12 Step Groups

SUBSTANCE USE & MISUSEVol. 38. No. 14. pp. 2017-2047. 2003

Attitudes and Beliefs About 12-Step GroupsAmong Addiction Treatment Clients andClinicians: Toward Identifying Obstacles

to Participation

Alexandre B. Laudet, Ph.D.*

National Development and Research Institutes. Inc.,New York, New York. USA

ABSTRACT

Participation in 12-step groups (12SG) during and after formaltreatment has been associated with positive outcome amongsubstance users. However, the effectiveness of 12SG may be limitedby high attrition rates and by low participation, areas on which therehas been little research. Clinicians play an important role in fostering12-step participation, and the Insights which they develop in theirpractice can greatly contribute to informing the research process.Yet, little is known about clinicians" attitudes about 12-step groups

* Correspondence: Alexandre B. Laudet, Ph.D., Principal Investigator. NationalDevelopment and Research Institutes. Inc. (NDRI). 71 West 23rd Street, 8th fl.NYC, NY 10010. USA; Fax: (917) 438-0894: E-mail: laudet{ ndri.org,

2017

DOI: 10.1081/JA-120025124 1082-6084 (Prim); 1532-249! (Online)Copyright 2003 by Marcel Dekker. Inc. www.dekker.com

2018 Laudet

or about their experiences in referring clients. This study surveyedclients (A'=10l) and clinicians (/V= 102) in outpatient treatmentprograms to examine l2-step-related attitudes and to identify poten-tial obstacles to participation, Data collection was conductedbetween May, 2001 and January, 2002 in New York City. Bothclient and clinician samples were primarily African-American andHispanic; 32% of clients reported substance use in the previousmonth, with crack and marijuana cited most frequently as theprimary drug problem. On average, clinicians had worked in thetreatment field for 8 years. Both stafT and clients viewed 12SG as ahelpful recovery resource. Major obstacles lo participation centeredon motivation and readiness for change and on perceived need forhelp, rather than on aspects of the 12-step program often cited aspoints of resistance (e.g.. religious aspect and emphasis on power-lessness). Clinicians also frequently cited convenience and schedulingissues as possible obstacles to attending I2SG- Clinical implicationsof these findings are discussed, including the importance oi' fosteringmotivation for change, the need to assess clients" beliefs about andexperiences with 12SG on a case-by-case basis, and to find a good fitbetween clients' needs and inclinations on the one hand, and the toolsand support available within 12-step groups on the other.

Key Words: 12-stcp; Alcoholics Anonymous; Self-help; Mutual-help; Treatment; Substance user treatment.

INTRODUCTION

Participation in 12-step groups (12SG) such as AlcoholicsAnonymous, both during and after formal treatment, is associated withbetter outcomes among substance users. Twelve-step groups (I2SG) are aform of mutual-help or mutual aid based on the premise that individualswho share a common behavior that they identify as undesirable cancollectively support each other and eliminate that behavior."* One of theessential aspects of mutual-help groups, in contrast to other, moretraditional forms of treatment, is the absence of professional involvement.

'Twelve-step groups such as AA, NA, and GA, OA are traditionally categorizedas "self-help" groups, which is misleading. A useful, and more accurate treatmentparadigm taxonomy, in a field deluged with many stereotypes and myths is:professional-based treatment; mutual-heip/aid and self-help or "natural recovery."

Obstacles to I2-Step Participation 2019

Alcoholics Anonymous, the first and largest twelve-step organization, wasstarted by a group of individuals dependent on alcohol at a time when littleor no assistance was available to such persons. Subsequently, theorganization contributed to the establishment of formal substance-usertreatment in the first part of the 20th century; over time, the medJcalizationof treatment services placed mutual-help organizations at the periphery ofservice delivery so that such organizations were sometimes viewed ascompeting with formal treatment and criticized for its lack of profession-alism. In the last 2 decades, 12-step organizations have become largelyintegrated with most formal treatment models, thus becoming somewhathomogenized and mainstrcamed [see next section; for a detailed discussionof the historical relationship between mutual-help organizations andtreatment services addressing substance use, see White (1998)1. Whileattending 12-step meetings is an important part of participating in theseorganizations, 12-step members are also encouraged to "work theprogram" and to embrace the 12-step ideology (see later discussion).

The effectiveness of 12-step groups may be somewhat limited by ahigh attrition rate. Moreover, a large minority of substance users neverattend 12-step meetings. Little is known about reasons for dropping outor for nonattendance. Treatment professionals can play a critical role infostering 12-step participation among their clients, yet. we know verylittle about professionals' attitudes and beliefs about 12-step fellowships.Several aspects of the 12-step program have been identified as potentialstumbling blocks for both clinicians and substance users. Little is knownabout the prevalence of these beliefs or about whether they constituteobstacles to participation. In this study, treatment professionals andclients are surveyed about their attitudes and beliefs concerning 12-stepfellowships toward identifying potential obstacles to participation.

According to the prevalent western view of substance-use disorders,addiction is a chronic, relapse-prone disorder (Leshner. 1997; AmericanPsychiatric Association, 1994). For many substance users, maintainingabstinence requires ongoing support. Twelve-step groups constitute such asupport; meetings are widely available and free of charge. Participation in

''The author recognizes that terms such as "addiction," "treatment," and"recovery" can be viewed in other cultures and from other perspectives onsubstance use as labels that may carry stigrnatizing connotations. Such termsare used here because they are widely accepted as convention and understoodin the field, particularly in the United States and where the English language isused in scientific literatureand should not be interpreted as an endorsement ofthe negative labels they sometimes convey.

2020 Laudet

I2SG during and after formal treatment has been associated with positiveoutcomes; while the majority of studies limit their investigation to sub-stance use outcomes (Fiorentine and Hillhouse. 2000; Kaskutas et aL,2002; Project MATCH Research Group, 1997). the few that have a.ssessedthe influence of 12SG participation on a broader set of dotiiains, such aspsychological adjustment, have also reported positive findings (Timkonet al., 1999; Vaillant el al., 1983). Several researchers have noted that, asthe duration and intensity of treatment services are decreasing, one of themost important tasks for clinicians is to foster stable engagement in I2SGso that clients have a support network available once they are no longerengaged in formal clinical services (Mankowski et al., 2001).

Role of Treatment in Fostering 12-Step Participation

Clinicians can contribute to the Institute of Medicine's (1990) goal ofbroadening the base of treatment for substance use-related problemswithin the community in which they work (Caldwell, 1999). The impor-tance of collaboration between service providers and I2SG has beenacknowledged by several professional organizations. For example, theAmerican Psychiatric Association has noted that "referral [to 12-stepgroups] is appropriate at all stages in the treatment process, even forpatients who may still be substance users" (American PsychiatricAssociation, 1995). Further, 12-step groups and 12-step tenets areincreasingly being integrated into formal services. According to a nationalstudy by Roman and Blum (1998) on a representative sample of 450private substance-user treatment centers, 90% of the facilities basedtheir treatment on 12-step principles and variations of this model, withnearly one-half of the remaining 10% incorporating 12-step principles incombination with other approaches, including encouraged attendance at12-step meetings (Roman and Blum, 1998). The prevalence of the latterwas demonstrated by results from a survey on 12-step referral practicesconducted among substance-user treatment program directors in theDepartment of Veterans Affairs health care system: 79% of patientswere referred to Alcoholics Anonymous and 45% to NarcoticsAnonymous (Humphreys, 1997).

