room for free will or conscious (rational) choice. From this perspective, 

resistance to accepting a diagnosis of alcoholism or of continuing to 

think and act in ways that promote drinking are aspects of alcoholism 

itself, just as much as physical tolerance is. The therapist can interpret 

resistance in these terms as follows:

■ “Alcoholism is in fact an illness—an illness of the mind and of the 

body. It affects you physically—for example, you’ve had blackouts. 

It also affects you mentally—in the way you think, even when you’re 

sober. When you went to that party last weekend, you convinced 

yourself that it would be okay to drink so long as you only drank 

wine with dinner. Then you went home and got drunk on bourbon. 

That’s the illness at work. It’s called `stinking thinking’ in AA.”
43

Topic 2: Step 1—Acceptance

■ “From the AA point of view, the fact that you don’t want to go to 

meetings is just another symptom of the illness. You know from 

experience that once you start drinking you can’t stop until you’re 

drunk, but you continue to convince yourself that you really don’t 

have this obsession or that you can control it in some way when the 

facts speak to the contrary.”

Finally, some therapists may find it helpful to approach denial by 

viewing it as an internal conflict. The alcoholic can be thought of as 

someone who has a “dual personality”: the part of the self that wants to 

stay sober and enjoys sober consciousness and sober living (the recovering personality) versus the part that resists the idea of limitation, 

craves alcohol, and will do anything to get it (the alcoholic personality). Recovery represents an ongoing struggle between these two forces 

within the alcoholic patient. The therapist needs to ally with the recovering personality and assist the patient in strenghthening it, while 

confronting the alcoholic personality consistently but with respect and 

compassion. Keep this phrase in mind throughout treatment: Denial 

never sleeps. Recovery demands eternal vigilance, which is what active 

involvement in the AA program can provide.

In order to align effectively with the recovering personality within the 

patient, the therapist must recognize the following facts:

■ Alcoholism is more powerful that the patient’s individual willpower 

alone, so the alcoholic personality and denial will inevitably win out 

if the patient chooses to fight them without help in the form of AA.

■ It is a normal human tendency to resist accepting limitation and to 

test limitation. This is deadly to the alcoholic in the long run.

■ The alcoholic personality is cunning and clever and will make every 

effort to lower the defenses of the recovering personality by trying 

to convince the alcoholic that s/he is safe (no longer needs AA or 

can drink safely). Some have compared being in recovery to walking 

up a down escalator: As soon as alcoholics stop working a recovery 

program, the illness will begin bringing them down. Alternatively, it 

could be said that recovery requires eternal vigilance.

45

Topic 3: Steps 2 and 3—Surrender

■ Review the patients’ journal, if they have kept one, and follow up 

on commitments that were made at the end of the previous session:

— AA meetings: What meetings were attended, and what were the 

patients’ reactions to them?

— Reading: What did the patients read, and what were their 

reactions?

NOTE: Explore failures to keep commitments by meeting patients 

on their own ground, in other words, by engaging patients in an 

open discussion of their reasons for not doing what they agreed 

to do. How might this be a reflection of denial? What attitudes lie 

behind the resistance? For example, do patients make excuses, 

ridicule AA, or believe that they are not really alcoholics?

One of the most common forms of denial is expressed in feeling 

different from people who go to AA meetings—”I’m not like those 

people.” Of course, every patient can be expected to be different in 

some ways from other alcoholics, and this can be readily acknowledged. The point behind AA is how the members of the fellowship 

are all the same, that is, in being unable to stop drinking. Does it 

make patients uncomfortable to think that they may be the same 

as “those other people” in this way? Discuss these issues as they 

arise, exploring the patient’s attitudes and then countering them 

by getting back to facts as established by the alcohol history and 

other information that has come to light. Continue to confront 

the patient by respectfully and frankly stating the facts as you see 

them. Ask patients to think about making an honest commitment 

to stop drinking and to give the fellowship of AA an honest try as 

a means of doing that. Emphasize the importance of keeping an 

open mind and ask patients to give AA a try without necessarily 

making a long-term commitment to it. Ask them to think of ways 

in which they are similar to others who go to meetings, especially 

with respect to drinking. If others are worse off, can the patient 

imagine ending up that way?

Review
46

Twelve-Step Facilitation Therapy Manual

■ Review slips

— When, where, with whom?

— What specific strategies could be used next time:

• Call the AA Hotline.

• Go to a meeting—any meeting.

• Call an AA peer.

NOTE: Because the goal of this program is to facilitate the patient’s 

entry to the fellowship of AA, it is important to de-emphasize reliance on the therapist as a means of staying sober, of coping with 

urges to drink, or of dealing with a slip. The material found in 

the book “Thing My Sponsors Taught Me,” published by Hazelden, 

provides a wealth of practical advice that you may want to share 

from time to time with patients relative to specific problems they 

encounter. In doing so, however, be careful to avoid becoming a 

surrogate sponsor for patients, who need to find their own sponsors through AA. It may be important in some cases to clarify from 

time to time your role as a therapist in this facilitation program. 

(Refer to “Therapist Guidelines.”)

■ Review urges to drink

— When and where?

— What did the patient do?

— How could the patient use AA to help with urges in the future?

■ Review sober days

— How many since the last session?

NOTE: It is more consistent with the AA view to congratulate 

patients for staying sober today than to get involved in counting 

sober days too much. The goal in AA is to stay sober today and not 

worry too much about yesterday or tomorrow. Accordingly, it is 

appropriate to congratulate patients on staying sober for a certain 

number of days, so long as you do not lose sight of the fact that a 

slip can happen at any time and what is most important is what 

patients are doing today about their drinking.
47

Topic 3: Steps 2 and 3—Surrender

NOTE: If Step 1 can be compared to admitting the problem, then 

Steps 2 and 3 are equivalent to accepting the solution. The two 

go hand in hand and together form the foundation for recovery 

through involvement in AA.

Introduce the new material by referring the patient to the chapters on 

Steps 2 and 3 in the “Twelve Steps and Twelve Traditions,” explaining 

that this should be a recovery task for the coming week.

Read Steps 2 and 3 aloud to the patient:

CAME TO BELIEVE THAT A POWER GREATER THAN OURSELVES 

COULD RESTORE US TO SANITY.

MADE A DECISION TO TURN OUR WILL AND OUR LIVES OVER 

TO THE CARE OF GOD AS WE UNDERSTOOD HIM.

Elicit reactions to Step 2:

■ What does the patient believe in? Who are his/her heroes? What 

are his/her most cherished values?

■ Does the patient have an open mind about what can help him/her 

abstain from alcohol?

■ What kind of Higher Power does the patient believe in? What are 

the qualities of this Higher Power?

■ Of what religious background is the patient? Does s/he still practice? If not, when and why did s/he stop?

■ In what ways has alcohol abuse caused insanity? One way to 

interpret “insanity” is that it is manifested in a tendency to repeat 

harmful, ineffective behaviors despite clear evidence of their harmfulness or ineffectuality. Another way to define it is that insanity is 

a failure of good judgment and clear thinking.

■ How has alcohol abuse led the patient to make poor decisions/ 

choices or to stay “stuck” with harmful or ineffectual behaviors?

■ Defiance and arrogance are common personality traits of addicts, 

whether or not they were this way before they became addicted.

— In what ways is the patient defiant or arrogant?

— How is this a reflection of denial—of the patient resisting his/

her limitation?

New Material: 

Steps 2 and 3
48

Twelve-Step Facilitation Therapy Manual

Elicit reactions to Step 3:

■ Step 3 is the “opening of a locked door”—the move away from denial 

and toward acceptance of addiction.

■ What does the idea of “turning over” your will mean to patients? 

Have they ever trusted another person enough to follow their advice 

blindly?

■ What are the patient’s attitudes regarding trusting others in general and the therapist in particular and accepting common wisdom 

such as that found in the AA program?

■ Discuss the “cult of self-reliance”—the contemporary popular 

notion that one can be totally responsible for one’s self as opposed 

to needing to rely on others to achieve personal goals. AA is based 

on the idea of interdependence as opposed to self-reliance.

— How much has the patient bough into the cult of self-reliance?

— Has the patient ever followed someone else’s advice, simply on 

the basis of trust and faith? If so, who and when? What about 

trusting the wisdom of AA based on faith?

— What resistance does the patient have to Turning It Over as 

opposed to “going it alone”?

Summarize:

■ What concerns or reservations does the patient have about the concepts presented in steps 2 and 3? Take the time to elicit these, to 

define them, and then to interpret them using whatever approach 

is most comfortable for you (see discussion on “Denial”).

Recovery Tasks

Which meetings will the patient attend? Is the patient ready to try 

out different kinds of meetings, such as Step meetings and discussion 

meetings, in addition to speaker meetings? If there is resistance to 

going to meetings, how might this reflect denial at work?

Suggested readings are as follows:

■ “Big Book”: “Bills’ Story,” “There Is a Solution,” “We Agnostics.”

■ “12x12”: pages 25-41.

■ “Living Sober”: pages 77-87.

Meetings

Reading
49

Topic 3: Steps 2 and 3—Surrender

Again, when presenting material on steps 1, 2, and 3, the best therapeutic stance is frank but nonjudgmental. The therapist must believe 

in the illness model of alcoholism: that alcoholism is an illness affecting 

the body, mind, and spirit. The therapist must be prepared, however, 

for the patient to resist these ideas, as the “Big Book” makes amply 

clear. Patients may criticize or demean AA and the 12 Steps or may 

attempt to draw the therapist into a discussion (or argument or debate) 

about whether alcoholism is really an illness or whether controlled 

drinking is possible. They may attempt to change the agenda of this 

program, for example, to make into marital therapy or psychodynamic 

psychotherapy. The therapist is advised not to enter into such debates, 

not to react defensively to criticism, and not to get off the track of the 

program. Keep the following in mind:

■ The objective of this program is facilitation of the patient’s active 

involvement with AA.

■ The therapist does not need to defend AA—it does very well on 

its own and will continue whether or not this particular patient 

believes in it.

■ Believing in the 12 Steps or in a Higher Power may be less important than simply going to meetings, which should be the first goal.

■ Alcoholism is a powerful and cunning illness, and patients may 

just insist on doing it their way for now.

■ Every sober day (and sometimes every sober hour) is important and 

should be recognized. Whenever you are confronted with a slip, 

think about how many sober days (hours) the patient has had since 

seeing you last.

■ Alcoholism is an illness that defeats the will and causes alcoholics 

to regress, becoming more and more infantile (impulsive, selfcentered) and difficult to deal with over time. This is their illness 

at work. It is important to separate the illness from the person it 

affects.

■ A patient who shows up drunk is a patient who needs social support. The therapist cannot be a support network or even a sponsor. 

Get the patient to use AA whenever possible. For example, encourage the patient to call the Hotline.

Troubleshooting

51

Topic 4: Getting Active

■ Review the patient’s journal, if s/he has kept one, and follow up on 

commitments that were made at the end of the previous session:

— AA meetings: What meetings were attended, and what were the 

patient’s reactions to them?

— Reading: What did the patient read, and what was his/her 

reaction?

■ Review sober days

— How many?

— Recognize each day of sobriety.

— Is the patient getting a feeling for the AA saying, One Day At A 

Time? If not, then take a few minutes to talk about the AA philosophy of living and staying sober now, without worrying too 

much about what happened yesterday or what might happen 

tomorrow. Encourage the patient to focus efforts on not drinking for the rest of today and then dealing with tomorrow when 

it comes.

■ Review urges to drink

— When and where?

— What did the patient do?

— How could the patient use AA to help with urges in th future?

■ Review slips

— When, where, with whom?

— What can the patient do differently? Emphasize three criical AA 

concepts:

• People, Places, and Things”.—Things that need to change, 

including familiar drinking places, drinking buddies, 

Review
52

Twelve-Step Facilitation Therapy Manual

enablers, and old habits. AA wisdom says to “avoid slippery 

people, slippery places, and slippery things” if you do not 

want to slip. What are some of the slippery people, places, 

and things in the patient’s life? How could they be avoided? 

How could they be replaced with nonslippery people, places, 

and things?

• Easy Does It.—The need to avoid trying to solve too many 

problems at once and thereby feeling overwhelmed. Patients 

may need to express their concerns and frustrations and 

to communicate their other problems of living. On the 

other hand, the therapist can support sobriety by helping 

patients monitor their level of overall stress and by encouraging patients to decompress through meditation, prayer, 

exercise, affirmation, or whatever works for them. The key 

insight to provide is the message behind the slogan, which 

advises us to “not bite off more than we can chew.”

