Addiction professionals' and substance abuse patients' attitudes towards and usage of 12-step-based self-help groups

Abstract

Bakgrunn Denne avhandlingen består av to studier; en undersøkte pasienters og en undersøkte ansatte i rusfeltet sine oppfatninger om og bruk av de mest vanlige selvhjelpsgruppene for rusmiddelavhengige i Norge; de 12-trinnsbaserte selvhjelpsgruppene Anonyme Alkoholikere og Anonyme Narkomane. Rusmiddelavhengighet oppfattes nå som en kronisk lidelse med høy tilbakefallstendens. Tolvtrinnsgrupper er et gratis, fritt tilgjengelig tilbud som kan være et langvarig og støttende felleskap for rusmiddelavhengige. Slike grupper er beskrevet som et positivt supplement til formell behandling og tilknytning til slike grupper parallelt med og etter behandling er assosiert med bedre behandlingsutfall i flere studier. Norske helsemyndigheter har ønsket en høyere bruk av selvhjelpsgrupper i tilknytning til helsetjenesten. Inntrykket før studien var imidlertid at selvhjelpsgrupper blir brukt i liten grad og ingen undersøkelser har kartlagt bruken av slike grupper i rusfeltet tidligere. Som en del av undersøkelsen blant ansatte ble det i tillegg gjort en tverrkulturell sammenligning med ansatte i rusfeltet i USA. I det amerikanske behandlingssystemet er det vanlig å anbefale og motivere rusmiddelavhengige pasienter å bruke 12-trinnsgrupper, noe som kan sette de norske funnene i kontrast.

Formål Den overordnede målsetningen med denne avhandlingen var å undersøke ansattes og pasienters holdninger til og kunnskap om 12-trinnsgrupper i omgivelser der en antok at kjennskapen til slike grupper var lav. I tillegg undersøkte en bruken av slike grupper blant de ansatte (i hvilken grad pasienter ble aktivt motivert til å delta i slike grupper) og pasienter (deltagelse og involvering). Mulige barrierer mot bruk av slike fellesskap ble også undersøkt.

Material og metode Begge studiene var tverrsnittsundersøkelser. Ansattstudien var en spørreskjemaundersøkelse som ble gjennomført vår/sommer 2008. Det ble i hovedsak brukt et spørreskjema utviklet i USA, utformet for å kartlegge ansattes holdninger til 12-trinnsgrupper og å undersøke mulige barrierer mot å anbefale pasienter å delta i slike grupper. Spørreskjemaundersøkelsen var selvadministrert og anonym. Respondentene (N=291, 80 % av de som fikk utlevert spørreskjema) var ansatte i rusfeltet i helseregion Sør, Norge. Det amerikanske utvalget i den tverrkulturelle sammenligningen (N=100) kom fra historiske data (2001). Respondentene i pasientstudien (N=139, 89 % av det tilgjengelige utvalget) ble inkludert på en avgiftningsavdeling ved Avdeling for rus- og avhengighetsbehandling, Sørlandet Sykehus HF i Kristiansand, Norge, fra september 2008 til august 2010. Det ble samlet inn data om pasienters oppfatning av fordeler og ulemper med å delta 12-trinnsgrupper, samt pasientenes intensjon om å delta i slike fellesskap etter utskrivning. I analysen ble intensjonsskalaen kategorisert til lav, moderat eller høy intensjon om å delta etter behandling.