Results from two studies conducted by Hutnphreys, Huebsch, Finney,and Moos speak to the important role that treatment and treatmentprofessionals play in facilitating clients" engagement in 12SG. The firststudy investigated how treatment programs' theoretical orientation influ-ences clients' participation in, and benefits derived from, 12-step groups(Humphreys et al., 1999). Findings indicated that clients in 12-step and

Obstacles to 12-Step Participation 2021

eclectic treatment programs (combining 12-step and cognitive-behavioralapproaches) had higher rates of subsequent 12SG attendance than didclients in the cognitive-behavioral (CB) treatment programs. Moreover,program orientation moderated the effectiveness of 12SG participation: asthe degree of programs' "!2-stepness" increased, the positive relationshipbetween 12SG participation and outcome (substance use and psycho-social) became stronger. The second study extended the investigation tocost effectiveness and reported that compared to patients treated in CBprograms, those treated in 12step oriented programs had significantlygreater involvement in 12-step groups at followup, fewer outpatientcontinuing care visits after discharge, and fewer days of inpatient care,resulting in 64% higher annual costs in CB programs (Humphreys andMoos, 2001). Psychiatric and "substance abuse" outcomes were compar-able across treatments, except that 12step patients manifested higher ratesof abstinence at followup. The authors concluded that professional treat-ment programs that emphasize 12-step approaches increase their patients"reliance on cost-free, mutual-help groups and thereby lower subsequenthealth care costs without compromising outcomes. Further evidence forthe important role that treatment professionals play in fosteringengagement in 12-step groups comes from an A A membership surveywhere one-half of respondents reported being introduced to the fellowshipby a treatment professional (Alcoholics Anonymous, 1998). Finally, theimportance of treatment professionals' role in fostering clients' 12-stepparticipation is also underlined by a recent study where the authorsreported that treatment clients' attendance at 12-step groups was consis-tent over a 6-month treatment episode, suggesting that the pattern ofattendance established early in treatment is critical (Weiss et al., 2000).

In spite of the crucial role clinicians can play in drug users* treatment,there has been very little research on their beliefs and practices (Formanet al., 2001; Kasarabada et al.. 2001). !n particular, although referrals to12-step groups are increasing (Weiss et al.. 2000), little is known aboutaddiction professionals' beliefs concerning these organizations or abouttheir experience in referring clients. Available findings suggest thataddiction professionals are favorable toward 12-step groups (Freimuth,1996). For example, results from a recent survey assessing staff members'beliefs about addiction treatment was conducted in Delaware prior toimplementing (NIDA's) CHnical Trials Network; 82% of staff surveyedagreed with the statement "H-step groups should be used more" (82%)and 84% with "spirituality should be emphasized more" (Forman et al.,2001). Although informative, such findings are limited and additionalresearch is needed. It is important to gain a greater understanding of whattreatment professionals think and believe about 12-step organizations.

2U22 Laudet

as these cognitions may influence referral practices and bear on clientoutcomes (Humphreys et al., 1996; Noordsy et al., 1994; Salzer et al., 2001).

Attrition to 12-step Groups and INon-attendance

Although the majority of substance users report some lifetimeattendance at I2SG (Humphreys el al., 1998), few maintain stableaffiliation over time. Attrition tends to be high. The few available studiesreport declines in participation beginning 3 to 6 months after initiation ofattendance (Kissin and Ginexi, 2000; Timko et al., 1993; Tonigan et al.,2000). Alcoholics Anonymous has noted that results from successiveTricntiial Membership Surveys show "a slow attrition of newcomersduring the first year" and acknowledged this phenomenon as "achallenge to A A " (Alcoholic Anonymous, 1990; Mclntire. 2000). Inaddition to the large number of substance users who may stop attending12SG, a significant minority never attend at all. For instance, in his24-month study conducted among cocaine users, Fiorentine (1999)reported that 26% of participants never attended 12-step meetings fol-lowing formal treatment. To date, little is known about obstacles toparticipation in 12-step groups (McCrady, 1998). Elucidating this issuehas important clinical implications because empirical evidence suggeststhat abstinence rates decline significantly following treatment amongsubstance users who never attend or who stop attending 12-step meetings(Fiorentine, 1999). We note that in the western context where substanceuse and its treatment have become niedicalized. "retent ion" in servicesand in other forms of help is viewed as a desirable and positive outcome.However, much social stigma is attached to substance use and byextension, to participation in substance-use services. Thus, one shouldconsider that if help-seeking and the desire to resolve substance-use-related problems are viewed as an effort at personal growth, retentionin substance-user services may be inconsistent with these goals because ofthe labeling attached to being "in drug t reatmenl" or "in AA (or NA) . "

Attitudes and Beliefs About 12-Step Groups

Participation in 12-step meetings is typically voluntary, especiallyafter treatment. Behavior is based on attitudes that rest on personalbeliefs (Fishbein, 1979). and il is reasonable to suggest that substanceusers" attitudes and beliefs about 12-step groups play a critical role inwhether they choose to participate. However, substance users' attitudes


about 12-step have received scant empirical attention. Tonigan, Miller,and Connors recently wrote: "conspicuously absent [from the literature]has been the measurement of the subjective reactions of individuals toAA related practices and beliefs" (Tonigan et al., 2000). In particular, theauthors pointed to the need to examine substance users' perceived help-fulness of AA to sobriety. In an investigation of predictors of engagementin formal treatment. Fiorentine, Nakashima, and Anglin reported find-ings suggesting that perceived utility or helpfulness of services is criticalto participation (Fiorentine etal., 1999). Three studies have examined theassociation between perceived helpfulness of 12-step groups and meetingattendance among samples of illicit drug users, alcohol-dependent clients,and dually diagnosed persons; they have shown a significant associationbetween positive attitudes towards 12-step's helpfulness and attendance(Bogenschutz and Akin. 2000; Brown et al.. 2001; Tonigan et al., 2000).Two large prospective studies have broadened the investigative scopebeyond perceived helpfulness to embracemenl of 12-step ideology orthe disease-model view of addiction (e.g., total abstinence goal, needfor lifelong 12-step attendance, importance of relying on external supportor "higher power"). Both research teams reported a significant associa-tion between beliefs consistent with the 12-step program and greatersubsequent levels of 12-step participation (Fiorentine and Hillhouse,2000; Mankowski et al.. 2001). These studies greatly contribute lo broad-ening our understanding of predictors of 12-step participation. However,they do not address directly an equally important question: What mayconstitute obstacles to participation in 12-step groups? Several aspects ofthe 12-step program have been identified as potential stumbling blocks.

Potential Obstacles to Participation in t2-Step Groups

In spite of being the most frequently used resource for substanceuse-related problems in the United States (Kurtz, 1990; Room andGreenfield, 1990; Weisner et al., 1995). 12-step fellowships have beenand remain the subject of controversy, and several aspects of the recoveryprogram have been identified as potential stumbling blocks for bothsubstance users and clinicians (Chappel and DuPont, 1999; Laudet,2000). This is due to a multiplicity of factors. The 12-step program'sviews of addiction and recovery are derived from a blend of tenets fromthe Oxford Group practicing First Century Christianity, the advice ofDr. Jung to an early AA member, and the observations of Dr. Silkworth;as such, they are neither scientific nor rational (Marron, 1993). Theprogram's emphasis on spirituality, surrender, and powerlessness

2024 Laudet

contradicts contemporary dominant western cultural norms of self-reliance and widespread secularism (Davis and .lansen, 1998) and consti-tutes stumbling blocks for many (Connors and Dermen, 1996; Ellis andSchocnfeld, 1990). Clearly, the social premium placed on self-reliance maybe more an idealized principle than an adaptive strategy, particularly inlight of overwhelming empirical evidence for the critical role of socialsupport in promoting physical and mental health and in coping withstress (Taylor et al., 1995). Nonetheless, the reliance on external supportand particularly, on spiritual support, that is one of the cornerstones of the12-step program has been identified as a potential cultural point ofresistance to these organizations (Peteet, 1993; Smith et al., 1993). Thatthis and related aspects of 12-step groups play a part in individuals'decision not to participate in 12SG was suggested recently by a smallstudy conducted among 19 (white, highly educated, and employed)members of Moderation Management (Klaw and Humphreys, 2000).Participants consistently attributed iheir decision to drop out of AAafter attending only a few meetings to an aversion to the spiritual focusof the program and to conflicts with AA's concepts of surrender andpowerlessness.'^

The spiritual aspect of the 12-step program is perhaps the strongestpoint of resistance but il is not the only one. Substance users often havequestions or express concerns when 12SG are introducede.g., theirproblem is not "that bad," they know of someone who relapsed whileinvolved in 12 step groups, they associate 12SG with "skid-row drunks"(McCrady, 1998). Some treatment professionals may also be concernedabout the "dangers" and limitations of 12-step groups (Cheiser, 1990;Galinsiky and Schopler, 1994; Kurtz, 1997). Common concerns aboutthese groups include their lack of professionalism, lack of empiricalsupport for their effectiveness, the risk that members become overlydependent on the group or get bad advice from other group members,and that the usefulness of these groups is limited in time (i.e., only neededin early recovery) or in scope (i.e., deals wilh only one substance whileclients have multiple issues [for a review, see Chappel and Dupont(1999)].

two other areas of conflict cited in the sludy were (a) Feeling out of placeamong AA members because one"s drinking problem that was less severe, and (b)being unable to relate to unemployed, homeless or otherwise "down and out"members. The authors note that Moderation Management members surveyedwere predominantly an "elite" of highly educated, employed, Caucasian persons.