• First Things First.—The need to stay sober is the first priority, since nothing else will matter if the alcoholic continues 

drinking. Given the fact that all patients can be expected 

to enter treatment with a multitude of problems, some of 

which are at least partly consequences of drinking, it is easy 

for both the patient and the therapist to either get off the 

track (of the goals of this program) or to feel overwhelmed 

and confused. When other issues arise, no matter how legitimate, both the patient and the therapist are advised to think 

of this slogan and to get back on track, since as this AA 

slogan points out, sobriety is the foundation for dealing with 

everything else. AA suggests that those who stay sober are 

those who are willing to go to any length to do so. Recovery 

is not a passive process, but one that requires effort and 

action.

NOTE: Once more it will be important at the outset of each session to “meet the patient where s/he is,” that is, to get a sense of 

how the patient is reacting to this program. Resistances that take 

the form of not going to meetings, not reading, or having reactions to both that are unbalanced in the negative direction should 

be explored. Using a formulation of denial that is most comfortable for you—see discussion on “Denial”—confront resistance in a 

straightforward but nonjudgmental manner.

“Getting active” refers to the idea that recovery comes only through 

working the program, by active involvement in the 12-Step program (as 

opposed to trying to not drink through solitary, white-knuckle determination or by simply attending but not participating in meetings).

New Material:

Getting

Involved
53

Topic 4: Getting Active

Present this material, adjusting it as necessary to the individual patient 

so as to make it understandable:

“Addiction is an illness that affects, among other things, the individual’s will. As alcoholism progresses into the illness of the mind that 

is characterized by obsession and delusion, it becomes stronger 

than the will. Some individuals may be able to stay sober when they 

are feeling good, but they will be vulnerable to slipping as soon as 

they are in situations that evoke particular emotions such as anger 

or loneliness or which leave them feeling tired—in other words, in 

any situation where willpower may be weakened. Each time the will 

is defeated, the alcoholic becomes more hopeless and alienated. 

Not a few alcoholics have committed suicide while in such a state 

of despair. Becoming active in AA, including doing things like getting phone numbers or helping make coffee, may seem pointless 

to patients when they are feeling good and in control, but it can 

save their lives in the long run since it will connect the patient to 

a fellowship—to a ‘Power greater than themselves.’ Similarly, the 

spiritual aspect of AA provides comfort and support to the individual whose willpower has been eroded by alcoholism. Steps 2 and 3 

challenge the alienated and defeated alcoholic to find faith, again in 

a Power greater than the self.’ Together, getting active and finding 

faith are vital to recovery.”

After checking to see that the patient understands the gist of the above, 

move on to a discussion of getting active:

“Following on these ideas, we need to discuss this matter of `getting 

active.’ The ‘Big Book’ tells us, ‘Faith without works is dead’ (p. 76). 

Beyond merely attending AA meetings—sitting there passively—

getting active involves ‘working the program’ in each of three areas. 

Let’s look at each of them.”

Attending meetings marks the start of establishing a new network of 

friends that will be critical to recovery. However, merely going to meetings without participating in them is not the same thing as working the 

12-Step program and is not likely to be helpful to recovering patients 

when they have strong urges to drink or have a slip. At those times, 

the patient needs to know what to do (whom to call and where to go) 

and to feel comfortable doing so without hesitation. That is why getting 

active is so vital.

There are many different kinds of meetings (speaker meetings, Step 

meetings, discussion meetings, women’s/men’s meetings). The therapist should work with the supervisor to select appropriate meetings 

for each patient. Some patients may be comfortable going to speaker 

and discussion meetings from the start of treatment (e.g., patients 

Participation
54

Twelve-Step Facilitation Therapy Manual

who have gone through an AA-oriented inpatient program); others may 

need to be eased into discussion meetings by attending some speaker 

meetings first.

The book “Living Sober” has many practical ideas for getting active. 

The therapist should be familiar with these and work with the individual patient to develop a program for getting active.

NOTE: Be as concrete as possible in this effort, developing an 

actual list of things to do that patients can take with them and 

that the therapist can use for followup purposes.

Examples of getting active include volunteering to make coffee or clean 

up after meetings, attending AA social events, and participating in 

discussion meetings. Another way of getting active is to make use of 

telephone therapy.

Patients will definitely not like everyone they meet at AA meetings, and 

the therapist should expect and respect this. On the other hand, the 

more meetings (and different ones) patients attend, the more likely it is 

that they will connect with at least a few people.

One goal of this facilitation program is to get patients not only to attend 

and participate in meetings, but to get phone numbers of people whom 

they can call. When should a recovering person use the telephone? 

Here are some examples:

■ Whenever they have an urge to drink.

■ After they have had a slip (as soon as possible).

■ When they are feeling lonely, angry, or tired.

■ When they feel overwhelmed by life’s problems.

■ When they feel good (and perhaps complacent) about their sobriety.

The more people they meet and talk to, the more phone numbers 

patients can get, and therefore, the more people they will have to call 

at those critical times.

Telephone therapy has long been a tradition in AA. Along with going 

to meetings and getting a sponsor, using the telephone is one of the 

cornerstones of recovery. Assure the patient that AA members expect 

to give out their phone numbers and expect to get calls. Often there is 

no need to even explain the reason for calling.

NOTE: Prepare patients to be asked for their phone numbers.

Using the

Telephone
55

Topic 4: Getting Active

Explore the patients’ resistances or anxieties about asking for phone 

numbers or using them:

■ When would they hesitate to make a call: The middle of the night? 

On a weekend? From work?

■ Why would they hesitate to make a call: When feeling angry? 

Depressed? Lonely? These are exactly the right times to call!

Work through patients’ resistances to using the telephone as much 

as possible, using role-playing (practice) if necessary to facilitate their 

willingness to try it as a recovery task for the next week.

Explain to the patient that the use of sponsors is perhaps the oldest 

tradition in AA. Originally, sponsors were people who were willing to 

take responsibility for visiting alcoholics in the hospital and for taking them to an AA meeting when they were discharged. Also, sponsors 

were used as resources for questions about material in the “Big Book.” 

Today, sponsors are obtained through meetings, and their role is not 

to visit inpatients or to explain the “Big Book” so much as it is to serve 

as a source of practical advice from someone who has been in recovery 

longer to someone who is less experienced. Even people who have been 

in recovery for years are apt to still have a sponsor, though in their 

cases the sponsor may be a peer in terms of recovery.

It is a privilege and a responsibility to be a sponsor. The sponsor 

is someone the patient can call (in addition, hopefully, to other AA 

friends) who can provide basic information about AA and its traditions, 

who can help to answer questions about the Steps, who can steer the 

patient toward meetings that might be helpful, and who can facilitate 

getting active.

A sponsor is not a therapist, a judge, or a parent. A good sponsor 

will not tell you what to do (but will give you suggestions if you ask) 

and cannot help you solve personal or marital problems, judge you, or 

take care of you. A sponsor cares about you, understands from personal experience the issues in recovery that you face, and is an ally. 

However, there is plenty of room for therapy in recovery, and having 

both a therapist and a sponsor should not present any conflict, so long 

as the therapist respects the patient’s 12-Step recovery program.

First, explore patients’ resistances to getting a sponsor. What concerns 

or reservations do they have? What qualities would they be looking for 

in a sponsor (age, background, etc.). AA suggests these ground rules:

■ Sponsors should be of the same sex as the patient.

Getting a

Sponsor

What a 

Sponsor Is

What a Sponsor 

Is Not

How To Get a 

Sponsor
56

Twelve-Step Facilitation Therapy Manual

■ Sponsors should be of the same age or older than the patient.

■ Sponsors should have at least a full year of sobriety and should be 

actively working the 12-Step program, including going to meetings, 

using the telephone, and having their own sponsor.

Next, explain the process for asking for a sponsor, which is simple: Go 

to a meeting, wait for announcements, and say that you need a sponsor. Alternatively, patients can just go to meetings, arrive early or stay 

late, and casually let people know that they are looking for a sponsor.

NOTE: Role-playing (practicing) the process of asking for a sponsor 

and discussing what characteristics to look for can be very helpful to many patients. In addition, it can be useful to discuss likely 

candidates that the patient has met. “Living Sober” contains 

some good material on sponsorship, as does “Things My Sponsors 

Taught Me.” The therapist may want to refer to both and also suggest to patients that they look for a copy of the AA pamphlet on 

sponsorship at a meeting.

■ Which meetings will be attended this week?

■ “Living Sober”: pages 13-18 and 24-30.

■ “Big Book”:

— How much has the patient read?

— What has been the patient’s reaction so far? What questions 

have arisen?

— What if any stories can the therapist recommend to this particular patient?

■ Ask patients to do two specific things toward getting active. Write 

these down and give them a copy.

■ Remind patients that one goal of the program is to get a sponsor. 

Patients need to keep this goal in mind when talking to people at 

meetings.

■ Help patients identify three key things they will be looking for in a 

sponsor.

Recovery Tasks

Meetings

Reading

Participating

Getting a 

Sponsor
57

Topic 4: Getting Active

■ Ask the patient to get three names and phone numbers of people, at 

least two of which have to be from members of the same sex.

■ Ask the patient to call one person whose phone number they get, 

just to establish contact. This call can be as brief as 5 minutes.

■ What did the patient understand this session to be about?

■ What did the patient learn from this session?

The therapist should be thoroughly familiar with the material in all 

readings: the “Big Book,” the “12 x 12,” and “Living Sober” and should 

make efforts to integrate readings from all three into each session. 

These books are filled with practical advice and wisdom and should be 

resources to therapist and patient alike. Do not hesitate to read a relevant passage together and discuss its relevance to any issue at hand.

Using the 

Telephone

Summary

Troubleshooting

59

Part 2: Elective Topics

Topics in this section (topics 5 through 10) should be incorporated into 

the individual patient’s treatment as appropriate and as time permits. 

The primary factor that influences which of these electives are pursued 

is the patient’s overall progress in getting active. For many patients, 

the main work of this program can be expected to be focused on the 

four core topics. However, as progress permits, one or more of these 

elective topics may be covered:

Topic 5: Genograms

Topic 6: Enabling

Topic 7: People, Places, and Things

Topic 8: HALT (Hungry, Angry, Lonely, and Tired) Topic 9: Steps 4 

and 5—Moral Inventories

Topic 10: Sober Living

NOTE: This facilitation program focuses primarily on three 

objectives:

■ Going to AA meetings.

■ Getting active in AA.

■ Getting and using a sponsor.

Even when the agenda for a session involves an elective topic, do 

not lose sight of the importance of these objectives. Take whatever 

time is necessary to explore resistances, to make suggestions, and 

to elicit a commitment to any reasonable progress in these areas.

61

Topic 5: The Genogram

Continue to begin each session, including those that cover elective topics, with the following basic review, taking 10-15 minutes to do so.

■ Meetings attended and reactions.

■ What is the plan for future meetings?

■ What resistance is there at this point to going to meetings?

■ What is the patient’s level of participation at meetings? 

■ How many?

■ Reinforce each day of sobriety.

■ How is the patient doing with living One Day At A Time?

■ When and where?

■ What did the patient do?

■ How could the patient use AA to help with urges in the future? 

■ When, where, with whom?

■ How is the patient doing at coming to terms with Step 1?

■ What can the patient do differently next time: People, places, and 

things to change.

■ What is being read?

■ What are the patient’s reactions?

■ What questions does the patient have?

Review

Meetings

Sober Days

Urges to Drink

Slips

Readings
62

Twelve-Step Facilitation Therapy Manual

■ What progress is being made?

■ What is the basis of any resistance?

■ What suggestions can the therapist make, and what commitments 

will the Patient make?

■ How is the patient doing at telephone therapy?

■ What suggestions can the therapist make, and what commitments 

will the patient make in this area?

The purpose of doing a genogram is to reinforce the concept of alcoholism as a disease that can usually be traced across generations (in 

other words, as a family illness) and to motivate the patient to break 

the cycle of addiction by working the AA 12-Step program. While it is 

important to complete the genogram itself, the exercise is primarily 

intended to serve as a catalyst for a discussion of how alcoholism has 

harmed not only the patient, but how it may have harmed others in the 

family and in previous generations. This should be encouraged so long 

as the focus of discussion is on alcohol and its consequences and not 

on tangential issues. Remember: First Things First.

