Modeling Ways to Enhance the Referral-Making Process to Twelve-Step Programs

Purpose:  Many substance abuse clients do not follow through with referrals made to twelve-step programs by substance abuse professionals.  The twelve-step approach is a key supplement to a majority of professional treatment programs, and because participation in twelve-step programs is associated with positive outcomes it is important to address this gap by enhancing referrals.

The objective of this study was to investigate important domains for enhancing twelve-step referrals as a mechanism for increasing referral follow-through rates.  Three domains were identified: (1) increasing familiarity with twelve-step culture; (2) willingness to integrate key twelve-step values into treatment sessions; (3) willingness to antecedently prepare clients for participation in twelve-step programs.  The following hypotheses were developed to test the relationships between these domains:  

1. The level of substance abuse professionals’ familiarity with twelve-step culture is positively associated with their willingness to prepare clients to participate. 
2. The extent to which substance abuse professionals integrate key twelve-step values into session is positively associated with their willingness to prepare clients to participate.
3. Twelve-step familiarity mediates the relationship between integrating twelve-step factors into sessions and preparing clients to participate in twelve-step programs. 

Methods:  A correlational design was used with substance abuse professionals (N = 284) from across a northeastern state completing an online survey (hosted by SurveyMonkey).  Participants were mostly white (75%) and female (63%), with a median age of 50 to 54 years.  All participants had an active clinical license or credential.  Participants were sent a link via email through two channels:  (1) directly using addresses obtained through the credentialing body of the state; (2) through the listserv of a state-wide, non-profit agency.  The data was analyzed using structural equation modeling with Mplus(v6.12).  Multiple imputed datasets were used to account for missing data.

Results:  Substance abuse professionals’ willingness to prepare clients to participate in twelve-step programs was effected by the extent to which they were familiar with twelve-step culture, willing to integrate spirituality-based twelve-step values, and willing to integrate twelve-step program material (e.g., the Big Book, step work) into their sessions with clients.  The results indicated that not all these factors need to be combined, but that multiple pathways are possible for increasing substance abuse professionals’ willingness to prepare clients for participation in twelve-step programs.

Conclusions and Implications:  Narrowing the gap between referrals made to twelve-step programs and clients following through on them depends on how prepared clients are to participate.  Thus, professionals need to be willing to antecedently prepare their clients for twelve-step program participation.  Their willingness to do this is influenced by their familiarity with twelve-step culture and their willingness to integrate valued twelve-step components into treatment sessions.  As such, it is important that supervisors and administrators in treatment settings provide training opportunities for staff so they can cultivate their proficiency in these domains and enhance their referral-making process.  Further research is needed to develop such training mechanisms and to conduct trials on whether developing proficiency in these important domains carries over to improved rates of client participation in twelve-step programs.