Overall, many widely held beliefs about the 12-step programwhether or not these beliefs are "accurate"may constitute obstaclesto participation. While much has been written about potentially limitingor controversial aspects of the 12-step program, little research has beenconducted to determine what substance users and referring cliniciansthink about these organizations. In particular, there has been virtuallyno research to determine whether controversial aspects of the 12-stepprogram constitute obstacles to participation or on what other factorsmay play a role in substance users' decision to not attend 12-step groups.In this regard, it is important to include frontline clinicians in the researchprocess as "they develop insights that might not occur to researchers"(Forman et a l , 2001).

This study seeks to identify potential obstacles to participation in12-step groups by surveying substance users and referring clinicians.The research questions addressed in the present study are:

1. What are substance users and clinicians" attitudes concerning thehelpfulness and usefulness of 12-step groups as a recoveryresource?

2. What do substance users and clinicians perceive to be majorpositive and negative aspects of 12-step groups?

3. What do substance users" and referring clinicians" perceive to beobstacles to 12-step participation?

METHOD

Samples

One hundred and one clients and 102 staff members were interviewedat five separate outpatient substance-user treatment programs InNew York City (all programs contacted agreed to participate). Theclient sample was selected from the client base of the collaborating agen-cies using a random number table. All staff members who have clinicalcontact with clients were recruited to participate in the study.Participation in ihe study was voluntary and based on informed consent.The study was approved by the Institutional Review Board of theNational Development and Research Institutes, Inc. (NDRI) and bythe review process of the agencies where participants were recruited.Data were collected using personal interviews that were conducted atthe programs and lasted approximately 40min for both clinicians andclients; participants received $20 for their time. Data collection was

2026 Laudet

conducted between May, 2001 and January, 2002.'' Refusal rate wasestimated at less than 5% for clients and 12% for staff.

Measures

The study used a questionnaire consisting of structured items andinventories (adapted from previous studies as noted in each individualsection below) and open-ended questions developed from qualitativeinlerviews conducted during the preliminary phase of the study andpresented elsewhere (Laudet, 2000). Parallel versions of the instrumentwere developed for clients and clinicians so that the wording of the itemswas similar for both groups of participants. Bolh versions of theinstrument began with a series of questions about sociodemographic andbackground information (substance use. treatment, and 12-stepattendance history for clients; education, training, and professionalexperience for staff members). The instrument was pretested for feasibilityand length; minor adjustments were made for clarity in the phrasing ofseveral items. The final Client instrument consisted of 290 items, theClinicians version, of 267 items (Flesch-Kincaid Grade Level score = 7.0for both). Following this introductory section, the domains and measuresused for this study were;

Attitudes about 12-step. (a) Helpfulness of 12-step groups: "In yourexperience, how helpful or harmful are 12-step groups?" This item waspreviously used by Salzer et al. (1994) in a study assessing mental healthprofessionals' views on mutual-help groups (scale ranges from O = veryharmful, to 10 = very helpful; 5 = neither harmful nor helpful); (b)Importance of 12-step groups; "How important a role do you believe12SG can play in a comprehensive treatment system?"" and "How impor-tant a role do you believe 12SG can play in the recovery process?" Ratingscale ranged from 0 =: nol at all important, to 10 = extremely important; (c)Role of 12-step groups in the recovery process: "Which of the followingbest describes the role I2SG should play in the recovery process?" Theanswer categories, reflecting the three positions identified byFarquharson's (1995) in his work with community mental health profes-sionals were; 12SG have minimal usefulness, 12SG are a useful addition toformal treatment, and 12SG are crucial to the recovery process; and d)

^Analyses conducted lo detect any differences in the variables under studybetween data collected before and after Sept. 11, 2001, yielded no significantfindings.


Level of interest in obtaining further information about 12-step groups:"How interested would you be in obtaining further training or informationabout 12-step groups?" {Extremely, very tnuch. moderately, a little, notat all).

Beliefs about 12-step groups. Three open-ended questions were usedto collect information about perceived benefits, limitations, and potentialdangers of 12-step groups: "What can 12-step groups do for people (whatare the benefits)?" "What can 12-step groups not do for people (what arethe limitations)?" "What are the potential dangers of 12-step groups?"Codes for the open-ended items used in the study were developed on thefirst 30 completed interviews: based on a subsample of 25 Instrumentscoded by two independent researchers, inter-rater reliability was r = 0.90.

Obstacles to participation. Information about potential obstacles to12-step participation was collected using both open-ended and structureditems. First, clients and clinicians were asked a series of open-endedquestions designed to elicit information about why substance users maychoose not to attend 12-step groups. Clients who were not currentlyattending 12-step groups were asked their reason(s) for not attendingand all clients, regardless of current attendance status, were askedabout obstacles to 12-step attendance using items phrased in generalterms (e.g.. "What are some of the obstacles to people becoming engagedin 12-step?"). It was felt using this phrasing wouid elicit information thatclients may be reluctant to reveal directly such as persona! reasons fornonattendance (e.g., ongoing drug use, ambivalence about quitting) andaspects of 12-step meetings or of the recovery program with which clientsmay be uncomfortable (e.g.. sharing personal information with othermembers, the concept of a Higher Power). Answers to these items werecoded as described in the previous section.

Next., participants completed a scale consisting of items describingpotential obstacles to participation. After determining through socialscience database searches that there was no existing instrument availableto assess clients' and staff members' beliefs about 12-step groups, aninstrument was developed. The instrument consists of items describingpositive and negative aspects of 12-step groups; the current study usesonly the negative aspect subscale. A pool of items was generated fromreviews of the extant literature {summarized above), as well as from pilotinterviews with both clients and staff members (author's citation) andfrom statements previously used by Meissen et al. (1991) in a study offuture clinicians' attitudes and intentions toward mutual-help groups(e.g., '12SGs can be dangerous because the leaders are not professionallytrained"). After deleting redundant items, the final list consisted of 12items presented in the Results section (Chronbach Alpha =0.74 for the

2028 Laudet

client sample and 0.67 for the clinician sample). Respondents were asked:"Please indicate the extent to which you agree or disagree with eachstatement." The response categories were 1 = strongly disagree,2 = disagree, 3 = agree. 4 = strongly agree. In an effort to maximize therichness of the information collected on potential obstacles to 12-stepparticipation, the open-ended items were asked first to ensure thatanswers would not be influenced by the content of the structured items.

RESULTS

Description of Samples

Clients

Samples characteristics are summarized in Table 1. Study participantswere mostly members of ethnic minority groups. Among the 26% ofrespondents describing themselves as Hispanic, 23% were PuertoRicans, 2% were from the Dominican Republic and one from Costa Rica.

Table I. Selected description of samples.

Clients (/V= 101)MaleAfrican-AmericanHispanic

Puerto RicoDominican RepublicCosta Rica

Primary substanceCrack-cocaineMarijuanaPowder cocaine

AlcoholHeroin

Substance use past yearSubstance use pasi monthTwelve-step attendance

LifetimeCurrent

50%59%26%

2321

31%2817

158

82%32%

66%43%

Clinicians iN 102)MaleA frica n-America nHispanic (Puerto Rico)Education

Graduate degreeBachelor's degree

HS/some collegeProfessional experience

In current job(mean yrs, SD)

In treatment fieldReferral to 12-step

(estimated mean %)Clients referred lo 12-stepReferred clients who

become alTili;ited

29%61%23%

34%40

26

5.3 (5.3)

7.6 (6.2)

75%

44%


Participants ranged in age from 18 to 59 (mean 36, SD 10). Over one-half (53%) did not complete high school. 27% held a high-school diplomaor GED, and 20% had some college or vocation training beyond highschool. The most frequently cited primary substance abuse problem wascrack-cocaine (31%). Mean age of first substance use was 16 years. Eightout of 10 (82%) reported using drugs or alcohol in the year preceding theinterview, one-third (32%) in the past month. Over one-half of partici-pants (59%) reported that this was their first enrollment in treatmentservices for substance-abuse problems. Two-thirds of participants (62%)reported some regular lifetime 12-step attendance (defined as "for otiemonth or longer"); 43% reported current attendance. Alcoholics andNarcotics Anonymous were the fellowships most often mentionedamong participants with lifetime attendance.