Resultater De norske ansatte i rusfeltet hadde moderat positive holdninger til 12­trinnsgrupper, men disse holdningene så ikke ut til å føre til en aktiv ”henvisningspraksis”; totalt sett ble kun 15 % av de ansattes nåværende pasienter aktivt motivert til å delta i slike fellesskap. Det var 38 % av de ansatte som bidro til denne henvisningsraten, 62 % oppgav å ikke henvise noen pasienter i det hele tatt. Kunnskapsnivået om 12-trinnsgrupper og troen på egen evne til å henvise pasienter var lav. I en multivariat analyse var det å bruke 12-trinnsfilosofien i eget behandlingsarbeid, høyere tro på egen evne til å henvise pasienter effektivt og større kunnskap om 12-trinnsgrupper assosiert med å henvise pasienter. Når det gjaldt barrierer mot bruk av slike grupper, ble 6 av 9 påstander i en ”12­trinns barriere”- skala støttet av mer enn halvparten av de norske ansatte. Sammenlignet med amerikanske ansatte kom den mest markante forskjellen frem i spørsmålet om de religiøse aspektene ved 12-trinnsgrupper. Mer en dobbelt så stor del av de norske kontra de amerikanske ansatte (70 % versus 29 %) så på de religiøse aspektene ved 12-trinnsgrupper som en mulig hindring for deltagelse. Som forventet hadde de amerikanske ansatte konsekvent mer positive synspunkter når det gjaldt rollen 12-trinnsgrupper bør ha i behandlingssystemet og rapporterte en høyere tro på egen evne til å få pasienter til å delta i slike fellesskap. I pasientstudien hadde mindre enn halvparten (48 %) av pasientene som kom inn til avgiftningsbehandling deltatt i 12-trinnsgrupper tidligere. En majoritet; mellom 55 % og 78 %, var enig i de fem påstandene som omhandlet mulige fordeler ved å delta, men likevel var det bare 4 av 10 som oppgav en høy intensjon om å delta i slike grupper etter utskrivning. Trettien prosent oppgav lav og 29 % oppgav en moderat intensjon. Oppfatningen om at 12-trinnsgrupper kan gi mot til forandring og gi avholdsspesifikk støtte var høyest korrelert med intensjon om å delta etter behandlingen. Blant fem påstander om mulige barrierer mot å delta ble ingen støttet av mer enn 37 % av utvalget. I en multivariat analyse med intensjon om å delta i 12-trinnsgrupper etter behandling som avhengig variabel, skilte de med høy intensjon seg fra de med moderat intensjon kun når det gjaldt oppfatning av større fordeler ved å delta. Det var ingen forskjell mellom disse to gruppene når det gjaldt oppfatning av ulemper. Til forskjell var gruppen med lav intensjon om å delta kategorisert både ved lavere oppfatning av fordeler samt høyere oppfatning av ulemper ved deltagelse enn både de med moderat og høy intensjon.

Background This thesis comprises two different studies that examine addiction professionals’ and patients' perceptions and usage of the most common self-help groups (SHGs) for addiction in Norway, the Twelve Step groups (TSGs; i.e., Alcoholics Anonymous and Narcotics Anonymous). Addiction is considered to be a chronic disorder with high relapse tendency. For addicted individuals, TSGs offer freely available long-term support, and participation in such groups after formal treatment has been associated with improved outcomes in several studies. In some countries this form of “after-care” is considered to be a valuable and positive adjunct to formal substance abuse treatment. Though Norwegian health authorities seek to promote self-help participation, the pre-study impression was that these community-based recovery fellowships are not utilized at a high level, but a structured assessment of the use of TSGs within the Norwegian addiction treatment field has not been initiated previously. As a part of the addiction professionals study, a cross-cultural comparison with addiction professionals from the U.S. was performed. In U.S. addiction treatment services, the use of TSGs as a complement to professional services is considered normal, which put the findings from Norwegian professionals into perspective.

Study aims The overall aims of this thesis were to investigate addiction professionals' and patients' attitudes towards and knowledge of TSGs in settings where they would be expected to be relatively unfamiliar with these groups. In addition, the utilization of TSGs among addiction professionals (TSG referrals) and patients (TSG attendance and involvement) was examined. Finally, the thesis aimed to examine potential barriers to attendance and engagement in these fellowships.

Materials and methods Both of the studies had cross-sectional designs. The addiction professionals study was conducted in mid-2008 using a questionnaire originally developed in the U.S. to explore clinicians’ attitudes/beliefs about and perceived obstacles to client participation in TSGs. The anonymous survey was self-administered. Respondents were addiction professionals in Health Region South, Norway, and the return rate was 80% (N = 291). The U.S. sample (N = 100) in the cross-cultural comparison was obtained from historical data (2001). Respondents in the patient study (N = 139, 89% of eligible respondents) were included at the detoxification ward of the Addiction Unit, Sørlandet Hospital in Kristiansand, Norway from September 2008 to August 2010. Data were collected on issues including patients' perceived benefits and barriers to TSGs and their intention to participate in these fellowships after discharge. A Likert-type intention scale was used; in the analysis categorized to low, moderate, or high intentions.

