Does treatment fidelity predict client outcomes in 12-Step Facilitation for stimulant abuse?

Objective: This study examined the relationships between treatment fidelity and treatment outcomes in a community-based trial of a 12-Step Facilitation (TSF) intervention. Method: In a prior multi-site randomized clinical trial, 234 participants in 10 outpatient drug treatment clinics were assigned to receive the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention. A secondary analysis reviewed and coded all STAGE-12 sessions for fidelity to the protocol, using the Twelve Step Facilitation Adherence Competence Empathy Scale (TSF ACES). Linear mixed-effects models tested the relationship between three fidelity measures (adherence, competence, empathy) and six treatment outcomes (number of days of drug use and five Addiction Severity Index (ASI) composite scores) measured at 3 months post-baseline. Results: Adherence, competence and empathy were robustly associated with improved employment status at follow up. Empathy was inversely associated with drug use, as was competence in a non-significant trend (p= .06). Testing individual ASI drug composite score items suggested that greater competence was associated with fewer days of drug use and, at the same time, with an increased sense of being troubled or bothered by drug use. Conclusions: Greater competence and empathy in the delivery of a TSF intervention were associated with better drug use and employment outcomes, while adherence was associated with employment outcomes only. Higher therapist competence was associated with lower self-report drug use, and also associated with greater self-report concern about drug use. The nature of TSF intervention may promote high levels of concern about drug use even when actual use is low.