Clinicians

Participants were mostly female. African-American, and Hispanic(Table I). One-third held a graduate degree. 40% a bachelors' degree,21% had some college credits, 6% a high-school diploma. Job titleswere: counselor (44%). social worker (20%)), case manager (17%)), clinicalsupervisor (13%)). and paraprofessional social worker (e.g., case aide6%).On average, participants had 5.3 years of experience in their currentposition (mean; SD 5.3) and a total of 7.6 years of experience in thetreatment field (mean; SD = 6.2). All clinicians reported referring clientsto 12SG; on average, they reported referring three-quarters of their clientsand estimated that 44 Vo of clients referred participated in 12 step-groups.

Attitudes About 12-Step Groups

Findings (summarized in Table 2) indicate that both clients andclinicians generally held highly positive views of 12-step groups.Clinicians consistently gave significantly more positive ratings thandid clients and expressed higher levels of interest in obtaining furtherinformation about 12-step groups.

Beliefs About 12-Step Groups

First, participants were asked about the benefits of 12 step-groups(Table 3). Twenty-three percent of the clients did not know and did not

2030 Laudet

Table 2. Ratings of 12-stcp group.s among outpaiieni drug user treatment clientsand elinicians.''

Helpfulness of 12-step groups''mean (S.D.)

Importance of 12-step groups incomprehensive treatment system*'

(mportance of 12-step groupsin the reeovery process''

Role 12-step groups should playin the reeovery process''12-stcp groups are of minimalusefulness12-step groups are a useful additionto formal treatment12-step groups are crucial to therecovery process

Interest in obtaining further training orinformation about 12-step groups'?'^Not at ail/a littleModeratelyVery much/extremely

Clients(A^=101)8.02 (2.14)

7.86 (2.30)

8.70(1.84)

5%

62%

33%

29%21%50%

Clinicians(A^^ 102)

9.57(1.17)''

9.27(1.40)^

9.52(1.06)''

0%

46%

54%

7%7%86%

"Independent sample /-tests were used to eompare continuous variables;Mantel-Haenszel tests for linear association were used for ordinal categoriealvariables.^O=Very Harmful lo 10 = Very Helpful.'0 = Not at all to 10 = extremely.'

provide an answer. Most frequent answers provided by both clients andclinicians were: the opportunity to help improve yourself and your life,help with sobriety and recovery, and fellowship with recovering peers.

Next, participants were asked what are the limitations of 12-stepgroups. Fully one-half of clients did not know and provided no answer.Substance users' lack of motivation or willingness to change was citedmosl frequently by clients and was the second most frequent answeramong clinicians ("no limitations" was the most frequent answerprovided by clinicians).

With respect to potential dangers of 12-step groups, the most frequentanswer among both clinicians and clients was '"nothing" followed by

Obstacles to 12-Step Partieipation 2031

Table 3. Perceived benefits, limitations, and dangers of 12-step groups amongoutpatient drug user treatment clients and clinicians.

Clients Clinicians

Benefits of 12-step groups A^= 10! A'=102Opportunity to improve yourself and your lifeSupport, fellowship with peersHelp with sobriety and recoveryEmotional well-beingRole models/positive environment for a drug-free lifeRemembering where you came fromMisc. otherDon't know, not sure

Limitations of 12-step groupsNo limitationsDenial/You have to want it/need motivationCannot change everything in your lifeCannot provide concrete servicesNegative mentions (e.g.. triggers relapse, chaotic)It is not for everyone (e.g.. on medieations)Negative comparisons to formal treatmentConvenieneeReiigious aspectConfidentiality issuesClients limitations (insecure, anxious)Don't know, not sure

Potential dangers of 12-step groupsNothingNot hearing what is said, does not address denialExpecting too much/Not recognizing

need for other kinds of helpRisk of confronting sensitive issues without

professional helpCan trigger relapseBreach confidentiality/Lack of anonymityGetting bad feedback/listening to wrong personMembers can become overly dependent on the groupNo professional supervision/Groups not monitoredAttend groups for social aspects only, e.g.,

meet male/femaleAvailability/instability of groupsBeing mandated to goNot being able to identify with other membersMisc. OtherDon't know

24%1820805223

7%3174000000051

33%136

25%373008000

29%250014101032250

44%190

533000

000530

423433

21150

2032 Laudet

"it does not address denial" (e.g.. not listening to what other memberssay, not doing the right thing).

Obstacles to Participation in 12-Stcp Groups

We first examined reasons lor nonattendance at 12-step groups amongclients who had reported no lifetime attendance and among clients whoreported past bul nol current attendance. Among never attenders (A' = 38),reasons for nonattendance were: do nol feel I need it (47%).. treatmentprogram is enough (21%), do not like or believe in groups (12%), stillusing or picked up (6%). unable to attend (e.g., time, health) (6%), notrequired to attend (6%). and did not know about ! 2-step groups (2%).Among substance users who reported prior bul no current attendance(iV= 19), reasons for nonaltendance were: do not like or believe ingroups (22%). still using or picked up (22%). unable lo attend (e.g..,time, health) (22%), I got the message (22%). and it did not help (12%).

Second, we asked all client participants: "Whal are some of thereasons why people do not attend 12SG?"" The most frequent answerwas "People don't want to or are nol ready to stop using" (39%), fol-lowed by "People can do it on their own" (21%) and negative view orignorance aboul 12SG (15%). The other answers were: still using (8%)and being embarrassed or nol wanting to be seen al 12-slep group (7%).Ten percent were not sure.

Third, we asked both clients and clinicians: "What are some of theobstacles to people/clienls becoming engaged in 12-step groups'?" Resultsare presented in Table 4. Denial, lack of readiness to slop, and "People.,places and things," a 12-step expression referring to people and situationsthat are associated wiih or trigger substance use. were the most frequentobstacles cited by clients. Denial was also a frequent answer amongclinicians. Over one-third of clinicians' answers centered on practicalissues of scheduling and convenience: gelting there (no childcare, lackof transportation, inconvenient meeting time or place) (27%), and timeconstraints/responsibilities (10%).

Turning to the "negative aspects of 12-step groups" scale, principalcomponents factor analysis with Varimax rotation produced four inter-pretable factors accounting for a total of 60Vo of the variance in the itemresponses. The four factors, consistent with prior literature identifyingpossible points of resistance to 12-step groups, were labeled "Negativeconsequences of participation," "Recovery stage limitation." "Religionand powerlessness," and "Lack of professionally trained leadership."The individual items and factor loadings are presented in Table 5. The


Table 4. Obstacles to participation in 12-step groups: clinicians' and clients'perspective.

Denial, lack of motivationUsing, not ready to stopPeople, places, and thingsGetting there (no child care, transportation,

convenience of meetings)Time constraints/responsibilitiesNegative view, ignorance of 12SGConfidenliality, visibilityClients' limitations and problems (e.g., anxious.

low self-esteem)NothingHaving to go aloneMisc.Don't know, not sure

ClientsA'=10I

14%21160

7550

500

27

CliniciansA^=102

25%80

27

10818

3550

items forming the four factors generally had moderate levels on internalreliability as measures by Chronbach Alpha (Negative consequences ofparlicipation, alpha0.62; Recovery stage limitation, alpha =0.65:Religion and powerlessness. alpha = 0.63; and Lack of professionallytrained leadership, alpha = 0.57). Independent Mests conducted to com-pare substance users' and staff members' four factors scores were all sig-niticant (/j

2034 Laudet

Tahle 5. Negative aspects of 12-step groups scale: clients and elinicians percentagrec/slrongly agree and factor structure.