Results Norwegian addiction professionals reported moderately positive attitudes towards TSGs, but these attitudes did not foster many TSG referrals; only 15% of the professionals' current patients were actively motivated to attend TSGs. Thirty-eight percent of the professionals contributed to the observed referral rates, meaning that 62% did not refer any patients at all. The level of TSG knowledge and self-efficacy for making referrals were low. Respondent integration of the 12-steps into their own treatment work, higher self-efficacy for making a successful referral, and greater TSG knowledge were associated with referring patients to TSGs. In terms of perceived obstacles to TSG participation, six of nine statements on the ‘TSG obstacle scale’ were endorsed by half or more of the Norwegian professionals. Compared with U.S. addiction professionals, the most notable sample difference on the ‘obstacle scale’ was in regards to the religious aspects of TSGs (i.e., the "higher power" concept), with more than twice as many Norwegian addiction professionals compared to those in the U.S. (70% versus 29%) viewing the religious aspect of TSGs as a potential obstacle to participation. As expected, the U.S. professionals had consistently more positive views about the role of TSGs in their treatment system and reported greater self-rated belief in their own ability to make successful TSG referrals. In the patient study, less than half (48%) of participating patients entering detox had ever attended TSGs. Nevertheless, the majority of patients, between 55% and 78%, agreed with each of five statements concerning the perceived benefits of TSGs. However, only 40% reported high intention to participate in TSGs after discharge. Thirty-one percent of patients scored low and 29% had moderate intention. The notions that participation in TSGs could instill the courage to change and provide abstinence-specific support were the constructs most strongly correlated with high intention to participate in TSGs following detox. Perceived barrier items were endorsed by a maximum of 37% or fewer respondents. In a multivariate analysis, patients with a high intention differed from those with moderate intention only by more perceived benefits and not in terms of perceived barriers to TSGs. In contrast, the ‘low’ intention group was categorized by more perceived barriers and not recognizing possible TSG benefits.

Discussion Although the addiction professionals had moderate positive attitudes towards TSGs, obstacle items were endorsed by a large proportion of respondents, suggesting a high degree of ambivalence towards TSGs. The lack of belief in one’s own ability to make TSG referrals and the low referral rate point to the need for education and training to increase awareness and knowledge about TSGs among addiction professionals unfamiliar with these fellowships. Findings from the cross-cultural comparison suggest that, to enhance the acceptance of TSGs among Norwegian addiction professionals, a central issue is to increase professionals’ knowledge of and understanding of the ‘higher power’ concept and how it is understood in TSGs. Overall, increased knowledge and improved familiarity with TSGs among the professionals may be expected to result in higher referral rates and utilization of these supportive recovery resources. Findings from the patient study suggest potential for motivating a majority of patients, with relatively simple means, to attend TSGs. A plausible strategy is to highlight the possible benefits of participation the patients rated as being highly relevant to their problem, including that participation in these groups could possibly provide the courage to change. For the one-third of patients with low intention to join these groups, potential barriers need to be explored more thoroughly, as these patients are more skeptical about attending TSGs. Processes to acquaint patients with TSGs could possibly reduce perceived barriers and enhance utilization of these fellowships.

Conclusions This thesis provides information to guide clinician-based strategies for meeting the Norwegian government's goal of enhancing the utilization of self-help approaches in conjunction with formal addiction treatment services. Higher awareness among addiction professionals of the benefits of TSG participation may lead to more patients being referred and being affiliated with TSGs, which would enhance the possibility of improved long-term outcomes in the treatment of substance-dependent individuals. The findings indicate substantial potential for greater use of such voluntary fellowships. Norwegian addiction professionals need to be better informed about the most available groups for addiction, the TSGs, as well as their principles, beliefs, and practices, and to learn about common objections to TSGs and effective strategies for addressing these objections. Patients should at least be made aware of these informal and accessible recovery resources at their disposal. Although TSGs might not be perceived as useful or benefit all problem drug users, greater emphasis on facilitating patients into TSGs by addiction professionals would likely lead to a higher referral rate, and benefits may be extended to broader groups. Further studies are warranted to explore the reasons for the perceived barriers towards TSGs expressed by some patients. This information would be useful for more detailed, culture-specific development of TSG referral strategies, and it may also speak to the need for establishing alternative SHGs in Norwegian settings, as few other SHGs for addiction exist, and none with a broad availability.