Substance use disorders are, for many, a chronic condition and recovery requires ongoing support . Public treatment systems are typically limited in resources and often cannot provide services of sufficient duration to address effectively the needs of severely dependent individuals. Self-help groups including Twelve Step groups (TSGs) such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) represent a useful complement to formal treatment services that contribute to sustaining treatment gains [2, 3]. These organisations offer recovery support that is continuously available and free of charge to those who wish to attend, though small donations are typically made at individual members' discretion. Humphreys & Moos have reported that promoting TSG involvement among treatment clients improves post-treatment substance use outcomes while reducing the costs of continuing care [4, 5]. Patients who choose to attend TSGs following formal treatment are more likely than those who do not to maintain abstinence, and greater TSG involvement is associated with more improvement on substance use outcomes [6–9]. In the literature, self-selection effects have been discussed as explanatory factors [10, 11]; however, recent evidence indicates that TSG attendance is beneficial, and importantly, is a practice that can be promoted by clinicians [12, 13]. Promoting TSG participation during treatment enhances the likelihood of stable TSG affiliation after treatment . Moreover, TSG participation contributes to changing the identity of substance users from socially problematic to helpers, a resource rather than a problem, according to the "self-help paradigm" [14, 15]. Therefore, referrals to self-help groups from health professionals deserve more attention in health services research.
Empirically demonstrated clinician or program characteristics identified to influence positively the referral tendency to TSGs include treatment orientation (e.g. working in a 12-step treatment oriented workplace) , or having integrated the 12-steps and using them in their own treatment work . Personal experience with TSGs (i.e. own TSG participation) [16, 17], more positive attitude towards TSGs , and more TSG knowledge have also been associated with higher referral rates . In addition, environmental factors, i.e. the social influence and self-efficacy (the perceived ability to perform the behaviour, here, the perceived ability with how to carry out a successful referral), can determine behaviour [19, 20].
Most studies about clinicians' attitudes towards TSGs have been conducted in the US [16, 18, 21]. To our knowledge, only one European study has specifically investigated clinicians' attitudes towards and referral practices to the TSGs . In the US, there is an extensive integration of self-help organisations with the substance abuse treatment system and the groups are socially accepted . The situation in several European countries is different, treatment professionals being more usually reticent – sometimes even openly opposed to TSGs, – to referring or even encouraging TSG participation as a part of standard professional practices [17, 22]. However, there are differences amongst some countries, e.g. Austria, where TSGs are generally ignored by the professional community. In contrast, Iceland's AA is well known and accepted by society, and the 12-step philosophy is integrated into many of the treatment institutions . The Norwegian addiction treatment field lies somewhere between these two models with respect to the relationship between professional substance abuse treatment and 12-step groups. Recently, the government issued a policy paper on a "National Plan for self-help", with the goal of enhancing the self-help perspective and utilisation of self-help groups in its health services . However, no study has focused on how Norwegian addiction professionals relate to the relevant groups in the addiction field, namely the TSGs. AA and NA are the only groups for substance dependent patients with a nationwide availability in Norway.
Alcoholics Anonymous was established in Norway in 1946 and Narcotics Anonymous in 1990. Together, these two fellowships currently hold 294 weekly meetings (AA = 208 and NA = 86), i.e. 6 meetings per 100,000 inhabitants [25, 26]. As a comparison, Iceland has about 80–90 AA groups/meetings per 100,000 inhabitants . According to AA/NA contact persons, the total combined membership of AA and NA in Norway is estimated at 3,000 members.
Currently, very few Norwegian centres base their treatment on the 12-step philosophy ("Minnesota Model"), and the general impression is of little integration of 12-step tenets into formal treatment. In Norwegian addiction treatment textbooks, referral to TSGs is generally recommended [27, 28]. However, strong polemics against some of the key 12-step concepts are also presented (e.g. the understanding of alcoholism as a "disease" and the concept of "powerlessness") [28, 29]. These contrasting views may lead addiction professionals to be ambivalent and cautious about recommending that patients participate in TSGs and compromise the effectiveness of the government's efforts to promote self-help participation.
It is not known whether US findings can be transferred to settings where TSGs are less integrated with formal services, e.g. Norway, making further research needed in treatment settings outside the US.
This study aims to describe attitudes towards, knowledge about TSGs and current referral practices among addiction professionals in a treatment culture largely unfamiliar with the 12-step philosophy. In addition, factors associated with active referral of patients to AA/NA in such settings are investigated.