1. Attitudes toward 12-step, Attendance Patterns and Reasons for Non-Attendance among Substance Users in Outpatient Treatment Alexandre B. Laudet National Development and Research Institutes, Inc - laudet@ndri.orglaudet@ndri.org Funded by National Institutes on Drug Abuse Grant R03 DA13432

2. Abstract Participation in 12-step groups (12SG) has been found useful in resolving addiction. Many substance users drop out early and some never attend. Little is known about reasons for disengagement and barriers to attending 12SG or about substance users ’ attitudes and beliefs about 12SG. Because such cognitions may influence behavior, elucidating substance users ’ attitudes and beliefs about 12-step may further our understanding of attendance patterns and can inform clinicians ’ referral practices. This exploratory study surveyed 100 clients of addiction treatment programs about their 12SG attendance and beliefs. Specifically, the objectives of the study were: (1) To develop a scale to assess beliefs about 12-step; (2) To examine the association between clients ’ 12SG attendance patterns and beliefs about 12-SG; and (3) To explore reasons for non-attendance. Forty-three percent of participants were currently attending, 20% had dropped out and 38% had never attended. Primary reasons for not attending were the belief that 12SG were not needed, and low readiness and/or motivation to stop using. Although the rated helpfulness and importance of 12SG was generally high, never-attenders held significantly less positive views about 12SG than did current and former 12SG attenders. Clinical implications of findings toward enhancing 12SG utilization are discussed, including the need to address clients ’ past experience with and beliefs about 12SG early on, and the possibility of drawing on the experience of clients who are 12-step members to inform new clients.

3. Background In the United States, 12-step groups such as Alcoholics and Narcotics Anonymous (AA and NA) are both the most prevalent types of self- help groups and the most common source of help sought by people with substance abuse problems. Participation in 12-step groups during and after formal treatment associated with reduced rates of substance use This is particularly true when 12-step participation is ongoing Concurrent use of 12-step and formal treatment has been shown to have additive effects

4. Background (contnd) Clients in treatment routinely encouraged to attend 12-step meetings Attendance rates vary and attrition is high: –Some never attend –Many drop out early on Little is known about obstacles to engagement in 12SG or about reasons for disengagement Need to broaden the scope of 12-step research to the study of subjective reactions to 12-step (e.g., attitudes about and experiences with 12-step groups)

5. Objective and Method OBJECTIVE: To examines the association between attitudes about 12-step and attendance patterns METHOD Recruitment at 5 large outpatient substance abuse treatment programs in New York City between May and December 2001 101 clients selected randomly from client base of the collaborating agencies Voluntary participation based on informed consent. Study approved by NDRI ’ s and programs ’ IRB. Estimated refusal rate: >5% Semi-structured interview (approximately 40 minutes) Participants received $20 for their time

6. Description of Sample (N = 101) Male50% Age (median)35 years African American 59% Hispanic 26 Education Less than High School54% High School/GED27 Some college15 College degree 4 Primary income Government assistance77% Job on or off the books14 Other legitimate income 9

7. Description of Sample (contnd) Primary substance Crack-cocaine 31% Marijuana 28 Powder cocaine 17 Alcohol 15 Heroin 9 Substance use past year 82% Substance use past month 32% First time in drug treatment59%

8. Past and Current 12-step Attendance* EVER ATTENDED 12-step62% Currently attending43% Past attendance-not current 19% NEVER ATTENDED38% EverHow long Among ‘ ever ’ attenders attended mean months Currently Alcoholics Anonymous65%1542% Narcotics Anonymous921486 Cocaine Anonymous6110 * Attendance defined as ‘ Regular ’ = for one month or longer

9. Reasons for not attending 12-step among never- and former attenders Never-attenders Drop-outs N = 38N = 20 Do not need it47% 0 Treatment program is enough 21 0 Do not like/believe in groups 12 22 Still using/picked up 6 22 Unable to attend (time, health) 622 Not required to attend 6 0 Did not know about such groups 2 0 I got the message 022 It didn ’ t help 012

10. Obstacles to Participation in 12-step groups (N = 101) What are some of the reasons why people would not attend 12-step? Don ’ t want to or not ready to stop using 39% Can do it on their own 21 Negative view or ignorance about 12SG15 Still using8 Embarrassed, don ’ t want to be seen7 Don ’ t know, not sure 10