Stage of recovery limitationCan't benefit from I2SG

early in recoveryl2SGs only helpful early in the

recovery processNeed to achieve sobriety before

starting 12SG.SRisks of participationCan get retraumatized or

triggered in a I2SG12SGs can lead to pick-up

or relapseCan become dependent on 12SGsReligion and powerlessnessl2SGs can be too intense

for some peopleReligious aspect of I2SGs is an

obstacle for manyEmphasis on "powerlessness"

can be dangerousLack of professionally trained leadership12SG meeting leaders dominate

the rest of the groupI2SG should seek professional

guidancel2SGs can be dangerous because the

leaders are not professionally trained

ClientsA'=101

18%

17

23

35%

34

55

68%

6J

48

2 1 %

56

26

Clinicians^ = 1 0 2

3%^

4"

T

64%*'

38

67

56%"

30*

2?"

16%*^

36='

14"

Factorloading

0.78

0.66

0.66

0.86

0.75

0.61

0.79

0.63

0.63

0.74

0.62

0.64

Mantel-Haenszel test for linear association '^p< .i)\. ^p< .05.

groups as a recovery resource?"' Trea tment clietits and clinicians surveyedheld positive views of 12-step g roups ' helpfulness, impor tance in therecovery process as well as in a comprehensive t reatment system. Thesefindings replicate earlier reports summarized in the In t roduct ion ( Brownet al. , 200) ; F o r m a n et al., 2001)-

The second research question was: " W h a t do substance users andclinicians perceive to be positive and negative aspects of 12-step g roups?"Both groups of par t ic ipants cited peer suppor t , help with recovery, and


the opportunity to improve one's life as the major benefits of 12-stepgroups. The major hmitation of 12SG, cited by both groups of partici-pants, can be succinctly expressed by the 12-step saying, "it works if youwork it." That is, 12-step groups cannot help persons who are not readyor willing to seek help (see later discussion). Indeed, nearly half of thechents who were not attending 12SG said they did not feel they neededit and another 20% felt the treatment program was sufficient. Whilesome substance users may be able to recover without the support of12-step fellowships (Timko et a l . 2000; Toneatto et al.. 1999). mostare not; 12-step groups are often cited as an important source ofsupport among individuals who have achieved stable recovery(Laudet et al.. 2002). Yet in the present study, less than one-half of clientswere attending 12SG. and clinicians estimated that less than half ofthe chents they refer to 12SG become affihated. This underlines theimportance of addressing the third research question: "What do .sub-stance users and referring clinicians perceive to be obstacles to 12-stepparticipation?"

In answers to the open-ended items, lack of readiness or motivationfor change was cited as a major obstacle to 12-step participation by bothsubstance users and by clinicians. Motivation has previously been identi-fied as a critical factor in both engagement in and outcome of formalsubstance user treatment interventions as well (Simpson and Joe, 1993).Over one-third of clinicians also cited practical issues of convenience(e.g.. lack of transportation or child care) and scheduling as potentialbarriers to I2SG participation; relatively few clients cited these concerns.In the United States, 12-step meetings are generally thought be widelyavailable to all who wish to attend because the 12-step fellowships holdnumerous meetings, especially in large cities such as New York Citywhere this study was conducted. However, it may be that practicalmatters such as not having access to child care or to transportationconstitute obstacles that tend to be overlooked by researchers. [Wenote recent findings by Mankowski et al. (2001) reporting a significantassociation between "geographical density" of 12-step meetings andgreater levels of participation]. Present findings on this issue emphasizethe importance of including frontline clinicians in the research process asthey can contribute valuable insights that may otherwise remain unex-plored.

Few study participants mentioned any of the "controversial" aspectsof the 12-step program reviewed earlier in their spontaneous answersconcerning hmitations of 12-step groups or obstacles to participation.When participants were asked to indicate their level of agreement withstatements describing these aspects of the 12-step program, findings

2036 Laudet

varied across broad dimensions. Over one-half of both substance usersand clinicians agreed that "tbe religious aspect of 12-step groups is anobstacle for many." and nearly one-half of clients agreed with "theemphasis on powerlessness can be dangerous." Consistent withrecommendations of the American Psychiatric Association that referralto 12-step groups is appropriate at all stages in the treatment process(American Psychiatric Association, 1995). few participants from eithergroup endorsed the belief that the usefulness of 12-step groups is limitedto a specific stage of recovery. Items concerning the lack of professionallytrained leadership received moderate levels of agreement. Of note is thefinding that significantly more substance users than clinicians agreed withthe statement "12SG should seek professional guidance." This isconsistent with the pattern reported earlier (Attitudes section) wheresubstance users consistently expressed less favorableand here, morenegativeviews of 12-step groups than did clinicians. The only exceptionto this pattern emerged in findings concerning potential risks of partici-pation in 12-step groups; in particular, nearly twice as many clinicians asclients expressed agreement with Ihe statement that "clients can getretraumatized or triggered in 12-step groups." This difference betweenthe two groups of participants may be due in part to the fact thatclinicians based their answers on years of professional experience withlarge numbers of clients and were therefore more likely to have observedinstances were clients were triggered as a result of attending a 12-stepgroup. Clients' answers, on the other hand, are likely to have been basedon their personal experience and/or that of a few members of their socialnetwork and thus to be more limited. This difference in perspectives mayalso partially explain the consistent pattern of findings indicating thatclinicians are significantly more positive about 12-step than are clients.

Present results have important clinical implications. First, a sizableproportion of clients had little experiential knowledge of 12-step groups.Nearly four out of 10 reported no prior attendance and a large minoritywere unable to mention benefits or limitations of I2SG. This suggest thatthere is a strong need for clinicians to inform and educate clients about12-step groups, In the present sample. 50% of substance users expressedrelatively little interest in obtaining further information about 12-stepgroups. It is not possible in this study to determine whether that is becausethey do not feel the need for such groups (and thus need no information,see below) or because they feel they "know all about it." Because 12-stepconcepts are ubiquitous in the treatment context and common lore amongsubstance users, it is important that clinicians open the dialogue withclients about prior experience with 12-step groups as well as about whatthey know and believe about these groups and where these cognitions

Obstacles to 12-S(ep Participation 2037

come from (e.g., personal experience or hearsay). Substance users are oftenambivalent about recovery, especially early on, and may be quick to forman opinion about 12-step groups based on limited experience or friends'accounts.*^ Clinicians should elucidate such questions, emphasize theimportance of keeping an open mind and of attending different types ofmeetings (e.g., round robin meeting, meetings for beginners, open andclosed meetings, as well as the many specialized meetings such as forwomen, gays and lesbians, veterans, etc., as appropriate) as some formatsare likely to be a better fit than others. In that respect, we note thatalthough 12-Step group meetings share a general structure, philosophy,and format, they also may be sufficiently flexible to reflect the local ecologyand the different needs and interests of participating community members(Humphreys and Woods, 1993). Consequently, 12-step groups may beequally utilized and effective because they attend to the needs and interestsof the gender and ethnic populations they serve (Hillhouse and Fiorentine,2001). Thus processes of engagement, participation, retention, attrition,and effectiveness are likely to be influenced not only by the general tenetsand format of the 12-step program (e.g., working the 12-steps, peersupport, emphasis on honesty and introspection) but also by the specific12-step meeting(s) clients attend. This suggests that in addition to famil-iarizing themselves with the 12-step model, clinicians would be well-advised to be informed about the individual group meetings that areheld in the communities (e.g., membership characteristics, group norms).

When discussing 12-step participation, specific clients" concerns andmisconceptions should also be identified and addressed on a case-by-casebasis. Overall, is it paramount that clinicians work in collaboration withclients to find a good fit between clients" needs and inclinations on the onehand and the tools and support available within 12-step groups on theother (Caldwell, 1999; Caldwell and Cutter, 1998). The author acknowl-

term ''recovery" as used most often in the literature, generally refersbroadly to positive outcome among substance users but is rarely defined. Whilea detailed discussion of the concept of recovery is beyond the scope of this study.we note that recovery is not a finite event but rather, a process that often beginswith multiple attempts to change and may ultimately include total abstinencefrom substance use. More importantly, recovery entails a lifelong complex,dynamic, and multidimensional effort toward self-ehange. F"urther. the term isalso bound in western culture and especially, in the ideology of 12-step programs.as members typically identify as being "in recovery" whereas persons whoresolved substance use-related problems through other means such as unassisted(natural) resolution may not readily identify with that term.