NOTE: Therapists who are unfamiliar with the use of genograms 

in therapy are advised to seek consultation prior to using this 

technique. Genograms have the potential to evoke intense emotional reactions, often after the session is over. It can also be 

difficult for an inexperienced therapist to keep the focus of the 

genogram as it is used here on the issue of alcoholism as a family illness. Practice using role-playing, as well as doing a personal 

genogram with a supervisor, can be good preparation for using this 

technique. Finally, refer to the “Troubleshooting” section for this 

session before going ahead with it.

A chalkboard or flipchart is helpful when doing a genogram. If these 

are not available, use as large a piece of paper as you can find.

Include at least three generations in the genogram, starting with the 

patient’s own generation. List the patient and all siblings. Then fill in 

the following information on the genogram itself for each sibling:

■ History of alcohol or drug abuse. Ask questions like:

— Do any of your siblings have what you would consider to be a 

drinking or drug problem?

Getting a 

Sponsor

Using the 

Telephone

New Material: 

The Genogram

The Genogram
63

Topic 5: The Genogram

— Which one(s)?

— What do they use?

— What negative consequences have they suffered?

• Legal (DWI, etc.)

• Social (divorce, etc.)

• Occupational (losing jobs, poor reviews, etc.)

• Physical (health problems)

• Emotional/psychological (depression, suicide, etc.)

• Financial (bankruptcy, etc.)

Next, fill in the genogram for the previous generation (the patient’s parents, uncles, and aunts). Collect similar information as for the siblings.

Next, obtain as much information as possible about the generation 

twice removed (grandparents).

Finally, if the patient has children, obtain information about them relative to alcohol or drug abuse.

Discuss the genogram and its implications:

■ How many people in the patient’s family, past and present, have 

been affected by alcohol or drugs?

■ What consequences did they suffer? Did anyone die or commit suicide either wholly or partly as a result of alcoholism?

■ Does the patient see any pattern(s) in the genogram?

■ What choices does the patient want to make about his/her life 

and that of his/her children? Where will the chain of addiction be 

broken?

■ Make a list of meetings to attend.

■ What kind of meetings are being attended?

■ What is the patient doing to get active?

Discussion

Recovery Tasks

Meetings
64

Twelve-Step Facilitation Therapy Manual

■ How many phone numbers will the patient be willing to get this 

week?

■ How many phone calls is the patient willing to make this week?

■ Has the patient gotten a sponsor? If not, what specific steps will be 

taken between now and the next session.

■ Encourage the patient to continue reading the “Big Book,” the “12 

x 12,” and “Living Sober,” making suggestions as to readings that 

might be particularly relevant to the individual patient.

NOTE: The therapist may recommend supplemental readings, for 

example meditation books, but should discuss their appropriateness in advance with a supervisor.

■ Ask patients to use their journals to write down reactions or 

thoughts following this session.

■ Make a point of asking patients to call (not normally encouraged in 

this program) in the event that they are experiencing distress as a 

result of the genogram exercise.

Any genogram exercise has the potential to stir up many emotions that 

may have been dormant, sometimes for years. Painful recollections of 

growing up in an alcoholic home, of abuse, abandonment, or neglect, 

can evoke intense anger, anxiety, and shame. The therapist may not be 

in a position to adequately work through such emotions but should be 

sensitive to them and prepared to offer helpful guidance:

■ Validate emotional reactions as appropriate to their context (“I can 

understand how you must have felt ashamed to bring friends home 

with your mother drunk most of the time.” “I can understand that 

it must have been frightening not knowing when your father might 

get drunk and become violent”).

■ Direct the patient to AA as a source of comfort from people who 

have no doubt had similar experiences. For example, you could 

suggest that the patient speak to an AA peer or sponsor about this 

exercise and reactions to it.

■ Encourage the patient to write down feelings and thoughts about 

the genogram and the issues it raised.

Telephone 

Therapy

Sponsor

Reading

Genogram

Troubleshooting
65

Topic 5: The Genogram

■ Suggest that the patient might experience an urge to drink as a 

result of this exercise and what should be done about it (for example, going to a meeting or calling an AA peer).

If a patient shows signs of extreme distress or discomfort during the 

genogram, it may be necessary to stop, to focus on those feelings and 

comfort the patient, and then to discontinue the exercise. It is also 

advisable to create some balance in the genogram by asking patients 

to give themselves or others credit for accomplishments and successes; 

in other words, to honor one’s self and others, as well as to acknowledge harm done through drinking. The point is that the people in the 

patient’s family are good people who had an illness that led them to 

behave in ways that were hurtful to themselves and others. This simple 

act of providing some brightness now and then in an otherwise grim 

picture can help to offset a patient’s tendency to fly into rage or to sink 

into shame and despair.

67

Topic 6: Enabling

NOTE: For patients who are in a relationship with a partner who 

is willing to participate in treatment, Conjoint Session 1 may be 

substituted for this session.

■ Meetings attended and reactions.

■ What is the plan for future meetings?

■ What resistance is there at this point to going to meetings?

■ What commitment is the patient willing to make?

■ What is the patient’s level of participation at meetings?

■ How many?

■ Reinforce each day of sobriety.

■ How is the patient doing with living One Day At A Time?

■ When and where?

■ What did the patient do?

■ How could the patient use AA to help with urges in the future?

■ When, where, with whom?

■ How is the patient doing at coming to terms with Step 1?

■ What can the patient do differently next time: People, places, and 

things to change.

Review

Meetings

Sober Days

Urges to Drink

Slips
68

Twelve-Step Facilitation Therapy Manual

■ What is being read?

■ What are the patient’s reactions?

■ What questions does the patient have?

■ What progress is being made?

■ What is the basis of any resistance to getting a sponsor?

■ What suggestions can the therapist make, and what commitments 

will the Patient make?

■ How is the patient doing at telephone therapy?

■ What suggestions can the therapist make, and what commitments 

will the patient make in this area?

Define enabling for the patient:

■ Enabling is defined as any and all behaviors by others that allow or 

have allowed the patient to continue drinking or avoid or minimize 

negative consequences related to drinking.

Check that the patient has a clear understanding of enabling, using a 

few examples:

■ Friends who buy you drinks when you are already drunk.

■ Friends who make sure they have enough liquor for you when you 

visit them.

■ Friends who joke with you about getting drunk, or drinking as 

much as you do.

■ Spouses who go to the store to buy liquor for you.

■ Spouses who make excuses for you when you are intoxicated (e.g., 

calling in sick for you when you are hung over).

Readings

Getting a 

Sponsor

Using the 

Telephone

New Material: Enabling

Definition
69

Topic 6: Enabling

Have the patient construct an “Enabling Inventory.”

NOTE: A chalkboard or flipchart is helpful for this. Have patient 

record personal examples in their journal.

■ List significant others who have enabled the patient.

■ List how they have enabled the patient (be specific).

Discuss the motivations for enabling.

■ People enable not because they want the alcoholic to be an addict, 

but out of a desire to protect the alcoholic. The motives for enabling 

are usually benign and loving, but they end up being mutually 

destructive to the alcoholic and the enabler alike.

■ How do enablers feel?

— Guilty because they sometimes fear that they either caused or 

contribute to the problem.

— Frustrated and angry because the alcoholic either will not 

change, will not listen to advice, or continues to relapse.

— Hopeless and depressed as a result of continued drinking and 

the progressive unmanageability of their own lives as a result of 

being in a relationship with an alcoholic.

— Alienated, meaning that they eventually give up and write off 

the alcoholic.

— Fearful and anxious because they are afraid that the alcoholic 

will abandon them.

Explain to the patient that a vital part of recovery involves acknowledging enabling and actively resisting it on a day-to-day basis.

■ Patients need to be honest about their addiction with their primary 

enablers. By the same token, significant others need to become 

knowledgeable about denial so as to become less vulnerable to 

denial and enabling.

■ Al-Anon is the best resource for partners of alcoholics who want to 

help themselves. Patients cannot “treat” their enablers.

■ Patients should begin and end every day with a personal acknowledgement of being an alcoholic. This is also reinforced by daily 

attendance at AA meetings.

Enabling 

Inventory

Motivation of 

Enablers

Resisting 

Enabling
70

Twelve-Step Facilitation Therapy Manual

NOTE: You may want to suggest that the patient purchase and use 

a daily meditation book, such as “Twenty-Four Hours a Day.”

■ Addicts need to own up to their methods for encouraging enabling 

in others, since the alcoholic typically uses many methods, such 

as guilt or fear, to promote enabling. For example, alcoholics may 

attempt to blame a binge on an argument with their partner or may 

arouse anxiety by claiming that their job will be in jeopardy unless 

a spouse covers up for them.

■ Ask patients to give a few examples of how they encouraged or 

coerced others into enabling.

■ Make a list of meetings to attend.

■ What kinds of meetings are being attended?

■ What is the patient doing to get active?

■ How many phone numbers will the patient be willing to get this 

week?

■ How many phone calls is the patient willing to make this week?

■ Has the patient gotten a sponsor?

■ If yes, how is the patient making constructive use of the sponsor?

■ If not, what specific steps is the patient willing to take toward getting a sponsor between now and the next session?

■ Encourage the patient to continue reading the “Big Book,” the “12 

x 12,” and “Living Sober,” making suggestions as to readings that 

might be particularly relevant to the individual patient.

NOTE: The therapist may recommend supplemental readings, for 

example, affirmation books, but should discuss their appropriateness in advance with a supervisor.

Ask patients to make three specific commitments regarding what they 

are willing to do with respect to reducing enabling. This does not mean 

trying to reform significant enablers so much as avoiding them or not 

encouraging or reinforcing them. There should be some discussion 

about enabling on the part of those who are closest to the patient, 

especially spouses.

Recovery Tasks

Meetings

Telephone 

Therapy

Sponsor

Reading

Enabling
71

Topic 6: Enabling

It is very important when discussing the concept of enabling to not 

encourage patients to blame others in any way for their drinking. 

Enablers are typically motivated out of concern, anxiety, or confusion 

about what to do. Wives of alcoholics, for example, may fear the loss of 

income or even spouse abuse if they do not somehow help their husbands. Husbands may fear humiliation if they do not cover up for their 

wives.

Alcoholics need to understand how enabling contributes to their drinking and also the role they play in encouraging that enabling. The key 

insight for alcoholics here is how they helped to create the enabling 

system that supports them. The first way to break out of this is to 

embrace Step 1 and openly acknowledge unmanageability and loss of 

control, not just once but on a daily basis. Second, enablers cannot be 

cured by the alcoholics they support; rather, enablers can get support 

for themselves through Al-Anon. Alcoholism as a family illness leads to 

life becoming unmanageable not only for alcoholics, but for those who 

are closest to them.

The goal in discussing enabling is to help patients make specific commitments to dismantling their enabling system by either avoiding 

enablers or by being honest with them about being an alcoholic.

Troubleshooting

73

Topic 7: People, Places, and Things

■ Meetings attended and reactions.

■ What is the plan for future meetings?

■ What resistance is there at this point to going to meetings?

■ What commitment is the patient willing to make?

■ What is the patient’s level of participation at meetings?

■ How many?

■ Reinforce each day of sobriety.

■ How is the patient doing with living One Day At A Time?

■ When and where?

■ What did the patient do?

■ How could the patient use AA to help with urges in the future?

■ When, where, with whom?

■ How is the patient doing at coming to terms with Step 1?

■ What can the patient do differently next time: People, places, and 

things to change.

■ What is being read?

■ What are the patient’s reactions?

■ What questions does the patient have about readings?

Review

Meetings

Sober Days

Urges to Drink

Slips

Readings
74

Twelve-Step Facilitation Therapy Manual

■ What progress is being made?

■ What is the basis of any resistance to getting a sponsor?

■ What suggestions can the therapist make, and what commitments 

will the patient make?

■ How is the patient doing at telephone therapy?

■ What suggestions can the therapist make, and what commitments 

will the patient make in this area?

New Material: People, Places, and Things

Alcoholics Anonymous has a long history of being very pragmatic about 

what it takes to stay sober: whatever works for the individual is fine. 

Bill W., cofounder of AA, devoted time over many years to answering 

letters in which recovering alcoholics asked many practical questions 

about staying sober. His strategy, which has become an integral part 

of the AA tradition, was to share suggestions about what others had 

found helpful in different problem situations.

This session is intended to review and address some of the practicalities of staying sober: what the patient should do about spending time 

with friends who drink, about going to parties, about changing habits 

that were intimately associated with drinking, and so on. Following 

the model of Bill W., the therapist should be prepared to be pragmatic, 

flexible, and nondogmatic. The objective is to brainstorm ideas with 

patients for how they can stay sober in different problem situations. 

