The first research question was “What are substance users and clinicians’ attitudes concerning the helpfulness and usefulness of 12-step groups as a recovery resource?” Treatment clients and clinicians surveyed held positive views of 12-step groups’ helpfulness, importance in the recovery process as well as in a comprehensive treatment system. These findings replicate earlier reports summarized in the Introduction (19
The second research question was: “What do substance users and clinicians perceive to be positive and negative aspects of 12-step groups?” Both groups of participants cited peer support; help with recovery and the opportunity to improve one’s life as the major benefits of 12-step groups. The major limitation of 12SG, cited by both groups of participants, can be succinctly expressed by the 12-step saying, ‘it works if you work it.’ That is, 12-step groups cannot help persons who are not ready or willing to seek help (see later discussion). Indeed, nearly half of the clients who were not attending 12SG said they did not feel they needed it and another twenty percent felt the treatment program was sufficient. While some substance users may be able to recover without the support of 12-step fellowships (58
), most are not; 12-step groups are often cited as an important source of support among individuals who have achieved stable recovery (60
). Yet in the present study, less than one-half of clients were attending 12SG and clinicians estimated that less than half of the clients they refer to 12SG become affiliated. This underlines the importance of addressing the third research question: “What do substance users and referring clinicians perceive to be obstacles to 12-step participation?”
In answers to the open-ended items, lack of readiness or motivation for change was cited as a major obstacle to 12-step participation by both substance users and by clinicians. Motivation has previously been identified as a critical factor in both engagement in and outcome of formal substance user treatment interventions as well (61
). Over one-third of clinicians also cited practical issues of convenience (e.g., lack of transportation or child care) and scheduling as potential barriers to 12SG participation; relatively few clients cited these concerns. In the United States, 12-step meetings are generally thought be widely available to all who wish to attend because the 12-step fellowships hold numerous meetings, especially in large cities such as New York City where this study was conducted. However, it may be that practical matters such as not having access to child care or to transportation constitute obstacles that tend to be overlooked by researchers. [We note recent findings by Mankowski and colleagues (9
) reporting a significant association between “geographical density” of 12-step meetings and greater levels of participation]. Present findings on this issue emphasize the importance of including frontline clinicians in the research process as they can contribute valuable insights that may otherwise remain unexplored.
Few study participants mentioned any of the “controversial” aspects of the 12-step program reviewed earlier in their spontaneous answers concerning limitations of 12-step groups or obstacles to participation. When participants were asked to indicate their level of agreement with statements describing these aspects of the 12-step program, findings varied across broad dimensions. Over one-half of both substance users and clinicians agreed that “the religious aspect of 12-step groups is an obstacle for many” and nearly one-half of clients agreed with “the emphasis on powerlessness can be dangerous.” Consistent with recommendations of the American Psychiatric Association that referral to 12-step groups is appropriate at all stages in the treatment process (12
), few participants from either group endorsed the belief that the usefulness of 12-step groups is limited to a specific stage of recovery. Items concerning the lack of professionally trained leadership received moderate levels of agreement. Of note is the finding that significantly more substance users than clinicians agreed with the statement “12SG should seek professional guidance.” This is consistent with the pattern reported earlier (Attitudes section) where substance users consistently expressed less favorable – and here, more negative - views of 12-step groups than did clinicians. The only exception to this pattern emerged in findings concerning potential risks of participation in 12-step groups; in particular, nearly twice as many clinicians as clients expressed agreement with the statement that “clients can get retraumatized or triggered in 12-step groups.” This difference between the two groups of participants may be due in part to the fact that clinicians based their answers on years of professional experience with large numbers of clients and were therefore more likely to have observed instances were clients were triggered as a result of attending a 12-step group. Clients’ answers, on the other hand, are likely to have been based on their personal experience and/or that of a few members of their social network and thus to be more limited. This difference in perspectives may also partially explain the consistent pattern of findings indicating that clinicians are significantly more positive about 12-step than are clients.
Present results have important clinical implications. First, a sizable proportion of clients had little experiential knowledge of 12-step groups. Nearly four out of ten reported no prior attendance and a large minority was unable to mention benefits or limitations of 12SG. This suggest that there is a strong need for clinicians to inform and educate clients about 12-step groups. In the present sample, fifty percent of substance users expressed relatively little interest in obtaining further information about 12-step groups. It is not possible in this study to determine whether that is because they 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-step concepts are ubiquitous in the treatment context and common lore among substance users, it is important that clinicians open the dialogue with clients about prior experience with 12-step groups as well as about what they know and believe about these groups and where these cognitions come from (e.g., personal experience or hear say?). Substance users are often ambivalent about recovery, especially early on, and may be quick to form an opinion about 12-step groups based on limited experience or friends’ accounts.5
Clinicians should elucidate such questions, emphasize the importance of keeping an open mind and of attending different types of meetings (e.g., round robin meeting, meetings for beginners, open and closed meetings, as well as the many specialized meetings such as for women, gays and lesbians, veterans etc. as appropriate) as some formats are likely to be a better fit than others. In that respect, we note that although 12-Step group meetings share a general structure, philosophy and format, they also may be sufficiently flexible to reflect the local ecology and the different needs and interests of participating community members (62
). Consequently, 12-step groups may be equally utilized and effective because they attend to the needs and interests of the gender and ethnic populations it serves (63
). Thus processes of engagement, participation, retention, attrition and effectiveness are likely to be influenced not only by the general tenets and format of the 12-step program (e.g., working the 12-steps, peer support, emphasis on honesty and introspection) but also by the specific 12-step meeting(s) clients attend. This suggests that in addition to familiarizing themselves with the 12-step model, clinicians would be well-advised to be informed about the individual group meetings that are held in the communities (e.g., membership characteristics, group norms).