2038 Laudet

edges that such "matching" of individual needs and circumstances tospecific types of help, while highly desirable, is difficult to implement inpractice and rarely is an integral part of treatment planning, implementa-tion and/or evaluation. Services that are most often delivered in groupsessions do not allow for individualization of treatment orientation orconsideration of individual life and/or recovery stage. When feasible,individual sessions between client and clinician should include a discus-sion of prior participation in and beliefs about 12-step groups so as tomaximize the Hkelihood that clients will consider such organizations as aresource in their change process. Finally, in discussing attendance at 12-step groups, it is important for treatment professionals to look beyondclinical issues (e.g., readiness for change, see below) and to address cli-ents" socio-environmental context on a case-by-case basis, as some obsta-cles to 12-step attendance may be overlooked (e.g.. availability of childcare or money for transportation).

The second point of clinical relevance concerns the finding thataspects oi the 12-step program previously identified as potential pointsof resistance, such as the spiritual emphasis, were rarely mentioned spon-taneously by either substance users or by clinicians. Instead, lack ofmotivation to enter recovery and/or reluctance to recognize that recoveryrequires external support ("1 don't need it") appears to be a major barrierto affiliation with 12-slep groups. Caldwell (1999) has discussed lack ofchange readiness as a possible obstacle to 12SG participation. Thechange process involves a fairly long initial stage in which denial aboutaddiction needs to be broken down (Marron, 1993). Individuals who donot believe they have a problem or who believe that that their problem isnot severe enough to require help are not likely to seek help. Asked aboutreasons why people may not attend 12SG. 20% of substance users saidthat "people can do it on their own" and only one-third of clients viewed12SG as crucial to the recovery process (vs. one-half of clinicians). Denialof a problem or of a prob!em"s severity is a major barrier to seekingand obtaining help. Decrease in denial during treatment is a significantpredictor of 12SG attendance after treatment (McKay et al., 1994).Commenting on high rates of early attrition, AA has suggested that itmay be that "some individuals are not convinced of their addiction"{Alcoholic Anonymous, 1999).

The only requirement for 12-step membership is "the honest desireto stop" substance use (Alcoholics Anonymous. 1939/1976). Giventhat desire, the 12-step program of recovery suggests that admittingpowerlessness over drugs and alcohol (that is, admitting that onecannot recover by will power alone) is the first step toward recovery.Current data suggest that low levels of motivation to change (desire to


stop) and the belief that one may not need external help to recover (i.e.,not being powerless over a substance or substance use) represent signifi-cant reasons why substance users may elect not to participate in 12-stepgroups. Because findings also indicate that substance users view 12-stepgroups as a helpful recovery resource, interventions designed to enhancemotivation for change (Miller and Rollnick, 1991) and recognition of theneed for external support are suggested as means of fostering 12-stepparticipation. Further, a number of factors have been identified aspredictors of help-seeking among substance users; while most studieshave investigated predictors of help-seeking in formal treatment services,findings may also help focus clinical strategies designed to enhanceparticipation in 12-step groups during and after treatment services.Predictors of help-seeking include greater severity of dependence, greatersubstance-related health and psychosocial problems, use of illicit drugs(vs. alcohol), especially heroin and cocaine, greater network encourage-ment to seek help and social pressure to cut down, belief that one isunable to quit on one's own, and belief in the efficacy of services orother form of help (Delaney et al., 1998; Hajema et al., 1999; Hasinand Grant, 1995; George and Tucker, 1996; Kaskutas et al., 1997;Kessler et al., 2001; Tucker, 1995). It is important to note that 12-stepgroups may not be suited to all substance users (Brown et al., 2001) sothat nonattendance or disengagement should not necessarily beinterpreted as a lack of commitment to the recovery process. A numberof addiction recovery mutual-help groups have emerged in an effortto provide support to individuals who find 12-step groups' goals orideology unsuitable. These groups include Secular Organization forSobriety (SOS), Rational Recovery, Women for Sobrietys (WFS), andModeration Management (Horvath, 1997; Klaw and Humphreys. 2000).However, because of the limited availability of meetings held by theorganizations and the wide availability of 12-step meetings, it isimportant to gain a greater understanding of why some substance usersdo not participate. We note that because findings from the current studysuggest that the main obstacles to participation in 12-step groups are not12-step-specific but rather, center on clinical issues (e.g., motivation forchange), present results may apply to participation in other mutual-aidgroups as well. Additional research is greatly needed in this area.

This study has several limitations that should be considered ininterpreting the results. In addition to the use of relatively small samplesof convenience, clients' prior and current rates of 12-step attendance werelower than reported elsewhere (Humphreys etal.. 1998). The relatively lowattendance rates may be explained in part to the high percentage ofparticipants who were receiving addiction services for the first time.

2040 Laudet

In addition to these sample limitations, other study limitations point todirections that future research might take in that area. This study focusedon identifying obstacles to participation in 12-step groups. It did notexamine the association among clients" stage of recovery. 12-step-relatedattitudes, and 12-step attendance, nor did it consider staff's recovery statusin relationship to attitudes about 12-step groups. One study examining therole of staff's recovery status on beliefs about addiction reported a positivebut nonsignificant association between being in recovery and endorsingthe disease-model view of addiction (Humphreys et al., 1996). Anotherimportant question that this study did not examine is that of the associa-tion between staff's attitudes about 12-step groups and referral practices.In spite of these limitations, this early study constitutes an important steptoward identifying and addressing obstacles to participation in 12-stepgroups. It is the authors' hope that findings reported here will contributeto focusing additional research on this important topic. Of particularinterest would be cross-cultural comparisons of clinicians' and substanceusers' views of 12-step groups and of other mutual-help recovery organi-zations, as well as comparisons between urban and rural geographicalregions where the availability of services and views on substance usemay vary significantly.

ACKNOWLEDGMENT

The work reported here was supported by National Institutes onDrug Abuse Grant R03 DA13432.

REFERENCES

Alcoholic Anonymous. (1990). AA I9S9 membership survey. NY: AAWorld Services.

Alcoholics Anonymous. (1939/1976). Alcoholics Anonymous: The Story ofHow Many Thousands of Men and Women have recovered fromAlcoholism. 3rd ed. NY: AA World Services Inc.

Alcoholics Anonymous. (1998). Comments on AA's Triennial surveys.New York: Alcoholics Anonymous World Services, Inc.

American Psychiatric Association. (1994). Diagnostic and StatisticalManual of Mental Disorders. 4th ed. Washington, DC: Author.

American Psychiatric Association. (1995). Practice guidelines for thetreatment of patients with substance abuse disorders: alcohol,cocaine, opioids. Amer. J. of Psychiatry 152:1-59.


Bogenschutz, M., Akin S. (2000). 12-Step participation and attitudestowards 12-step meetings in dual diagnosis patients. .AlcoholismTreatment Quarterly i8(4):31-45.

Brown, B., O'Grady, K.. Farrell, E., Flechner, I., Nurco. D. (2001).Factors associated with frequency of 12-step attendance by drugabuse clients. Amer. J. of Drug & Alcohol Abuse 27(1): 147-160.

Caldwell, P. E. (1999). Fostering client connections with AlcoholicsAnonymous: a framework for social workers in various practicesettings. Social Work in Health Care 28(4):45-61.

Caldwell, P., Cutter, H. (1998). Alcoholics Anonymous affliction duringearly recovery. J. of Substance Abuse Treatment 15(l):22l-228.

Chappel, J., DuPont, R. (1999). Twelve-step and mutual-help programsfor addictive disorders. Addictive Disorders 22(2):425-446.

Chesler, M. A. (1990). The "dangers" of self-help groups: understandingand challenging professionals' views. In: Powell, T. J.. ed. Workingwith Self Help Silver Spring. MD: NASW Press, pp. 301-324.

Connors, G., Dermen. K. (1996). Characteristics of participants insecular organization for sobriety (SOS). Amer. J. Drug AlcoholAbuse 22:2Sl-295.