The assumption is that it is not realistic for patients to expect the world 

to change in response to their efforts to stay sober; rather, patients 

must learn to change their lifestyle in order to stay sober. Moreover, 

any tendency to think that recovery can occur without fundamental 

changes in attitudes and behaviors is unrealistic.

Convey the following information to the patient:

“An adage within the AA movement goes something like this: `Avoid 

slippery people, slippery places, and slippery things, unless you 

want to slip.’ The wisdom in this slogan refers to the need to change 

many aspects of one’s lifestyle in the interest of recovery. In many 

ways, the word ‘routine’ (those things we tend to do day in and day 

out) could be added to this list of slippery things.”

Lifestyles and 

Recovery

Getting a 

Sponsor

Using the 

Telephone
75

Topic 7: People, Places, and Things

The starting point for the session can be the fact that the alcoholic’s 

lifestyle has drifted toward people and situations that facilitate and 

support drinking, and that s,/he has developed a range of habits and 

rituals associated with drinking. Some of these may have to do with 

daily routines such as cooking meals, ironing, cleaning the house, coming home from work, or watching the 6 o’clock news on television. Other 

drinking rituals may involve certain people or even certain places. This 

process of connecting drinking with people, places, things, and routines happens naturally as drinking becomes habitual. The alcoholic 

is someone who is increasingly preoccupied with maintaining a certain 

level of alcohol in the body and whose drinking in turn becomes connected to habits and rituals. In time, many of the alcoholic’s old habits 

and interests give way to new ones that support drinking.

In order to stay sober, alcoholics need to change many patterns associated with habitual use; otherwise, their willpower will be no match 

for the power of ritual and habits combined with their obsession with 

alcohol.

■ Can the patient identify any rituals associated with drinking? Is 

there a certain sequence of events that s/he follows? (Most alcoholics readily own up to their ritualistic behavior around drinking, and 

the therapist who has a feeling for this concept of ritual can usually 

elicit these patterns. This will be very helpful in this session).

■ Can the patient identify certain routines that are associated with 

drinking? For one woman, it was ironing; for a man, it was the ride 

home on the commuter train.

■ Can the patient identify a list of drinking partners?

■ Can the patient appreciate the power of habit; in other words, how 

powerful these rituals can be and how they can actually be stronger 

than willpower?

■ Can the patient see how preoccupation with drinking will be no 

match for personal willpower in one of these slippery situations?

Explain to the patient that, given the above, it follows that recovering 

alcoholics need first to identify and second to change, people, places, 

things, and routines associated with drinking if they hope to sustain 

sobriety. To help the patient in this effort, the following exercise can 

be useful.

Purpose: To help the patient do a “people, places, and things” inventory 

to identify what needs to be given up and what needs to be substituted.

Lifestyle 

Contract
76

Twelve-Step Facilitation Therapy Manual

Without both parts of the exercise, the patient is apt to fail. In other 

words, giving up old, drinking-associated habits will not work in the 

long run unless they are replaced with new, sobriety-associated habits. 

That is the purpose of this exercise.

NOTE: A chalkboard or flipchart is helpful for this exercise. Have 

patients make notes in their journal.

■ People

— Who did the patients spend time drinking with in the past? 

Who, in other words, are the drinking buddies they need to give 

up?

— How will the patient develop a new social network—a new group 

of (sober) friends?

■ Places

— Where did the patients spend most of their time drinking?

— Where will the patients spend their time in the future? Included 

here should be places that are associated with a variety of 

activities:

• Going to meetings.

• Exercise/recreation.

• Hobbies/interests.

■ Things

— Where did the patient keep the main supply of liquor, as well as 

hidden supplies?

— What might need to be changed regarding these caches?

■ Routines

— What day-to-day routines have been associated with drinking?

— How will the patient change these routines?

The therapist should keep notes of the people, places, things, and 

routines that the patient has decided to change, as well as their replacements. If the patient has not kept notes, then a copy of the therapist’s 

notes should be given to the patient. It is important to help the patient 

make small but specific commitments to change and to follow up on 

these commitments.
77

Topic 7: People, Places, and Things

■ Make a list of meetings to attend.

■ What kind of meetings are being attended?

■ What is the patient doing to get active?

■ How many phone numbers will the patient be willing to get this 

week?

■ How many phone calls is the patient willing to make this week?

■ Has the patient gotten a sponsor?

■ If yes, how is the patient making use of the sponsor?

■ If not, how can the therapist facilitate this objective?

■ Encourage the patient to continue reading the “Big Book,” the “12 

x 12,” and “Living Sober,” making suggestions as to readings that 

might be particularly relevant to the individual patient.

NOTE: The therapist may recommend supplemental readings, for 

example meditation books, but should discuss their appropriateness in advance with a supervisor.

■ How will the patient make a start on this? What specific commitments is the patient willing to make relative to the recovery 

contract? Write these down and have the patient write them in his/

her journal.

Much of the material in “Things My Sponsors Taught Me” (a Hazelden 

publication) may be useful to the therapist in this session, particularly 

the following sections:

■ “About the Old and the New You in Alcoholics Anonymous,” page 

39.

■ “About Cocktail Parties,” page 51.

The therapist should review these prior to session 7 and pick out one 

or two points that may be especially relevant to the particular patient. 

Go over these points and brainstorm with the patient about how they 

apply to his/her life. This can provide the initial focus for the “Lifestyle 

Contract” exercise.

Recovery Tasks

Meetings

Telephone 

Therapy

Sponsor

Reading

People, Places, 

Things, and 

Routines

Troubleshooting

79

Topic 8: HALT (Hungry, Angry, 

Lonely, Tired)

■ Meetings attended and reactions.

■ What is the plan for future meetings?

■ What resistance is there at this point to going to meetings?

■ What commitment is the patient willing to make?

■ What is the patient’s level of participation at meetings?

■ How many?

■ Reinforce each day of sobriety.

■ How is the patient doing with living One Day At A Time?

■ When and where?

■ What did the patient do?

■ How could the patient use AA to help with urges in the future? 

■ When, where, with whom?

■ How is the patient doing at coming to terms with Step 1?

■ What can the patient do differently next time: People, places, and 

things to change.

■ What is being read?

■ What are the patient’s reactions?

■ What questions does the patient have about readings?

Review

Meetings

Sober Days

Urges to Drink

Slips

Readings
80

Twelve-Step Facilitation Therapy Manual

■ What progress is being made?

■ What is the basis of any resistance to getting a sponsor?

■ What suggestions can the therapist make, and what commitments 

will the patient make?

■ How is the patient doing at telephone therapy?

■ What suggestions can the therapist make, and what commitments 

will the patient make in this area?

New Material: Hunger, Anger, Loneliness, 

and Fatigue

The purpose is to help the patient identify emotions which, according 

to AA lore, are most often associated with slips. These are the emotions 

that most often lead to taking that first drink, which in turn sets off the 

alcoholic’s craving and leads to compulsive drinking.

Present the idea to patients that they need to be able to identify the 

following feeling states and do something about them before they are 

induced to drink them away:

• LONELINESS • ANGER • GRIEF

• ANXIETY • RESENTMENT • SELF-PITY

It is also a maxim in AA that alcoholics are most vulnerable to the 

above emotions—most apt to drink them away—when they are either 

hungry or tired. Therefore, AA puts a strong emphasis on getting rest 

and eating well.

After going through the general material below, the therapist should be 

flexible so as to work with those emotions that are most relevant to the 

individual patient.

Many AA sayings and slogans—Easy Does It, Let Go and Let God, One 

Day at a Time, First Things First, Turn It Over—relate to one or more of 

the above feelings. They reflect common wisdom for handling difficult 

emotions. Their value lies in their simplicity. Through these saying and 

slogans, the fellowship teaches alcoholics how they can live sober. The 

therapist should therefore be familiar with these slogans (see references below) and use them in treatment. In addition, teaching patients 

to connect particular slogans to situations in their lives that trigger 

risky emotions can be extremely helpful.

Getting a 

Sponsor

Using the 

Telephone
81

Topic 8: HALT (Hungry, Angry, Lonely, Tired)

■ Reference: “Living Sober,” pages 22, 30

Recovering alcoholics need to develop a lifestyle that allows them to get 

adequate rest. A state of exhaustion is an invitation to drink. Related 

to this is physical conditioning—a body in poor physical condition will 

get tired more quickly than one that is being taken care of.

■ How much sleep does the patient get, on average? Is this adequate? 

What changes, if any, could be suggested with regard to rest?

■ Has the patient ever experienced drinking, or having a strong desire 

to drink, when feeling especially tired?

■ What is the patient’s state of health? Is s/he capable of some form 

of regular exercise in the interest of gaining energy?

Along with the need to avoid exhaustion, AA emphasizes the need for 

the recovering alcoholic to avoid excessive hunger. Regular meals are 

encouraged and, beyond that, the alcoholic is encouraged to snack so 

as to avoid getting too hungry. The use of small amounts of sweets now 

and then may help to satiate the alcoholic’s taste for the sugar that is 

in the alcohol they used to drink.

■ Does the patient sometimes experience cravings for something 

sweet?

■ How can the patient satisfy this need? (Point out that whatever 

sweets they eat in recovery probably will not have as many calories 

as the alcohol they drank).

■ Reference: “Living Sober,” pages 18, 32, 41, 44.

Anxiety has many sources, but one form of anxiety that runs as a 

theme through AA writings concerns making decisions—knowing what 

to do and feeling right about it. Much of the spirituality of AA is directed 

at relieving the sense of confusion and anxiety associated with being 

alone, of having no one (or no faith) to rely on. The “serenity prayer” 

addresses feelings of isolation and confusion:

GOD GRANT ME THE SERENITY

TO ACCEPT THE THINGS I CANNOT CHANGE, 

COURAGE TO CHANGE THE THINGS I CAN, 

AND THE WISDOM TO KNOW THE DIFFERENCE

Hungry and 

Tired

Anxious
82

Twelve-Step Facilitation Therapy Manual

Read the serenity prayer aloud and ask patients for their reactions to 

it.

■ Do patients relate to experiencing “existential anxiety”: the feeling 

of being isolated, of facing difficult decisions and choices but feeling 

totally alone in making them?

■ Have they (do they) ever pray, or meditate, or otherwise turn to a 

Higher Power in times of stress, despair, confusion, or anxiety?

■ Do patients relate to having difficulty deciding at times what they 

cannot change versus what they can (and should) change?

■ How would patients feel about saying the serenity prayer at these 

times, of otherwise praying, or about talking to other AA friends 

about the dilemmas they face?

Other methods of dealing with anxiety are found in the following AA 

slogans.

The first priority for alcoholics is to not take that first drink. At times, 

alcoholics, like everyone else, will be in conflict—will have to choose 

taking care of themselves versus taking care of someone else. At times, 

the choice may be please yourself or please someone else; make yourself 

happy or make someone else happy. Patients need to be encouraged 

to make their ongoing sobriety their first priority, even if that means 

frustrating or disappointing someone else.

The therapist might elicit examples from patients of situations in which 

they felt conflicted about taking care of themselves versus taking care 

of others:

■ What could be the price of pleasing or satisfying others at your own 

expense?

■ What did you do in that situation? Was it consistent with putting 

your sobriety first?

The pressures of deadlines and overcommitment create stresses that 

invite drinking as a means of coping. The AA adage, “easy does it,” 

speaks to this particular issue.

■ Does the patient identify with the stresses created by having to 

meet deadlines or competing commitments?

■ What in the patient’s life contributes to stress, to time pressure, or 

to overcommitment?

Easy Does It

First Things 

First
83

Topic 8: HALT (Hungry, Angry, Lonely, Tired)

Strategies for dealing with this form of stress are built around developing a system of realistic priorities.

■ Make a list of things to do today, then discard half of it.

■ Schedule things twice as far in advance as you usually would.

■ Sit quietly for 15 minutes a day.

■ Talk to someone else (preferably a recovering person) about your 

feelings of being overextended.

■ References: “Living Sober,” pages 10, 37, 47.

“Releasing Anger” (Hazelden pamphlet).

Anger and resentment are pivotal emotions for most recovering alcoholics. Anger that evokes anxiety drives the alcoholic to drink in order 

to anesthetize it. Resentment, which comes from unexpressed (denied) 

anger, represents a constant threat to sobriety for the same reason.