When discussing 12-step participation, specific clients’ concerns and misconceptions should also be identified and addressed on a case-by-case basis. Overall is it paramount that clinicians work in collaboration with clients to find goodness of fit between clients’ needs and inclinations on the one hand and the tools and support available within 12-step groups on the other (11
). The author acknowledges that such “matching” of individual needs and circumstances to specific types of help, while highly desirable, is difficult to implement in practice and rarely is in an integral part of treatment planning, implementation and/or evaluation. Services that are most often delivered in group sessions do not allow for individualization of treatment orientation or consideration of individual life and/or recovery stage. When feasible, individual sessions between client and clinician should include a discussion of prior participation in and beliefs about 12-step groups so as to maximize the likelihood that clients will consider such organizations as a resource in their change process. Finally, in discussing attendance at 12-step groups, it is important for treatment professionals to look beyond clinical issues (e.g., readiness for change-see below) and to address clients’ socio-environmental context on a case-by-case basis as some obstacles 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 that aspects of the 12-step program previously identified as potential points of resistance, such as the spiritual emphasis, were rarely mentioned spontaneously by either substance users or by clinicians. Instead, lack of motivation to enter recovery and/or reluctance to recognize that recovery requires external support (“I don’t need it”) appears to be a major barrier to affiliation with 12-step groups. Caldwell (11
) has discussed lack of change readiness as a possible obstacle to 12SG participation. The change process involves a fairly long initial stage in which denial about addiction needs to be broken down (43
). Individuals who do not believe they have a problem or who believe that that their problem is not severe enough to require help are not likely to seek help. Asked about reasons why people may not attend 12SG, twenty percent of substance users said that “people can do it on their own” and only one-third of clients viewed 12SG as crucial to the recovery process (vs. one-half of clinicians). Denial of a problem or of a problem's severity is a major barrier to seeking and obtaining help. Decrease in denial during treatment is a significant predictor of 12SG attendance afterwards (65
). Commenting on high rates of early attrition, AA has suggested that it may be that “some individuals are not convinced of their addiction” (29
The only requirement for 12-step membership is “the honest desire to stop” substance use (66
). Given that desire, the 12-step program of recovery suggests that admitting powerlessness over drugs and alcohol (that is, admitting that one can not 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 significant reasons why substance users may elect not to participate in 12-step groups. Because findings also indicate that substance users view 12-step groups as a helpful recovery resource, interventions designed to enhance motivation for change (67
) and recognition of the need for external support are suggested as means of fostering 12-step participation. Further, a number of factors have been identified as predictors of help-seeking among substance users; while most studies have investigated predictors of help-seeking in formal treatment services, findings may also help focus clinical strategies designed to enhance participation in 12-step groups during and after treatment services. Predictors of help seeking include greater severity of dependence, greater substance-related health and psycho-social problems, use of illicit drugs (vs. alcohol), especially heroin and cocaine, greater network encouragement to seek help and social pressure to cut down, belief that one is unable to quit on one's own facilitated help-seeking and belief in the efficacy of services or other form of help (68–74 It is important to note that 12-step groups may not be suited to all substance users (36
) so that non-attendance or disengagement should not necessarily be interpreted as a lack of commitment to the recovery process. A number of addiction recovery mutual-help groups have emerged in an effort to provide support to individuals who find 12-step groups’ goals or ideology unsuitable. These groups include Secular Organization for Sobriety (SOS), Rational Recovery, Women for Sobriety's (WFS) and Moderation Management(50
). However, because of the limited availability of meetings held by the organizations and the wide availability of 12-step meetings, it is important to gain a greater understanding of why some substance users do not participate. We note that because findings from the current study suggest that the main obstacles to participation in 12-step groups are not 12-step specific but rather, center on clinical issues (e.g., motivation for change), present results may apply to participation in other mutual aid groups as well. Additional research is greatly needed in this area.
This study has several limitations that should be considered in interpreting the results. In addition to the use of relatively small samples of convenience, clients’ prior and current rates of 12-step attendance were lower than reported elsewhere (25
). The relatively low attendance rates may be explained in part to the high percentage of participants who were receiving addiction services for the first time. In addition to these sample limitations, other study limitations point to directions which future research might take in that area. This study focused on identifying obstacles to participation in 12-step groups. It did not examine the association between clients’ stage of recovery, 12-step related attitudes and 12-step attendance, nor did it consider staff’s recovery status in relationship to attitudes about 12-step groups. One study examining the role of staff’ recovery status on beliefs about addiction reported a positive but non-significant association between being in recovery and endorsing the disease model view of addiction (22
). Another important question that this study did not examine is that of the association between staff’s attitudes about 12-step groups and referral practices. In spite of these limitations, this early study constitutes an important step toward identifying and addressing obstacles to participation in 12-step groups. It is the authors’ hope that findings reported here will contribute to focusing additional research on this important topic. Of particular interest would be cross-cultural comparisons of clinicians and substance users’ view of 12-step groups and of other mutual-help recovery organizations, as well as comparisons between urban and rural geographical regions where the availability of services and views on substance use may vary significantly.