Strengthening the Working Alliance through Familiarity with the 12-Step Approach to Recovery

Background and Purpose:  The working alliance between substance abuse clients and substance abuse clinicians plays an important role in the treatment process and in treatment outcomes, making the determinants of it important to understand.  One possible determinant of the working alliance in substance abuse treatment is how the 12-Step approach is experienced by clients in working with their clinicians. With the 12-Step approach known among many clients and clinicians, it may well factor into the therapeutic relationship.  For this study, we investigated how the 12-Step approach might factor into the working alliance between substance abuse clients and substance abuse clinicians, including possible differences based on a clinician’s recovery status.  Specifically, we tested the following hypotheses:

1. A client’s perception of how familiar their clinician is with the 12-Step programs impacts their working alliance.
2. The percentage of time in-session allotted to discussing 12-Step programs impacts the working alliance between clients and clinicians.
3. The effects of 12-Step familiarity and in-session time allotted to discussing 12-Step programs on the working alliance is moderated by a clinician’s recovery status

Method:  We conducted a secondary study using data from 180 substance abuse clients and 31 substance abuse clinicians at eight residential substance abuse treatment centers in a northeastern state.  Approximately 81% of client participants were male, and approximately 65% of clinician participants were female.  We tested the hypotheses using a population-averaged model in Stata (v.14.2). 

Results:  How substance abuse clients rated their clinician’s familiarity with the 12-Step approach affected the clients’ rating of the working alliance.  The client-estimated amount of in-session time spent on the 12-Step approach did not have a statistically significant effect on ratings of the working alliance.  A clinician’s recovery status did not affect the working alliance, nor did it moderate the relationship between 12-Step familiarity and the working alliance. 

Conclusions and Implications:  The working alliance is important to positive outcomes in substance abuse treatment.  These results suggest that substance abuse clinicians can influence how their clients perceive the working alliance by being familiar with the 12-Step approach to recovery.  Although a clinician’s recovery status did not have a significant direct effect on the working alliance, their familiarity with the 12-Step approach did have a significant impact.  On the face of it, one interpretation is that while familiarity is critical, a clinician does not necessarily need to be in-recovery to convey familiarity with the 12-Step approach to their clients.  This would mean that for those not in recovery, such clinicians can become familiar in other ways, such as training, work experience, or both. This might be particularly salient for substance abuse clinicians providing treatment at agencies that incorporate on some level the 12-Step approach to recovery.