The therapist should talk to the patient about anger and resentment:

“Resentments, reflecting as they do unexpressed anger, represent 

past issues. The recovering alcoholic cannot afford to live in the 

past but must live in the present (One Day At A Time). Therefore, 

resentments must be confronted and let go in favor of more effective ways of dealing with anger in the present.”

■ What situations are patients resentful over?

— How did they handle these at the time they happened?

— Can they see how these issues cannot be resolved now, but 

that, on the other hand, they can learn how to express anger 

better, so as to avoid building up stores of resentments in the 

future?

The materials found in the references are useful in working with 

patients on resentment and anger. Use the following guidelines when 

working on these issues:

■ Identify sources of resentment: What experiences is the patient 

resentful over?

■ What did they do in those situations versus what they think they 

should have done?

Anger/ 

Resentment
84

Twelve-Step Facilitation Therapy Manual

■ Can the patient make the connection between unexpressed anger 

(at the moment) and resentment (holding on to anger)?

■ What can the patient learn from those experiences so as to not 

avoid being honestly angry in the future?

■ What would stop the patient from expressing anger in the future?

■ Can patients Turn It Over (meaning their anger) to a Higher Power—

have the faith to express their anger and trust that their honesty 

will prove to be the better course in the long run?

■ What makes patients angry in the here and now? Are they willing 

to make a commitment to expressing their anger honestly and to 

having faith that it will be better if they do that?

■ Reference: “Grieving: A Healing Process” (Hazelden pamphlet).

Grief is as important a subject as anger and resentment in the AA 

literature. In the course of addiction (and often before alcohol abuse 

begins), the alcoholic typically experiences many losses that have gone 

ungrieved. The therapist should be familiar with the stages of grief:

■ Denial. Minimizing the importance of what was lost, including 

denying its importance.

■ Bargaining. Attempting to replace the lost thing with something 

else without acknowledging its loss.

■ Anger. The breakdown of denial and the natural reaction to loss.

■ Sadness. The true expression of undenied loss.

■ Acceptance. This comes slowly, only as denial breaks down and 

the individual feels able to come to terms with the reality of loss (or 

limitation) and is ready to move on.

Ask patients to go through the above process, identifying one loss in 

their lives that they have worked through in this way. Then ask them 

to identify one loss that they have not worked through, that they may 

be in denial about. Alcoholics need to come to terms with the “loss” of 

alcohol as a means of coping and as a “friend” of sorts. Another way to 

look at it is that they need to accept their limitation, which is that they 

cannot control their use of alcohol and have to give it up.

The recovery task for this session aims at facilitating the grief process 

with respect to alcohol. It asks patients to write a “goodbye letter” to 

alcohol, as if they were writing a goodbye letter to a lover. Dependency 

Grief
85

Topic 8: HALT (Hungry, Angry, Lonely, Tired)

on alcohol needs to be conceptualized as a relationship that must be 

broken and grieved in the interest of recovery. This requires sensitivity 

and respect on the part of the therapist, along with an appreciation for 

the grief process and an ability to work with patients in a sympathetic 

manner through their grief over the loss of alcohol.

■ Make a list of meetings to attend.

■ What kind of meetings are being attended?

■ What is the patient doing to get active?

■ How many phone numbers will the patient be willing to get this 

week?

■ How many phone calls is the patient willing to make this week?

■ Has the patient gotten a sponsor?

■ If so, how is the patient making use of the sponsor?

■ If not, what specific steps is the patient willing to take between now 

and the next session?

■ Encourage the patient to continue reading the “Big Book,” the “12 

x 12,” and “Living Sober,” making suggestions as to readings that 

might be particularly relevant to the individual patient.

NOTE: The therapist may recommend supplemental readings, for 

example, meditation books, but should discuss their appropriateness in advance with a supervisor.

■ Write a goodbye letter to alcohol as if it were a relationship that you 

have decided to end.

■ Write in your journal about losses that you have not adequately 

acknowledged and grieved, including losses in each of these areas:

— Relationships (people).

— Self-esteem.

— People, pets, or things.

— Goals.

Recovery Tasks

Meetings

Telephone 

Therapy

Sponsor

Reading

Grieving
86

Twelve-Step Facilitation Therapy Manual

Troubleshooting The importance of going to meetings, getting involved 

in them, and developing relationships with other recovering alcoholics 

cannot be overstated. The patient can use the fellowship of recovering 

alcoholics as a source of support, advice, and comfort. By now, going 

to meetings should be a part of the patient’s lifestyle; if it is not, the 

therapist should spend more time uncovering and working through 

the patient’s resistance to this. A contracting approach can be a useful 

technique wherein the therapist and patient agree that the patient will 

try out a certain number of AA meetings or experiment with some form 

of participation. Patients’ experiences at meetings, like their reactions 

to the “Big Book,” need to be processed at each session.

Role-playing can be another effective technique to help the shy or 

shameful patient overcome internal barriers to going to meetings or 

participating in them. Have patients practice, for example, saying their 

names out loud, as if they were doing so at a meeting. Assure the 

patients that they will not be pressured at meetings to say more than 

they feel comfortable with.

Once patients have become regular in their attendance, the next step 

is to encourage them to talk. Meetings and subsequent contacts with 

fellow AA members can be used as opportunities to talk about ongoing 

sources of resentment and grief. Patients who merely attend AA meetings and do not participate or develop communicative relationships 

with other recovering men and women are handicapped in their ability to resist denial and are apt to slip into alcohol use as a means of 

drowning those emotions.

Troubleshooting
87

■ Meetings attended and reactions.

■ What is the plan for future meetings?

■ What resistance is there at this point to going to meetings?

■ What commitment is the patient willing to make?

■ What is the patient’s level of participation at meetings?

■ How many?

■ Reinforce each day of sobriety.

■ How is the patient doing with living One Day At A Time?

■ When and where?

■ What did the patient do?

■ How could the patient use AA to help with urges in the future?

■ When, where, with whom?

■ How is the patient doing at coming to terms with Step 1?

■ What can the patient do differently next time: People, places, and 

things to change.

■ What is being read?

■ What are the patient’s reactions?

■ What questions does the patient have about readings?

Topic 9: Steps 4 and 5—Moral 

Inventories

Review

Meetings

Sober Days

Urges to Drink

Slips

Readings
88

Twelve-Step Facilitation Therapy Manual

Getting a 

Sponsor

■ Does the patient have a sponsor yet?

■ If yes, how is the patient making use of the sponsor?

■ If no, then what suggestions can the therapist make in this regard, 

and what commitments will the patient make?

Using the 

Telephone

■ How is the patient doing at telephone therapy?

■ What suggestions can the therapist make, and what commitments 

will the patient make in this area?

New Material:

Steps 4 and 5

The Moral

Inventory

Alcoholism is described in AA literature as a physical and a spiritual 

illness. It is an illness of the spirit in the sense that alcoholics are 

driven by their disease to behave in ways that compromise their personal ethics and values. Alcoholics commit crimes and misdeeds in 

the process of satisfying their obsession with alcohol or as a result of 

impaired judgment while under the influence. This undermines their 

self-esteem, promotes alienation, and makes finding faith and reaching out to others more difficult. Steps 4 and 5 implicitly recognize the 

fact that alcoholics suffer feelings of guilt and shame related to their 

behavior and also that acknowledging and sharing these feelings has 

value.

This session has three goals:

■ To further work through resistance to Step 1 by asking patients to 

think and talk about some of the “wrongs” and “errors” they have 

committed as a result of alcohol abuse.

■ To explore the extent to which patients experience guilt that has 

not been shared and that can therefore threaten their recovery.

■ To balance recognition of wrongs done with equal recognition of 

positives.

NOTE: The goal of this session is not to conduct a complete—

searching or fearless—moral inventory, in the truest sense of Steps 

4 and 5. In general, such a moral inventory is best attempted by 

an alcoholic who has been actively working a 12-Step program for 

at least 6 months. It needs to be shared with a trusted person such 

as a sponsor or a member of the clergy. It is more often a process 

than an event. The goals of Steps 4 and 5 in the context of this 

facilitation program are more limited: to accept some degree of 

responsibility for consequences of drinking and to release some 

guilt. The therapist needs to keep these limited goals in mind 

while at the same time acknowledging to the patients that they 

will need to do more work on Steps 4, 5, 6, and 7 in the future.
89

Topic 9: Steps 4 and 5—Moral Inventories

The therapist should be thoroughly familiar with pages 42-54 (Step 

4) and 55-62 (Step 5) of “Twelve Steps and Twelve Traditions” 

and should review these chapters as necessary prior to conducting this session. Therapists who have not conducted such a moral 

inventory of themselves are advised to do so, and to share it with 

an appropriate other, prior to attempting this technique with 

patients.

There are two key issues to keep in mind when talking with patients 

about their moral (ethical) history. These need to be communicated to 

patients in a way that is understandable to them. They are, respectively, honesty and balance.

■ Honesty.—To be of real value, a moral inventory must be honest. Patients must be carefully guided—without being judged or 

censured—to own up to ways in which they have hurt others, 

either willfully or accidentally, or have compromised their ethics 

as a result of alcohol abuse. In this regard, patients need to be 

encouraged to admit their contributions to strained marriages or 

friendships, problems with children, and so on. Obviously, this is 

sensitive therapeutic work. The practiced therapist who is secure 

in the belief that alcoholism is an illness that is ultimately stronger 

than individual willpower will be most successful in guiding the 

patient through these treacherous waters, encouraging frankness 

without promoting needless guilt. The goal of a successful moral 

inventory is not guilt but commitment to recovery.

■ Balance.—A moral inventory should also be balanced, meaning 

that it should not lose sight of the patient’s positive qualities, right 

choices, and heroic efforts. Even the most severe alcoholics are 

capable of doing things right now and then. It will not jeopardize 

the goals of this work if the therapist encourages patients to think 

about and share positive things about their character and actions; 

on the contrary, discussing the positives can help minimize excessive guilt and form the basis for renewed self-esteem in recovery.

Begin the moral inventory by reading aloud Steps 4 and 5 from the “12 

x 12”:

STEP 4: MADE A SEARCHING AND FEARLESS MORAL INVENTORY 

OF OURSELVES

STEP 5: ADMITTED TO GOD, TO OURSELVES, AND TO ANOTHER 

HUMAN BEING THE EXACT NATURE OF OUR WRONGS

Explore the meaning of these steps with the patient. Explain that they 

are concerned with character defects: those negative qualities and 

Facilitating a 

Moral Inventory
90

Twelve-Step Facilitation Therapy Manual

tendencies that each and every person (not just alcoholics) possesses. 

In the case of alcoholics, character defects tend to be exacerbated due 

to their illness, which takes over the will and leads them to make ethical and moral compromises.

Character defects include qualities such as:

• Jealousy • Greed • Selfishness

• Impulsiveness • Grandiosity • Arrogance

• Self-pity • Meanness • Resentment

Alcohol abuse and alcoholism have predictable effects on personality, one of which is that character defects that were evident before the 

illness will get worse. Still others may emerge as a consequence of 

becoming obsessed with alcohol. Most alcoholics, for example, become 

more infantile (demanding, selfish) over time.

■ Which character defects have emerged in this patient as a result of 

alcohol abuse?

■ Elicit specific examples of these character defects and how others 

have been hurt by them. Take time to explore one or two key incidents in which the patient, under the influence of alcohol, has done 

something that hurt someone else and which s/he now regrets.

After exploring the negative, finish this part of the session by taking 

some time to explore some of the patient’s better qualities, supported 

by specific examples of behavior that reflect them. Look for specific

examples of qualities such as the following:

• Generosity • Heroism • Charity

• Altruism • Kindness • Humility

• Love • Sharing • Compassion

Document examples of these qualities.

■ Make a list of meetings to attend.

■ What kind of meetings are being attended?

■ What is the patient doing to get active?

Assets

Recovery Tasks

Meetings
91

Topic 9: Steps 4 and 5—Moral Inventories

■ How many phone numbers will the patient be willing to get this 

week?

■ How many phone calls is the patient willing to make this week?

■ Has the patient gotten a sponsor? If not, what specific steps will be 

taken between now and the next session?

■ Encourage the patient to continue reading the “Big Book,” the “12 

x 12,” and “Living Sober,” making suggestions as to readings that 

might be particularly relevant to the individual patient.

NOTE: The therapist may recommend supplemental readings, for 

example meditation books, but should discuss their appropriateness in advance with a supervisor.