Davis, D. R., Jansen, G. G. (1998). Making meaning of AlcoholicsAnonymous for social workers: myths, metaphors, Metaphors,and realities. Social Work 43(2): 169-182.

Delaney, W., Grube, J. W., Ames, G. M. (1998). Predicting likelihood ofseeking help through the employee assistance program amongsalaried and union hourly employees. Addiction 93(3):399^IO.

Ellis, A., Schoenfeld, E. (1990). Divine intervention and the treatment ofchemical dependency. J. of Suhstatue Ahu.se 2(4):459-468.

Farquharson, A. (1995). Developing a self-help perspective: conversationwith professionals. Canadian J. of Community Mental HealthI4(12):81-89.

Fiorentine, R. (1999). After drug treatment: are 12-step programseffective in maintaining abstinence? Am. J. Drug Alcohol Abuse25(0:93-116.

Fiorentine, R., Hillhouse, M. (2000). Drug treatment and 12-stepprogram participation: The additive effects of integrated recoveryactivities. J. of Substance Abuse Treatment 18(I):65-74.

Fiorentine, R., Hillhouse, M. P. (2000). Exploring the additive effects ofdrug misuse treatment and twelve-step involvement: does twelve-step ideology matter? Substance Use ond Misuse 35(3):367-397.

Fiorentine, R., Nakashima, J., Anglin, M. D. (1999). Client engagementin drug abuse treatment. Journal of Substance Abuse Treatment17:199-206.

2042 Uudet

Fishbein, M. (1979). A theory of Reasoned action: some applications andimplications. In; Page, M. M., ed. Nebraska Symposium onMotivation. Lincoln: University of Nebraska Press.

Forman, R., Bovasso, G., Woody, G. (2001). Staff beliefs aboutaddiction treatment. J. of Substance Abuse Treatment 21(I):l-9.

Freimuth, M. (1996). Psychotherapists beliefs about the benefils of12-step groups. Alcoholism Treatment 14:95-102.

Galinsiky, M., Schopler, .1. (1994). Negative experiences in supportgroups. Social Work in Health Care 20(I):77-95.

George, A. A., Tucker, J. A. (1996). Help-seeking for alcohol-relatedproblems: social contexts surrounding entry into alcoholismtreatment or Alcoholics Anonymous. J. Stud. Alcohol

Hajema, K. J.. Knibbe, R. A.. Drop. M. J. (1999). Social resources andalcohol-related losses as predictors of help seeking among maleproblem drinkers. J. Stud. Alcohol 60(\):\20-\29.

Hasin, D. S., Grant. B. F. (1995). AA and other help seeking for alcoholproblems: former drinkers in the U.S. general population. J. Subst.Abuse lQ):2S\-292.

Hillhouse, M., Fiorentine., R. (2001). 12-Step program participation andeffectiveness: do gender and ethnic differences exist? Journal of DrugLssues 31(3):767-780.

Horvath, A. T. (1997). Alternative support groups. In: Joyce. H.Lowinson, Pedro Ruiz, Robert. B. Millman, John, G. Langrod,eds. Substance Abuse: A Comprehensive Textbook. 3rd ed.Baltimore[MD]: Williams & Wiikins, pp. 390-396.

Humphreys, K. (1997). Clinicians' referral and matching of substanceabuse patients to self-help groups after treatment. P.svchiatricServices m\\):\44^\U9.

Humphreys, K.. Huebsch, P.. Finney, J., Moos, R. (1999). Acomparative evaluation of substance abuse treatment: V.Substance abuse treatment can enhance the effectiveness of self-helpgroups. Alcoholism Clinical and Experimental Research23(3):558-563.

Humphreys., K., Kaskutas, L.. Weisner, C. (1998). The relationship ofpre-treatment Alcoholics Anonymous affiliation with problemseverity, social resources and treatment history. Drug


Humphreys, K,. Noke. J., Moos, R. (1996). Recovering substance abusestaff members' beliefs about addiction. / . of Substance AbuseTreatment 13(l):75-78

Humphreys, K., Woods, M. D. (1993). Researching mutual help groupparticipation in a segregated society. The fournal of AppliedBehavioral Science 29:181-201.

Institute of Medicine. (1990). Broadening the Base of Treatment for AlcoholProblems. Washington, DC: National Academy Press.

Kasarabada, N., Hser, Y., Parker, L., Hall, E., Anglin, D., Chang, E.(2001). A self-administered instrument for assessing therapeuticapproaches of drug-user treatment counselors. Substance Use andMisuse 36(3):273-299.

Kaskutas, L. A, Weisner, C , Caetano, R. (1997). Predictors of helpseeking among a longitudinal sample of the general population,1984^1992. J. Stud. Alcohol 58(2):155-161.

Kaskutas, L.. Bond, J., Humphreys, K. (2002). Social Networks asMediators of the Effect of Alcoholics Anonvmous Addiction.97(7):891-900.

Kessler, R. C , Aguilar-Gaxiola. S.. Berglund, P. A.. Caraveo-Anduaga,J. J., DeWit, D. J., Greenfield, S. F. (2001). Patterns and predictorsof treatment seeking after onset of a substance use disorder.Archives of Gettertd Psychiatry 58(1 l):1065-107L

Kissin, W., Ginexi, E. (2000). The impact of selflielp involvementon recovery course. Presented at the 62nd Annual ScientificMeeting of the College on Problems of Drug Dependence,San Juan, PR, June.

Klaw, E., Humphreys, K. (2000). Life stories of ModerationManagement mutual help group members. Contemporary DrugProblems 27:779-803.

Kurtz, L. F. (1990). The self-help movement: review of the past decade ofresearch. Social Work with Groups 13:101-115.

Kurtz, L. F. (1997). Self-Help and Support Groups: A Handbook forPractitioners. Thousand Oaks. CA: Sage Publications.

Laudet, A. (2000). Clinicians' roles in enhancing affiliation withself-help recovery groups. Presented at the 128th Annual Meetingof the American Public Health Association. Boston. MA.

Laudet, A. (2000). Substance abuse treatment providers' referral toself-help: review and future empirical directions. International J.of Self-Help & Self-care 1(3): 195-207.

Laudet, A.. Savage, R., Mahmood, D. (2002). Pathways to long-tennrecovery: a preliminary investigation. Journal of PsychoactiveDrugs 34(3).

2044 Laudet

Leshner. A. (1997). Addiction is a brain disease, and it matters. Science

Mankowski, E., Humphreys, K., Moos, R. (2001). Individual and con-textual predictors of involvement in 12-step self-help groups aftersubstance abuse treatment. Amer. J. of Com. Psy. 29(4):537-563.

Marron, J. T. (1993). The twelve steps. A pathway to recovery. PrimaryC/r('20(l):107-119.

McCrady, B. (1998). Recent research in twelve step programs. In: Schultz.T., Graham, A., eds. Principles of Addiction Medicine. 2nd ed. ChevyChase, MD: Amer. Soc. of Addiction Med.. pp. 707-718.

Mclntire, D. (2000). How well does AA work? An analysis of publishedAA surveys (1968-1996) and related analyses/comments.Alcoholism Treatment Quarterly 18(4): 1-18.

McKay, J., Alterman. A., McLellan, A., Snider, E. (1994). Treatmentgoals, continuity of care, and outcome in a day hospital substanceabuse rehabilitation program. Amer. J. of Psychiatry 151(2):254-259.

Meissen, G.. Mason, W., Gleason, D. (1991). Understanding theattitudes and intentions of future professionals toward self-help.Amer. J. of Community P.sychology 19(5):699 714.

Miller. W., Rollnick, S. (1991). Motivational interviewing. PreparingPeople to Change Addictive Behavior. New York: Guilford Press.

Noordsy, D., Schwab, B., Fox, L., Drake. R. (1994). The role of self-helpprograms in the rehabilitation of persons with severe mental illnessand substance abuse disorders. In: Powell. T. J.. ed. Understandingthe Self-Help Organization: Frameworks and Findings. ThousandOaks, CA: Sage, pp. 314-330.

Peteet, J. (1993). A closer look at the role of a spiritual approach inaddictions treatment. J. of Substance Abuse Treatment10(3):263-267.