11. Attitudes and Beliefs about 12-Step by Attendance Pattern TOTAL ATTENDANCE NeverDropout Current N = 101382043 Which statement best describes the role 12-step should play in the recovery process? Of minimal usefulness 5% 14%-- Useful addition to treatment62%62536 Crucial to recovery process 33%244735 (Chi square, p value)(10.8,.03) Importance/helpfulness ratings (Mean) a How helpful are 12-step groups? 8.07.48.48.4* Importance of 12-step in treatment system 7.97.37.88.4* Importance of SHG in recovery process 8.78.18.49.4*** a Not at all = 0; Very = 10

12. Attitudes and Beliefs about 12-Step: Scale Development Attitudes and Beliefs about 12-Step: Scale Development After determining that there existed no suitable instrument to assess attitudes and beliefs about 12-step groups, the study set out do design and test an instrument. We started from a list of statements previously developed for a study of future clinicians' attitudes and intentions toward self-help groups. 1 The list was augmented by items developed from clients' answers to open-ended questions during the pilot phase of this study. After pre-testing, the final list consisted of 12 items rated on a Likert- type scale (strongly disagree-strongly agree). 1 Meissen, G.J., Mason, W.C., & Gleason, D.F. Understanding the attitudes and intentions of future professionals toward self-help. American Journal of Community Psychology, 19 (5): 699-714, 1991.

13. Attitudes and Beliefs about 12-Step: Scale Development (contnd) Principal components factor analysis with Varimax rotation yielded two interpretable factors accounting for 42.6%and 14.0% of the variance, respectively. –The first factor was labeled “ 12-step groups as a recovery resource “ (8 items, Cronbach  =.89). –The second factor, "Possible risks of 12-step participation “ (4 items, Cronbach  =.74). [DELETE: Internal consistency was high for the both factor]

14. Attitudes and Beliefs about 12-Step by Attendance Pattern: 12-step as recovery resource TotalAttendance Pattern NeverDrop outCurrent N = 101382043 Factor 1: ‘ 12-step as recovery resource ’ Mean score-.30.03.25* Substance users need be more open to 12-step 3.12.92.93.3* Self-help groups work for most people 3.02.83.13.2** 12-steps are a good bridge to treatment 3.23.13.13.3 12-steps are a great source of support3.13.03.33.2* 12-steps good relapse prevention3.12.93.13.3* 12-steps give you place to vent feelings 3.23.13.23.2 12-steps help you achieve/maintain sobriety 3.12.93.13.2* 12-steps help you learn coping strategies 3.13.03.13.2 a 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree * p <.05 ** p<.01

15. Attitudes and Beliefs about 12-Step by Attendance Pattern: Possible risks of 12-step TotalAttendance Pattern NeverDrop outCurrent N = 101382043 Factor 2: ‘ Possible risks of 12-step ’ Mean score.28.19-.33* Need to be cautious in referring to 12-step 2.83.02.92.6** 12-steps can be dangerous: leaders not professionally trained2.32.62.32.1* 12-steps can lead you to pick up or relapse2.32.42.52.1** Can get retraumatized/ triggered in a 12-step 2.42.42.32.3 a 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree * p <.05 ** p<.01

16. Summary of Findings Participants generally held positive attitudes about 12-step as important and helpful to the recovery process. Yet, a significant number of participants were not attending such groups Perceived need for 12-step groups and motivation to quit using drugs appear to play a critical role in substance users ’ attendance in 12-step. DELETE: Significant association between previous treatment experience and 12-step attendance history Significant differences in attitudes about 12-step among substance users who are currently attending, those who began attending and disengaged and those who never attended. In particular, never-attenders gave significantly lower ratings to 12-step in terms of helpfulness and importance in the recovery process; never attenders also had significantly higher levels of agreement that 12-step participation “ Can lead to pick up or relapse. ”

17. Implications for Clinicians As formal services are being reduced, an important task for treatment providers is to facilitate clients ’ transition into the post-treatment phase of recovery. While not every client will become successfully engaged in 12-step, most can benefit from participation both during and after treatment. It is therefore crucial that substance users enrolled in treatment be encouraged to attend 12-step for a sufficient duration that they can form their own opinion about whether or not to continue participating. Clinicians can promote 12-step participation among ambivalent clients by –addressing barriers to the effective use of specific tenets of the 12-step program; and –by working 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 programs on the other. Important to open the dialogue with clients early on, to find out not only whether they are currently or have attended 12SG in the past, but also to elucidate what they think and have heard about 12SG. Consistent with 12-step tradition, clients who are already engaged in 12-step may represent a valuable resource for clinicians: Clients who are ambivalent about recovery and about 12SG may be more open to listening to a peer than to a treatment provider.