Patients may occasionally experience periods of intense guilt or shame 

associated with Step 4. This may occur during the course of the session, but it is even more likely to occur after the session, when the 

patient has time to reflect on this material. It can be helpful to prepare 

patients for this eventuality as well as giving them specific suggestions 

for what to do in that event. Some key points to keep in mind include 

the following:

■ The concept of amends: The idea that alcoholics who have the courage to face their moral mistakes may be able to at least acknowledge 

them and, in some cases, to do something to make up for them. This 

gives them an advantage over those who refuse to even acknowledge their defects. The question then becomes: When are amends 

appropriate, and what constitutes appropriate amends?

■ The alcoholic should not be allowed to assume that nonalcoholics 

do not make moral mistakes. In fact, alcoholics who keep an ongoing moral inventory may very well lead more spiritual lives than 

many nonalcoholics.

■ Patients should be encouraged to keep their positive qualities in 

mind, without avoiding or minimizing character defects. Helping 

patients to design one or more personal affirmations—statements 

that assert positive qualities and which the patient can be encouraged to repeat several times a day—can help counter unreasonable 

guilt and depression. Many affirmation books are available.

■ Sponsors and AA friends, as well as clergy, can be key sources 

of support during a time of guilt and shame. Patients should be 

Telephone 

Therapy

Sponsor

Reading

Troubleshooting
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Twelve-Step Facilitation Therapy Manual

encouraged to identify specific sources of support: people they 

could talk to who they think could understand their feelings.

■ The therapist should not minimize, rationalize, or avoid patients’ 

feelings of guilt and shame. Experiencing these feelings can help 

undermine resistance to acceptance. It can also have the effect of 

making patients feel all the more isolated with their feelings. It can 

help to remind patients that they are not responsible for their illness, though they are responsible for their recovery. Reinforcing 

this idea can be especially helpful at this time, since it offers hope 

at the same time that it acknowledges responsibility for harm done.

■ Be prepared to talk about the patients’ need to grieve the loss of 

self-esteem associated with the mistakes made under the influence 

of alcohol.

■ Advise patients that it would be appropriate in this case to contact 

you between sessions if they are experiencing an intense emotional 

reaction to the moral inventory work. An emergency session can 

be appropriate here, much as is the case when doing a genogram 

(topic 5).
93

Topic 10: Sober Living

■ Meetings attended and reactions.

■ What is the plan for future meetings?

■ What resistance is there at this point to going to meetings?

■ What commitment is the patient willing to make?

■ What is the patient’s level of participation at meetings?

■ How many?

■ Reinforce each day of sobriety.

■ How is the patient doing with living “one day at a time”?

■ When and where?

■ What did the patient do?

■ How could the patient use AA to help with urges in the future? 

■ When, where, with whom?

■ How is the patient doing at coming to terms with Step 1?

■ What can the patient do differently next time: People, places, and 

things to change.

■ What is being read?

■ What are the patient’s reactions?

■ What questions does the patient have about readings?

Review

Meetings

Sober Days

Urges to Drink

Slips

Readings
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Twelve-Step Facilitation Therapy Manual

■ What progress is being made?

■ What is the basis of any resistance to getting a sponsor?

■ What suggestions can the therapist make, and what commitments 

will the patient make?

■ How is the patient doing at telephone therapy?

■ What suggestions can the therapist make, and what commitments 

will the patient make in this area?

Books such as “Living Sober” devote a good deal of attention to the 

matter of changing habits (lifestyle) in the interest of recovery. The following areas are most relevant to recovery:

■ Nutrition

■ Exercise

■ Hobbies

In this session, the therapist should feel relatively free to explore different aspects of the patient’s lifestyle. The expectation is that alcoholism 

“shrinks” the lifestyle. Over the course of the illness, the patient loses or 

abandons old friends, old hobbies and interests, activities, and so on. 

Life becomes progressively more centered around alcohol—obtaining 

it, hiding it, using it. In early sobriety, the relative emptiness of alcoholics’ lives drives them back toward drinking out of sheer boredom.

A good way to approach the issue of sober living is to help the patient 

explore what life was like before alcoholism and from that discussion to 

set some specific (and realistic) goals for the short-term future.

■ How was the patient’s diet affected by alcohol abuse?

■ What did s/he typically eat during the course of a day?

■ What kind of changes need to be made in order to correct for nutritional deficiencies or to create a more balanced diet?

NOTE: Depending on the patient’s physical condition, it may be 

appropriate to suggest a consultation with a nutritionist.

■ Has the patient gained or lost a good deal of weight (more than 15 

pounds) in the last year? Does s/he need to gain/lose weight in the 

interest of health?

Getting a 

Sponsor

Using the 

Telephone

New Material:

Living

Recovery

Nutrition
95

Topic 10: Sober Living

NOTE: Avoid supporting diet fads that appeal to the need to look 

good as opposed to enhancing health.

■ In discussion with the patient, establish several nutrition goals. 

■ What is the patient’s state of health?

■ What major medical conditions or illnesses does the patient have? 

How are they being cared for or treated?

■ Does the patient have any medical conditions that would restrict 

ability to exercise regularly?

■ What kind of exercise can the patient begin to do on a regular basis 

(3 times/week)? (Caution: Keep it simple. Walking a mile, using a 

stationary bike or rowing machine, and similar activities are more 

likely to last than are overly ambitious plans.)

■ Set several specific exercise goals.

■ What did the patient do for fun before alcohol came along and 

replaced it?

■ What activities interest the patient? (Keep it simple!)

■ Set several specific goals for sober recreation and fun.

■ Make a list of meetings to attend.

■ What kinds of meetings are being attended?

■ What is the patient doing to get active?

■ How many phone numbers will the patient be willing to get this 

week?

■ How many phone calls is the patient willing to make this week?

■ Has the patient gotten a sponsor? If not, what specific steps will be 

taken between now and the next session?

Exercise

Hobbies

Recovery Tasks

Meetings

Telephone 

Therapy

Sponsor
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Twelve-Step Facilitation Therapy Manual

■ Encourage the patient to continue reading the “Big Book,” the “12 

x 12,” and “Living Sober,” making suggestions as to readings that 

might be particularly relevant to the individual patient.

NOTE: The therapist may recommend supplemental readings, for 

example, meditation books, but should discuss their appropriateness in advance with a supervisor.

■ Ask patients to make one specific commitment to improve their lifestyle in each of these areas: nutrition, exercise, and hobbies.

This session can be fairly free ranging, though it is advisable to touch 

on each of the above areas. Keep in mind that, when making commitments to change, “less is often more.” Resist any attempts by the 

patient to make commitments that are clearly too ambitious. It can 

take a lot of time to whittle down excessive optimism to a level closer to 

reality. Setting goals too high, like trying to make too many changes at 

once, will likely lead either to failure or to avoidance of getting started.

Reading

Troubleshooting

Living Recovery
97

Part 3: Termination

The termination session, like the introductory session, has its own 

unique format. The review part of this last session should be brief, to 

allow for adequate time for the therapist and patient together to process the patient’s experience with the 12-Step facilitation program.

99

Final Core Session: Termination

■ Meetings

■ Sober Days

■ Urges

■ Slips

■ Readings

The 12th and final session should focus on helping the patient honestly 

evaluate the treatment experience and establish goals for the future. 

The following questions can be used as guides in this process:

■ What were the patients’ views of alcoholism prior to treatment, and 

what are they now?

— Do they view alcoholism as a character defect or an illness? 

What kind of illness is alcoholism?

— Do they now believe that alcoholics can control their use or are 

they out of control of use?

— How would the patients describe the alcoholic part of their personality? How does it work to defeat the recovering part of the 

personality?

— Do patients understand that one way to look at denial is as the 

natural human tendency to resist accepting personal limitation, 

in this case the limitation of not being able to control drinking?

— Do patients understand that alcoholism is an illness of the mind 

characterized by being obsessed with drinking?

■ What were the patients’ views of Alcoholics Anonymous prior to 

treatment, and what are they now?

— What has been their experience with—

Review Briefly

New Material:

Termination
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Twelve-Step Facilitation Therapy Manual

• Going to meetings?

• Getting a sponsor?

• Getting active?

• Calling AA friends?

■ What were the patients’ views of their own alcohol use prior to treatment, and what are they now?

— Do the patients regard themselves as alcoholics?

■ What were the most useful parts of this treatment program to the 

patient?

■ What were the least useful parts of this program to the patient?

■ What information was most useful to the patient, and why?

■ Would the patient recommend this treatment program to someone 

else who wanted help with an alcohol problem? If so, why? If not, 

why not?

■ What are the patient’s plans regarding AA for the 90 days after the 

treatment program?

— How many meetings will the patient make a commitment to 

attend in those 90 days?

— Is the patient willing to continue keeping a journal?

Though this facilitation program focuses at most on the first 5 Steps 

of the AA program (and even then on limited aspects of them), the 

full AA program includes 12 Steps. Truly working a recovery program 

means working all 12 Steps, with the help of a sponsor and AA friends. 

Patients who have begun this work should be commended and at the 

same time advised that their work so far represents only the start of 

recovery. There is no room for complacency in recovery.

It might be appropriate to end this facilitation program with a quote 

from the “Big Book”:

If you still think you are strong enough to beat the game alone, 

that is your affair. But if you really and truly want to quit drinking 

liquor for good and all, and sincerely feel that you must have some 

help, we know that we have an answer for you. It never fails, if you 

go about it with one half of the zeal you have been in the habit of 

showing when you were getting another drink (p. 181)

The Twelve 

Steps
101

Final Core Session: Termination

In helping patients evaluate their experience in this facilitation program, the therapist needs to encourage honesty. Most likely, different 

patients will have found different parts of the program more or less 

helpful. Encouraging honesty in terms of feedback will help to facilitate 

honesty in making meaningful commitments for how many meetings 

the patient will attend afterward. Therapists may find it helpful to 

take notes regarding patient feedback for use in consultation with a 

supervisor.

Regardless of the patient’s degree of objective success in the program 

(sober days versus slips), treatment should end on a respectful note. 

Keep in mind that even patients with many slips and those who are 

intensely in denial may someday “see the light.” Perhaps it will come 

after the next negative consequence or maybe not until many consequences have taken their toll. The information provided to them 

through the treatment program could be what they need at some point 

down the road, when they are ready to absorb and act on it.

End the final session with a handshake and a reminder that the AA 

Hotline is listed in every phone book under Alcoholics Anonymous, and 

that AA is there 24 hours a day, 365 days a year.

Troubleshooting

103

Part 4: Conjoint Sessions

This 12-Step facilitation program includes two sessions intended for use 

with patients who are in relationships. Any individual whom patients 

consider their partner, regardless of their marital status or how long 

they have been in a relationship, is eligible to participate in these conjoint sessions. The conjoint sessions, however, are not intended to be 

in addition to the basic 12 sessions; rather, they should be included as 

part of the 12-session program. They should be scheduled only after 

the four core topics have been covered.

The objectives of the two conjoint sessions are—

■ To estimate the level of partner involvement in alcohol or other substance abuse.

■ To describe the 12-Step facilitation program.

■ To encourage the partner to attend Al-Anon, Family Groups, or AA, 

as appropriate.

Partners who are judged to have no harmful involvement with alcohol 

will be educated regarding-

■ The facilitation program.

■ The concept of enabling.

■ The concept of detaching.

■ Al-Anon.

Partners who are suspected of being harmfully involved with alcohol or 

other mood-altering chemicals will be informed about the facilitation 

to seek an independent assessment of their own use and possible need 

for treatment.
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Twelve-Step Facilitation Therapy Manual

NOTE: For their own reference, it is recommended that therapists 

using this manual familiarize themselves with the material in the 

pamphlet, “Detaching With Love,” by Carolyn W., published by 

Hazelden Educational Materials.
105

Conjoint Session 1: Enabling

Conjoint session 1, which may take as long as 11/2 hours, should 

be prepared for in advance by the therapist, who should contact the 

partner by phone (and who should also have informed the patient in 

advance that there will be two such sessions).

Begin the first conjoint session by explaining that its purpose is to 

outline this 12-Step facilitation program that the identified patient is 

enrolled in, to answer questions, and to explain the concept of enabling.

In outlining the 12-Step facilitation program, try to cover the following 

essential points before fielding questions from the partner:

“The program is grounded in the principles of Alcoholics Anonymous.

■ We view alcoholism as an illness of the body, mind, and spirit that 

is characterized by loss of control and obsession with drinking. 

Alcoholism has predictable symptoms and a predictable course 

which, if untreated, may lead to premature death or insanity.

■ While there is no cure at present for alcoholism, it can be arrested. 