Project MATCH Research Group. (1997). Matching alcoholismtreatment to client heterogeneity: Project MATCH post treatmentdrinking outcomes. J. of Studies on Alcohol 58:7-29.

Roman. P. M., Blum. T. C. (1998). National Treatment Center Study.Summary Report (No. 3): Second Wave On-Site Results.Unpublished Manuscript, University of Georgia.

Room. R., Greenfield. T. (1990). Alcoholics Anonymous, other 12-stepmovements, and psychotherapy in the U.S, population. Addiction88:555-562. 1993.

Salzer, M., McFadden, L.. Rappaport, J. (1994). Professional views ofself-help groups, Administration and Policy in Men ted Health22(2):85-95.

Ohstacles to 12-Step Participation 2045

Salzer, M,, Rappaport. J,, Segre, L. (2001). Mental health professionals'support of self-help groups. J. of Community & Applied SocialP.sychology 11(1):1-IO

Simpson, D., Joe. G. (1993). Motivation as a predictor of early dropoutfrom drug abuse treatment. Psychotherapy 30:357 368.

Smith, D., Buxton. M., Bilal, R., Seymour, R. (1993). Cultural points ofresistance to the 12-step recovery process. J. of Psychoactive Drugs25(l):97-108.

Taylor, S. E. (1995). Health Psychology. NY: McGraw.Timko, C , Finney, J., Moos, R., Moos, B,. Steinbaum, D. (1993). The

process of treatment selection among previously untreatedhelp-seeking problem drinkers. J. of Substance Abuse 5(3):2O3-22O.

Timko, C . Moos. R. H., Finney, J. W., Moos, B. S., Kapiowitz, M. S.(1999), Long-term treatment careers and outcomes of previouslyuntreated alcoholics. Journal of Studies on Alcoholics A'il-AAl.

Timko, C . Moos, R., Finney. J,, Lesar M. (2000). Longterm outcomes ofalcohol use disorders: comparing untreated individuals with thosein AA and formal treatment. J. Stud. Alcohol 61:529-540.

Toneatto. T., Sobell. L. C , Sobell, M. B.; Rubel, E. (1999). Naturalrecovery from cocaine dependence. Psychology of AddictiveBehaviors 13(4):259-268,

Tonigan, J., Miller, W., Connors. G. (2000). Project MATCH clientimpressions about Alcoholics Anonymous: Measurement issuesand relationship to treatment outcome. Ale. Treatment Qutrly

Tucker, J. A, (1995). Predictors of help-seeking and the temporalrelationship of help to recovery among treated and untreatedrecovered problem drinkers. Addiction 90(6):805-809.

Vaillant, G. E., Clark. W., Cyrus, C , Milofsky, E. S.. Kopp, J., Wulsin,V., Moglielnicki, N. (1983). Prospective studies of alcoholismtreatment: Eight-year follow-up. American Journal of Medicine75:455^63.

Weisner, C , Greenfield, T,. Room. R. (1995). Trends in the treatment ofalcohol problem: in the U.S. general population. Amer. J. of PublicHealth 85:55-60.

Weiss, R., Griffin, M., Gallop, R.. Luborsky. L., Siqueland, L.. Frank,A., Onken, L., Daley, D.. Gastfriend, D. (2000). Predictors ofself-help group attendance in cocaine dependent patients. J. Stud.Alcohol 6\{5):1\4-1\9.

White. W. L. (1998). Slaying the dragon: The History of AddictionTreatment and Recovery in America. Bloomington, IL: ChestnutHealth Systems/Lighthouse Institute.

2046 Laudet

RESUMEN

La participacion en grupos de 12 pasos (12SG) durante y despues deltratamiento se ha asociado con el resultado positivo. Sin embargo,la eficacia de I2SG puede ser Umitada por tasas altas de desgaste yparticipacion baja; es sabido poco acerca de obstaculos a la participacionen 12SG. Los clinicos juegan un papel importante a fomentar la participa-cion en 12SG y las perspectivas que ellos desarrollan en su priictica puedencontribuir a informar el proceso de investigacion. Todavia, es sabido pocoacerca de actitudes de clinicos acerca de los grupos de 12 pasos o acerca desus cxperiencias referendo a los clientes. Este estudio ha habiado conclientes (A'= 101) y clinicos (A^= 102) en programas de tratamiento paraexaminar sus actitudes relacionadas a los grupos de 12 pasos y para iden-tificar obstaculos a la participacion. La coleccion dc datos se condujo entreMayo 2001 y Enero de 2002. Los participantes eran principalmente Afroamericano e Hispano; 32% de clientes habian usado drogas en el mesprevio. con la "crack" y la mariguana siendo los problemas mayor. Enel promedio, los clinicos habian trabajado en programas de tratamientopor 8 aiios. Tanto el personal como los clientes vieron 12SG como unrecurso util de recuperacion. Los obstaculos mayor a la participacion en12SG centro en el motivo para e! cambio y en la necesidad percibidapara la ayuda, antes que en aspectos del programa de 12 pasos que secitan a menudo como puntos de la resistencia (por ejemplo, el aspectoreligioso y la impotencia ante las drogas). Los clinicos tambien citaron amenudo asuntos practico como obstaculos a asistir a los 12SG. Las impli-caciones clinicas de estas conclusiones se discuten. inclusive la importanciade fomentar el motivo para el cambio, la necesidad para valorar lascreencias y las experiencias de los clientes acerca de 12SG individualmente.y la importancia de encontrar puntos de correspondencia entre las necesi-dades y inclinaciones de clientes por un lado. y en los recursos disponiblesdentro de los grupos de 12 pasos por otro lado.

RESUME

La participation dans les groupes de 12 etapes (I2SG) pendant etapres le traitement a ete associee avec des resultats positifs. Cependant.l'efficacite des groupes peut etre limitee par de hauts taux d'attrition etpar la non-participation; On sait tres peu sur les obstacles a la participa-tion dans 12SG. Les praticiens jouent un role important pour encouragerla participation dans les groupes de 12 etapes et la perspective qu'ilsdeveloppent dans leur pratique peut contribuer a informer le procede


de recherche. Pourtant, on sait peu des opinions des praticiens vis a visdes groupes de 12 etapes ou de leurs experiences a suggerer que les clientsparticipent a ces groupes. Cette etude a collectionne des donnees parmiun echantillon de clients (A'^ = 101 ) et de praticiens (A'^ ^ 102) dans desprogrammes de traitement de drogues pour examiner leurs attitudes vis avis des groups de 12-etapes et pour identifier les obstacles a la participa-tion. La collection des donnees a ete effectuee entre mai 2001 et Janvier2002. Les deux echantillons etaient principalement Africain Americainset Hispaniques; 32% des clients avait utilise de la drogue le mois pre-cedant, le crack et la marijuana etant cites le plus frequemment commesubstance problematique. En moyenne, les praticiens avaient travaille enprogramme de traitement depuis 8 ans. Le personnel et les clients regar-dent les 12SG comme une ressource de retablissement utile, Les obstaclesmajeurs a la participation se centraient sur la motivation pour le change-ment et sur la perception du besoin d'aide, plutot que sur les aspects duprogramme de 12 etapes souvent cites comme les points de resistance(par ex.. Taspect religieux et Pimpuissance devant les drogues). Les pra-ticiens ont aussi frequemment cite des questions pratiques comme obsta-cles possibles a assister aux 12SG (par ex., emploi du temps et acces). Lesimplications cliniques de ces resultats sont discutees, y compris I'impor-tance d'encourager la motivation pour le changement, le besoin d'evaluerdes croyances des clients ainsi que leurs experiences avec I2SG indivi-duellement. et de trouver des points de correspondance entre les besoinset les inclinations des clients d'une part, et les ressources disponibles dansgroupes de 12 etapes d'autre part.

THE AUTHOR

Alexandre B. Laudet, Ph.D., is an NIH-funded Principal Investigator at theNational Development and ResearchInstitutes, Inc. (NDRI) in New YorkCity. Her research focuses on elucidat-ing processes of addiction and recoveryover time, in particular, on psychoso-cial factors that promote the mainte-nance of lifelong recovery, such associal support and affiliation -with 12-step groups. She is also interested incross-cultural perspectives on addictionand reeovery.

Documents

12 Step Groups