The best method for this is active involvement in AA.

■ Alcoholics resist the idea that they are actually addicted to alcohol 

(cannot effectively control or limit drinking). This is called “denial.” 

There are many forms of denial, but its essence is that alcoholics 

try to convince themselves and others that it is safe for them to 

have a drink.

■ AA is based on the idea that the alcoholic needs to resist taking the 

first drink that will trigger the compulsion to drink, and needs to do 

this one day at a time.

■ Having a “slip” means drinking after a period of sobriety. Slips are 

unfortunate, but given the fact that alcoholism is a cunning, powerful, and baffling illness, what is most important is how the alcoholic 

responds to a slip. A slip is not an excuse to drink more. AA believes 

that going to meetings, calling an AA friend or sponsor, or calling 

Program

Outline

(10 minutes)
106

Twelve-Step Facilitation Therapy Manual

the AA Hotline are the best ways to deal with urges to drink as well 

as with slips.

■ This program is based on the idea that alcoholics are responsible 

for their own recovery. While many factors may lead a person to 

use alcohol as a way of coping, addiction is ultimately a personal 

problem and recovery a personal challenge. Alcoholism cannot be 

blamed on anyone else, nor can anyone else take responsibility 

(credit or blame) for the alcoholic’s slips or, for that matter, for the 

sober days.”

NOTE: A popular Al-Anon adage goes like this: “You didn’t Cause 

the illness of alcoholism, you can’t Control it, and you can’t Cure 

it.”

Following the above introduction, solicit questions and answer them 

frankly, but limit the time for this to 10 minutes by explaining that 

important material is still to be covered.

It can be helpful even at this point to refer the partner who has many 

questions (or who exhibits strong reactions or who has a long laundry 

list of complaints) to Al-Anon as a resource for further information, 

advice, and support.

NOTE: The book “Al-Anon Faces Alcoholism” is especially helpful. Some partners may want to get this book, which is available 

through Al-Anon and in some bookstores. Therapists should be 

familiar with it and should also have an Al-Anon Family Group 

meeting schedule on hand and available for patients to use.

It is important to ask partners (with the patient present) about their 

use of alcohol and other mood-altering chemicals. Again, since time is 

limited, general questions such as the following may be most useful:

■ “How often do you drink alcohol or use any other mood-altering 

chemicals (marijuana, etc.)?”

■ “Have you (or your partner) ever felt that you had a problem related 

to alcohol or other substances?”

■ “Do you know where you could go if you ever wanted to get an honest evaluation of your own alcohol/substance use?”

Partner

Substance Use 

(15 minutes)
107

Conjoint Session 1: Enabling

Explain to both partners that enabling and detachment represent dysfunctional and functional responses, respectively, to addiction. This 

session focuses on enabling and the next one on detaching.

Enabling refers to any behaviors that mitigate the natural consequences 

of alcohol or drug abuse or support it. Enabling has the effect—often 

unintended—of allowing alcohol abuse to continue (and get worse) by 

cushioning the alcoholic. Examples of enabling include-

■ Making excuses (covering up) for individuals when they are drunk 

and would otherwise get into trouble.

■ Calling in sick for the person who’s hung over.

■ Excusing or justifying hostility or abuse that results from drinking.

■ Accepting guilt-ridden apologies after the fact for harm done while 

drunk.

■ Lending the alcoholic money for liquor, forgiving bad debts, or buying liquor as a gift.

■ Making beer runs to liquor stores in order to keep an alcoholic off 

the street (to avoid a DWI arrest, an accident, or an injury).

■ Defending alcoholics to their accusers for inappropriate behavior.

■ Giving spouses liquor in order to calm or quiet them.

The common theme in all of these examples is that enabling is any 

behavior or attitude that has the effect of avoiding the real issue, which 

is alcohol abuse or alcohol addiction.

The above examples should provide a springboard for a discussion of 

how the partner has enabled the patient in treatment. To be certain 

that both partners clearly understand the concept of enabling, elicit 

several examples of enabling in their relationship.

NOTE: If there appears to be any doubt about the partner’s understanding of enabling, review it briefly and try to get the patient to 

give some examples. The partner’s capacity to understand detachment is partly dependent on being able to understand enabling 

and how it has been operative in the relationship.

If enabling has the effect of making the problem worse, then why do 

people enable? Do they, either consciously or unconsciously, want the 

alcoholic to continue drinking?

NOTE: Some people argue that enablers do indeed derive some 

form of secondary gain from enabling—usually some control over 

Motives for 

Enabling

Enabling

5
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Twelve-Step Facilitation Therapy Manual

the relationship. Yet when you interview enablers, the impression 

you most often get is oneof great frustration and a sense of impotence, combined with anger and resentment—in other words, just 

the oposite of feelings of power and control.

Ask the partner what motivated the enabling. Typical responses will be 

something like the following:

■ “I did it because I didn’t want him to get into trouble.”

■ “I was afraid that I’d lose the relationship.”

■ “I was scared and didn’t know what else to do.”

■ “Not helping seemed like a cruel thing to do.”

Acknowledge any or all of the above motives for enabling and the fundamental intent behind them. Doing that will help reduce any stigma 

associated with enabling, which in turn will enhance motivation for 

detaching. If the partner has trouble attributing any motivation at all 

to enabling, solicit some feedback from the patient and reinforce the 

above types of motivations. Alternatively, the therapist can suggest 

such motives and ask the partner to think about them.

Make the point to both partners that enabling is usually encourages by 

alcoholics, since it promotes their need to continue drinking and avoid 

facing their limitation.

Engage the couple in a discussion of how the patient has either encouraged or coerced enabling in the past. The most common methods for 

this are to appeal to anxiety or guilt:

■ Anxiety: “If you don’t help out (cover up), something terrible will 

happen that will affect us both (loss of a job, etc.).”

■ Guilt: “Either it’s your fault that I have this problem (therefore you 

owe it to me to cover up for me) or else you should cover up for me 

out of loyalty.”

List ways in which the patient promoted enabling.

Typically, enabling (not unlike addiction) follows a predictable course. 

In most cases, enablers initally react with concern and a desire to help. 

As time goes on, however, and the problem gets worse instead of better, 

concern and anxiety usually give way to anger, resentment, and finally, 

alienation.

NOTE: Do not be surprised to encouter alienation, frustration, and 

resentment in the partner of the alcoholic patient.

Reactions to 

Enabling
109

Conjoint Session 1: Enabling

They may have been the route, meaning treatment, before. They 

may resent not only the patient, but also the therapist or a treatment program that purports to be able to do what they could 

not—get the patient to stop drinking.

After suggesting that the foregoing responses to enabling are common 

and normal, try to elicit the partner’s own feelings at this time. Validate 

feelings of frustration and resentment, and even alienation, suggesting 

that the couple may wish to pursue marital therapy at some point in 

the future.

NOTE: Do not attempt to dissuade partners who imply that they 

may divorce a patient who fails to stay sober or who state that 

they are considering divorce. After all, this may be another natural consequence of alcoholism. Do not attempt to resolve marital 

conflicts or to explore sources of resentment in any detail in this 

session. Instead, if any of these situations arise, suggest that the 

couple may wish to seek marital therapy, but that they may want 

to wait until (1) the patient has completed this facilitation program 

and (2) the partner has attended at least six Al-Anon meetings.

Finish the first conjoint session by—

■ Thanking partners for coming in, indicating your sympathy with 

the fact that they may have felt resentful about it.

■ Encouraging partners to try out Al-Anon as a source of support in 

letting go of the alcoholic and beginning to pay attention to their 

own growth and needs. Emphasize that giving it a try does not imply 

making a long-term commitment to attending Al-Anon meetings.

The most likely problems to arise as a result of the two conjoint sessions 

are—

■ Partner resistance (anger, resentment).

■ Partner substance abuse.

■ Emergency calls from partners.

In this treatment program, partners can only be invited and encouraged to participate in the two conjoint sessions, which are primarily 

psychoeducational (as opposed to psychotherapuetic) in structure and 

purpose. the partner who initially refuses to attend, or who fails to 

show up, should be contacted by phone at least once. The therapist 

should make a reasonable effort to get partners to commit to coming in 

for the first session. They can be assured that they do not have to like 

Resistance

Wrap Up
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Twelve-Step Facilitation Therapy Manual

it and will be welcome to express their honest opinions and reactions. 

They will then be free to decide either to drop out or to attend the second session. Reassure the angry or anxious spouse that the conjoint 

sessions are not therapy nor are they intended to diagnose the partner.

Partner substance abuse is at the same time a delicate issue and one 

that needs to be addressed. If the therapist has reason to believe that 

the partner is abusing alcohol or other chemicals, the agenda for session 2 may be dropped in favor of pursuing an assessment of substance 

use and referring the partner to an appropriate treatment program.

Partners are most likely to call the therapist if their partner has a slip 

or if a conjoint session evokes strong reactions (anger, depression). 

Consistent with what is done elsewhere in this facilitation program, the 

strategy to pursue in such cases is to encourage the partner to contact 

Al-Anon or to seek individual counseling independent of the treatment 

program. If an emergency session seems essential, it should be held 

with the patient and the partner conjointly. This may mean waiting 

a day—for example, to give a patient who has had a slip time to get 

sober. The therapeutic goal in responding to any emergency is to give 

advice consistent with 12-Step Al-Anon. For example, do not encourage a partner to bring a drunk patient to an AA meeting or to call the 

patient’s sponsor. Discourage partners from arguing with (or otherwise 

trying to communicate with) a drunk patient. Help the partner see to it 

that the patient who has slipped is physically and medically safe but to 

detach from taking further responsibility.

Partner 

Substance Abuse

Emergency Calls
111

The goals of this session are—

■ To define and illustrate “detaching” using examples drawn from the 

couple’s own experience together.

■ To define “detaching with love” and help the partner discriminate 

detachment from enabling.

■ To describe Al-Anon and encourage partners to attend six Al-Anon 

meetings of their choice.

Briefly inquire about questions the partner may have about the material covered in the first conjoint session, making every reasonable effort 

to limit this discussion to approximately 15 minutes. Questions that 

seem directed at wanting to know what to do can be postponed with 

an explanation that the material presented in this session may help to 

answer that question and provide partners with some direction.

Introduce Al-Anon as a fellowship of men and women who are in 

relationships with alcoholics and who gather in order to take care of 

themselves and seek support for their own growth process. Going to an 

Al-Anon meeting does not imply any blame for the alcoholic’s problem 

drinking; on the contrary, Al-Anon was originally formed by spouses 

of alcoholics in order to help them learn to detach from any feelings 

of shame or guilt associated with their partners’ illness. Meetings are 

anonymous, there are no fees, and the only condition for membership 

is being in a relationship with an alcoholic.

Ask the patient’s partner if s/he would be willing to attend six Al-Anon 

meetings. If the answer is yes, provide an Al-Anon Family Group meeting schedule and take a minute to identify two or three meetings that 

might be convenient to where s/he lives or works.

If the partner expresses reservations about Al-Anon, explore these by 

asking what questions s/he has or concerns that would stop him/her 

from trying Al-Anon. Typical concerns are—

Conjoint Session 2: Detaching

Review

Al-Anon
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Twelve-Step Facilitation Therapy Manual

■ “What kinds of people will I find there?”

Answer: All kinds of people, some like you and some not like you. 

What you all have in common is being in a relationship with an 

alcoholic.

■ “What will I be expected to do?”

Answer: You are not required to do anything. You can just go and 

listen and see if listening to others who are in or have been in the 

same boat as you is helpful to you in any way. If you want to, you 

can talk to some of the other people who are there after the meeting 

is over.

■ “What is the benefit of Al-Anon?”

Answer: Living with an alcoholic is like living with anyone who has 

a chronic illness—it affects not only the person with the illness, 

but those around him/her. Over time, their lives get out of control 

too, and they often experience stress or depression, not to mention 

frustration. They often do not know the right thing to do. The best 

source of help for these people is others who have had to deal with 

similar situations. Al-Anon offers a program for starting to take 

care of yourself instead of everyone else.

■ “What will I be committing myself to?”

Answer: Nothing. We are asking you to try out Al-Anon, not to commit to it. If you do not think it is helpful after six meetings, just stop 

going.

NOTE: Some patients may resist making a commitment to Al-Anon 

even after all of their questions have been answered. Others may 

simply refuse to consider it. Do not pursue the issue beyond eliciting concerns and questions and answering them as best you can.

Explain to patients and their partners that detachment is the opposite of enabling. Whereas enabling protects alcoholics, detachment 

means allowing alcoholics to deal with the natural consequences of 

their abuse.

Detaching makes sense to most people, yet on a practical level, I daily 

of these same people find it hard to adopt a detached attitude and to 

allow alcoholics to experience and deal with whatever consequences 

come their way. Having made this point, ask the partner, “Why is this 

so?”

The most common barrier to effective detachment is guilt, which usually has one (or both) of two sources:

Detaching
113

Conjoint Session 2: Detaching

■ Guilt due to believing that allowing the alcoholic to suffer negative 

consequences is somehow unloving or disloyal.

■ Guilt over anger and resentment that leads to a vindictive (“you 

deserve it”) attitude that the partner is secretly ashamed of.

Guilt that stems from feeling disloyal can be worked through by 

acknowledging the positive motives for enabling while also pointing out 

how enabling is self-defeating in the long run and how it unwittingly 

allows a drinking problem to get worse.

Guilt over feeling angry and resentful can be uncovered and worked 

through by acknowledging such feelings as normal consequences of 

enabling and then by clarifying detachment as not being vindictive but 

benign. Detachment comes from letting go of as opposed to holding on 

to anger and resentment, whereas enabling builds both. Reinforce this 

idea of detaching as being the more functional response to problem 

drinking. Give the partner permission to be angry and resentful while 

suggesting that it is in fact loving to let the alcoholic go.

Ask the partner and the patient to think of two specific situations that 

might arise and to identify enabling versus detached partner responses 

in each one.

Example: The alcoholic wakes up hung over and leaves for work more 

than an hour late.

■ Enabling response: The partner calls in with an excuse.

■ Detached response: The partner lets the alcoholic deal with the 

employer and refuses to act as a middle man.

Wrap up this second conjoint session by encouraging the partner to 

make use of any or all of the following resources:

■ Al-Anon, including Al-Anon sponsors and friends.

■ Individual counseling, preferably with a professional trained in 

addictions treatment.

■ Marital counseling after the patient completes the 12-Step facilitation program.

Wrap-Up
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Twelve-Step Facilitation Therapy Manual

Probably the most common therapeutic complication of this session 

will be the alcoholics’ reactions to their partners becoming involved 

in Al-Anon. This is where detaching needs to be conceptualized as a 

reciprocal process. Not only must partners detach from alcoholics and 

allow them to be responsible for their own recovery, but alcoholics 

must also allow their partners to take care of their needs and issues, 

including how alcoholism has affected them and how they should act 

in the future. The therapist should try to be an advocate of both partners’ right to take responsibility for their own issues and to seek the 

support and guidance of peers.

The second possible complication is that strong emotions will be 

aroused, especially anger and resentment on the part of the partner. Here again, the therapist must be cautious to avoid being drawn 

into marital therapy. With only two conjoint sessions, there is little 

chance of healing longstanding resentments. Rather, the couple can 

be encouraged to look into marital counseling after the patient has 

completed the program and after the partner has attended at least six 

Al-Anon meetings. Recognize that problems exist and that the future 

of the relationship may be in doubt. On the other hand, both partners 

may stand to gain by putting off any decisions until both have had a 

chance to work a recovery program.

Troubleshooting
115

Appendix A—Jellinek Charts for

Men and Women
116

Twelve-Step Facilitation Therapy Manual

Symptoms and phases of alcoholism in men

Have you ever experienced— YES?

Prodromal phase

1. Increased tolerance (need to drink more to get the same effect)? _______

2. Temporary loss of memory (blackouts, times you couldn’t remember what you did)?_______

3. Sneaking a drink when no one was looking? _______

4. Preoccupation with drinking (thinking about drinking while working, etc.)? _______

5. Hurried drinking (“chasing a high”)? _______

6. Avoided talking about your drinking because it made you uncomfortable? _______

7. Loss of memory (can’t remember things you said, what you were supposed to do)? _______

Crucial (basic) phase

8. Loss of control (unable to predict how much you’ll drink)? _______

9. Justifying (making excuses for drinking)? _______

10. Disapproval from others about your drinking? _______

11. Being extravagant with money? _______

12. Aggression (verbal or physical)? _______

13. Remorse (or guilt or depression about drinking)? _______

14. Periods of abstinence (times when you tried to stop drinking)? _______

15. Changes in your pattern of use (switching types or brands of alcohol)? _______

16. Losing friends (or having fights with them) on account of your drinking? _______

17. Losing a job or getting into trouble at work on account of drinking? _______

18. Giving up old hobbies or activities in order to spend time drinking? _______

19. Having to get treatment of some form for your drinking? _______

20. Feeling resentful a lot toward others? _______

21. Escape (moving or changing friends in an effort to get a “fresh start”)? _______

22. Protecting your supply (hiding a stash of alcohol)? _______

23. Drinking in the morning (or before work)? _______
117

Appendix A—Jellinek Charts for Men and Women

YES?

Chronic phase

24. Drinking more or less continuously for at least 18 hours (a “binge”)? _______

25. Doing things that violate your own ethical or moral standards? _______

26. Inappropriate (or confused) thinking, such as hearing voices or not knowing 

 where you are? _______

27. Decreased tolerance (feeling and acting drunk after just one drink)? _______

28. Vague fears or anxiety? _______

29. Tremors (shaky hands)? _______

30. Feeling hopeless or suicidal? _______

Source: Adapted from Jellinek, E.M. A chart of alcohol addiction and recovery. Journal of Iowa 

Medical Society Mar. 1964.
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Twelve-Step Facilitation Therapy Manual

Symptoms and phases of alcoholism in women

Have you ever experienced— YES?

Prodromal phase

1. Increased tolerance (need to drink more to get the same effect)? _______

2. Unwillingness to discuss drinking? _______

3. Feelings that women who drink excessively are worse than men? _______

4. Personality changes when drinking? _______

5. Drinking more just before your menstrual period? _______

6. Feeling more intelligent and capable when drinking? _______

7. Being “supersensitive”? _______

Early stage

8. Periods of abstinence (times when you’ve tried to stop drinking)? _______

9. Disapproval from others about your drinking? _______

10. Rationalizing (making excuses for) drinking? _______

11. Temporary losses of memory (blackouts, times you couldn’t remember what 

 you did) when drinking? _______

12. Unexplained bruises or injuries? _______

13. Drinking before facing a new situation? _______

Middle stage

14. Neglecting eating? _______

15. Protecting your supply (hiding a “stash” of alcohol)? _______

16. Self-pity (feeling sorry for yourself)? _______

17. Feeling resentful toward others? _______

18. Being permissive or lax with your children because of guilty feelings 

 about drinking? _______

19. Drinking to feel happier but finding yourself feeling more depressed? _______

20. Being told by others that you “couldn’t be an alcoholic”? _______

21. “Predrinking”—drinking before a drinking occasion; or “postdrinking”— 

 continuing to drink after a drinking occasion? _______
119

Appendix A—Jellinek Charts for Men and Women

YES?

22. Feeling guilty about drinking? _______

23. Drinking more or less continuously for a period of at least 18 hours? _______

Late stage

24. Starting the day with a drink? _______

25. Tremors (shaky hands)? _______

26. Decreased tolerance (feeling and acting drunk after just one drink)? _______

27. Sneaking drinks? _______

28. Gulping drinks? _______

29. Persistent remorse? _______

30. Devaluing personal relationships? _______

31. Carrying liquor in your purse? _______

Source: Adapted from James, J.E. Symptoms of alcoholism in women: A preliminary survey of AA members. Journal of Studies on Alcohol 36(11):1564-1569, 1975. © by Journal of Studies on Alcohol, Inc., 

Rutgers Center of Alcohol Studies, New Brunswick, NJ 08903. Used with permission.

121

Specifications of treatment in manuals is intended to define and differentiate psychotherapies, to standardize therapist technique, and to 

permit replication by other investigators. However, it is essential that 

manual-guided therapies be implemented by qualified therapists who 

are trained to perform them effectively. Project MATCH uses extensive 

procedures to select, train, and monitor therapists in order to promote 

delivery of study treatments that are specific, discriminable, and delivered at a consistently high level of quality. These include (1) selection 

of experienced therapists committed to the type of therapy they would 

be performing, (2) extensive training to help therapists modify their 

repertoire to meet manual guidelines and to standardize performance 

across therapists and across sites, and (3) ongoing monitoring and 

supervision of each therapist’s delivery of treatment during the main 

phase of the study to assure implementation of study treatments at a 

high and consistent level.

All MATCH therapist candidates are required to meet the following 

selection criteria: (1) completion of a master’s degree or above in counseling, psychology, social work, or a closely related field, (2) at least 2 

years of clinical experience after completion of degree or certification, 

(3) appropriate therapist technique, based on a videotaped example 

of a therapy session with an actual client submitted to the primary 

investigator at each site and to the Yale Coordinating Center, and 

(4) experience in conducting a type of treatment consistent with the 

MATCH treatment they would be conducting and experience treating 

alcoholics or a closely related clinical population.

These criteria are intended to facilitate (1) selection of appropriate therapists for the training program, as training is not intended to train 

novice therapists, but to familiarize experienced therapists with manual-guided therapy, and (2) implementation of MATCH treatments by 

experienced and credible therapists. For example, therapists selected 

Therapist

Selection

Appendix B—Therapist Selection, 

Training, and Supervision in

 Project MATCH
122

Twelve-Step Facilitation Therapy Manual

for the Cognitive-Behavioral Coping Skills Therapy (CB) are experienced in cognitive and behavioral techniques; thus, the CB therapists 

are predominantly doctoral or masters-level psychologists. Therapists 

for the Twelve-Step Facilitation Program are predominantly individuals who have gone through 12-Step recovery themselves, have been 

abstinent for several years, and are typically masters-level or certified 

alcoholism counselors. Therapists selected for the recently developed 

Motivation Enhancement Therapy (MET) have worked extensively with 

alcoholics and typically have experience in systems theory, family therapy, and motivational counseling.

Training, supervision, and certification of therapists was centralized 

at the Yale Coordinating Center to facilitate consistency of treatment 

delivery across sites. Each therapist came to New Haven for a 3-day 

intensive training seminar, which included background and rationale 

for Project MATCH, extensive review of the treatment manual, review of 

taped examples of MATCH sessions, and practice exercises. Each therapist then returned to their clinical site and was assigned a minimum 

of two training cases, which were conducted following the MATCH protocol (e.g., weekly individual sessions, a maximum of two emergency 

and two conjoint sessions, truncated sessions for patients who arrived 

for a treatment session intoxicated).

All sessions from training cases were videotaped and sent to the 

Coordinating Center for review of the therapists’ (1) adherence to 

manual guidelines, (2) level of skillfulness in treatment delivery, (3) 

appropriate structure and focus, (4) empathy and facilitation of the 

therapeutic alliance, and (5) nonverbal behavior. Yale Coordinating 

Center supervisors review all training sessions and provide weekly 

individual supervision to each therapist via telephone. Supplemental 

onsite supervision is delivered weekly by the project coordinator at 

each Clinical Research Unit.

Therapists were certified by the Yale Coordinating Center supervisors 

following successful completion of training cases. Therapists whose 

performance on initial cases was inadequate were assigned additional 

training cases until their performance improved. The average number 

of training cases was three, and therapists completed an average of 26 

supervised sessions before certification.

To monitor implementation of Project MATCH treatments, facilitate 

consistency of treatment quality and delivery across sites, and prevent 

therapist “drift” during the main phase of the study, all sessions are 

videotaped and sent to the Coordinating Center, where a proportion 

of each subject’s sessions (one-third of all sessions for CognitiveBehavioral and Twelve-Step Facilitation, one half of all MET sessions)

are reviewed by the supervisors. Telephone supervision is provided on 

a monthly basis by the Coordinating Center supervisors and supplemented with weekly onsite group supervision at each Clinical Research 

Unit.

Therapist

Training

Ongoing

Monitoring
123

Appendix B—Therapist Selection, Training, and Supervision in Project MATCH

All sessions viewed are rated for therapist skillfulness, adherence to 

manual guidelines, and delivery of manual-specified active ingredients 

unique to each approach. These ratings are sent monthly to the project 

coordinators at each site to alert local supervisors to therapist drift. 

Therapists whose performance deviates in quality or adherence to the 

manual are “redlined” by the Coordinating Center, and the frequency 

of sessions monitored and supervision is increased until the therapist’s performance returns to acceptable levels.

* U.S. GOVERNMENT PRINTING OFFICE: 1998 - 444 - 740 / 90799